In the mid-1980s, Gadchiroli, dubbed the most “backward” place in Maharashtra, appeared to hit a very elusive goal for much of the rest of the country: it had the best record in the state for family planning targets.
In reality, the district was a public health disaster. Statistics that showed a slowing population growth simply masked a grim truth—the district had an exceedingly high child mortality rate.
Starkly, more than one in 10 babies born in Gadchiroli would not make it past their first birthdays as a mortality rate of 121 for every 1,000 live births marked this district in south-eastern Maharashtra.
The Union government now plans to replicate the ‘home-based neonatal care’ model developed by Abhay Bang and his wife
Today, this rate in Gadchiroli has plummeted to less than 30, far below the national average of 58. The credit for this transformation goes to two doctors, Abhay and Rani Bang, who gave up opportunities to pursue lucrative careers after graduating from the prestigious Johns Hopkins School of Public Health in Baltimore, and came here instead.
“We believed that children here didn’t have to wait till circumstances improved for them to have a better chance at survival,” says Abhay Bang.
For as long as anyone could remember, the people of Gadchiroli followed rudimentary birthing practices, which partly contributed to the high mortality rates. Soap or disinfectants were never used. A sickle was used to cut the umbilical cord and a paste of mud and oil was applied on the stump. Cold water would be poured on newborns to make them cry. Breastfeeding would be initiated after three days because villagers here believed the initial milk to be impure.Such was the Gadchiroli the Bangs came to in 1986.
In 1950, Dr Abhay was born to parents who believed in the Gandhian welfare movement known as Sarvodaya. “I spent my early childhood in Gandhi’s Sevagram ashram, in the company of luminaries like Acharya Vinoba Bhave,” says Dr Abhay, referring to the man who is considered the spiritual successor of Gandhi. “These influences have shaped me to a large extent.”
One of his earliest defining moments was a conversation with his elder brother Ashok as they cycled through the countryside in Wardha. “We have to decide what we want to do with our lives,” Ashok said.
After a 10-minute discussi-on, the two concluded that the country’s main needs were food and health care—and chose their vocations accordingly. While the older brother went on to study agricultural sciences, Dr Abhay took up medicine. He graduated from Nagpur University and enrolled at the Postgraduate Institute of Medical Education and Research (PGIMER) at Chandigarh for his medical degree. There, he was agitated to see the government spending significant sums of money to train doctors—only to lose them to the US.
Disillusioned, Dr Abhay left the institute, despite being a topper, and started an organization called Medico Friend Circle to engage medical professionals in working for the poor in rural India.
He eventually returned to Nagpur University to complete his postgraduation—and met his future wife.
Rani Chary hailed from an Iyengar family and was inspired to pursue medicine by following in the footsteps of her father, who was a general physician. The youngest of five children, Rani’s parents had big dreams for her. She, however, was drawn to the idea of working with the rural poor.
“My family initially resisted the idea,” she recalls. “My father wanted me to go abroad and study and probably look at practising in a big city.”
After she completing her training as a gynaecologist, the two doctors got married. Even their marriage was shorn of any extravagance. “We had a very simple ceremony. We didn’t even have rice thrown because Abhay thought it would not be right when so many people don’t have food to eat,” recalls Dr Rani. The couple moved to Wardha to join Chetna Vikas, another non-profit organization started by Dr Abhay’s family.
Dr Rani took to the Gandhian life wholeheartedly, including wearing khadi, which she continues to do even today.
The doctor couple began working in the villages in Wardha district, beginning a period of intense education about the realities of life in rural India. During this period, they realized that their training as clinicians was inadequate to address larger health-care issues as they had no grounding in community health or research. “To develop sustainable solutions, we had to adopt a community-based approach. This necessitated conducting research, based on which we could develop new knowledge and practical, replicable public health models,” says Dr Abhay.
They left India and enrolled at Johns Hopkins, one of the best public health institutes in the world, to acquire these skills and degrees in public health.
And then they chose to return.
They picked Gadchiroli, a largely tribal district that subsists mostly on forest products such as bamboo, tendu leaves (used in making bidis) and firewood, about 175km from Nagpur. According to the Bangs, they chose Gadchiroli because it was the most backward region in the state: “It is best to go where the need is greatest,” Dr Abhay says.
They moved to the district with their two sons, Anand and Amrut, at that time six years and six months old, respectively.
