Through American Eyes: The C-NES Boat Clinics
Intern’s Report:
Through American Eyes: The C-NES Boat Clinics
By: Arunava Sarma
(May/June 2012)
Introduction
For a public health and molecular biology student, the prospect of touring areas of rural India via boats on the crisscrossing channels of the Brahmaputra and providing healthcareto underserved populations is very attractive. For such a student with ancestral Assamese roots, the opportunity is nigh impossible to ignore.Thus, when my aunt Bhaswati Goswami (Communications Manager, C-NES) mentioned the possibility of doing such work in Assam through the Centre for North East Studies and Policy Research (C-NES), the wheels quickly set in motion sending me off to “Ships of Hope.”
Assam
Assam lies in North-East India, barely connected to the rest of India by a thin strip of land squeezed between Bhutan and Bangladesh. I have found that, in my home state of California in the US, Assam is an unknown state. Many times when I say my that family is from Assam, I receive blank stares; on occasion, the additional mention of Assam tea, famous world-wide, causes a glint of recognition in the eyes of a few caffeine enthusiasts.Assam has other claims to fame besides the beautiful tea gardens. Its tropical climate makes it a canvas for lush forests and copious wildlife, preserved from the encroachment of cities in several natural parks. The sheer
variety of people that live in Assam is a collage of humanity as more than 20 major ethnic groups exist in Assam. The state’s culture a similarly rich mixture of the many people that have touched its history. Running through the state, also influencing many aspects of Assamese existence is the lifeblood of the state The Brahmaputra River, a living entity which grows and shrinks with the seasons not a lifeless river. The population of Assam has increased dramatically in recent years and the already weak infrastructures of major cities have become weaker still-electricity still flickers on and off and water shortage has hit cities of Assam. Like most of India, social disparities exist towering cement houses sit next to small houses with walls made of woven thatch, and giant malls spring up next to small ‘10X10’ family shops. Beyond all these facts, Assam is also the homeland of both my parents, and thus, I consider it a second home albeit a home I have experienced very little of. My experiences this summer has opened my eyes just a little to Assam.
C-NES and the Boat Clinics
It is on the banks of the Brahmaputra that this summer’s unfolds. The Brahmaputra River is a constantly changing entity. In the monsoon season the river roars, fed by the heavy rains, its increased girth and depth swallowing up landmass. In the drier seasons its rage calms and the water levels recede. On these volatile landmasses in and around the river, populations of human play out their lives. They live, ready to move out at any given moment in the rainy season, their homes can be on land one minute, and underwater the next. Because of the migrant nature of their lives, the inhabitants of these small villages tend to be of lower income, with little access to what we call ‘modern technology’. They have no electricity and no running water and no access to healthcare. Though lack of electricity and running water remain unsolved issues of infrastructure, the Centre for North East Studies and Policy Research (C-NES) has set in place a program to provide basic medical care to the people in these communities.
The Centre for North East Studies and Policy Research, C-NES , is a non-governmental organization established in 2000 by Sanjoy Hazarika, a noted journalist and former New York Times correspondent, who is its Managing Trustee. It was established to seek tostrategies to improve the conditions of living in the North Eastern states. They have a number of projects in the fields of education, heath, environment, gender issues, etc. but their flagship program is the Boat Clinic health outreach initiative. The boat clinics bring health service to socially, geographically, economically secluded populations on the Brahmaputra chars/saporis, or river islands. The program began as a concept which was awarded a World Bank grant. The grant provided for the building of the program’s first boat, Akha.
Akha, which aptly means hope in Assamese, continues to serve the upper Assam tea district of Dibrugarh. The project has since then blossomed and five more boats have been constructed, several more hired. Many more districts have begun to serve communities of people on the Brahmaputra. The project now runs via grants from the National Rural Health Mission, Govt. of India and a total of 13 districts are served by 15 clinic units all year long. The efforts of the boat clinics have reached over 800,000 of people to date.
