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Inside Kerala's Pathanamthitta, the best constituency in India

Kerala's Pathanamthitta, the constituency that hosts religious flashpoint Sabarimala, has India's best child health indicators. (Alamy)Premium
Kerala's Pathanamthitta, the constituency that hosts religious flashpoint Sabarimala, has India's best child health indicators. (Alamy)

  • Pathanamthitta has India’s cleanest air, and HDI that match any first-world country, especially in child healthcare
  • Social movements against caste divisions, its culture and openness to foreign influences, have helped Kerala focus on development

Pathanamthitta, Kerala: In the heart of southern Kerala, where the road meanders around the edge of the Western Ghats, lies Pathanamthitta that shot to prominence because of the Sabarimala controversy. But there is a more important reason for the Lok Sabha seat’s claim to national prominence in the run-up to Elections 2019: the region in central Travancore has India’s cleanest air (among 123 major cities), and human development indicators (HDI) that match any first-world country, especially in health.

In a country where focus on healthcare is sparse at best, Pathanamthitta is an outlier. The parliamentary constituency, which goes to polls on 23 April, ranks as one of the best places in India to be a child, according to a recent report compiled by public health experts from Harvard University and Tata Trusts who have begun to map development indicators on to parliamentary constituencies (instead of district-wise) for the first time in an effort to make members of Parliament (MPs) more accountable. Only 12.5% of Pathanamthitta’s children ( under the age of five) are underweight, compared with the national average of over 33%.

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The healthcare system

It is easy to realize why economists such as Amartya Sen find the “Kerala model" of healthcare so remarkable when one visits a primary health centre in Pathanamthitta. During a recent visit, Vimitha Murali—a young doctor in her 30s who studied medicine at a state-run hospital at half the fee of a private hospital—enthusiastically gave a tour of her workplace.

The hospital building looks like a beautiful house. The rooms are clean. The walls host pleasant artwork. The compound includes a small front lawn. The primary health centre was transformed into a family health centre—a first level health delivery point—under Mission Aardram, launched by the new state government in 2017. This meant, among other things, the facility will be open from 10am to 6pm, instead of till 1pm earlier.

The hospital building looks like a beautiful house. The rooms are clean. The walls host pleasant artwork.
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The hospital building looks like a beautiful house. The rooms are clean. The walls host pleasant artwork. (Nidheesh M.K./Mint)

Every week, she said, there are specialty clinics on certain days as per what is needed in the locality—for instance, Mondays are for pregnant women, Fridays are for those who are depressed, and Saturdays are marked to discuss adolescent issues. In the morning, a dozen people walk in for yoga classes in an attempt to cultivate better lifestyle habits. By evening, the place is buzzing with kids attending Karate classes.

Most people who visit the centre, Vimitha said, are from low-income households. The lab tests are free. The medicines are free. The consultation is also free but one has to collect a pass, called outpatient ticket or OP ticket for just 5, which is further subsidized for those below the age of 18 and other vulnerable groups.

Dr Vimitha Murali has worked in a private hospital in Bengaluru, but working at the grassroots—in Pathanamthitta—gives her more satisfaction.
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Dr Vimitha Murali has worked in a private hospital in Bengaluru, but working at the grassroots—in Pathanamthitta—gives her more satisfaction. (Nidheesh M.K./Mint)

When a patient arrives, there is a woman to give the OP ticket and another woman officially called a “crowd-manager" takes them for pre-consultation check-ups like measuring pulse rate. Out of four doctors, only two are available, one is on personal leave and another on maternity leave. The biggest chunk of the centre’s staff, though, do not have to be within the premises. They are called Accredited Social Health Activist (ASHA) workers, a trained force who go around town every day, keeping a check on public health and spreading general health awareness.

Solar panels power the whole complex, at times returning additional power generated to the state power board. The salary of doctors is on par with the industry standard and, further, the team insists high morale is a reason for coming to work. “I’ve worked in a private hospital too in Bengaluru. But working at the grassroots gives me more satisfaction," said Vimitha.

Mostly, this is how primary health centres are run all across Kerala. There are at least two primary health centres for every three villages, that is, one primary health centre for every 3.95 kilometres (km), against the national average of one for every 7.3km, according to National Sample Survey Office data.

But beyond the appearance of a functioning system, the best thing about the Pathanamthitta health centres is this: there are hardly any patients.

“I’d credit the grass roots (Asha) workers for the success of our healthcare model, especially when it comes to children, because they are so good at early detection. They are self-motivated, and then, there is strict, monthly supervision from the top," said Vimitha.

