Networking for rural healthcare in tribal regions of Tamil Nadu

Coimbatore, Tamil Nadu

A bungled surgery to remove a tumour from her spine when she was six years old, left Lakshmi with a damaged nerve, incontinence, and a walking difficulty. For more than ten years after that, she remained confined to her home. Her parents, Krishnan and Annamayil, both daily wage farm labourers, at Poombarai village in Dindigul district in Tamil Nadu, did their best to get her treated with their limited resources, but had lost all hope.

"My family was ostracised. No one would play with me, saying I smelled bad. I even stopped going to school," Lakshmi, who is 22 years old now, told Gaon Connection. Fortunately, for her, her story took a happy turn. "I met Abirami akka, who was on a visit to our village. She persuaded my father to allow me to accompany her to meet more doctors to see if my condition could be improved," she said.

Abirami D and her husband Aravindan R, who are based in Coimbatore, Tamil Nadu, co-founded DoctorNet India in 2017, and have since guided and supported more than 1,000 people like Lakshmi who needed health care, but did not know how to go about getting it. DoctorNet India's mission is to make medical advice and treatment accessible to those in rural and tribal areas across the state, who are unable to do so due to ignorance, poverty or both.

Abirami also recalled her first meeting with Lakshmi. "It was on a field visit to Poombarai about five years ago that we met Lakshmi and her family. She was reclusive, was reluctant to come out and had not studied beyond primary school," she told Gaon Connection.

But, with the help of the non-profit, Lakshmi was treated, and today she is married, has a child and lives in Tirupur in Tamil Nadu, with her husband Sivakumar.

"Over the years, we have realised that for many of the people living in remote villages, healthcare is not even an option. Often the PHCs [Primary Health Centres] are too far away, or under-equipped to help them with serious medical issues," Aravindan told Gaon Connection. "The essence of our intervention lies in the emotional support provided during the hospitalisation," he added.

The non-profit works with an informal network of about 400 doctors across Tamil Nadu, who may be private practitioners, attached to corporate hospitals or serving in government hospitals.

"We usually work with hospitals and doctors in government medical setups, wherever they accept the government insurance scheme, or offer subsidised care," Aravindan explained.

Serving tribal communities

Mrudula Rao A is the medical superintendent, at ASHWINI (Association for Health Welfare in the Nilgiris), located at Gudalur, in the Nilgiris. The district is inhabited by a large tribal population made up of the Betta Kurumbas, Moola Kurumbas, Paniyas, Irulas and Kattu Nayakans. "We cover over 20,000 tribal inhabitants in the area across 320 hamlets," Rao told Gaon Connection.

"While we can manage health care up to a point, there are occasions when we need to refer our patients to a higher centre. And that is where Abirami and Aravindan have been of great support," she said.

In the past five years, DoctorNet India has connected patients from ASHWINI to doctors who would treat them at affordable costs. "Whenever we have patients who need further care and they cannot afford it, DoctorNet India takes over. The non- profit takes care of appointments, the travel of our patients, doctor consultations and so on," Rao explained.

The doctor explained the struggle to get tribal patients to go elsewhere for treatment. Their reluctance to do so often led them to abandon followup treatment. But, in just the last one year, Aravindan and Abirami have helped at least 15-20 patients with blood, setting up tests, appointments, being there with them if they were having surgeries… All the logistics are worked out by them," Rao said with obvious relief.

Volunteers of DoctorNet India, once they have established contact with the patients, guide them to doctors and hospitals for treatment. While the non profit has about 15 volunteers of its own who interface with the doctors and patients, it is facilitated by hundreds of other grassroots volunteers of the other non profits.

The pandemic years

During the pandemic, DoctorNet India educated volunteers from 400 villages across Tamil Nadu about the coronavirus, helped with early identification of COVID and provided guidance and emotional support during home isolation.

The non profit, along with the Tamil Nadu wing of the Bengaluru-based Society for Community Health Awareness Research (SOCHARA) called Makkal Nalvazhvu Iyakkam provided free tele-counselling helpline service for the people to cope with pandemic related anxiety/stress/fear.

