|Year : 2016 | Volume
| Issue : 4 | Page : 135-140
The tribal hospital: An interview with Dr. Regi George of the tribal health initiative
Tony Abraham Thomas
Continuing Medical Education, Christian Medical College, Vellore, Tamil Nadu, India
|Date of Web Publication||22-Nov-2016|
Tony Abraham Thomas
Continuing Medical Education, Christian Medical College, Vellore - 632 002, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Thomas TA. The tribal hospital: An interview with Dr. Regi George of the tribal health initiative. Curr Med Issues 2016;14:135-40
| Introduction|| |
Dr. Regi George and Dr. S. Lalitha have been involved in transforming the health of the tribal community in the Sittilingi valley and the surrounding mountains for the past 24 years. They pioneered the "Tribal Health Initiative" (THI) which grew as an expression of their desire to empower tribal villagers to take care of their own health. The THI has achieved this through various initiatives that have not only improved the health of the tribals but also improved their financial status and community well-being. Whether training tribal women to deliver health to their community, reviving tribal art, or forming a society of organic farmers, they have consistently strived to empower the tribal community that they chose to serve. In an informal interview, Dr. Regi George describes the beginnings of the "Tribal Hospital" and the various projects under the THI that have contributed to this transformation [Figure 1].
| How Did the ‘Tribal Health Initiative’ and Your Work among the Tribals of Sittilingi Start?|| |
Lalitha and I wanted to do something for the poor with the medical training that we had received. I had specialized in anesthesia with some training in surgery and Lalitha had trained in obstetrics and gynecology. While working in a hospital in Gandhigram, we saw several people coming to the hospital from distant regions for treatment of illnesses such as diarrhea and childhood pneumonia, which were easily preventable. We realized that preventive medicine which could significantly impact these villagers was not a priority in most hospital settings and also that there was more to health delivery than just hospital-based care. We were also influenced by Gandhian ideals, which essentially emphasized giving power to the people so that they do not have to rely on outside help. That is when we decided to explore other models of health care.
With this in mind, we backpacked for a year and visited various hospitals and institutions around the country. We visited all kinds of institutions (not just medical), especially those situated in tribal areas. The impression we gathered out of this year was that there was a huge need out there, not just for clinical care, but also for preventive care and the need to help tribals to take care of their own health. This was when we considered the option of training tribals in basic health care so that they could provide the same to their community. After some research, we decided to come to Sittilingi in Dharmapuri district. This place was chosen because it filled our most important criterion - it had very poor access to health care and was the farthest away from any quality health-care facility. At that time (1992-1993), Dharmapuri was among the worst five districts in India in health-care indices - infant mortality was around 147/1000 and maternal mortality was very high. We had meetings with the tribal villagers and decided on a site to set up a hospital. We did not have money to buy land, so we set up a small clinic in government land which was nothing more than a small two-roomed hut built by the tribals themselves.
| Was There a Problem Getting the Tribals to Accept You?|| |
That was not a problem at all since they were very eager to have us - they had not seen a real doctor in a long time. A retired IIT engineer (Mr. Arun) initially helped us in identifying the land, setting up our hospital hut, and other aspects. Thus was born the "Tribal Health Initiative." This is a charitable trust which was formed with four of our friends [Figure 2] and [Figure 3].
| Could You Describe Your Initial Work among the Tribals?|| |
In the year 1992, we worked out of a hut and this continued to be our clinic for 3 years. The hut acted as an outpatient and inpatient facility. We dealt with deliveries, minor surgeries, and lots of abscesses. Diarrhea and pneumonia were common. By 1997, the hut clinic grew into a hospital and we started some emergency surgeries and a few elective surgeries. Gradually, a laboratory and other facilities were added, and today we even have an Intensive Care Unit for the very sick.
| The People|| |
The people served by the hospital are from the Malayali tribe or "people of the hills" (derived from "Malai" and "Aalu") who speak Tamil. In fact, this is the largest tribe in Tamil Nadu. They form the predominant population of the surrounding Servarayan hills, Jawadhi hills, Kalrayan, and Sittheri hills. We also serve two Lambadi (gypsy) villages and one scheduled caste village. Most villagers are farmers with small land holdings. The hospital now caters to a one lakh population, which includes the tribals from the hills and those from the surrounding villages. Respiratory and gastrointestinal illnesses are the most common illnesses we encounter. There is at least one person with pulmonary tuberculosis in our outpatient clinic every day.
| Training Tribal Women|| |
Our clinical work grew over the years, yet we did not lose the sight of our primary aim, which was to train and empower the local tribals to be health-care providers. Hence, even when clinical work became overwhelming and started taking most of our time, we decided to restrict our clinical work so we could focus on training young women.
