The 20000 odd tribals in the Gudalur valley, classified by the Government as “Primitive tribes” belong to four main groups, the Paniyas, Bettakurumbas, Kattunaikkans and Mullakurumbas with a few Irulas. They have been displaced, time and time again- first by the British who cleared vast tracts of the Adivasis’ forests to plant tea, and then by local plantation owners and others who migrated to the area. The Indian government, at the time of Independence, nationalized the remaining forests and designated them as wildlife sanctuaries.
With the forests rendered inaccessible, their way of life was destroyed. Their status in society ensured that they received no assistance- they were considered below even the lowest rung of the caste system. Beyond being just untouchable, Adivasis would turn away and face the wall to avoid eye contact with others- direct eye contact was considered profoundly inauspicious. They were prone to exploitation, financially, physically and mentally.
The plight of the Adivasis reflected in their health. Malnutrition was rampant. Women died in childbirth. The Bettakurumbas, observed a custom of burning down the hut where a mother had died. On an early village visit, there were three recently burnt huts in a single village. Dysentery, tuberculosis, typhoid and anemia were significant killers. People stoically awaited death at home, rather than go to an unfriendly, alien hospital far away.
The birth of ACCORD, AMS and ASHWINI
In 1986 two activists Stan and Mari Thekkaekara, set up ACCORD to help the Adivasis fight for their land, stop their exploitation and to help them become self-sufficient again. They organized the Adivasis into village level sangams (groups), who federated to form a registered society, the Adivasi Munnetra Sangam (AMS), a peoples’ movement bringing all the five tribes together to fight for their rights. Over 10,000 Adivasis marched through Gudalur town in 1988- a landmark moment for a people so disenfranchised.
It was soon clear to Stan and Mari that development work was not possible without interventions in health. Most village meetings ended in them having to cart a pregnant woman with seizures or a child with severe diarrhea to the existing hospitals. News reached Deva and Roopa, two doctors fresh out of medical school, and they joined to tackle the healthcare problem. A community health program was started in 1987. With patience and commitment, they trained a cadre of Adivasi women as ‘health workers.’ They soon realized that therapeutic services must supplement preventive health to change the paradigm of care delivered.
It was then that Dr. Nandakumar Menon, a surgeon, and his wife Shyla, a gynecologist had just returned from the United States, wanting to start a hospital for the poor in rural India. ACCORD had been envisaged as a catalyst to bring about a change in the lives of the tribals. But healthcare was going to need a different approach, and ASHWINI was formed. This was the beginning of The Gudalur Adivasi Hospital( GAH). From the outset the vision was clear- hospital-based care would be complementary and not replace the community health work. It would be owned by the people and if it is the best in the area and sought by non tribals, it would help to change the social equations.
The early years.
The main focus in the early days was on the health of pregnant women and under-five children, the most vulnerable groups. Health Workers (HW) were selected from the community, usually a person with some standing, sometimes an enthusiastic youngster. The HWs played a key role in getting the people to overcome their fear of the outsiders and of modern medicine. A mobile health team with doctors went from village to village, providing preventive and curative care. They were supported by the HWs. They carried common medicines and these were provided at the village level. More HWs joined the team and the work spread to over 200 hamlets.
In keeping with the vision of empowering the community, there was a gradual process of decentralization and devolution of power. The mobile clinics were held in a common spot for four to five neighboring villages. The HWs and the people had to take the initiative and develop a health seeking behavior.
But then came the issue of providing care to patients needing hospitalization. It was all very well to talk about preventive care, but if you cannot take care of them when they fall ill, people will have no faith in you. Private hospital were ill equipped and too expensive. Deva and Roopa tried volunteering in the Government hospital where all tribal patients were admitted to the diarrhea ward, no matter what illness they came with! The doctor in charge would cut out orders for medicines; one such instance led to the death of a child with meningitis.
A big meeting was held with community members. there was only one way out. We would have to have our own hospital. It would be more effective and acceptable to the people. Drs Nandakumar and Shyla came forward to set this up.
In 1990 in a rented building with a few mattresses on the floor, an outpatient examination table under the staircase and an eight by six-foot operating room, GAH started functioning. Six young school dropouts belonging to the different tribes began training to become nurses. Each year a fresh batch of students joined to be trained as nurses, accountants, lab technicians, pharmacists, and all the other components that make a hospital function. Intensive training in each field including necessary mathematical skills like addition, and basic English.
From bolting at the site of a non-tribal, these youngsters blossomed to become skilled at each of the roles taught to them. Today they are expert midwives, nurses, accountants, pharmacists. The hospital grew steadily with more Adivasis getting over their fear of modern medicine. The presence of staff familiar with their culture and language gave them added confidence.
The initial admissions were for life-threatening conditions. A young man, mauled by bears, with a tracheal injury was taken to the Government hospital where they spent hours suturing all the wounds with cotton thread. He was referred to us when in respiratory distress. An emergent tracheostomy and suture removal were made possible by the recently acquired power generator. A few days into the treatment, the patient fled, returning to the forest with the hospital’s only tracheostomy tube!
