Reaching the Village
Posted by Peter on 30 September, 2010
There is quiet literally nowhere that I would rather be than in a village in a developing country, so today for me has been the highlight of the trip. When my mind wanders, which is, let’s face it, pretty frequently, it wanders to rural Uganda. Now it has somewhere else to wander.
The day starts with Luis’ irritating bird tweet alarm which never wakes him but never fails to wake me. 5.30 am. At least today it is actually set for the time we have to get up and not some random time in the middle of the night, probably a coincidence. Christie is in the shower before me but I beat Sapna and Luis. Kumar has made us breakfast and coffee and with eyes burning from the DEET cloud that seems to permanantly exist outside the door I make it to the car. So far so good. The plan is to meet the Health Management Research Institute (HMRI) mobile unit at a small town 60km away and follow them to the village. After a good 30 minutes escaping from the Hyderabad suburbs we emerge with only minor concussion from the fiercely staccato urban drive into the countryside. The sky is blue and the sun is blasting through the windows of the car as we pass out a truck that is passing out a bicycle with another truck coming straight at us. Fortunately the horn protects us, presumably the sheer vigour with which it is employed generates enough sound energy to force both trucks out of our way. The thought of being part buried in Columbia, part in Toronto, part in Ireland, part in Gujarati Ohio, part in San Francisco, part in Saint Louis fades from my mind again and I relax. It’s not the first time on this trip I’ve had this thought. I like to share it with my colleagues at particularly tense moments.
We belt on through the lush tree lined road. What look like Rhesus monkeys are playing on the tarmac, whole families of small light brown red-faced macaques with their young clinging to them basking lazily in the heat. Apparantly the best way to deal with monkeys is the same way you deal with large trucks- accelerate and drive straight at them with the horn blaring. Shobha intervenes and communicates in Hindi that we would like to leave at least some monkeys alive. Our driver does not seem too impressed, however no monkey is harmed in the making of this blog.
After several stops and phone calls for directions we arrive at a town crossroads. We pull off the road barely avoiding a small shop and its line of customers. Just as we do so the HMRI vans appear in the distance. They are big square vans, two in total. We join the convoy and follow them. We have to remind our driver not to overtake them, he has a tendency to overtake vehicles he is supposed to be following. Habit I suppose. We drive along quiet roads through rice fields and small corn fields, until we arrive in the middle of a small little village. The van stops at a one room concrete building with a porch. This is the focal point of the village, a type of communal hall used for various village functions. We also manage to park although with a lot of horn blaring. Not entirely necessary I think as there is no other car within ten kilometers, and I’m pretty sure everybody in the village has noticed us.
Without a pause the activity begins. The van doors open and almost ten staff emerge. They quickly set up five metal tables. Number 1 has a laptop and web-cam- this is the registration table. Number 2 is the weighing station- it has a standard and infant scales and a measuring tape. Next is the lab.
The lab consists of a haemometer which gives a haemoglobin measurement. Blood is mouth pipetted from a pin-prick into a glass tube where it is mixed with some HCL and water, allowed to settle and a reading is taken from the graduated side. There is a glucometer, urinalysis dipstix and some pregnancy test strips. Table 4- blood pressure. Table 5- counselling, nutritional advice. There is also a small dispensary. There are no doctors here but there are nurses and health officers. The drugs have been prescribed by a physician who is several miles away and the vans bring the medications with them on this monthly visit to save the long journey to the pharmacy. The drugs are standard fare. There are folic acid tablets for the pregnant women, metformin, theophylline, phenytoin, paracetemol syrup. The van doubles as a chart store and examination room especially for antenatal checks.
Soon there is a buzz about the place. At first there are one or two elderly men and women in their lungis and saris. They have expressive, weatherbeaten faces and their clothes are old and stained but clean. One tall elderly man has a woolen pullover on and is carrying his heavy blanket. It must be about 40 C. I am trying to avoid heat stroke. Just looking at him is making me light-headed. The elderly women bring the infants. I am not sure why, I think it is likely that the young are working. If this was sub-Saharan Africa it would be for different more tragic reasons, but thankfully the HIV epidemic has not yet devastated India in the way it has Africa. The operation is orderly and smooth. We are not party to the health advice, I have forgotten most of the Telegu I learnt as a child, and Sapna’s consists of adding the suffix “doo” to the end of every word (“breadoo”), with only limited success. Shobha is able to make some progress in Hindi. Overall everyone seems happy with the service, a very important component of which is prevention. Antenatal checks like these will flag pregnancies that are not progressing well. Low haemoglobins will be referred for follow up, especially in pregnancy. Child progress in charted on growth charts, blood pressure and urine sugars are checked.