The Focus:
Immunization of children, care for pregnant women and general treatment of adult groups. Ante-natal check-ups are especially emphasized given the high mortality rate in Assam. Assam has the highest maternal mortality rate at 390 deaths per one one hundred thousand live deliveries.
My Internship
During the duration of my internship with C-NES, I visited a number of day health camps in lower Assam in the districts of Nalbari, Kamrup, and Bongaigaon.
Though each district is run by a different group of people, the basic framework is the same. My day trips began in the respective district offices. The district offices range from warehouse rooms with a computer desk on one side, to quaint residence-cum-office buildings with staff members and government issued medicine stocks residing side by side. These sleepy offices turn into a bustle of activity as members of the clinic staff arrive and begin sorting through the large stocks of medicine and supplies, packing the necessary articles into canvas bags and small crates. These supplies are then loaded into a clinic truck. Once all the precious supplies are loaded into the trucks, the staff slide their way into the seats and begin the journey.
The trips from the district offices to the riverbank start sites were not short it could take as much as an hour and a half and several muddy potholed roads to reach the site where the boat anchored overnight. The length of the trips was augmented by the required detours to pick up additional members of staff and to government distribution centers. These centers, though old and decrepit looking from the outside, contained precious vaccines which we collected from cold freezers. The vaccines only remain viable for 48 hours after being removed from sub-zero temperatures and thus the utmost care is taken in packing the vaccines into cold boxes for transport. With the precious vaccine cargo added to the already busy car, the staff was ready to head to the boats.
The take-off points for all the clinics I visited were out of the way, in the corner of a little village or under a bridge, with no paved road to point the way. The boat clinics take good care of their teams, with a hearty breakfast and lunch. Breakfast is a social affair, served on the boat with
staff members gathered around various tables the ship’s hold. The ride to the camps is long, as much as two hours upstream so no time is wasted the boat sets in motion even before breakfast is served.
The river, at the time of my visit, was not yet in full swell and only starting to rise above its winter levels. Still, it had risen enough that the hike from the boat to the clinic site was drastically diminished; only at one camp did we have to walk more than a mile distance. At the other sites, the water level had risen enough that the boat could anchor very close to the camp location.
The clinics are supposed to be held in the local school buildings but, more often than not, they are organized near the boat in tents or nearby the school at a residence. This is because C-NES and the staff do not want to disrupt the learning environment of the schools. Very quickly, light plastic tables, the same tables that are used for staff dining, are set up into several stations. The first station that patients visit is the intake station where they are given a sheet of paper with name and ticket number. Sometimes additional information is written down on these sheets such as weight and blood pressure. This little sheet of paper is the intake form of the clinic and guarantees service at the rest of the stations.
The next station that patients visit is the doctor’s station it is here that the people get to state their health complaints and receive a diagnosis. Sometimes they are simply prescribed a medicine:the doctor writes down a medication for their symptom on the form and sends the patient off to the pharmacist’s table for collection. The pharmacy table sits stacked high with medicines with the pharmacist presiding over the copious supplies ensuring that each patient receives the right medication and the right dosage information. At other times the doctors send the patients off to the lab technicians table to get some vital information prior to prescription. The lab technician is able to analyze both blood and urine samples with mobile technology. With these samples he can conduct tests for hemoglobin, pregnancy, malaria, HIV, blood type, urine content, and more. Each district has a different set of tests they run, based on what stocks they have and the need they perceive; one of the districts I visited regularly conducted HIV tests. Only two conducted
malaria tests regularly and all the camps conducted blood hemoglobin tests. After the tests, the client returns to the doctor for prescription.
Aside from this systematic care, the clinics also provide immunizations and ante-natal care. Nurses are in charge of this department and they carefully catalog the people who come in for this care in a large roster book to ensure follow up is tracked. The health camps go on for up to four hours and in that span as many as one hundred and fifty patients are seen.