Twenty four professional psychologists counselled 400 distress callers from small towns and villages across Tamil Nadu. The non-profit also guided more than 150 COVID patients from more than 400 villages in the state, through tele-consulting and follow up.

Volunteer-driven

"Many volunteers are drawn from the very same villages where the patients live. Or they have worked with the villagers for years and earned their trust," Abirami added.

Rajkumar Ramasamy and his wife Mary Ramasamy, both doctors, run the KC Patty PHC at Palani Hills, 50 km east of Kodaikanal. Along with a team of 12 people drawn from local communities, they serve a population of about 15,000 over approximately a 50 km radius, mostly living in isolated villages in the area.

In a webinar organised by DoctorNet India, on November, 28, 2021, Ramasamy spoke of the inequity of health care for those living on the fringes, and often inaccessible areas. "Many of our patients are Adivasi and poor with very limited awareness of their rights and capacity to negotiate an increasingly complex and unfamiliar referral pathway," he said. So when tertiary treatment is essential for them they are often completely unable to access these services, he added.

Ramasamy said that it was only through organisations such as DoctorNet India, that social justice and equality in health care could be achieved. "The existing health system fails to provide for the needs of those who are culturally different and socio-economically disadvantaged. DoctorNet India bridges the huge gap between our patients and the existing system. The non-profit found ethically practising doctors who we could refer to," he said.

Ramasamy described DoctorNet India's role as fundamentally essential if the health system is to care for everyone including the most marginalised people.

In a conversation with Gaon Connection, Anand Bharatan, Consultant Surgeon, Sri Ramakrishna Hospital, Coimbatore, who has treated many patients referred to him by DoctorNet India reiterated the problems of inequity in the field of health care.

"There is a need for people to step forward and help. Aravindan and Abirami set right the information imbalance," Bharathan said. He too mentioned the social barrier and the hesitation of patients to engage doctors in conversations and ask questions.

"DoctorNet India asks the doctors the questions for them about their illness, how long the treatment might take and so on. Abirami and Aravindan have a calling, there is no doubt about it. They tirelessly follow up with the doctors and patients," Bharathan said.

Here, Abirami gave the example of farm labourer Sivagami from a village near Kodaikanal. Sivagami found a lump on her breast and the PHC where she went asked her to get a mammogram to rule out cancer.

All Sivagami knew about cancer was that it killed and that it was way above her means to treat. She preferred not to get herself tested further. But, the volunteers persuaded her to go for a mammogram. As it turned out, it was not cancer after all. "Sivagami is fine now but the few months she spent not knowing were hell for her. She later told me how she would sit in the fields for hours crying her heart out, worrying helplessly about who would look after her child. And she would have lived with that despair, had the intervention not happened," Abirami said.

Working in tandem with other NGOs

There are several non-profits working in the remote areas, such as AID India; India Nirman Sangh that works in economic, social and cultural development of the poor in the Palani and Kodaikanal Hills; the Tamil Nadu unit of Ekta Parishad that works for tribal welfare and rights besides several self help groups.

"Many organisations and individuals do meaningful work in these remote rural and tribal areas inhabiting Lower Kodaikanal hills, Gudalur, Anamalai range, Nilgiris, Idukki district, Cuddalore district and Erode district in Tamil Nadu. When they come across patients who need help, they refer them to us," said Aravindan.

"DoctorNet India is also working on preventive health, that is the best and the most effective way forward in rural healthcare. It is inexpensive and will positively impact a much larger number of people," said Bharathan who is vocal about the unremitted promises of the government and the sometimes not-so-straightforward workings of private hospitals.

Meanwhile, Aravindan and Abirami have just completed a year's fellowship at a Community Health Learning Programme, offered by Society for Community Health Awareness Research and Action (SOCHARA), to better understand the underpinnings of rural health care.

"Curative healthcare guidance is just a start. We have plans to work on health education, preventive health, community health and mental health aspects," Aravindan concluded.