We decided to train women in the basics of health. Women were chosen because our aim was to tackle the issues of maternal and infant mortality and we felt women were best suited for this work. We started with young women but later decided to induct older women as trainees. Each village was asked to choose one married woman (in her thirties or forties) and offer her as a trainee. We called them health auxiliaries.
One of the major hurdles in training was that the women were illiterate. Therefore, in the first 3 months, we just taught them Tamil, English, and Mathematics. After this, we introduced the medical subjects. The training was based on the book "Where there is no doctor" by David Werner. Werner's emphasis was on tailoring training based on local needs and peculiarities rather than just teaching facts and skills. We adapted our training methods similarly to meet the local needs. Initially, the women themselves set the syllabus based on the common problems they saw in the villages - cough, fever, diarrhea, etc., Along with that, we taught basic anatomy, physiology, and pharmacology.
Today, a fresh batch of 6-8 tribal girls undergo training here every year, taking classes for 2 days every fortnight for 1-1½ years. They are trained in the basics of sanitation, hygiene, childbirth, antenatal care, complications of childbirth, nutrition in children, and methods of communicating this knowledge to the community through stories and songs. They are taught to detect and optimally manage two common illnesses - pneumonia in children and dehydration in diarrhea (illnesses which contributed to about 80% of childhood mortality) and the use of four medications such as paracetamol, antacid, dicyclomine, and septran. After every session, they are sent to their community to impart health education to the community, detect common illnesses, and refer the sick to the hospital. They are taught to keep records and report to the hospital for every 2 weeks. Because they are from the village, they accepted and the knowledge they possess remains in the village.
| The Mother and Child Program|| |
The next step in training was to go into the villages and train them on the job. We started antenatal clinics in the villages once in 6 weeks, taking even some laboratory facilities along with us. The health auxiliaries would gather the antenatal women in one place, measure the basic health parameters, and the doctor would then examine them. More importantly, this was an opportunity for imparting health education to the pregnant women.
| What Was the Impact of the Training of Health Auxiliaries?|| |
With the help of the trained health auxiliaries, our antenatal coverage improved from 11% to 88% and slowly infant mortality and antenatal maternal mortality reduced. Since 2003, we have not had any maternal mortality in the 21 villages covered by our hospital. The health auxiliaries were also trained to assist in home deliveries for normal pregnancies - ensuring that handwashing and other hygienic practices are followed. High-risk pregnancies were detected by them and referred for hospital delivery. We have also seen the infant mortality rate (IMR) reduced from 140 to about 20/1000 currently (which is about half of the national IMR).
| Community Health Habits|| |
The goal of using trained health auxiliaries from the village is to inculcate a form of community knowledge or health habits so that it becomes a habit to seek medical help when there is sickness or a complicated pregnancy. Earlier, there was no health care-seeking behavior even if a child or woman was seriously ill. Today, no one needs to tell the villagers to go for a checkup; they just know when to go. However, it took us about 10 years to form these habits, and the health auxiliaries played an important role in this.
| Ten-year Evaluation|| |
After 10 years of our work, we had an evaluation of the program to look at our future direction. We organized padayatras (walking journey) to the villages and had multiple meetings with the villagers to talk about their problems. The conclusion of the evaluation was that while we had succeeded in improving the health in terms of health indices such as maternal and infant mortality, there were other significant issues faced by the villagers which affected their health and well-being. There were two major issues - the villagers were struggling economically because of poor yields from farming and many were in serious debt to moneylenders. The lack of money in a family resulted in poor access to nutritious food and medicine in case of sickness.
Disease is not only caused by germs or wrong practices but also by poor economic status, poor food, lack of education, and an unstable income. If we did not address these issues, we would not be making further improvement in the health status of the villages. Hospitals often have a blinkered view of health work which is often restricted to clinical and community health initiatives. The other determinants of health such as economic status and education are seen as being outside the purview of a hospital. We, therefore, decided to improve the financial health of farmers by improving the farming practices and crop yields.
| Organic Farming|| |
From the numerous discussions with villagers, we realized that most farmers in the villages were in debt and that these same farmers had been following inorganic farming. Hence, we decided to train the villagers in organic farming using traditional methods. We brought organic farmers from outside who trained the tribals in their own language and idiom and soon many villagers took up organic farming. We brought in standards to ensure that our products are certified organic which ensures a premium price for our products when sold in cities. One of the reasons for promoting organic farming (apart from bringing down debt) was to promote the cultivation and consumption of millets which is superior to rice in nutritional value and is also less demanding to cultivate. It uses less water and is more disease resistant. Millets also provide much more micronutrients and protein compared to rice. I believe that the consumption of millets has helped in bringing down the incidence of malnutrition and anemia in the tribal population [Figure 4].
| Sittilingi Organic Farmers Association Society|| |
The Sittilingi Organic Farmers Association (SOFA) was formed in 2008 to promote organic farming among the local tribal farmers. Starting with four farmers, this society has been training farmers in organic farming methods and helps in marketing the crops. Apart from farmers, the SOFA society includes women entrepreneurship groups who prepare value-added products such as pappads, powdered millets, organic soaps, and biscuits from the agricultural products. Today, there are about 166 women in these groups and about 300 farmers in the SOFA association.
