When thinking of a disease, it is natural to think of it in medical terms – questions of how rare, how curable, what medicines and procedures have been developed against it. But what this outlook sometimes ignores are the social realities that perpetuate diseases, perhaps making their impact far greater than those used to modern medicine would expect. There is a lot more that needs to be addressed when looking at health problems, public health specialists have often argued – awareness around diseases, access to an affordable healthcare system and the right medication, adequate nutrition to preserve the body’s immune system and the existence of sanitation facilities.
In an attempt to understand rural health in Chhattisgarh and the extent to which the problem is not medical but social, the Jan Swastha Sahyog (JSS) has brought out An Atlas of Rural Health.
The JSS is a collective of health professionals and workers who run rural health programmes in central India. Over the past 16 years, their rural community health project has spread to 2,500 villages in north-western Chhattisgarh and south-eastern Madhya Pradesh.
“Our work and our experience has taught us that disease is the biological embodiment of deprivation,” the book’s introduction says. In a unique, detailed collection of their experiences with different health problems, they have tried to explore and understand not just the proximate, biomedical causes of diseases but also their social, economic and cultural roots. The book has focused on the ailments that are seen most often at JSS hospitals and health centres in Ganiyari, Shivtarai, Semariya and Bamhani.
There are several commonalities in the case studies done by the JSS. For almost all the people mentioned, going to a healthcare facility involved surmounting geographical and monetary hurdles – facilities are far and there are no services provided to take patients there. Awareness is another issue, with people often not taking their health problems seriously until it is very late. There is also the larger problem of the lack of adequate nutrition, making people weak and susceptible to disease.
Take malaria, for instance. According to World Health Organisation data, 80% of the world’s malaria cases come from India, Ethiopia, Pakistan and Indonesia. In January this year, one in seven Indians faced the risk of catching malaria. Official numbers put Chhattisgarh as the state with the second highest number of cases in 2014 – with 1,28,000 reported cases.
Between October and December 2010, there was a malaria outbreak in Chhattisgarh. The state government reported a total of 32 deaths. But JSS community workers involved in a rough survey learned that 200 people died of malaria in Bilaspur’s Kota block alone. In most of these cases, deaths occurred at home, and were thus not counted as malaria deaths.
Eight-year-old Shyamlal Yadav had fever and a headache for three days. When his body began to turn yellow, his parents called a “witch-doctor” to get rid of the evil spirits that had taken over him. They also took him to a local “quack”, who gave him an injection. The next, Shyamlal’s fever increased substantially. His father wanted to take him to the primary healthcare centre, but the closest one was in Ratnapur, 25 km away, and the last bus had already left. The village sarpanch arranged a motorcycle. In Ratnapur, the doctor on duty detected malaria and asked that the boy be taken Bilaspur, another 30 km away. The family didn’t have enough money for the journey and treatment. Though Shyamlal’s father asked the doctor to keep the boy overnight while he went to arrange for the money, the doctor didn’t agree. They got the same answer at a nearby private hospital, so ended up taking the last bus back to the village. Shyamlal was coming in and out of consciousness by this point. That night, his father mortgaged an acre of his land, along with the standing crop. But Shyamlal didn’t make it till morning.
Three days later, Shyamlal’s cousin, one-year-old Tilakram showed the same symptoms. His family had more money on hand and rented a car to take him to a community health centre on Kargi Road to Bilaspur. But the authorities there didn’t provide an oxygen tank for the infant, who died on the way to Bilaspur.
These are instances where the cause of death is, in statistical and medical terms, a disease – malaria. What statistics masks, however, are the social factors that aggravated the illnesses and created circumstances where what could have been treatable turned fatal. And that is what the JSS is attempting to highlight.
Dr Yogesh Jain, a doctor with JSS, writes about how malaria incidence and deaths peak in November and December – months that are relatively cooler. This can be explained by the fact that food stocks are low in this pre-harvest period, Jain argues, making it even more clear that these deaths can’t be attributed only to a disease.
American physician and anthropologist Paul Farmer would have called these ‘stupid deaths’, the book argues, “because they were not caused by a mere sting of a mosquito but a collective stupidity of policies, politics, health systems, inaccessibility, lack of doctors, lack of basic infrastructure and, most importantly, inequality”.
Not just malaria, all the instances of disease chronicled in JSS’s book cannot be explained only in medical terms. The point the organisation is trying to make is that without addressing the socio-economic circumstances that lead to and exacerbate the illnesses, change will be hard to come by.
Adequate nutrition adds immensely to the body’s ability to stay healthy and heal itself in case of illness. Jain writes in the Atlas that in tribal-dominated Chhattisgarh, men and women are at least ten kilos lighter than the average Indian. While mostly families are extremely dependent on the public distribution system for their grain, the subsidised rice they receive from the government lasts less than two weeks.
This poverty-induced undernutrition is clearly linked to the prevalence of different types of diseases in the area, the JSS finds – from tuberculosis and malaria to heart disease and cancer. Jain refers to the picture he sees, where diseases are only an embodiment of injustice and deprivation, “violence”. Part of the problem is the lack of understanding, Jain argues, where a large part of the privileged Indian population is ignorant about the huge health costs of undernutrition and hunger.
The conversation around ‘food security’ needs to shift dramatically if the health consequences of the lack of adequate nutrition are to be addressed, Jain argues. The random quantities of food that are far from enough to feed a family for an entire month is one problem. The fact that only cereals are provided, which have only limited nutritional value, is another.
Deficiencies in nutrients can lead to several illnesses. Vitamin B12 deficiencies are extremely common in India, given the vegetarian diet. It can manifest itself in various ways, from fatigue and depression to mouth ulcers and gastro-intestinal disturbances. Dietary inadequacies can also lead to iron deficiency anaemia, as JSS saw in Chhattisgarh. Haemoglobin dropping below a certain level is life threatening, but easily avoidable if there was more awareness on and access to balanced diets.
In addition to all of this, government health centres and hospitals often treat poor patients and their families without respect, not explaining the problem or its solutions. All this does is create a further distance between people and the medical system. People are also less likely to want to return once they are treated with no dignity. Often at JSS clinics, the book says, people are surprised at the care with which they are treated.
The Atlas of Rural Health is a detailed, ethnographic account of why health isn’t only a medical issue. With every case and illness talked about, whether common or rare, there is space for public policy, awareness campaigns, education, sanitation and nutrition, in addition to better and more accessible medical facilities, to have made a difference. By using personal narratives, this unique ‘atlas’ makes the complex human geography of rural health accessible to all readers.