By the Brahmaputra (Vol: 43)
(For the Quarter July – September 2018)
Researcher on the Boat Clinic:
Pratyasha Acharya, a Market Research Associate working for the US based UnitedHealth Group, accompanied the Kamrup Boat Clinic health team Kaltuli char of Chhaygaon, Kamrup on 10th July 2018. She also visited the Boat Clinic unit at Dibrugarh on 12th July and accompanied the health team on a overnight camp Her trip was to observe the health camp and services delivered by the Boat clinic. Follows her report:
I am a Market Research Associate working for an MNC. While working long hours and trying to gain some knowledge on the health indicators in India, I realized that there is so much we need to know about the public health landscape before we devise mechanisms for trying to bridge the gaps. I was scouting different sources for a suitable learning opportunity which would feed my curiosity and provide a fresh perspective. Then I came across a BBC news article which covered the innovative boat health clinic initiative by the C-NES. What caught my attention was that these mobile clinics have been operating successfully and diligently for quite a good number of years. It takes grit, determination, a strong vision and a completely cohesive team to pull this off. This was exactly what I needed and I was on board within a couple of days after contacting the team at C-NES. I took a complete week off from work and flew down to Assam to be a part of this mission in some capacity.
Many relatives warned me about how the Brahmaputra during the monsoons would be in a spate, but I knew deep inside that come what may I needed to take the plunge. After meeting the team at Guwahati and gathering more background information about this initiative, I took off for my first health camp to ‘Kamrup’ the next day. Kamrup is a rural district in the remote interiors of Assam with a population of around 17,000. Since this was lower Assam, the river waters weren’t that tricky to navigate and this was a day health camp where the main focus was on women and reproductive health. The folks residing there gathered at the camp within no time. They were mostly women with newly born infants and children. It was as if they were waiting for the camp to be set up and were thankful that the team had arrived. The team comprised of the District Program Officer (DPO), two doctors, one Auxiliary Nurse Midwife (ANM), a pharmacist and a lab technician for the blood tests. The local residents started queuing up outside the camp and proceeded one by one to the camp. They seemed pretty shy while interacting with me and another fellow intern and were not very open at once. I surmised from this that the C-NES, during the initial phase, must have worked tirelessly to convince them of the necessity of regular health checkups and this may not have been an easy task. This challenge is compounded by the fact that the men are usually the chief decision makers within households and until they are convinced the women would not come forward howsoever pressing their health needs might be. This was a Day health camp, and so, honestly speaking, I didn’t have much time to gather all relevant experience and insights I needed.
The major game changer was at Dibrugarh where I spent two days in the boat clinic, traversing the rough waters of Brahmaputra in upper Assam. The captain deserves special mention and credit for his mastery at navigating those waters. We covered a couple of ‘char’ or ‘sapori’ villages during the span of those two days. Wherever necessary, we walked down to the villages for the mothers who had just delivered infants weren’t in the condition to walk up to the boat clinic. While negotiating my way through the muddy terrain I wondered about the living conditions of the local inhabitants. The ASHA worker was delighted to lead us inside the village towards the patients’ modest huts, and she told us about the various difficulties they face while commuting which is a major problem in these areas. It made me think that in a short while I would be back in my safe and secure surroundings in a metropolitan city, but the locals will have to contend with their surroundings on an everyday basis. Their huts would be hit by the floods, they would have to travel for three hours to reach Dibrugarh in case they needed special medical attention, and they would face many other situations, both imaginable and unimaginable. However, among all these adversities, the boat health clinic tries to bring some much-needed relief and medical attention, particularly primary healthcare to them by visiting them every month. What is more important and noteworthy, is that the doctors are very different from the doctors we would see sitting in the hospitals in cities. They know the patients by their names and they make it a point to follow up with the community workers on patients they haven’t seen for a while. Every single person associated with the boat clinic is highly motivated and deeply committed to the cause. This noble cause is what ties them together and they don’t seek credit or recognition for their work.
Interacting with both the rural population in these remote areas and the boat clinic teams has been both a very humbling and richly rewarding experience for me. This has given me a new direction, a stronger motivation and further goals to work on.