The two doctors were convinced that they could reduce the burden of child deaths even in this limited resource setting. Through research, they identified the main causes for infant mortality in the region and devised a strategy of home-based neonatal care to address them. The strategy involved teaching dais (traditional birth attendants) and village health workers to conduct deliveries, care for newborns, diagnose and treat illnesses, including pneumonia, the leading cause of deaths among children.
Today, when the health workers set out to make calls, they carry with them a medical kit that contains iron and calcium tablets, ointments, artificial nipples and medicines for respiratory tract infections. Sometimes they even carry a device called a “breath counter”, developed by Dr Abhay, which is used to diagnose pneumonia. The dais’ accuracy in pneumonia diagnosis is as high as 82%.
It took the Bangs more than five years to bring down the infant mortality rates through research and implementation of their findings. A subsequent project implemented in other districts of Maharashtra saw infant mortality rates drop to 33 in less than three years.
The workers are as efficient as most trained paramedics, using disinfectant, gloves and sterilized scissors for deliveries. They can even perform vaginal examinations, diagnose and treat some gynaecological diseases, and give injections—commendable considering most of them cannot even read.
The success of this effort, which came to be called the “Gadchiroli model”, has earned acclaim for the doctors and their organization, the Society for Education, Action and Research in Community Health, better known as SEARCH. In fact, the government now plans to replicate the “home-based neonatal care” model to bring down infant mortality rates across the country. The model involves a standard protocol in which the village health workers receive training.
In its latest annual report, the ministry of health and family welfare cites Bangs’ work: “The Government of India has recently approved the implementation of home-based newborn care (HBNC), based on the Gadchiroli model, where appreciable decline in infant mortality rates has been documented on the basis of work done by SEARCH.”
The project will be piloted in two districts each in Madhya Pradesh, Uttar Pradesh, Orissa, Rajasthan and Bihar. Accredited social health activists will be trained on aspects of newborn care, including injecting antibiotics for diseases such as sepsis and pneumonia. The government hopes that this will reduce infant mortality rates from the current level of 64 per 1,000 live births in rural India to 27 per 1,000 births by 2015. The average infant mortality rate for the country is 58 per 1,000 births.
Other developing countries, too, have shown an interest in replicating the model developed by the Bangs.
Last November, key decision makers from African countries such as Ethiopia, Kenya, Uganda, Zambia, Malawi, Mozambique and Madagascar visited Gadchiroli to study the pioneering work that the two doctors have done on newborn care. The African continent has a high burden of infant mortality, with more than one million babies dying within the first month of birth. With SEARCH’s help, many of these countries are now working on developing their own programmes to reduce infant mortality.
Though the two doctors are best known for their work on infant mortality, their contribution spans various aspects of community health. Dr Rani led the first study to identify the burden of gynaecological diseases among rural women and they have also been involved in conducting de-addiction programmes in rural Maharashtra, where alcoholism is rampant. They set up the only hospital and research centre, called Shodhgram (meaning research village), on the outskirts of the tribal region. The 20-bed hospital, with its cluster of single-level, hut-like structures, looks like a cross between a Gandhian ashram and a tribal village.
At the gates of Shodhgram is a temple of the tribal goddess Danteshwari and the hospital itself is called Maa Danteshwari Dawakhana.
The architecture of the hospital building resembles a tribal house; living chambers surround an open space and verandas traverse the chambers.
“People here are indebted to the doctors and to SEARCH, especially those who have survived snake bites due to the treatment provided at the hospital and those that have been cured from alcohol addiction through the de-addiction programmes,” says Tushar Khorgade, a local who has been working with SEARCH for more than a decade.
According to Khorgade, the most significant change has been that now even the traditional doctors from the tribal regions contact the hospital for medical help.
For their work, the Bangs have received awards from the non-profit Save the Children and the MacArthur Foundation, among many other recognitions. Besides the public accolades, the doctors have inspired countless young medical professionals.
“Their pioneering work in infant mortality has been instrumental in bringing this issue to light. They have also demonstrated that such major issues can be dealt with efficiently with the right inputs,” says Dhananjay Kakde, project officer at Sathi, a non-profit that focuses on healthcare research and advocacy for the well being of the disadvantaged people, including the rural poor. “What’s most important is that they have shown this works in reality and not just in some academic research.”
Sixty in Sixty is a special series that we are running through 2007, the 60th anniversary of India’s independence. We will introduce you to sixty Indians—both here and abroad—who are not rich or famous. These are people who are making quiet, but important, contributions without seeking headlines, to help make India and, in some cases, the world a better place. We also welcome your suggestions on people whom you think should be profiled in this series. Please send your suggestions by email to email@example.com