January 18, 2012

People living in tribal villages in central India are caught up in the conflict between Maoist rebels and government forces. Dr. Rebecca Cuthbert describes how MSF takes the clinics to them.



India 2012 © MSF

Dr. Rebecca Cuthbert leans against an MSF truck in Bijapur, Chhatisgarh state.

In the forests of central India, Maoist rebels called Naxalites are fighting government forces to control great swaths of the interior. People living in dozens of tribal villages are caught up in the conflict, unable to reach the Ministry of Health’s clinics in Chhattisgarh state. Dr. Rebecca Cuthbert describes how Doctors Without Borders/Médecins Sans Frontières (MSF) takes the clinics to them.

It takes five minutes to walk down the sandy back lane to our office, where I open the padlocks on the doors with my jailer-size ring of keys and check the whiteboard I prepared last night about the work for the day ahead.

We run five mobile clinics every week; today there will be 14 of us, which means carrying a lot of water. In the summer, when temperatures are highest, we take up to three liters of water for each person. We will also carry all our supplies, including lab equipment and drugs, health cards and registration books, plastic sheeting and privacy screens, and two cold chain boxes.

As the team starts to arrive, everyone starts in on their assigned tasks, though the cooks have been working since 5:00 a.m. to prepare our lunch. Ice packs are placed in coolers. Backpacks are stacked and ready for loading.

At the morning meeting, we get our security updates. We’ve heard that the Naxalites may impose a bandh, a travel ban, which means roads could be blocked by tree trunks or newly dug trenches. Next, we rush through a host of last-minute questions: Where is the driver? Where are the snacks? Where is my phone? Then everyone piles into two cars and we’re off.

Buffalo amble languidly along Bijapur’s main road, competing for space with bicycles and cars and children walking to school. We drive through a checkpoint and out into the country, taking care to avoid chickens, piglets, dogs, and cows, and waving to excited children who run through the fields towards us.

An hour later we park, shoulder our backpacks, and then set off single file behind a team member carrying the MSF flag. Towels, hats, and scarves protect our heads from the already burning sun. The narrow path winds though forest, around paddy fields, and across rivers that are waist-high and fast-flowing in the rainy season but little more than puddles now. Along with the occasional villager, we pass women carrying bundles of rice or loads of firewood on their heads and children on their hips, and hunters with their bows and arrows.

After walking for an hour, we arrive at the village and set up the clinic. Like clockwork, the team affixes swatches of green material between poles to make separate screened-off areas for antenatal and post natal visits, for patients waiting to be seen, for a laboratory, and for vaccinations. The drug dispensers arrange boxes of medications on an old cot. Scales for weighing children are hung and the nurses get ready to vaccinate for polio, diphtheria, tetanus, pertussis, measles, and hepatitis B. The doctor gets prepared, while the health educator begins speaking with people waiting to be seen about treatment and prevention for diarrhea, scabies, and malaria—all common in these parts.

The Basics of the Mobile Clinic

The first patients are registered. Communication takes time and patience, since information must often be translated into Hindi, which the nurses speak, English, for the expats (if necessary), and the local dialect. MSF has a translator on hand who picks up registration cards and calls patients in to see the doctor. They and their caretakers are interviewed at length about their medical histories and their most recent visits to health care facilities. After seeing the doctor, some are sent for additional tests or for medications, while others go for vaccinations or wound care (all children younger than five go to the nurses for vaccinations). Pregnant women and people seeking treatment for malnutrition are sent directly to the nurses. Anyone with a fever is immediately tested for malaria. (We see less malaria in the summer than in later months, but rapid diagnostic tests can detect both falciparum and mixed malarial infections.) Anyone with tuberculosis sees the health educator for support and counsel.

As time passes, we try to move the lab out of the heat and cool the thermometers in the cold chain. It’s very hot and very dusty, but the team remains in good spirits, focused on their work. The drug dispensers patiently explain how patients should take their medicine, using small bags with pictures of the number of tablets required at each time of day to convey the information to a population who did not have the opportunity to learn to read and write. Some children get their first dose of malaria treatment ground up and administered with water and sugar.

Most of these children are quite skinny. Illnesses decrease their body weight, especially between the age of one and two; many qualify for supplementary feeding or admission into the intensive feeding program. MSF provides mothers with nutrient-rich therapeutic food as well, using community health and outreach workers to explain how important adherence to a regular feeding schedule is and later to trace the progress the children make.

Referring Life-Threatening Emergencies

I remember a young man came to the clinic with a big cloth covering a massive, bone-deep axe wound in his forehead that he said happened five days earlier. We cleaned the wound on site, then first took him to the Bijapur district hospital and later arranged his referral to the neurosurgical department in Raipur some 10 hours drive away.

This patient’s wound eventually healed and he was able to return home, but referrals are complicated undertakings. The team leader, the counterpart (a staff member from the Ministry of Health or another relevant NGO), and the doctor evaluate all emergencies that require immediate treatment. We have to take into account the fact that many people will not feel comfortable going into town given the political climate in the area and the possibility that any patient can be stopped and questioned at checkpoints along the way. All patients need a caretaker with them as well, and a male relative has to give consent if their female family member needs an operation or a blood transfusion. If patients need to go to our Mother and Child Health Care facility in Bijapur, MSF makes sure they are able to get there.

Because the local diet involves mainly rice, vegetables, and dal, many expectant mothers arrive frighteningly anemic. This creates complications in childbirth and means we need to monitor hemoglobin levels, provide iron supplements, and occasionally carry out transfusions. MSF has been working with the Bijapur district hospital to set up a blood storage unit that can provide blood when necessary, such as in the event that obstructed labor necessitates emergency obstetric surgery. MSF also now performs C-sections when required; the alternative is referral to a hospital four hours away.

Wrapping Up and the Sun Begins to Set

The team leader and counterpart keep a close eye on the time, knowing that we need to be back in the office before 5:00 p.m. to avoid being out after dark. Since we won’t be back for a week, they make sure there is enough time to see all the remaining patients and do all the necessary tests, then dismantle the clinic, walk back to the cars, and drive back to Bijapur.

When we set off, our backpacks are lighter but everyone is still shouldering a considerable load. None of us has eaten since we arrived, so we stop along the way for a snack—small packets of spicy Indian noodles—and some water. It’s still very hot and the team is largely quiet as we walk, the song of cicadas is the only sound on an otherwise silent journey.

Upon reaching the two white MSF vehicles, we eat some more and drink cool water, then drive back down the makeshift mud roads and onto the cement roads that lead to the office. “Good clinic?” the project coordinator asks when we return. “How many patients did you see?”

It was a good clinic. This is what we are here for: the good days and the hard days, days which start early and finish late, and the feeling of doing decent work with the support of an enthusiastic and dedicated team.

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