Market Research Associate
Boat Clinic: Write ups and Media Coverage
Loksabha TV’s coverage of the Jorhat Boat Clinic(left) Programme Manager Ashok Rao and Communications Officer Bhaswati Goswami with the Lok Sabha TV producer Mamta Singh after their interview(right)
Dr Lopamudra Das Roy, founder of Breast Cancer Hub with many years of experience in Research, Teaching and Mentoring undergraduate and graduate students (Ph.D. candidates) in the field of Genetics and Breast & Pancreatic Cancer Research visited the C-NES office at Guwahati. She founded Breast Cancer Hub with a vision to globally connect and help increase the survival frequency of women and men with Breast Cancer through Awareness and Research. Follows her report:
It was my immense pleasure meeting Ashok Rao, Manik Boruah, Bhawati Goswami and Dr. C. R Hira, on 12th July, 2018 at Guwahati C-NES office. I shared my thoughts on why the survival frequency of Breast Cancer in NE India is a huge concern. It is the embarrassment and taboo, society imposes. Women are shy to speak about their Breast health. The other factor that plays a role is “Ignorance”. Women and Men are not aware that Breast Cancer can cost life and early detection is the key. I was happy to see a positive response from C-NES.
We plan to collaborate and work together to spread breast cancer awareness and distribute free Breast self-exam cards in local languages in the areas where C-NES work – among some of the most marginalized and vulnerable communities dwelling in the Brahmaputra river islands in Assam, India. The other aspect I mentioned was the epidemiological study we propose to do together by generating a survey, a simple anonymous study but impactful. We can then analyze the data, compile and publish together.
I also connected with the Boat Clinic team at Dibrugarh led by District Programme Officer Arup Saikia and Bhaskar Bhuyan, the Coordinator of C-NES’ Community Radio Station, Radio Brahmaputra as it is popularly known. An interactive session was organized by Arup Saikia at the C-NES office at Dibrugarh on 20th July, 2018 and I gave a presentation. Dr. Juganta Kumar Deori and Arup Saikia shared their experiences that I captured as a video to be published on Breast Cancer Hub website so that people understand the scenario of Breast Cancer taboo and real life stories will help to break the taboo. It was also a pleasure meeting Nandita Kalita, Damayanti Das, Devarani Deori, Dr. Bhaben Chandra Bora, Siddhanath Gogoi, Ramakant Yadav, Rakesh Doley from the Boat Clinic team and Dipankar Bird Chonre from BCRS
Radio Brahmaputra can play a huge role and I can keep sending brief talks for future deliveries that might be helpful to combat the critical situation with Breast Cancer in NE India. Bhaskar Bhuyan invitied me to Radio Brahmaputra 90.4 FM where my radio talk focused on removing embarrassment, taboo, ignorance and bringing the breast self-exam (how to perform) process to both women and men into picture. If the public are reinforced about the importance of taking care of Breast Health, then we can decrease the mortality rate from Breast Cancer especially in NE India.
I am so amazed to know about Boat clinics and the tremendous amount of work done to reach the islands where access is minimal. Excellent outreach and work and I am so honored and happy to collaborate with C-NES! We would like to build the collaborative project as an epidemiological research study along with awareness & education!
My sincere thanks to you for your selfless efforts and outstanding work you are doing for mankind. I am spell bound getting to know your work!
Dr. Lopamudra Das Roy
Founder and President
Breast Cancer Hub Foundation
Trust Meeting at Guwahati
PMU members with Managing Trustee Sanjoy Hazarika and C-NES Trustees Patricia Mukhim, Mahfuza Rahman(right) at the Trust Meeting
A C-NES Trust meeting was held at Guwahati on 29th August 2018. Trustees Dr. Jayanta Madhab, Patricia Mukhim, Mahfuza Rahman, and Jayanta Bhattacharya, Advisory Council Member were present along with Sanjoy Hazarika, Managing Trustee. Program Manager, Ashok Rao made a presentation on the Boat Clinics and expressed gratitude to the Boat Clinic teams for their hard work and dedication. He briefed about programme updates and mentioned the hurdles and challenges faced in the year 2017-18 especially the difficulties from the delay in receiving funds from NHM- due to which the performance had considerably gone down compared to previous years. Based on his presentations relevant issues were raised by the Trustees present.