No one is turned away. Only after every individual at the camp, as well those who come late and come to the boat for last second care, is seen, does the team return back to home base. The return trip is accompanied by a late and spicy lunch prepared by the boat cook. The day ends at around 4 PM or 5 PM, with the return to shore. The clinic staff disperse to their homes but they see each other soon enough. Every month, they work together for 16 camps.
The Night Camp
Along with the day camps, I also got a chance to be a part of an overnight boat camp done by the Jorhat district. The chars in the Jorhat area are too far to reach and treat in one day so instead the health camp staff stays on the boat for six nights and goes down river from village to village, giving care along the way. The set-up of the health camp portion of the overnight trips is similar to those of the day camps with the same stations and format of care. They do have the luxury of starting as early or as late as is convenient for the villages; they can wait for school to finish before starting the camp because there is no rush to leave for the mainland. Because of this, the Jorhat DPO also arranged an art contest for the school children. The art contest was well received by the village children not only did they get a chance to be creative, but they also get a pack of crayons, a prized possession.
One of the village children refused to color in his drawing simply because he wanted his prized colors to remain pristine. In one of the communities, the DPO found that the children were more interested in singing and dancing than drawing. After several impromptu traditional song and dance routines, she proposed that next time they hold a show, an idea gleefully received by the children. Clearly, the boat clinic team is not just interested in the personal health of members but also the community benefit. In the evening, if a combination of factors such as electricity, weather, proximity to the village fall into place, the night clinics also hold awareness camps.
C-NES bought a number of projectors and NHRM/UNICEF provided a cute little cartoon video to show to via the projectors. The themes of the video emphasized such topics as the importance of education for both girls and boys, the necessity of proper quantities of food, and the very basics of how to treat diarrhea. I personally was very skeptical of the utility of the projectors simply because of the feasibility of showing the movie. Most villages did not have electricity for the projector to run on. The boats have generators but most villagers are unwilling to walk the distance to the boat in the dark of the night. In any case, in the summer months, the constant possibility of rain makes outdoor showings impossible.
The clinic got lucky though, and was able to show the program in the school building, after making a call asking that the switch director leave the villages lights on for a little bit. After seeing the excitement on the villagers faces at the thought of seeing the video, I had to reformulate my idea of the effectiveness of the projectors. Even if the projectors can only be used ever so often, the attention and excitement of the villagers may have made it worthwhile.
Hopefully their excitement translates into and understanding and consideration of the material presented. I mentioned that the boat clinics take good care of their staff, and I will repeat that here: staying two nights on the boat, though not a luxurious experience, was not unpleasant. The boat had plenty of space for living with several shared rooms and a main room where all socialization occurred.
The Health Team
The work done at the boat clinics is made even more impressive by the relatively small size of the teams. The number of workers on each boat is no more than 15 one district program officer, two doctors, three nurses, one pharmacist, one lab technician, about three community workers, and at least three more boat crew, ranging from cook to driver. The teams are close knit; they have to be given the fact they work closely. A few of the members even live together in the res-cum-office buildings. Naturally, the talk on the journey to and from the islands is jovial and friendly. Most of the teams consist of young people. Older members are not unheard of though.
Doctors in Assam are required to serve one year of rural service after receiving their doctor degree-some are drawn to the boat clinic program by the fewer work days and the slightly higher pay. This means that many of the doctors are very young, and the turn over time for their work is about one year. Still, all the doctors I saw were highly qualified, listening to the concerns of the villagers with a great deal of patience and quickly diagnosing conditions. Though all were efficient, some doctors adopted a more businesslike approach to medicine, simply asking the required questions and their follow ups.
While more efficient, I preferred the working of one of the newer recruit he was more personal, friendly and cordial, taking care to talk to the person instead of to his sheet of paper.
Unfortunately, his careful addressing of his patients took a little longer than the doctors of the other camps. There is an unfortunate trade-off between such meticulous care and efficiency, especially in camps that see up to 150 people in one day.
