Bringing health care to a contested corner of India

The 9-year-old girl's smile glows in the dim light of a mud-floor clinic in Tuining, a small village in the Indian state of Manipur, as she listens intently to a health counsellor. Domhring is HIV-positive; so are her mother and father. Every month, she travels 3 hours by bus to this rural Médecins Sans Frontières clinic to get her antiretrovirals. Last month, she missed her appointment and is now behind 2 doses. Counsellor Daniel Traite explains gently how the drugs might stop working if she doesn't take them regularly, how she might get ill again and end up in hospital — again. When Domhring first came to the clinic last summer she weighed only 20 pounds and was promptly hospitalized. Without the antiretrovirals program, “the whole family would be in trouble,” says Traite.

They aren't alone.

Theoretically, there are adequate state health services in Manipur. In reality, though, the northeastern state, bordered by Myanmar, has a dysfunctional health system that's struggling to cope with the effects of a 45-year-old multi-faction civil war. Three competing ethnic groups and some 25 warring underground insurgent groups fight one another and New Delhi with demands ranging from sovereignty to self-determination. To support their causes, they routinely extort money from anyone with means — including physicians and bureaucrats, who dare not refuse; the newspapers are filled with reports of homemade bombs, shootings, kidnappings and beatings. Last year, there were 408 insurgency-related deaths.

All this has wreaked havoc on the state health system. On paper, it's adequately resourced. In 2006/07, its medical and public health budget was Rs 681 million ($17.5 million); this year it's Rs 761 ($19.5 million). But, the reality is that extortion and corruption cripple state services. A government HIV lab remains closed due to a lack of electricity, while the state HIV program struggles to function because project directors keep resigning due to extortion. At state-run health clinics, payment is demanded for allegedly free services. An appointment with a private family physician costs Rs 50 ($1.25), when an unskilled labourer earns Rs 80 a day. Typically, these clinics are open briefly, 11 am to 1 pm, if at all. With secure jobs, there's no incentive for ministry of health physicians to work more hours. Besides, they often need to run private practices to supplement their incomes due to extortion demands. In addition, their security is routinely threatened. A physician at one hospital was told he'd be killed if a patient died. A grenade was tossed into another physician's kitchen. Not surprisingly, health professionals go into hiding. There's reportedly a new medical officer in one of the rural areas where Médecins Sans Frontières works, but they've been assured he'll never show up.

“There's been a major breakdown of primary health care,” says Médecins Sans Frontières physician Dr. Minthang Singson. “Before the ethnic crisis there was well-functioning primary health care,” says Singson, who recently visited the Indian state of Uttar Pradesh, which is supposed to have one of the most backward health care systems in India. “But their system is better than ours. There's a law and order problem here. You don't go out at night.”

The omnipresent Indian army and 5 paramilitary groups have pumped about 50 000 troops into the state (1 for every 46 residents) in an attempt to keep a tenuous peace, but most communities have a self-imposed curfew at nightfall. The International Committee of the Red Cross is denied access to the state's prisons and detention centres. And the Armed Forces Special Powers Act gives security forces free rein to arrest, detain, search and kill in any “disturbed” area (i.e., all of Manipur since 1980) without being held legally accountable. The Act was extended another year in December 2007, despite recommendations that it be repealed from the UN Human Rights Committee and an independent Indian government committee.

“There are many places in India that are just as deprived,” says Médecins Sans Frontières Project Coordinator Ya-Ching Lin. “But here people can't access health care. The conflict prevents the development of infrastructure and adequate health care.”

The Médecins Sans Frontières office and residence compound is protected by a high, barbed-wire topped wall and a 24-hour guard, but the real guarantee of security “is our relationship with the community,” says Lin, who is Taiwanese American. “People see we are able to work full days, give no preference to people with connections or money and provide free treatment to under-served areas. The community supports and sticks up for us, they appreciate that we are here and what we are doing.”

Foreigners are not welcome and must jump bureaucratic hoops to obtain a letter of permission to enter Manipur. Médecins Sans Frontières (Holland) negotiated access after convincing the state it could provide meaningful assistance. It is now the only organization with a permanent expatriate presence in Manipur. In December 2004, it opened a basic health care clinic in Churachandpur (population about 75 000) — offering everything from antenatal care and vaccinations to HIV testing and treatment — and added 4 mobile clinics to serve outlying rural communities, including Tuining.