Mid-morning we get a chance to wander around the village. This is the standard size village that the HMRI vans will visit for half a day, approximately 1500 people. There is a short main street with some small streets off to the sides. Most houses are brick and concrete or mud with low straw outhouses for the cattle and goats. There is a water pump outside the village hall. There are lots of open drainage and lots of open stagnant water containers, ideal breeding sites for mosquitos. Wandering up the road we some across the village health centre, a tiny single roomed house with a red cross painted on the walll. This is were the village asha (health worker) stays. A little further up there is a little statue with the old men sitting around talking and the school. We are ushered into the school and the head master brings us to see the children. There is great excitement and they all stand up and greet us. Songs are sung, photos taken and of course pandemonium when they see themselves in the pictures. The children use chalkboards to learn to write. There is no furniture, they sit cross-legged on the floor. On the whole they are sweet. happy little things, clean and bright-eyed, full of the same joys that children possess exclusively all over the world. Leaving the school, past the fire with it’s giant cooking pots, some of the smaller ones run past barefoot hitting tyres with sticks. Children’s games are the same everywhere. Or at least they used to be, before Nintendos and 24 hour cartoon networks.
Back at the village hall (room would be more accurate, it is an undecorated bare room with piles of rice and pots and pans in the corner) the clinic is in full swing. Patients move from table to table. More infants have appeared and young pregnant women. A barber has set up shop under the shade of one of the straw and mud walled houses and, sitting cross-legged on the ground behind his client he watches the proceedings, his scissors flickering in the sun light. There is also someone who must be the village shaver shaving his clientele with his trusty cut-throat, brush and soap. Every now and then a herd of goats, or cows, or sheep are marched past. The locals are enjoying having their photos taken and seem to be very grateful to be photographed, even when they do not see the results. This perplexes me a little. They are even happier when I show them the pictures, they look approvingly at the camera and smile and shake their heads. I know they don’t expect to receive copies but I hope that I can get somehow get some to them.
The medical care that HMRI provides on these trips is basic but it is organised and systematic. There are different types of mobile clinic services in different parts of the world, even including mobile operating theatres. These are usually run by NGOs. HMRI is a public-private partnership with the Indian Government. What makes their operation particularly impressive, besides it’s integration into the health service, is the sheer scale of the operation. As Shobha has already mentioned there are over 400 (I think the figure was around 475) vans on the go constantly. They service villages over 3 miles from basic health centres (which are usually staffed by a nurse of midwife). Some are many more miles away. They provide care for half a day a month for villages of 1500 people, each van will travel to two villages a day or stay a whole day in the bigger villages where the populations are around 3000. Overall HMRI provides a once monthly visit to 38 million people. The service operates in a hub and spoke manner, the vans return to their hubs at night where they can be serviced, fueled, restocked for the next day. The level of organisation involved is very impressive. I very much admired the systemic approach to the operations. Each van operates in the same manner, is equipped the same and follows the same protocols. The system is computerised but not overly so, each van has a laptop and webcam that can be used to keep track of patient demographics and registration. The service is not overly complicated, instead of providing more complex care for a few they have opted for basic healthcare for many: nutrition, antenatal care, childhood health checks, basic health advice, reassurance, counseling, providing medications, but also facilitating referral to higher level health services, even attempting to provide transport to patients on the visit days if required. If a patient needs a HIV test they can provide the counseling and then try and arrange for the patient to be tested at a government testing site. A woman with complications of pregnancy can be referred to higher level care earlier. Staff can also access a doctor by phone on their own 104 healthcare line. It does not attempt to duplicate services, only to increase access to present services.
HMRI is a good example of the benefits of public-private partnerships in health care. As a private albeit not for profit organisation it has efficiencies and freedoms that government organisations do not have. It has more streamlined operations and the flexibility to scale up or scale down or adapt to changing situations more rapidly. It may have to compete with other projects for funding which can reduce costs and encourages innovation and operational research. The government on the other hand is in a better position to provide the large amounts of funding required for the services and to leverage funding. Paradoxically the major disadvantage of this system is that should the government decide not to renew funding then the operation will collapse and as such it’s continued existence is at the whim of a labile political system and could also fall foul of corruption. Finding non-government donors for this scale of operation would be very difficult, especially at short notice. The programme is easily and rapidly reproducible, at least within India and there is interest from other states in providing a similar service. It also has potential as a model of care for other developing countries. It does seem to be particularly suitable in India where road infrastructure, ability of at least the better off states to fund the initiative and the large rural population are conducive to a service of this nature. It is an excellent programme, innovative and well designed and while it remains vulnerable to political decisions and cutbacks it provides very important services to millions of people who have none.