The rest of the team is just as young as the doctors but just as good at their jobs. The pharmacist has to sort through tremendous stocks of medicine ensuring that the patient has the right
medicine and knows the correct dosage, translating medical jargon to Assamese. They must do this despite the many different dialects in every area of Assam. The lab technician runs a
multitude of tests, keeping track of numerous blood samples and tests at the same time-I know I would have gotten different people’s test confused after doing so many at the same time.
The community workers come from near the area and help with intake, taking names, pressure, weight, and in general being entirely useful and easing along the process. Along with the boat clinic staff, there is an additional crew member of the team in the village-an ASHA volunteer who serves as the liaison between the boat clinics and the village population, informing villagers of when the next boat clinic will occur, where, as well as taking the daunting task of reminding people of their follow up visits for vaccinations and antenatal check-ups.
When I initially learned of the boat clinics, I had doubts about the efficiency of the follow up and the degree of trust needed between this organization and the rural villagers. My doubts were very quickly assuaged by the efforts of the community workers and the ASHA volunteers-having members of the village communities work with the boat clinic team has truly helped build a sense of trust between the villagers and the staff. The boat clinic staff are not foreign authorities encroaching on the lives of the villagers but are people intent on helping improve the lives of all they meet.
Beneficiaries: a Profile
The people of the chars are not homogenous, but rather vary from location to location. The lower Assam camps, in Kamrup, Bongaingaon, and Nalbari, serve populations very different from the so called “standard” Assamese people. The people of the villages are mainly Muslims, with women with sunburst noserings and a dialect of language somewhere between Assamese and Bengali. The people are mainly farmers and fisherman, though in the Bongaigoan camp there were some coal industry workers due to the area industry. The upper Assam populations were similar to lower Assam populations in some aspects, different in others. The people in the
area of the Jorhat clinic sites were not of the same Muslim group that I had seen in lower Assam. They were standard Assamese people with a smattering of a few tribal groups such as the Mising. In these areas people wear hand woven Mehkala Sadars instead of saris, which speaks of their strong Assamese roots.
The diets of the villagers consist mainly of a large amount of rice, an amount of tuber locally called “kosu” and a large amount of chili peppers. It is a diet that the doctors of the clinic constantly lament. Many people come to the clinics complaining of dizziness and tiredness-upon inspection of blood hemoglobin levels, the reasons for their conditions become starkly clear. The normal hemoglobin level for women is between 12 to 16. Not a single person tested had a hemoglobin level higher than 8 and most were in the range of 4 to 6. This included pregnant women.
It is astounding that women are able to survive birth given this severe anemia. The diets of the villagers are simply not balanced and there is a lack of iron in the diet. Interestingly, the villagers actually grow leafy greens that could provide them with at least some of the iron that is required in the diet. However, the staple food Assam is rice and thus people put more importance in buying rice than having a balanced diet; the villagers thus sell their greens to get money to buy rice. Thus many iron pills are given out by the health camps. However, there is the issue of ensuring that the women take the pills. The pills tend to have an unpleasant smell makes some people adverse to taking them. The lower Assam teams also informed me that the villagers prefer liquid/syrups as compared to pills. In their minds, the syrups are the better, more effective medicines, despite the same active ingredients in the pills. To them, the better doctor is one who gives syrups, not pills. Needless to say, this causes some difficulties for the health camps. It is harder for the health camps to carry syrup medicines to the camps because they are
not as space efficient nor as easily distributed. Still this in an improvement from when the health
camps initially came around. Then the villagers believed that the only doctors who gave shots to cure people were the good doctors.
