A fisherman stands knee-deep in the river as a boat pulls up to the bank in the northeastern Indian village of Tengatoli. A crew made up of doctors, nurses, and one pharmacist grab bags of medical supplies and lug a large generator toward the bamboo homes in the distance.
Outside a thatched house, a bare-chested man squats on the ground next to a basket of fresh chiles. He holds down a piece of bamboo with one hand and whacks it with a sickle with the other. Outside a thatched home, young men sort peanuts spread out before them. Inside, a family of baby chickens chases each other under a makeshift wooden bed.
The boat crew sets up the generator and a projector and screen inside a bamboo structure that serves as the village’s schoolhouse. Women in brightly colored saris with babies in arm file into the schoolhouse-turned-cinema to watch a film about family planning, child immunizations, and the importance of antenatal checkups. Much of the film is in Assamese, and these women speak Bengali. But they watch intently. For most of them, it is the first time they have ever seen a video.
About three million people live in socially and geographically isolated villages like this one along the Brahmaputra, a massive river that stretches from Tibet to Bangladesh. Most of the villages do not have electricity, roads, secondary schools, clinics, or proper toilets. Five years ago, an organization called the Centre for North East Studies and Policy Research (C-NES)—realizing the government was not in the position to build clinics on these islands and the people could not access services on the mainland—decided to take healthcare to the islands.
“Sixty years after independence, we still have a situation where millions of people across the country don’t receive basic services because governance and government don’t deliver them,” says Sanjoy Hazarika, an expert on India’s Northeast and the managing trustee of C-NES. “We’ve developed this partnership, because you can’t reinvent government, where we work with the government in meeting these basic needs and in that process enable people to have a healthier and more meaningful life.”
Starting with one boat in 2005, C-NES began providing basic health services to these islands. For many of the families, the clinics have provided them their first ever health care.
One of the women watching the video is Anuwara Begum. Dressed in a vibrant yellow, orange and red sari, she wears her head covered, an assortment of bangles and a nose ring. Like many girls in her community, Anuwara got married at 12 or 13. She had her first child at around 15. Her youngest child, her fourth, will be her last. Anuwara’s husband works as a farmer and does relatively well, but he must support three wives and 10 children on the equivalent of roughly $180 a month. Anuwara, who is the first wife, says the family cannot afford to have any more children. She will begin using oral contraceptives, provided for free by the boat clinics.
Less than a quarter of married women between the ages of 15 and 49 living in rural Assam use a modern form of contraception, according to the government’s 2005-2006 National Family Health Survey. While a change in family planning practices is coming slowly and is far from universal, public health experts in Assam say they see an increase in the use of contraceptives in villages like Tengatoli.
Family planning is considered an important aspect of maternal health and would help reduce Assam’s maternal mortality rate, which at 480 deaths per 100,000 live births is the highest in India. With about 70,000 deaths every year, India contributes almost a quarter of the world’s maternal deaths.
After decades of neglect, the government began prioritizing maternal health care five years ago, and family planning initiatives like the boat clinics are now an integral part of its flagship rural health project. Awareness about family planning has increased across India, but there is now a problem of getting modern contraceptives to families who live in remote areas like jungles, hill communities, and villages along the Brahmaputra, according to Dr. Hari Singh, a project director for EnGenderHealth India. He says about 20 percent of women in India who want to limit their childbearing do not have access to family planning methods.
The boat clinics also provide immunizations, antenatal care to pregnant women and basic healthcare. They have reached about 300,000 people in the past five years, but financial, geographic and cultural obstacles limit the impact the clinics can make. With only 10 boats, the clinics cannot visit each village more than one to three times a month. Furthermore, the boats depend on the river. If the water gets too high or too low, the boats cannot travel.
There are other challenges, however. Deeply ingrained cultural attitudes among the villagers challenge the best intentions. In another village along the river, a C-NES nurse pleads with a pregnant 15-year-old to use the government’s cash incentive and give birth in a medical facility on the mainland. But the girl, reluctant to be seen naked by a male doctor, says she will give birth at home.
The nurse scolds the girl like a parent, asking her what will happen if she has a complication and is in a tiny hut on an island far from medical help. The teenager, dressed in an orange sari that falls over her tiny frame and slight bulge, shrugs and says, “If I die, I die.”
Sometimes, even the most dedicated medical professionals, even those that that lug generators across peanut fields, prove no match for social customs. But, as the boat clinics demonstrate, they're a start.
This reporting was facilitated by a grant from the Pulitzer Center on Crisis Reporting. Learn more about this project here.
For more about C-NES, click here.
Photograph courtesy of the writer.