Health despite politics

The focus on development and attention to primary healthcare is part of a long-standing, yet nuanced, tradition. Kerala has its own vexed fault lines along caste and religious divides, like the rest of India. Pathanamthitta is even the ground zero of one of the biggest religious battles to have rocked the state—the Sabarimala question. How then did questions of healthcare sneak through to find primacy in a volatile political landscape, and what lessons does the Kerala experiment hold for the rest of India?

On 28 September, the Supreme Court granted women of all ages the right to enter the Sabarimala temple, reversing the Kerala shrine’s tradition of barring girls and women of menstruating age — 10-50 years.
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On 28 September, the Supreme Court granted women of all ages the right to enter the Sabarimala temple, reversing the Kerala shrine’s tradition of barring girls and women of menstruating age — 10-50 years. (PTI)

Following a landmark Supreme Court ruling in September, which struck down an age-old tradition that prohibited females of menstruating age from entering the Sabarimala temple, violent protests erupted in the state. Naturally, shoring up the healthcare system is not the top election issue. Angry pilgrims and what they would do is the usual poll conversation, said Thomas Uzhuvath, a retired professor. He took his phone out to show evidence. “You see," he said as he opened his Facebook account and showed the account of a person whom he knew as a Congress supporter, “look at the posters he has been sharing". They all said the Communist Party of India (Marxist), or CPM, candidate for the polls, Veena George, was silent during the whole Sabarimala campaign. “They are peddling this to show that Congress candidate (Anto Antony) is more pro-Hindu than the others in the fray," Uzhuvath said.

Angry pilgrims and what they would do is the usual poll conversation, not healthcare, says Thomas Uzhuvath, a retired professor in Pathanamthitta.
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Angry pilgrims and what they would do is the usual poll conversation, not healthcare, says Thomas Uzhuvath, a retired professor in Pathanamthitta. (Nidheesh M.K./Mint)

This is where any marker of performance based on one indicator, like child healthcare, meets the reality of an Indian election. And it is a strange reality, especially because Kerala’s chief election commissioner Teeka Ram Meena on 11 March strongly warned candidates against seeking votes on the Sabarimala issue, and by extension, religious matters. What is even more strange is that the CPM strategy to counter this blistering attack using religion is also based on religion.

The CPM is banking on the support of minority Christian voters who are apparently unhappy with the Bharatiya Janata Party (BJP) for playing the Hindutva card aggressively, according to a local businessman close to the CPM, who requested not to be named. “The more aggressive the BJP is, it will, in fact, benefit the CPM. As they will be able to promote themselves among the minorities as the secular guardian," the businessman said.

Both George and Antony were unavailable for immediate comment since they were busy with poll campaigning.

Kerala Chief Minister Pinarayi Vijayan. The CPM is seen banking on support of minority Christian voters who are apparently unhappy with the BJP for playing the Hindutva card aggressively.
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Kerala Chief Minister Pinarayi Vijayan. The CPM is seen banking on support of minority Christian voters who are apparently unhappy with the BJP for playing the Hindutva card aggressively. (Ramesh Pathania/Mint)

Christians are a significant group in the region when it comes to swinging the balance of power. The local buzz is every major Christian denomination in the south will find a church in Pathanamthitta. It is also a very organized religion compared to others, according to Uzhuvath.

For ages, Pathanamthitta’s people, especially the minorities, were the beneficiaries of what is locally known as “passport culture"—emigration to Western countries in search of prosperity. Until two decades ago, the district topped the remittance income flowing into Kerala. The Church has been a key player in not only creating the infrastructure for such progress—schools, colleges, hospitals and so on—but also in filling the social vacuum in families that are left behind by emigrants. Issues of representation matter a huge deal for the Church.

Religion and caste guide the election process right from the selection of candidates. Congress candidate Antony, a two-term MP seeking another term, belongs to and is a favourite son of the Roman Catholic Church. The CPM made its own religion-based calculations when the party fielded Veena George. She was a popular television anchor and her husband was an executive member of the Orthodox Church, who are influential in Pathanamthitta. George became a member of legislative assembly (MLA) in 2016.