Changes in the Ways of Thinking:
The boat clinics have done some good in informing these people that care does not just come in the form of needles. There have been other improvements since the clinics began their rounds. From the medical side, more children have been getting vaccinated (there was a measles campaign before I arrived), and people have been provided medicines for various symptomatic illnesses. There have also been changes from the social side. I spent some time admiring the lovely bright colored clothing of the women who came to the clinics. When I mentioned it to one of the staff, he told me that when the clinics first started people simply came with their dirty work clothes, straight from the fields. The staff had to point out that it was neither sanitary nor appropiate for them to come in that manner. Slowly, the shift towards wearing clean garments began. The clinics have now become almost a social occasion where the people come to get
care, but also to talk to neighbors and watch the work of the doctors. As I mentioned before, the clinics try to be respectful of the schools, trying not to disrupt the learning environment. However, this is to little avail because children filter out of the schools just to see the spectacle of the clinics. They watch, wide-eyed, until they are chased back into the school building. At least, that is the case for those who do go to school. In some of the villages, the children simply do not go to school because the school buildings are just too far away, or the school teacher does not show up either, simply collecting paychecks without working. Such is the corruption that India faces, not just at the top levels of society but even lower down. Though the boat clinics have helped with some things, they are not all powerful.
They can tell people of the importance of going to school but sometimes the lives and ideas of
the villagers do not line up in the same direction.What, for example, does a daughter do when her father passes away? In the village culture, and much of the rest of India, she pulls out of school as early as 3rd grade to help her mother at home. She never gets the chance to return to school because her mother passes away and she is left to take care of her siblings. Such was the story of one of the girls; she could not have been more than 25 and she was providing the best she could for her family. She has done well for her family though managing to even get her younger sister married. Still, this is not the ideal life that the clinic would like to promote.
Diarrhea and gastric issues remain common, despite the efforts of the clinics, due to poor diet and water conditions. Ear infections are common due to bathing and swimming in river water. Worms stem from walking around barefoot in the muddy shallows. Seasonally the conditions change: in the drier season respiratory illnesses are common. There is also the problem of medication not being used by the patients. Hopefully this is an issue that will be solved as the clinics continue and more faith is put into the words of the doctors. The clinics are definitely a multitude of steps in the right direction.
Upper Assam Differences
The health clinics set up by C-NES are intended to have a focus on women and children, but the staff also helps men as well! In the clinics of lower Assam, hardly any men came: five out of one hundred. However, at the Jorhat clinic more men made their way to the clinic for care, and a few, as I was happy to see, took interest in the health of the children, even bringing them for care. In the lower Assam areas, the fathers did not seem to be involved with the care of the children but here they took an active role.
The people of the upper Assam districts also grew sugarcane and thus had a staple crop to depend on for income. The people in these areas are a bit more educated in terms of medicine.
None of the team was aware of any preference towards or against particular forms of medicine, syrup, needle or pill. This may be because the areas that I visited in upper Assam were closer to “modern society” and there was some exposure to medicine. One of the sons of an ASHA worker actually had some medical training and returned after his studies to provide very basic care to people in his area.
Findings and suggestions:
Anemia
Despite these positives, difficult health conditions abound. Anemia remains rampant, aches and pains from hard field work remain, gastric issues are common. Lifestyle changes, not just medication, would be required to make a major difference in these areas and those are the hardest to instate.
There is a potential solution to the issue of anemia in rice eating areas of the world. An international nonprofit organization called Path has made a pasta grain that resembles rice and contains micronutrients and iron. It is mixed in small portions (1 grain of ultra to 100 grains of normal rice) and prepared as normal. It was made with the intention of being given to low income, grain centered societies as a way of preventing malnutrition without intruding upon their normal lifestyles. The most exciting part about Ultra Rice is that it is entirely affordable-it costs about 0.50 American cents or 25 rupees to provide a school age child with fortified grain for an entire school year. Better yet, Path made these grains affordable by selling the recipe for production to several plants across the globe.
One of those plants is in West Bengal. It would be great if Ultra rice could be distributed to rural areas. It would provide less invasive and more long term treatment for anemia though there might be issues of people not mixing in the rice properly. That is an issue very similar to people
not taking their iron pills. However, I feel that this would be a more accepted method of taking iron because it lacks the strong smell of the iron pills and is integrated into daily diet.