Pregnant women with eclampsia were brought in having convulsed at home for three days before arriving at the hospital. We intubated one such patient, and bagged her for a week! We are proud to say, the patient went home alive, despite a hemiparesis. Thanks to the meticulous nursing care, 1kg birthweight premature infants were saved.
Nandakumar’s experience in treating critically ill patients was a boon. We had patients in septic shock with central venous lines, the pressure being measured on an IV pole with markings on it. Saving these sick patients, helped to gain the confidence of the community. Detecting and treating tuberculosis or saving a dying mother in a village meant the whole-hearted support of the entire village.
The rented building soon became insufficient. We moved into an office building owned by ACCORD in 1993. Meeting rooms were converted into wards and offices to outpatient clinics. We could now accommodate 25 patients; mostly with mattresses on the floor. Beds were reserved for the ICU. The operating room was basic with a home-made table whose head-end could be moved up or down. When tall surgeons operated, the table was placed on bricks, but it served its purpose. Many a complicated surgery was done with these minimal facilities. The outcomes were good, which proved to us that much could be done with minimal resources.
The community program evolved into a comprehensive health care model. 8 area centres were set up. Two trained tribal community health nurses called Health Animators (HAs) were in charge of each. Services expanded to cover non communicable diseases like diabetes, cancer and hypertension. A community mental health program was started in 2005 and had a huge impact. More health workers were trained and their roles became more skilled. Deaths from preventable diseases were becoming a rarity. Immunisation of children was over 90 % and Infant mortality rates fell from 250 per 1000 in 1987 to around 20 per 1000. Maternal deaths became fewer each year. The area centres became decentralised and planned their own programs based on the needs of the villages.
The mobile clinics were discontinued. The people would now come to the area centre for treatment. The HAs visited the villages to provide ongoing training and support the HWs. Doctors held clinics at area centres to see patients referred by the HAs.
By 2008, it was clear that a temporary arrangement for GAH would not suffice. The Adivasis were keen on taking the hospital forward. They wanted all their health needs taken care of at GAH, without having to be referred. Work started on the construction of a 50-bed hospital. Seeing this effort, The Tata Trust, one of the most prominent philanthropic foundations in India, came forward to help complete the infrastructure.
By 2014, a full-fledged 50-bed secondary care hospital with all the necessary facilities for laboratory investigations, imaging, endoscopy and blood banking was complete. It had two well-equipped operating theatres with laparoscopic capabilities.
Today, The Adivasi Hospital is one of the most sought after hospital in the Gudalur valley, not only by the tribals but also by the non-tribals of the local area. Patients are brought from distant villages by ambulance and good quality care is given. As most of the staff are from the community and can talk the tribal languages, the tribal patients feel at home. Efforts were constantly made to keep the place culturally acceptable to them and the community gradually adjusted to the change.
Training and Capacity building
Participatory development programs are a norm today. In 1990 it was an alien concept. However, we felt intuitively that taking the idea one step further and promoting community ownership, would be the best approach to empowering a community.
For most Adivasis, their low standing in society was primarily due to discrimination, lack of opportunity and broken self-esteem. Given a chance, we were confident that they would excel. Having a hospital staffed by members of the community would also encourage people deeply mistrustful of the health system, to access health care, and serve as an inspiration to young Adivasis.
None of the youngsters had completed school, but they were honest, intelligent and meticulous. Teaching them skills was probably easier than teaching the formally trained students. Language continued to be a challenge as most drugs, dosages, and instructions were in English, a language they struggled to pick up. With time and persistence, they made significant gains.
We also had to ensure that their training had some legal standing. To address this issue, the ASHWINI Institute of health was started in 2010 to offer vocational training courses to tribal students under a central government initiative. Classes are offered to train lab technicians, pharmacists, and administrative assistants. Most of the existing staff went through this course and got certified; giving them some legitimacy in the public eye and boosting their esteem.
Thanks to the intervention of the education team at VBVT, we had students graduating middle school every year. Many went on to high school but encouraging them to take the next step and pursue a college education was less successful. Most were too scared or lacked financial resources to continue education away from home.
The ASHWINI Adivasi School of Nursing was inaugurated in 2017, as a means of offering these students further education in a comfortable environment and provides auxiliary nurse midwife training to 20 students a year. 19 tribal girls have started training.In addition to these programs, students who are eligible are mentored and supported financially to seek further professional training outside. Many of them have since returned to work at GAH.
Monitoring and review of the activities, both in the villages and in the hospital are done by the staff themselves in the monthly meetings. A management committee looks ahead, takes care of the long term planning, budgeting and other policy issues. They are answerable to the Board of ASHWINI which is composed of senior Adivasi leaders and staff of the sister organisations.
Long term support has been rendered by many friends as well as small funding organisations. Some of the larger funding support was received from CEBEMO, The Tata Trusts, Skillshare International, The Poristes Stiftung, The Government of Tamil Nadu, The Charities Advisory Trust.