Dr Bang brings modern maternity care to Indian's isolated tribal communities

Shocked by the state of neonatal care in rural India, Dr Abhay Bang has established a network of nurses, known as 'arogyadoots', who provide education, diagnose medical conditions and administer medicines. His ideas have been endorsed by the WHO, Unicef, Save the Children and USAID.

Dr Bang visits Meena Dhit and her newborn baby in her home for health checks. Dr Bang has created teams of health workers known as arogyadoots, for home-based neonatal care, that have dramatically reduced infant mortality rates in rural India's villages such as Bodli, in Maharashtra. Andy Hall
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GADCHIROLI // With India facing a crisis in state-run health care, one doctor is applying simple yet radical solutions drawn from his upbringing on Gandhi's ashram to dramatically reduce child mortality rates, while also reaching out to isolated tribal communities caught in a war zone.

Dr Abhay Bang, 50, tells the driver to stop at a bridge deep in the Gadchiroli district of Maharashtra. "This is a very important place to me," he says, pointing at where an older bridge had collapsed into the river.

It was here in 1993 that a woman from the nearby village of Khursa found her path blocked as she tried to carry her dying child to Dr Bang's newly established clinic a few kilometres down the road. Corrupt contractors had not used enough cement and the bridge had collapsed some months before. The government had promised a new one, but it had yet to materialise. Heavy rains meant the woman had to wait all day until the water was low enough to cross.

"When the child finally reached me, it was gasping its last breath," said Dr Bang. "He had diarrhoea, malnutrition and pneumonia. Within two minutes of starting the examination he was dead."

The event had a transformative effect on how the young paediatrician looked at healthcare in India.

"I counted 18 reasons behind this child's death: there was corruption and poverty, the mother was illiterate, the father was alcoholic, they had tried black magic rather than come straight to a doctor. My initial impulse was that we can't save these children if there are so many causes.

"But then I realised that we only have to target the weakest link in the chain. I started to look at which causes we could make a difference to, and we decided that it had to start by providing care in the village. This is how we could break the chain of death."

Through his charity Search (Society for Education, Action and Research in Community Health) which he runs with his wife Rani, Dr Bang established a network of around 40 local neonatal nurses, known as "arogyadoots" meaning "health messengers".

The arogyadoots provide education and support. Controversially, they also diagnose medical conditions and administer basic medicines.

The concept flew in the face of medical orthodoxy, which said that only fully trained medical practitioners should treat patients. But the results have been a revelation, with child mortality rates in the district falling from 121 per 1,000 births in 1988 to just 30 per 1,000 today - less than half the national average, even though Gadchiroli is one of India's poorest and most isolated districts.

Much of Dr Bang's inspiration stems from his childhood in Mahatma Gandhi's ashram at nearby Sabarmarti, where his father was a devoted follower.

"Gandhi very seriously criticised lawyers and doctors - he said they have a vested interest in quarrels and sickness," Dr Bang said. "He felt that every village should be able to look after itself."

In rural India, where patients often have to walk many hours to reach a doctor, the need for local support is great, but Dr Bang's team of nurses still faced a long struggle in winning the confidence of their communities.

Maya Adunutalwar, an arogyadoot in the village of Rajgatta Char who treats around 40 children a year, said: "When I was new, there was a child born in the seventh month - very underweight. After 10 to 15 days it developed sepsis but the parents didn't trust me. It was only when the doctor said the baby was about to die that they finally let me give an injection.

"The baby survived and it was a real turning point for the whole village and how they think about treatment."

Many superstitions and misconceptions also had to be overcome. Anjana Uikey, one of the first arogyadoots to be trained, said: "Fear of the 'evil eye' meant mothers and babies could not leave the room for seven days - even to go to the toilet.

"Faeces, urine and placenta could not be seen by outsiders or black magic would be done so it was all kept in a pit in the same room as the mother and baby. It was hard to convince people to change at first, but when they saw the results it became easy."

Dr Bang also turned his attention to the tribal communities living in the surrounding forests, where a Maoist insurgency has been raging for decades.

Tribes in this area, long exploited by the government, have a natural suspicion of outside assistance, so earning their trust was more complicated.

Dr Bang's solution was to involve tribal religious leaders in designing his clinic: "They told us they did not like hospitals because they were godless places and because the doctors wear white, which is a symbol of death."

He responded by placing a shrine to the tribal goddess Ma Danteshware at the entrance to the clinic, and inviting their religious leaders to stage their annual festival within its grounds. These meetings also allowed Dr BAng and his team to listen to tribal health concerns and devise treatment programmes.

By engaging on their own terms, and gaining the religious sanction of their leaders, Dr Bang has created one of the few clinics embraced by tribals in India.

That trust has also allowed him to continue operating despite continuing violence between the Maoists and state forces.

His neonatal system has been endorsed by the World Health Organisation, Unicef, Save the Children and USAID, and is being applied across parts of South Asia and Africa.

It also has the support of the Indian government, which now sends village health assistants to learn neonatal care at Dr Bang's clinic.

But the scheme also highlights the government's dramatic failure on public health. India spends just 1.1 per cent of GDP on health, one of the lowest proportions in the world, and its promises to raise this to 3 per cent have so far failed to materialise. A recent Lancet study said the figure would have to increase to 6 per cent by 2020 if the government was serious about its promise of providing universal health care.

During the past two decades, the gap has increasingly been filled by the private sector, which now accounts for 80 per cent of outdoor consultations and half of indoor admissions. It is estimated that a quarter of all patients are pushed below the poverty line by hospital debts.

Nurturing newborns is vital to limiting future costs, says Dr Bang, who remains confident that the country can still salvage its crumbling health system. "The vision is there, but there are many gaps in implementation and very little political will to change anything.

"My chief concern is that newborns have very little political weight - they don't even vote. It is my job to give them a voice."