The problem with anemia for pregnant women comes during childbirth. Blood loss and hemorrhage are common, and for people with low blood levels, even the smallest amount of loss can be fatal. There is a drug called Oral Misoprostal that has been shown in recent studies to reduce incidence of postpartum hemorrhage by 50%. “Oral misoprostol in preventing postpartum haemorrhage in resource-poor communities” by Derman outlines the study of the drug in a randomized control study.
The study was done in rural India, in an area with a high prevalence of anemia, and thus can be seen as a proxy to areas in rural Assam. The pill is also relatively cheap, about 1 dollar or 50 rupees a dose, and is possibly life-saving. If the pills could be handed out via the clinics, to either the expecting mothers with explicit instructions on how to take the medication or to midwives given with a little training on the use of the drug, there could be great potential for aid and prevention of postpartum death.
Personal Observations:
It was interesting and a bit odd to view the clinics from an American perspective. There were certain things that I saw that would never be allowed in an American clinic. For one thing, privacy was not an issue that anyone was concerned with Coming from America, I was incredibly nervous and hesitant to pull out my camera. In America, encroaching on someone’s privacy in a medical setting could very easily become legal trouble. So ingrained is that mentality in my psyche that, at first, I did not want to take any pictures. In India, though, no one really cared about privacy-medical examinations were done in the open, vaccines and injections
were given in front of the crowds. The only procedure done behind a screen at every clinic was an antenatal examination. At one clinic, they did give injections behind the curtain though. In some cases this privacy was good: getting an injection is a rather vulnerable experience, one that many do not care to share. At the same time, I will admit there was some benefit in having injections in public. It assuaged some people’s fears to see the procedure being done so easily and quickly on other people. I also observed someone afraid to be get an injection but convinced by their neighbors. The private setting for vaccinations did not allow this change of mind to occur. Personally, as an American, I am more inclined to private treatment, to the idea of private care.
I also observed a variety of techniques for withdrawing blood from a pinprick for testing. After making a pinprick, a small amount of blood was drawn to be used into a variety of tests. The blood was usually withdrawn via a capillary tube or syringe. Those lab technicians who used capillary tubes either used a bulb for drawing the blood, or, much to my surprise, used their mouths to pull up the blood into the capillary tube. It seems dangerous to be bringing a blood filled tube to one’s lips and is not a practice done in the US. I do know that the old medical colleges used to pipette by mouth but that practice has been abandoned. Another worrisome factor was that the capillary tubes were not disposed of after each blood draw-the tubes were just placed into a container of solution, most likely water. When dealing with blood, in the US, extreme care is taken, simply because of the risks of disease transference. Though capillary blood draws are less dangerous than needles, I feel that some sort of procedure drawing blood without mouth should be instated, and a method to either cleaning or disposing of capillary tubes between uses should also be considered.
Disposal of Needles and Waste
The C-NES health clinics are wonderful, but there are definitely some issues that I saw that should be dealt with. I volunteer for a free clinic back in Berkeley and, when it comes to needles, the is the upmost care taken in their disposal. At the Berkeley Free Clinic, the instant after a needle is used, it is disposed, immediately. The disposal of the needles used for drawing blood or giving vaccines at the clinics was sporadic and varied greatly between camps.Some clinics cut the tips off of needles and disposed of them into wastebaskets immediately after use. Other camps though simply stacked them up, used needle tips exposed until there was a break in the crowd.Only then did they cut the tips off the needles.
Needless to say, this was a disconcerting situation to me. It would be incredibly easy for someone to pick up a needle and, out of curiosity, play with it, or accidently get stuck by a fallen needle. Even after the needles were cut, they remained stacked upon a bench. I actually saw a little child playing with a detipped needle. Though not as dangerous as an uncut needle, it just shows how easy a single needle could slip into the hands of a patient.