For the BJP, things have started to look a bit ironical. While his Hindu religious identity is the calling card for the BJP candidate K. Surendran—one of the many general secretaries of the party, and a star of the Sabarimala movement—he may be disadvantaged by his caste location. Surendran belongs to the Ezhava community, which is considered to be in the lower rungs of the caste hierarchy. And in Pathanamthitta, he would have a tough time earning the support of the predominant upper caste Nairs, according to a BJP leader, who was closely involved in the Sabarimala protests and the campaign, but who did not wish to be named. The Nair outfit, Nair Service Society, was very upset with the CPM over the handling of the Sabarimala issue and is seen by analysts as the primary vote bank for the BJP.

Demographic investments

Old-timers remember Pathanamthitta as being a very backward district at one point. “Financially, it was a very backward place for a long time," said Sajan Mathews, the current head of Pathanamthitta’s general hospital, the largest public hospital in the district, housed in a large, multi-storeyed building that includes three super specialty wards. “I remember, in my childhood, going to a government hospital that was inside a dilapidated building. They were called dharmashupathrikal (charity hospitals)," he added.

Financially, Pathanamthitta was a very backward place for a long time, Sajan Mathews, the current head of the city’s general hospital.
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Financially, Pathanamthitta was a very backward place for a long time, Sajan Mathews, the current head of the city’s general hospital. (Nidheesh M.K./Mint)

“The only thing available in those days in a hospital was tablets like paracetamol and sheets of newspapers to wrap them up. The doctors would advise patients to swallow those pills with lots of water. That’s it," he said.

The progress is equally visible in other sectors too. For starters, the district itself was carved out of neighbouring Kollam, Idukki, and Alappuzha in 1982 in order to focus on development.

Now, it has two international airports within a distance of 100km and a third one is in the making; a small interior pocket called Kumbanad is famous for having at least one branch of almost all major banks and some 5,400 crore as deposits, most of it funded by emigrants from West Asia, US and Singapore; and of course good quality public hospitals and schools.

How does a constituency that is caught up so spectacularly in a web of sectarian considerations end up remarkably better off on its development credentials?

A 2004 World Bank report that probed why Kerala and Uttar Pradesh are such different worlds may have some answers.

A small interior pocket called Kumbanad is famous for having at least one branch of almost all major banks and some  <span class='webrupee'>₹</span>5,400 crore as deposits, most of it funded by emigrants from West Asia, US and Singapore.
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A small interior pocket called Kumbanad is famous for having at least one branch of almost all major banks and some 5,400 crore as deposits, most of it funded by emigrants from West Asia, US and Singapore. (Nidheesh M.K./Mint)

History helped, the report said. “Even though its consumption-related poverty was among the highest in India, Kerala already led in human development in 1956 when it was reconstituted as a new Indian state. Long-standing social movements against caste divisions, its culture (including matrilineal inheritance in certain communities), and openness to foreign influences (including missionary-led education) all helped," it said.

“But history is not all," it added. “Much of Kerala’s spectacular achievements came after the mid-1950s. Adult literacy has risen from around 50% in 1950 to more than 90% now and life expectancy at birth from 44 years to 74 years."

Clearly, religious and caste issues may have driven the discussion on Kerala polls but did not consume it altogether.

“The basic emphasis on health and education goes back to the E.M.S. Namboodiripad-led government in 1957, that probably gathered momentum in the later Marxist governments in the 70s," said Narendar Pani, a writer, political analyst and faculty at the National Institute of Advanced Studies. “Then, it became true of all the parties (in the state). That’s a very strong tradition in Kerala. It’s a tradition which also makes it very clear that health is something that has to be managed not through insurance but through state investment," he said.

Rise in expectations

In Pathanamthitta, the equations became more sharpened by the rise of private wealth too, said Uzhuvath. While the remittance economy fuelled the demand for better private hospitals and schools, the aspirations that came to be attached with public infrastructure rose too, he said.

Also read: Inside Jharkhand's Singhbhum, the worst constituency in India

Everything, from roadside hoardings to online posts, screams the amount of money each candidate has been able to spend on public infrastructure. To Veena George, some of the biggest talking points are the 1,328 crore marked for development projects in the constituency by the state government and the restoration of an almost extinct river called Varattar. For Antony, it is his last ten-year track record of development initiatives. As a keyword, development is inescapable.

“All politicians are competing to market their development," said Mathews. “The public will be pressured to learn that this much work has been done by this government over here. All candidates who have tragically failed to deliver on education and health have usually met with defeat in Pathanamthitta, no matter what their religious or caste affiliations may be," he said.

Pani puts it more bluntly: “It (health investments) is not a question of an incentive anymore. It is a question of punishment if you don’t."

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