Meeting with US Consulate Kolkata
Officials from the US consulate Kolkata Saadia Azim, Public Affairs Specialist, Jay Treloar, Assistant Affairs Officer, Rupam Sen, Manager, Web and Social Media at a lunch meeting with Ashok Rao, Dr CR Hira and Bhaswati Goswami on Sep 1st at Guwahati.
Solar IRL Inauguration
On 25th July 2018 the Joint Director of Health Service, Tinsukia along with other DHS members- Addl. Chief Medical Officer, Regional Project Officer UNDP,Dibrugarh Region, Vaccine & Logistic Cold Chain Manager,Tinsukia, DPM, DME,DDM from NHM Tinsukia visited the Tinsukia Boat Clinic unit to inaugurate the solar ILR which was donated by the Bengaluru based SELCO foundation. The visitors also visited a Boat Clinic health camp at Erasuti sapori.
Officials from Andaman & Nikobar Islands
The officials being felicitated by the Kamrup Boat Clinic team
A two member team from Andaman & Nikobar comprising of Assistant Commissioner, Directorate of Tribal affairs, Rose Shimray and Dr HM Siddaraju Deputy Director (FW, HE & HIC) and Joint Director (NHM), visited the C-NES Regional Office at Guwahati on 23rd August to know about the Boat Clinic health outreach programme. The next day (24th August) they visited the Boat Clinic unit at Kamrup along with Associate Programme Manager Manik Boruah and interacted with the health team. The visitors were accompanied Dr. Jaydeep Das from the Regional Resource Centre. At the C-NES office Communications Officer Bhaswati Goswami gave them a presentation of the Boat Clinics.
C-NES Intern: Abhimanyu Hazarika
Boat Clinics have provided opportunities to students doing research on delivery of primary healthcare and education to the islands on the Brahmaputra. Research studies have been conducted by students from across the globe for the last over ten years.
Abhimanyu Hazarika pursuing his graduation from the Symbiosis School for Liberal Arts,Pune interned with C-NES’ Boat Clinics at Tinsukia and Dibrugarh in June 2018. Follows his report:
I was privileged to intern with C-NES’ boat clinic programme. Through the Tinsukia unit, I was part of 2 trips, of 3 day and 6 day durations including commute. The first trip covered villages under the Laika division (Pomua, Phasidia) as well as Erahoti. The former were by and large people of the Mising tribe and constituted much of the island population of the Tinsukia division.
Each trip of the boat to an island (or two if logistics permitted) thus covered excess of 500 people with a sizeable portion of adults among them showing up for the health camps with their infant children. The first trip had me covering 6 interviewees including 2 females, besides informal conversations with villagers. From conversations with the doctor as well as programme coordinator, it became clear that many of the ailments affecting the people can be traced to the practices essential to the Mising community. A meat intensive diet, rearing of pigs (in a non-dairyfarm fashion due to poverty) are practices that observation indicated as being significant contributing factors to the treatments sought for commonly – high blood pressure, worms, skin rashes, fever etc.
It was revealed that poor family planning is a rampant practice, with kids amongst Mising tribals often running into double digits with minimal age gaps amongst them. This contributes to a poorer immune system in offspringi. When supplemented with the iron-filled drinking water that the island dwellers are forced to use for consumption, it explains the prevalence of ailments stated earlier.
The trip undertaken through the Dibrugarh unit also produced similar results to a significant extent. I covered the villages of Chekiya and Charkhila. Both these villages also had a combined population of over 850 people and consisted mostly of British-era migrants from the Purvanchal region of India (UP-Bihar border).
These islands were geographically located in closer proximity to the town hub of Dibrugarh and the answers revealed that island residents were heavily dependent on travel to town for remuneration. This has translated into smaller landholdings among residents here, except those employed to disburse benefits of government schemes. Given that in this case the patients came to the boat for their diagnosis, the involvement of the A.S.H.A workers were greater in mobilizing numbers for the camps. It also negated possible delays and issues in logistical arrangements that could result out of inclement weather.
