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Interpreters of maladies

The dilapidated Primary Health Centre in Sultanganj does not serve the needs of the population. Photo: V.V. Krishnan  

S.S. Pal’s Ayurvedic clinic is in a roadside market in Sultanganj of Mainpuri district in Uttar Pradesh. He started it six months ago, after retiring from government service. On a tray under a table, Pal keeps a packet of syringes. It is not an instrument used in Ayurveda, but Pal, who has a Bachelor’s degree in Ayurveda, Medicine and Surgery, casually confesses that he prescribes allopathic medicines too. The Indian Medical Association would label him a quack.

A recent report published by the World Health Organisation (WHO) says that 57 per cent of doctors practising allopathy in 2001 did not have the necessary medical qualifications. And Mainpuri district, the pocket borough of Samajwadi Party leader Mulayam Singh Yadav, is named in the report as one of the 30 most backward districts in terms of the density of qualified doctors.

The ratio of doctors to patients is abysmal: just three for every lakh.

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It is 8.50 a.m. and the Primary Health Centre (PHC) in Kushalpur village is desolate. It has four rooms and is painted pink, like the others in the district. It has posters of the government’s flagship National Rural Health Mission, launched in 2005. The programme was meant to address the health needs of under-served rural areas. A man in his 50s walks in and points to another dilapidated building meant for doctors in residence. Weeds grow out of the pale yellow building and, clearly, no doctor wants to reside here. The man says, “The doctor will be here in 10 minutes. The dispensary opens at 9.00 a.m. and closes at 1.00 p.m.”

The doctor does indeed arrive at the designated hour, opens the shutters of his room, and launches into conversation. “I treat around 100-150 patients every day, and we have enough medicines to serve our patients,” the 60-year-old doctor says. The villagers join in, chorusing praise about the physician. Soon, they dismiss healthcare, and speak instead about other things that affect their daily lives.

Less than a kilometre away, in Saidpur village, Naresh Singh, 40, a daily wage labourer, has a rather different story to tell. “Not a single person in our community goes to that government dispensary,” he says with anger. “Doctors shout and misbehave with us. The compounder asks us for a commission at every step. Medicines are never available. There is no point going there.” His father, bent with age and hard of hearing, recalls not being able to get tuberculosis medicines for 15 long days from the dispensary, after which he had no choice but to go to a private doctor.

The plagued public health system pushes people like Singh and his father to private healthcare, which takes a heavy toll on their income. Singh earns Rs. 100 to Rs. 200 every day and one visit to a private doctor costs him that much. “No one listens to us in the government PHCs and private doctors just want to make money,” says Singh’s neighbour. Another neighbour recalls how a villager died because of a wrong vaccine administered by the compounder of a private clinic.

So, jholachap doctors or quacks become the ‘saviours’. “They don’t have a degree. But their medicines work most of the time,” says Singh. This speaks volumes about the economics of rural healthcare — quacks, being cheap and more accessible, meet the demand for affordable healthcare. “One of them makes regular visits to our village and turns up at home after a phone call. It is very convenient,” Singh adds.

Singh and the other villagers who have joined the conversation remember Dr. Ali, who served the PHC 20 years ago. “There used to be a long queue when Dr. Ali was here. He prescribed top-class medicines.”

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Across the road is Rampur, a relatively developed village, with around 40-50 households of upper-caste Thakurs. A young boy with spiky hair, wearing a funky T-shirt and capris, is sitting on the spacious lawn of his big house. He doesn’t go to the Kushalpur PHC either. But the city’s private doctors treat him for free. Ironically, he gets free private treatment because his mother is an auxiliary nurse midwife, the grassroots worker in the public health system.

And 30 kilometres away, Byontikurd village greets visitors with a spanking new underpass, an aesthetically pleasing structure, raising questions about the budgetary priorities of the village administration because here, too, the PHC story is similar to that of Saidpur.

Villagers say the doctor is often drunk on duty. Nitin, 19, is listening to local songs on his mobile phone. He says the compounder erased the toll-free helpline number from the wall when Nitin said he would lodge a complaint.

In Darwah village, there is no PHC at all. “We have a population of around 4,000. Shouldn’t there be a PHC?” asks Rajnesh, who has just finished his B.Sc. and hopes to join the army. Darwah residents go to Anil Kumar, referred to as “doctor” by the villagers, who doesn’t have a medical degree. He treats villagers for coughs, stomach aches and fever, among other ailments. Next to his clinic, his relative runs a veterinary centre for goats and buffaloes.

Darwah, however, doesn’t have the time to worry about doctors. Its residents are mostly concerned with the ongoing desilting of the Arind river, which has made it so deep they find it hard to cross over to their fields. They want this fixed at the earliest.

It is only for primary healthcare that villagers seek out private doctors. For major diseases or accidents, the Mainpuri government hospital is the place. Tertiary care in the private sector is well beyond the reach of most villagers. But Rajesh Kumar Gupta of Mainpuri town hasn’t had a pleasant experience at the government hospital either. Gupta owns multiple businesses and is sitting comfortably outside one of his guest houses. He has on leather shoes, a polo T-shirt, a gold ring and a gold-plated watch. “I took my daughter to the Mainpuri government hospital last week. The doctor said she had tuberculosis and her lungs were filled with water. They didn’t answer any of my questions,” he says. He then took his daughter to a private hospital in Noida, five hours away. “The doctors there told us she only had a mild infection and pneumonia.” Yet, Gupta believes Mainpuri has “developed” significantly over the last decade.

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On the brighter side, villagers have great things to say about the ambulance service. The ambulance usually takes 30 minutes to arrive, and takes patients to the hospital: a lifeline for those who don’t own a vehicle. Health may not be on top of the electoral agenda, but some buses in the district flaunt the success of the ambulance scheme, displayed with a photograph of Chief Minister Akhilesh Yadav.

ASHA workers, trained community health activists who are the interface between the community and the public health system, are present in all three villages we visit. Saurabati has been an ASHA worker in Darwah since 2006. “For deliveries, I take the woman to hospital. Twice a month, on the second and fourth Wednesdays, we set up a booth in the village to administer vaccines to infants and pregnant women,” she says.

Access to clean water and sanitation is often held to be the first measure of a health policy. And these villages say clean water, at least, is available from the community hand pumps, though many aspire to get their own tap connections. But whether in Byontikhurd, Darwah or Saidpur, residents say that they are unable to afford toilet construction. No government toilet scheme has reached them yet. “Who would not want a latrine in the home?” Rajnesh asks. Pointing to the path that leads to the primary school, he says, “It is impossible to walk there. The path is full of faeces.”

Most villagers appear to be aware of the importance of toilets. Says an old man, on his way to the farm, plough in hand, “Girls refuse to marry if there is no toilet in the boy’s house. The flies are a health menace.”

On the 300-kilometre road trip from New Delhi to Mainpuri, clusters of medical facilities emerge every now and then, especially in places like Palwal and Agra. Advertisements for doctors and clinics are plastered on brick walls along the highway. In Mainpuri, the density of qualified doctors is not as grim today as in 2001. But there still aren’t enough doctors and the quality of healthcare continues to be desultory. The quacks reign.

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Printable version | Dec 2, 2020 5:00:02 PM | https://www.thehindu.com/features/magazine/Interpreters-of-maladies/article14517155.ece

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