Client visits have increased from about 600 a month to more than 4700; in all, 100 000 clients have been served. The organization employs 86 staff including 13 nurses, 5 health educators, 8 physicians, 6 lab technicians, 6 counsellors and a psychologist. Lin, who has been the project coordinator for more than a year and is a 10-year Médecins Sans Frontières veteran, says the plus side to working in Manipur is its well-educated and motivated national staff, who are “a treat to work with.” Only 5 are expatriates — Lin, 2 physicians, an American nurse and an Italian psychologist — but due to licensing restrictions, the health care workers can't practice in India. Instead, they train, coordinate and supervise.

The organization's most popular program is the free antenatal care, with more than 24 000 women enrolled in the last 2 years and some 1000 visits a month. Part of its popularity is due to the free bed net, medication and home or hospital delivery kit given to each client. “Sometimes we get a truckload of women,” laughs Lin.

Staff also provide care for patients with gastrointestinal infections, skin problems, respiratory infections, tuberculosis and HIV. Manipur has the third highest prevalence of HIV in India (an estimated 1.3%), exceeded only by Andhra Pradesh (2%) and Nagaland (1.63%). The overall prevalence of Indian adults with HIV is about 0.36% (2 to 3.1 million people). The high rates in Manipur are largely due to the ready and cheap ($1.25 per injection) supply of heroin coming through the porous Myanmar border, and the thriving sex worker industry. The town clinic has about 1200 registered HIV-positive patients while the local government clinic has another 1000 or so. In 2006, Médecins Sans Frontières set up the area's first antiretroviral treatment program; 495 people are now on the fixed-dose combination therapy.

Lin says the program has done a lot to reduce the stigma around having HIV. “It's no longer a death sentence. People are coming out of the woodwork looking for treatment.”

Sarree has walked 5 km through the bush to get to the mobile clinic in the village of Saiton Khullen, a 30-minute drive north of Churachandpur. With the aid of a translator, the 45-year-old talks about her 2 sons, aged 19 and 12, about how her husband left her and married another, about her tuberculosis. She is quiet and cautious; a 2-inch-long scar across her temple speaks of previous violence. During her initial visit to the clinic, she was referred to a hospital, where she spent 2 months. Finally, she admits she is HIV-positive and on antiretrovirals. But, she hastens to explain, she got the disease during a blood transfusion. She's feeling well now and “loves” her work in the rice fields.

Both Sarree and Domhring have benefited from Médecins Sans Frontières' memorandum of understanding with Shalom, a pioneering non-profit 20-bed hospital that provides care for HIV-positive patients. “They offer care in a welcoming supportive environment that is unusual,” explains Dr. Anthony Solomon, Médecins Sans Frontières' United Kingdom physician, who is in charge of HIV care.

Shalom's physician-in-charge, Dr. Lalbiakdik says the introduction of antiretrovirals has “been like a miracle happening again and again in this place. They walk again when you never expect them to, and they go back to their families.”

Mental health issues are also a primary need due to the continuing violence, substance abuse, uncertainty and high unemployment. In November 2007, Médecins Sans Frontières brought in a psychologist who is training 6 local counsellors to deal with the effects of fragmented families, including some recent suspected sexual abuse cases.

Dr. Caroline Kowal, an emergency department physician from Winnipeg, Manitoba, is developing a protocol for dealing with sexually abused children, among a never-ending list of other responsibilities. She typically works 12-hour days, managing the basic health care component of Médecins Sans Frontières' activities including antenatal care, transfers to other institutions (mostly pregnancy related), developing medical protocols and the laboratories.

Kowal, 32, arrived in Churachandpur in November 2007 for her first mission with Médecins Sans Frontières and is adjusting to the challenges of switching from hands-on clinical care to management and supervision. “Writing reports — it's all new to me,” she laughs.

Médecins Sans Frontières is committed to staying until there are sufficient local resources, or until the violence restricts humanitarian access, or the violence ends; which seems unlikely after 44 years.