In the islands under the two districts of Dibrugarh and Tinsukia, an agrarian society with de facto patriarchy was observed. None of the women interviewed had avenues to participate in individual enterprise and were dependent on income earned from the sale of produce. At the same time, digital and telecom proliferation meant that basic mobile connectivity was present in most of the islands which eased the process of communicating with locals on the itinerary of the boat clinic. Constitutionally mandated governance structures at the grassroots level, viz the ward/panchayat system, was the mode of availing government schemes in diverse areas including but not limited to, ration, gas connections, electricity, pucca housing, health coverage, infant nourishment and child education.
In their capacity as basic medical service providers, the boat clinic staff facilitated general diagnoses, infant vaccines, laboratory facilities to gauge sugar/hemoglobin/pressure levels, pharmaceutical sales and general awareness on health issues. This was at each and every stage done such that the island dwellers bore no costs and received due treatment free of charge.
Insights from the field
The connectivity issues in terms of changing water levels and ever widening width of the Brahmaputra river, result in frequent trips required for the island residents to nearby urban/semi-urban areas. These are for reasons like need to procure basic household items, sell farm produce, emergency health services, children’s education from middle school onwards, buying housing materials, procuring forms to avail banking/telecommunication services, among others. Depending on the proximity to the mainland from their homes, the round trips costs per person at current fuel rates can be in the range of Rs 40-Rs400, which increases when accounting for lodging expenses off-shore running into multiple days.
Several claims of the government as made to the mainland population also fall flat on examining the scenarios in the islands. Electricity has only reached every village to the extent of some purchasing solar panels of their own or being provided by NGOs, rather than the standard government definition of minimum electrification which stipulates 10% of households over and above schools, health centres, community halls, offices being connected to the gridii.
With ration of essential foodstuffs being a dated government service, especially after passing of food security bills, one would expect the same to be present on an interval-based, if not regular basis on the islands as well. However, none of the islands attested to having received ration otherwise available to the mainland, with the handouts only being limited to rice and kerosene, eliminating the common practice of also giving pulses and flour. This propounds the need for travel to town hubs as stated earlier, and the shops within the islands have to resort to selling at a few rupees over the MRP to cover their fuel expenses.
Another common and grave problem that was observed was the inaccurate beneficiary lists of several schemes which prevented an egalitarian welfare benefit for each island resident. On talking to the village heads, it was made clear that uneven disbursal of schemes resulted in their low coverage. This meant that only a few received pucca houses, gas cylinders subsidized tubewells, health scheme benefits, fertilisers, tractors and in some cases even toilets as mandated under the Swach Bharat programme.
Going by some of the trends seen as made evident by the interviews, there is every possibility, particularly among males, that the island population will reduce given the preference to reside and work in towns, amidst declining agragrian incomes due to rising input costs. This could result in a replication of the Kerala experienceiii seen after the boom in expatriate oil jobs in the gulf, and would pose worrisome health questions in terms of significantly higher average age of population coupled with lower than (national) average life expectancy.
The lack of family planning as stated in the preface can, as was left for inference through the interviews, be attributed to the lack of avenues for female folk of the islands to indulge in avenues for minimum self-generated income through sale of handicrafts or the sort.
The boat clinic initiative, as gathered from my experiences, is extremely popular with the island inhabitants across districts. Apart from the odd lamentation about the boat not being able to diagnose serious illnesses, there is gratitude among the folk at the overall health and immunity situations of the villages covered notably improving.
Overall, my experience at the baot clinic opened my mind up to new realities and the sorry state of affairs of many of our less privileged in both the economic and geographic sense. Through my field work and interviews as part of the internship I attempted to analyse the health scenarios, livelihood and living condition of the island residents. The simple fact is that I learnt more in my days with the boat clinic staff about my state than any news item or documentary could teach me, and for this I will remain grateful to C-NES always.
From The Field:
In June 2018 the Barpeta Boat Clinic, Unit- II as part of the IDCF (intensified diarrhea control fortnight) which begun from the 29th May to 9th June, distributed ORS and zinc tablets among children and infants between 2 months to 5 years.