Native seeds and organic methods, on the other hand, yield less but result in good profits for the farmer. Gradually, the villagers realized that this method was better than inorganic methods and slowly they were out of debt. When the family had more money, their health improved as well.
The society has resulted in a profound impact on the tribal community. Farmers are out of the debt trap and free from moneylenders with their exorbitant interest rates. Employment opportunities have increased for women and others who were otherwise unemployed. The villagers are also more aware of opportunities outside their community.
The society has now registered as a private company with the farmers as shareholders and is managed by the tribals. The profits go back into the society and therefore to the tribals involved in this. Today, we doctors provide very little input into the running of the venture - the tribals run it by themselves. The current CEO of the company is a person named Manjunathan who is from the tribes [Box 1]. The company has now diversified from agricultural products to biscuits, powders, and other edible items, and we sell most of the goods in cities such as Bengaluru and Chennai under the brand name "Svad." The organic products are today exported to several European countries. The turmeric produced is of high quality and is in great demand outside India. The curcumin content (active ingredient of turmeric) in the turmeric grown by the SOFA farmers is the second highest in India, after Alleppey turmeric. This therefore fetches much higher prices than turmeric grown inorganically.
| Porgai Project - Handicraft and Embroidery|| |
The organically grown cotton from the Sittilingi valley is made into cloth which is then fashioned into designer clothing by local women's groups. Lalitha, my wife, involved some of the gypsy women in developing their traditional designs for embroidery and manufactured dresses which were then marketed. Today, we have about sixty artisans and a few tailors involved in this work called the Porgai project, and the products are sold in cities. This provides the villagers involved with extra income for themselves and their families.
| Tribal School|| |
A school was initiated for the education of the tribal children which emphasizes the traditional modes of learning, and children are taught farming, craft, and taken for nature walks along with the usual subjects such as Mathematics and languages. The syllabus conforms to a standard educational board, but the method of teaching is very different. We have also started a vocational training center for youth.
| New Directions in Health|| |
Once infant mortality and maternal health improved, we identified psychiatric illnesses and diseases associated with the elderly as major health issues in the community. Health auxiliaries were trained to identify the mentally sick and refer to the hospital. With the help of Dr. Anna Tharyan from CMC, Vellore, we have started treating psychiatric illnesses in the tribal population. The elderly are a vulnerable population. An insurance policy was initiated for their welfare where they pay Rs. 100 a year and all their health issues are managed without further charge by the hospital. This has been running well and is much appreciated by the community.
Hypertension (mostly systolic) is becoming very common among the tribal groups. Renal failure and stroke are some of the consequences. Intensive surveillance programs have been started for those above 40 years of age, and health auxiliaries have been taught to take blood pressure readings in the villages. We are planning to include those above 20 years in the next phase.
| How Are You Able to Manage So Many Initiatives and Programs at the Same Time?|| |
We started programs with the intention of handing it over to the tribals so that they can manage these themselves. The training of health auxiliaries was intended to enable the tribals to detect and manage the common illnesses within the community itself. The farming initiative has improved the economic status and thus the health of the villages; today, it is a company managed by the tribals themselves. It is the same with the handicraft initiative and the school. This has always been our aim to start programs and give them over to the tribals so that they are empowered to take care of themselves, and to some extent, we have been successful in this.
| What Are Your Plans for Tribal Health Initiative in Future and How Can Young Medical Graduates Contribute to This Initiative?|| |
THI has no plan for future, and planning is done according to what the people here need. This is totally unconventional, but THI believes that we are here to serve the needs of the people and not to thrust our "plans" on them. Hence, the farming, craft, old-age initiatives - all of these were voiced by the community and we took it up. So, if you had asked us 10 years earlier, if we had plans for organic farming, I would have said no - but here we are now with a successful farming initiative. Totally unconventional, but believe me it also works!!
India needs many more interventions like these and young doctors should take the lead. Being doctors in a community definitely gives you the credibility to tackle health as well as other community issues. Our request would be that the doctors passing out today consider spending a couple of years in good peripheral hospitals to learn the ropes, finish their postgraduate, and then strike out in groups. THI has been seeing a steady inflow of young doctors in the recent years, and we are confident that more will follow.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]