I understand how hectic the clinics are espeicially after seeing the constant stream of patients and can perceive the difficulty in taking the time to snip off the needle tips in-between patients but the risk of someone getting stuck is far too large to take. I think there should be a sort of “sharps container” instilled so that the needles can be disposed of immediately. The sharps containers do not have to be fancy and Government issue. A milk carton can be made into an impromptu sharps container and can very successfully keep the needles out the reach of curious characters.Despite the lack of a standardized disposal system for the needles, I was glad to find that the clinic had a Post exposure prophylactic program in place just in case of staff exposure to needles. Though the needle issue still needs to be addressed, it is good to know that considerations have been made for the unfortunate situation of someone getting pricked by a dirty needle.
The clinics try to be as undisruptive as possible to the schools but the health camps are disruptive in a lot of ways, some worse than others. They are spectacles, people come out to simply see the health camp boats. Thus disruption is innocuous enough. However, I noticed that in some of the clinics, not all, left their waste at the site of the camp. Needle wrappers and old medication boxes littered the ground after the clinic and were left there even after the camp packed up. Leaving medical trash puts a burden onto the village. It is not fair to leave the burden of cleaning up to the villagers. Waste is not that hard to collect, and with the use of baskets, the trash could very easily be disposed of back in the main office.
Medical Logistics:
There is another mentionable issue with the clinics. It is the matter of medication logistics. When the clinics need medicine they receive a stock from the government and an additional 5000 rupees to buy any extra medications they feel that they need. The 5000 rupees is insubstantial because it provides for very little extra medicine but the stocks of government issued stocks are substantial. They consist of nutrient supplements, analgesics, antidiuretics, cough suppressants, and more. When the medications are passed out by the government, there is no consideration about what conditions are most prevalent, during which season, and in whatever area.
There is no record kept of how many drugs are given per trip nor is there a record of what is taken on each trip-medications are simply grabbed and tossed into canvas bags for transport. This haphazard transport of medications is troublesome but not as much sheer wastage of medicine that occurs because medication is given in bulk regardless of what ailment is common at the time. In each office there are stocks of medicine that have
expired because theyhave no use at the time. They sit alongside the unexpired medications which made me very nervous that somehow an expired drug would slip in with the quickly grabbed medications and find it’s way into someone’s hands. During my trip with the clinics, I did not see expired medicine passed out, but I did see a box of expired medicine
that had made its way onto the boat. Luckily, it was noticed and separated. The expired medications sit on the selves next to the other medicines because the government provides no easy way to dispose of them. More useful than a disposal system would be a system where the clinics are able to say “We need this much of this drug for this season, and only a little of this drug.” The government could then give them what they need, much less drug wastage. This would require the clinics to keep track of illness trendsand the amounts of medication they give out. It would also require that the government have a system for drug requests that is efficient. The process of instating such standards might be difficult but, in the end, I think it would decrease drug wastage as well as provide solid statistics on the boat clinics to better track disease and progression of care.
Conclusion and Thanks
This year’s trip to Assam was entirely unique and extraordinary. I know I will associate an innumerable amount of emotions with this trip for many years to come-affection towards the staff who were so kind as to take me in and show me their day to day work, amusement at the eagerness of the sapori children in getting their photos taken by this strange American girl. Not all the feelings though are positive-the situation of some of the villagers is saddening in that many of their conditions are entirely preventable by way of education and regular care. Still others have simply had harsh lives thrust upon them and have no way to get out.In addition, I know this trip has helped me reinforce my determination to enter the medical field.
I owe a great number of people thanks for this opportunity. Many thanks go to Sanjoy Hazarika and all the members of his NGO C-NES for providing such a service to the rural populations of Assam and allowing me to take the tiniest peek into their work. I must also thank my family who took care of me and took the time to shuttle me around to the camps regardless of every pothole they hit. And of course, thanks to the people of the villages I visited. I thank them for allowing me to watch their experiences, speak to them about their lives, and even joke (or rather have them joke with me) about my future marriage possibilities. I look forward to returning in a few years, to be absolutely astounded at the changes that the boat clinics have made on rural India.
(Photographs of camps with captions were sent earlier as an album and has since been uploaded in the C-NES website- www.c-nes.org)