Bringing health care to a contested corner of India

Online Appendix

A glimpse of Churachandpur, Manipur

CMAJ Deputy Editor, News and Humanities, Barbara Sibbald visited the Médecins Sans Frontières (Holland) project in Churanchandpur, Manipur in November 2007 and recorded the following impressions.

1. Registration staff at the Médecins Sans Frontières (Holland) clinic in Churachandpur, Manipur, India warm up between clients. Each month, some 4700 patients visit the MSF town clinic, up from 600 in 2005.

2. Clients waiting the MSF town clinic in Churachandpur, which offers general health care, prenatal and antenatal care, vaccinations and more.

3. The top floor of the Churachandpur District Hospital has been under construction for 5 to 10 years — no one recalls precisely how long.

4. Virtually every Christian denomination is represented in Churachandpur. On Sundays, dueling bells ring out over the valley.

5. Scores of vendors sell used clothing along the main streets of Churachandpur.

6. A tyke takes a nap on a downtown street. Note the empty box of rum to the right; Manipur is an alcohol-free state.

7. The view from the Seligat bridge separating the north and south Churachandpur.

8. A five-star hotel. Due to security issues, few foreigners or Indian nationals visit Manipur, despite the fact that it is heavily promoted in glossy brochures as the jewel of India.

9. Dr. Tony Solomon, an MSF physician from Wales in the United Kingdom who is in charge of HIV care, prepares dinner at the MSF staff compound.

10. Dr. Caroline Kowal, an MSF physician worked at emergency departments in Winnipeg, Manitoba prior to coming to Churachandpur in November 2007. Typically, she works 12-hour days, managing the basic health care component of MSF's activities including antenatal care, transfers to other institutions (mostly pregnancy related), developing medical protocols and running the laboratories.

11. Unemployment hovers around 80% in the state of Manipur.

12. Local transportation enroute to Tuining, 1 of 4 MSF mobile clinics in and around Churachandpur. The back roads, in general are in a deplorable state, while the main highway is frequently barricaded by insurgents who demand a "toll."

13. Security is always problematic in Manipur. MSF and its staff must remain neutral, in fact and in perception. Multi-levels of security are the norm.

14. The MSF mobile clinic in Saiton Khullen, a 30-minute drive north of Churachandpur, offers antenatal and general health care. Tuberculosis and low body mass index are 2 present concerns. In the summer, the staff attend to about 100 clients per day.

15. It's vaccination day at the Saiton Khullen mobile clinic. Most local residents work in rice fields. The area high school recently shut down because teachers were afraid of being kidnapped and of extortion demands.

16. The mobile lab at the Saiton Khullen clinic allows staff to collect sputum and blood samples, perform glucose testing and more.

17. Jehovah Jire, an MSF health educator, takes advantage of waiting patients at the Tuining mobile clinic to give a lesson in family planning. Here, she explains the finer points of the female condom.

18. Dr. Lalbiakdik (left) came to work at the Shalom hospital for a month 2 years ago. She's now the physician in charge. MSF (Holland) has an agreement with Shalom, and regularly transfers patients with HIV to the hospital. Standing with Lalbiakdik is the MSF Project Coordinator Ya-Ching Lin (American Taiwanese).

19. The military presence is ubiquitous in Manipur. The Indian army and 5 paramilitary groups have about 50 000 troops in the states — 1 for every 46 residents.

20. A sign on the wards at the Churachandpur District Hospital.

21. A few kilometers from the publicly funded Churachandpur District Hospital, but a world apart in terms of quality of care and cleanliness is the private Selimat Christian Hospital, which even has a good recycling program.

22. A gathering of some of the 86 MSF staff, which includes 13 nurses, 5 health educators, 8 physicians, 6 lab technicians, 6 counselors and a psychologist.

23. Sarree walked 5 km through the bush to get to the mobile clinic in the village of Saiton Khullen for a check-up and to obtain her antiretroviral medication.