On 25th July, 7 beneficiaries from Ramapara Pam village, who were motivated after regular counselling were inserted IUCD in the boat, a big success for the Barpeta II Team. Swapna Das(sitting, right) ,DPO Barpeta Boat Clinic Unit II helping in conducting the camp. World Population Day on July 11 is an annual event, which seeks to raise awareness of global population issues. The event was established by the Governing Council of the United Nations Development Programme in 1989. Efforts was made by the Boat Clinics to increase Family planning performance. The Barpeta Unit II was successful in inserting IUCDs to 18 beneficiaries. Six awareness meetings were conducted specifically on family planning & breastfeeding by the unit.
Dr Milan Baruah , Member Advisory Council, C-NES was present with Ashok Rao, PM and Manik C Boruah on a review visit to the Barpeta Boat Clinic district on 26th September 2018. They are seen here with the health team of Barpeta Boat Clinic II.
Barpeta Unit I
Community workers of the Barpeta Boat Clinic Unit I carrying medicines on way to a health camp with flood waters submerging the village.
Dr Milan Baruah , Member Advisory Council, C-NES was present with Ashok Rao, PM and Manik C Boruah on a review visit to the Barpeta Boat Clinic district on 26th September 2018. A review of the work done during the past six month and the challenges faced during the period was done. Seen here with the Barpeta Unit I team.
Kamrup Boat Clinic team on way to a health camp to screen SAM (severe acute malnutrition) children accompanied by the district nutrition counselor on 26th September 2018.
World Breastfeeding Week 2018
Hayat Institute of Nursing Education and Association for Promotion of Child Nutrition, Assam (APCN) with the help of Boat Clinic, Kamrup observed the World Breastfeeding week 2018 on 6th August 2018. The function at Toper pathar char under Chhaygaon, Kamrup was attended by Dr. CR Hira, Technical Consultant for C-NES and Dr. Adhikary, Pediatrician from APCN.
MR campaign in Nalbari
India’s MR campaign against measles, a major childhood killer disease and congenital rubella syndrome (CRS), responsible for irreversible birth defects has been one of the world’s largest vaccination campaign. It demonstrates once again,India’s commitment to improve health and well-being of its people by protecting children against vaccine preventable diseasesThe photographs show the recent MR campaign by C-NES’ Nalbari Boat Clinic(along with the rest of the 14 Boat Clinic units across Assam) where school children from remote island villages were actively involved.
Village elders attending a camp conducted by the Jorhat Boat Clinic team in June 2018
Bongaigaon : Nutrition camp
In June 2018 the Bongaigaon Boat Clinic team conducted awareness and screening camps on nutrition. Nutrition counselor Mondakini Bardoloi deputed from the civil hospital accompanied the team. The objective of the programme was to identify SAM (severe acute malnutrition) children. During the screening process of under 5 children, 5 SAM cases were detected and necessary actions taken.
At Sonitpur the Boat Clinic team conducted regular awareness sessions during June 2018 apart from regular health camps where the importance of Measles and Rubella(MR) vaccine was extensively stressed upon. Parents and teachers meetings were also conducted in schools for upcoming the MR campaign. In the field of family planning, 9 laparoscopic sterilizations and 14 IUCDs were successfully conducted under boat clinic’s initiatives, the outcome of motivating beneficiaries for family planning in all targeted island villages as a part of the World Population Fortnight from 11th July-2018.
The Goalpara Boat Clinic team got conducted 11 laparoscopic sterilizations at Lakhipur BPHC on 31st July and 16 laparoscopy surgeries at Agia BPHC on 4th August as part of a successful World Family Planning Fortnight initiative through positive counselling on a regular sustained manner among the beneficiaries.
