Wednesday, 17 January, 2007

Inspiration at Neelganj

Generations of medical students and many of our community health fellows and interns have heard me begin my narration of public health experiences from the early lessons at the Neelganj refugee camp (July – Sept 1971). Some experiences in life are very formative and these three months were among them, making a deep impression on me and on my choice of vocation and profession.

Over 9 million refugees from East Pakistan (before it finally became Bangladesh) walked across a 1500 mile common border with India, to escape the ravages of a political genocide in early 1971. The government of India was forced to organise nearly 1000 small and large camps, as close to the border as possible and made a national appeal for volunteers, social workers and health professionals to help serve the refugees.

Three of us, young interns from St. Johns Medical College, Bangalore – Dr. Vikram Venugopal, Dr. Gouri Thattil and myself volunteered and reached the Neelganj refugee camp of over 5000 inhabitants in early July 1971. The camp between Barasat and Barrackpore in the 24 Parganas district of West Bengal was one of many supported by Caritas India. Along with a pathology technician and two religious sisters who were also trained nurses, the three of us managed the basic health services from a bamboo hospital that we constructed as a symbol of appropriate technology in cooperation with the refugees. As the only member of the team who had working knowledge of Bengali, I became the informal team leader as well as the roving doctor who along with a basket of essential medicines made home visits (if you could call the 3’ x 6’ brick lined, thatch and bamboo camp sites which were the temporary shelters for these refugees as ‘homes’).

As I read through the letters I have written to my medical college – fourteen of them over three months, that had been displayed on the student and hospital notice boards to inspire and provoke more students and interns to volunteer, I recalled some inspiring experiences, some touching moments and many learning experiences. These included:

  • The challenges of organising the health care of 5000 people on a piece of land, a little smaller than an average football field.
  • The creative challenge of designing a small dispensary with beds and stands for intravenous drips and small partitions for delivery and dressing rooms – all of them using bamboo and jute and thatch.
  • While two of my colleagues treated the dysenteries, pneumonias and malnutrition of the majority, the technician and one of the trained nurses managed the skin, ear, and eye infections. I and one of the sisters did the camp visits, the onsite TB injection service, and managed the deliveries.
  • TB was rampant and you did not need an x-ray to make a diagnosis. A good history skillful auscultation and tapping, gave adequate clues to extensive cavitations and the therapeutic response to early treatment was dramatic!
  • Amidst all the distress and overt suffering it was people’s capacities that were inspiring. These included the patience shown by the women and children as they waited in queues for food, milk, clothes, blankets, medicines; how the refugees were always finding time for some laughter, merriment and singing of haunting Bengali rural melodies; our team being involved in making makeshift fishing nets and traps. These were all thought provoking experiences illustrating the survival capacity of the human spirit- a lesson never taught in medical school.
  • Illness was just one of many challenging episodes in a life full of challenges. It didn’t stop life, work, shopping, entertainment, gossip or conflict. Child bearing and rearing went on as they had always gone on- normally as part of life without waiting for medical intervention. Another of those little details not taught in medical school!
  • While we knew that health was ‘physical, mental and social well being’, our medical education had taught us little about mental health- much less about the trauma of disaster, rape, displacement, abandonment and genocide. There was an epidemic of psychosomatic complaints and it took us many weeks to understand the determinants of these problems and at the same time discover the ‘miracles of healing’ that a little listening, a little affirmation, a little pat on the back and loving attention could achieve.
  • Delivering these hardy Bengali women of their small malnourished little babies without the aseptic environment and stainless steel paraphernalia of hospital labour rooms was a challenge. The next day we found them back in the queues and involved in the demands of daily living. Postnatal advice taught to us in medical colleges suddenly became slightly irrelevant!
  • Finally, training our own ‘barefoot brothers’ who were not doctors but functioned as auxiliaries to distribute bread, milk, mats, soap and handle epidemics of scabies, conjunctivitis and cholera was a great learning experience. We were inspired by common sense rather than any medical college dictums.

Years later, when the Alma Ata Declaration was evolved in 1978, the lessons of equity, appropriate technology, intersectoral development and community participation which we learned in these formative community experiences in a refugee camp were formally endorsed. None of us were public health experts – just a bunch of young medicos with piles of enthusiasm, some common sense and a lot of youthful overconfidence that saw us through those early experiences. Three little anecdotes are also part of my repertoire of community stories from the Neelganj experience.

An old woman reappeared in the patient queue the day after she had been given two weeks ration of vitamins, claiming to have finished swallowing all those vitamins and not feeling better. It took us a while to realize that what she was seeking was psychological support and some company, in an otherwise desolate and hopeless personal situation.

A young 18 year old boy was diagnosed as being mad and violent. His feet were tied to a bamboo pole but he was fed and cared for by his camp neighbours. My ethical conscience at a very early stage of formation was appalled at this community-mediated restraint. Persistent talking and listening in a gentle but confident way to all his shouting and growls for a little while each day for nearly a week, including sitting closer and closer to the boy who was a ‘violent psychotic’, was an experience in patience. I broke through the psychological barrier on the 7th day. What could have been a physically violent experience if he had attacked me as predicted by all concerned resulted in a bear-hug full of emotion and uncontrollable sobbing, once I undid the rope restraining him. The personal story that followed was one of greater anguish. Of a young 18 year old who had seen his mother and sister being raped by the soldiers and had been unable to do anything but run away in fear! This had made him very angry, guilty and uncontrollable, leading to a violent psychosis. It needed patience and listening skills to get through but are we as young doctors taught to listen?

On the day before some of my fellow team members were returning to Bangalore, after a spell of volunteering, the informal community leaders of the refugee camp invited us for a late evening get together with a request to receive some ‘precious gifts’ from the community for the services we had rendered them in the camp. We counseled the community with some degree of youthful arrogance not to spend their meager resources of distributed rations and supplies in buying us gifts from the local market. The ‘precious gift’ they offered us was an evening of folk music accompanied by a small harmonium, and drums loaned from the local market. We were humbled when they told us that ‘Tikka Khan’ the Pakistani general who led the genocide could not take away their Bengali culture which included the songs of Tagore and Nazrul Islam, since it was an inseparable part of them. It was the deepest lesson in community health that I have received in 35 years – that the culture of a community is a unique, significant and basic unit of their lives. Whether poor or rich, destitute or refugee, one’s culture is one’s asset!! Yet most of us complete professional medical education in this country with seldom even one lecture on culture!

The little album of photographs (taken by me with a little, borrowed, old box camera) and the file of published letters and reports has been a constant reminder of these first learning experiences based on an intense community based and community oriented field posting. The first of several, over the last three decades but probably the most inspiring.

4 comments:

rakhal said...

Dear Ravi,

I read with great interest your description of the Neelganj experience. It is strange (or actually not so) how each one of us can think back to an emergency / crisis situation as an inspiration / turning point. I think that this is because it is probably the first time in our lives we are forced to think outside the box, the first time we are forced to challenge the limits that institutionalised bio-medicine sets for us as medicos, the first time we have to take risks, the first time we can't (and probably can't imagine) calling for help as we feel no one will understand what we are going through.... I think it is really the creative tension / crises when we learn to become irreverant and challenge.... and moved by more than a brilliant diagnosis, and see counselling and the much looked down upon placebo effect as our greatest friends... that we are inspired.... and make the break...

rakhal

Cosmic Voices said...

Wonderful post!

I wish the medical profession had more people like you.

NIMAL KRISHNA said...

thank you sir
found it touching and informative

NIMAL KRISHNA said...

thank you sir
found it touching and informative