A path winding through paddy fields led to Bhuiantola, a hamlet where Bhuian Dalit families lived, on the outskirts of Tarwadih village in Jharkhand’s Latehar district.
That month, eight individuals in Tarwadih were on treatment for tuberculosis(TB), a serious bacterial infection that most commonly affects the lungs. Four of them lived in Bhuiantola.
The previous night, Radha Devi, the village sahiya or frontline health worker, an Accredited Social Health Activist(ASHA) had finished helping a woman delivery a baby in the hamlet. Now, walking down the paved path, she called out to Ramavtar Ram who was working in the fields. “Nine number” medicine is over for you. You will be on “CP” from now on,” she told Ram, a farmer in his 50s who was afflicted with TB, and had grown leaner from the infection.
Devi did not train as a doctor or a nurse, and studied till only class IV. As one of over 1,325 health activist appointed under the National Health Mission’s community health programme in Latehar, she had supervised Ram’s TB treatment and infection control for the last six months. “I am not fully literate, but I can recognize the medicines as a number or an alphabet in the drug’s name,” said Devi, explaining how she had memorized the long, complicated names in english, an unfamiliar language, of 13 drugs used in TB treatment.
TB is fully curable by antibiotics taken for six months. Yet, India accounts for a quarter of new cases of TB infection, and a fifth of TB deaths worldwide. In Jharkhand, nearly 40 people die of TB every day.The government recognizes those living in remote tribal districts who get poor nutrition and face difficulty in accessing treatment as a priority group for reducing TB transmission.
Crucial infrastructure is absent in Jharkhand’s Adivasi villages. Dr Rajabau Yole a World Health Organization TB consultant in Jharkhand said that though every community health center was supposed to have a X-ray machine for radiological examinations and a courier system to transport sputum samples that needed to be tested for TB, this was missing in most districts.
There is also a major shortfall of doctors. Dr Raksh Dayal, Jharkhand’s state TB officer, said that the state had only 2,200 of the 3,400 doctors and about half of other contractual health staff it needed, and this affected the TB treatment programme. In Latehar, where Tarwadih lies, for instance, in the district TB hospital, 13 of 23 posts were vacant, including the post of a medical officer for TB, which had not been filled since five years.
In such a situation, health workers like Radha Devi filled a vital gap.
Latehar, where Bhuiantola lies, is one of the poorest Adivasi regions in Jharkhand. The families here are especially vulnerable also because they migrate to work in brick kilns in Varanasi in UP, and Aurangabad in Bihar when the paddy produce is exhausted in a few months. Working in kilns, they are exposed to smoke which damages the lungs, and reduces immunity to infections such as TB.
“Many migrant workers hide it if they develop TB, and often they take medicines for only 3 to 4 months and do not complete the treatment,” said Ramesh Chaubey, Latehar’s district welfare officer.
Radha Devi, who was chosen as the sahiya in 2007 by the village’s residents while she was in her late 40s, had worked in brick kilns most of her life. The labour contractors offered sums of Rs 10,000-12,000 as “advances”, she said, and this was a big draw, but later did not pay regular wages. “At the kiln sites, away from towns, there are no health facilities,” said Devi. “Many workers develop alcoholism at the kilns. Some do not like the taste of the medicines, and some worry about adverse side effects. All these are the reasons why they do not complete treatment.”
Of the eight TB patients in Tarwadih, whom Devi was administering treatment to, Bartu Oraon, an Oraon Adivasi, was undergoing treatment for a relapsed infection. Mohan Bhuian, a brick kiln worker, had developed Multi Drug Resistant(MDR) TB, a more deadly form of TB infection, that develops if a patient gets incomplete or inadequate treatment. In MDR-TB, two of the most powerful TB drugs stop working. Those with MDR-TB can transmit this deadlier form infection to others in close contact through air droplets in the same way as regular TB. MDR-TB is treated with highly toxic drugs over a protracted two years period.
Devi said to control the spread of infection, she had been trained by the staff at the TB hospital in Latehar to ask ask patients to spit in a pan and cover it with ash. “I ask them to take precautions, to use ash to cover their spit, or cough only into a gamcha and boil it in water to prevent further infection,” said Devi. “If they don’t like the aftertaste of the drugs, I even buy them small packets of namkeen with the drug,” she said, showing a small packet of snacks she had carried for a patient. She had also been counseling Neetu Devi, a young farm workers, who had recently delivered a boy, that while she had TB she had to cover her mouth while breastfeeding to prevent the infection from spreading to her baby.
Seeta Bhuian, whose husband Mohan Bhuian had the most serious infection in the village with MDR-TB, said Mohan had taking TB drugs irregularly for five years while migrating to work at the kilns and over time, he had got so sick that he could no longer stand. After he was diagnosed with MDR-TB last year, Bhuian had to take 13 medicines and an injection daily for six months and since the last three months, he had been on seven drugs daily.
“The sahiya came home to give him the medicines daily,” said Seeta Bhuian, Mohan’s wife. She added that Radha Devi had also traveled with Bhuian twice to Itki, 110 kilometers away. This is where the government ran a TB sanatorium, an indoor facility where Bhuian had been diagnosed with MDR-TB.
After nine months of treatment, Bhuian had recovered enough strength to walk, and had taken the cattle grazing that afternoon. But his family was anxious and concerned because one of the medicines, Kanamycin, had had a severe adverse effect on him making him lose his hearing four months into the treatment.
Radha Devi had traveled with Bhuian to Itki while he was in the most infectious state, accompanied by his younger relatives. “At the sanatorium, the doctor told us the medicines were so toxic that they could make Mohan depressed, paralyzed, or deaf,” she said. “Sadly, I have seen Mohan go through all of these stages this year.”
After getting Mohan Bhuian admitted, Radha Devi had traveled over a 100 kilometers from her village to Itki a second time to act as his counselor when he started developing side effects. “Mohan called me on the phone and said he felt he was going to go mad,” she said. “I was scared I may get lost while traveling alone from our village, but somehow I managed to get to the city. I felt like he was my son and was worried.” For her travel costs, Mohan Bhuian had later reimbursed her Rs 400, after the government hospital staff did not pay her anything for the trip.
As a sahiya or ASHA worker, Devi is supposed to get Rs 100 as “incentive” for each TB case that she reported, but she said she had not received any payments till now.
Devi added that she had heard that the government had promised to double the honorarium of ASHA workers and other ground health and nutrition staff this year. “I have heard ASHA will get paid high amounts of honorarium totaling Rs 3,500-5,000 a month for the work we do,” said Devi. But in the past 16 months, there had been delays in sanctioning sahiya payments, said Suranjeen Pallipamula, a health activist in Ranchi.
“For more than a year now, I have not got paid anything,” said Devi.
An edited version of the story in The Hindu Sunday Magazine here.
All photographs by Manob Chowdhury.