Journey to Kobu Sapori
A report by Kakoli Gogoi
Due to the increasing current of the Siang the camp at Kobu Sapori was not conducted in June 2018. But ASHA Geeta Devi of Kobu Sapori repeatedly called the Boat Clinic team and asked them to conduct the camp. The DPO and community workers discussed the present situation of the river with the ferry services and with the C-NES Regional Office after which the team decided to conduct the camp at Kobu Sapori on 28th July 2018. We hired another boat that was in a good condition so that we may not face problems in sailing. On 28th July 2018, the team headed to their destination at around 6.30 A.M. On the way to the camp, the team stopped at Simen Sapori to have their breakfast and continued the journey of two and half-hours by road to Tinmail ghat. The team had to go approximately 12 kms between the Poba Reserved forest and the Siang River to reach the boat where it was anchored. While moving around 1 km the van got stuck in mud. We decided to walk to our destination. We hired two cycles from the forest reserve to carry the medicines. It was not easy since the condition of the road was bad. Moreover Poba Reserved forest is known for wild elephants, snakes and leeches. As we started walking leeches started falling from trees and sideways. We had to be very careful whole way, leeches started crawling inside our clothes and we keep on shouting and jumping. We are getting stuck in the mud, slippers getting torn out. After walking a few kilometres we got an autorickshaw but as soon as we entered it we found lot of leeches inside. We cleaned the rickshaw but still many leeches were falling from top no us.
At around 1.15 P.M we reached the ghat where the boat was anchored. Now the main risk was the river. Just to start the boat it took 15 minutes as the boat got stuck due to sediments. After moving for few minutes, the current of the river started increasing due to flow. Everyone in the boat got tensed including the boat crew. Luckily we crossed the river safe and reached destination at around 3.00 PM. Within one and half hour the team conducted 115 General Checkups, ANC, PNC immunization and awareness camp.
We could spend as much time as we would have wanted to due to the risks involved in the travel and the unpredictability of the river. At around 4.30 PM we returned and luckily this time there was no problem. And a big thanks to the auto rickshaw drivers who stayed back for us although it was dangerous to stay at forest in evening. By 6.00 P.M we reached the reserved forest where we had our meal after hours, each one famished. At around 6.45 P.M we returned back after this extremely challenging journey, physically exhausted but happy that we could reach our beneficiaries.
Programme Manager, Ashok Rao and Associate Programme Manager, Manik Boruah visited four Boat Clinic units in Lower Assam- Dhubri Unit-I and II, Bongaigaon and Goalpara from 11th September to 14th September, 2018 to review the programme. The DPOs were asked to conduct at least one mega awareness camp each month by inviting experts from the DHS and also to develop well designed plan for improving the performances. CWs and ANMs were asked to prepare the beneficiary list well ahead to be submitted to the DPO before proceeding to the camp site. The importance of conducting the 4th ANC for pregnant women for all registered cases. Severe anemic patients were asked to be taken to the higher institution and anemic patients to be advised for consuming moringa leaves to overcome anemia.
Boat Clinics: Shots from the Tinsukia Boat Clinic Unit
The Boat Clinic health camps are held under extremely challenging conditions. During summer there is no respite from the scorching sun and heat for the teams while conducting health camps in remote flood vulnerable Brahmaputra river islands. They have to walk for long distances to reach interior villages where the camps are scheduled. Monsoons find the Boat Clinics struggling their way through angry rivers with strong water currents, full to the brim and often overflowing banks making it mandatory for the team members to wear life jackets to ensure their own safety. During monsoons and post monsoons the roads to the river banks are often damaged and full of potholes, negotiating through these stretches, in most cases only an apology for a road is a challenge. During the dry winter months with river water subsiding, the boats often get stuck in the river bed and it is only after a lot of struggle that they are freed. The walking distance to the camp also increases much more during winters due to the boat not being able to reach the village banks with subsiding water level. But camps are never missed.
In September 2018, C-NES’ Community Radio Station, Radio Brahmaputra organized narrow casting sessions on Disaster & Nutrition focusing on nutrition for pregnant women, lactating mothers and complementary feeding among the riverine, tea garden and indigenous communities from the most flood affected areas of four districts of upper Assam. Radio Brahmaputra is based at Dibrugarh, very close to where the mighty river flows by at Maijan ghat. The station is unique in the sense that it caters to the needs and aspirations of people belonging to as many as five communities residing around the area in as many local languages – Shadri (dialect of the tea tribe community), Assamese, Bhojpuri, Bodo, and Mishing. While BCRS seeks to reach the most marginalised groups in 14 islands and 30 tea plantations and more than 180 villages in Dibrugarh district, its footprint reaches across the Brahmaputra to other districts as well.