A painful period in the salt pans of Little Rann of Kutch
Women salt farmers go through a cycle of agony in the eight months they toil in salt pans, where poor water availability and lack of medical help make monthly bleeding scary Kutch, Gujarat: It is a white desert like no other. Nature lovers and travel buffs find inspiration in this vast expanse of nothingness, where the still blue sky adds a hue of solitude. The rustle in the Agariya settlements in the Little Rann of Kutch (LRK) seem to dissolve in this quietude, so do the problems of women working in the salt pans here. A 3,500 sq km salt marsh, LRK encompassing Kutch, Patan, Surendranagar, Banaskantha and Rajkot is crucial for inland salt production, contributing one-third of the country’s supply. It is also a key source of ginger prawn exports. Despite such unique contributions, there has hardly been any government effort to ensure dignity of life for the workforce here — one of its manifestations being in the form of medical conditions caused by lack of menstrual hygiene. There are six salt zones in LRK, where the Scheduled Caste community of Agariyas toil for eight months of the year. During the monsoon period between June and September, the area sees saltwater ingress from the Gulf of Kutch. When the monsoon time ends, worker families arrive mainly from four neighboring districts of Surendranagar, Patan, Rajkot and Kutch and settle in makeshift sheds for the next eight months. A glimpse of water scarce Agariya settlement (Photo - Amarendra Kishore, 101Reporters) Water scarcity is a silent predator in LRK, birthing a cascade of health crises stemming from lack of menstrual hygiene. Jauriben Chhotabai, a salt farmer in Surendranagar, attests this, so do Jalpa (18) who suffers from infections and white discharge and Vimla who deals with painful urination. If neglected, lack of menstruation hygiene can lead to toxic shock syndrome, reproductive tract infections and other vaginal diseases. Excruciating abdominal pain, medically termed as painful cramps, accompany these conditions. Bhartben Shailbhai (19), a salt pan farmer from Gosana village in Dasada taluka of Surendranagar district, has been going through it every month for the past three years. According to her, medical treatment has not helped. "The pain begins in my lower abdomen and spreads to my back and thighs," she says, her voice heavy with despair. “Once trapped in an infection, liberation from it seems incredibly difficult. The lack of water prevents proper cleaning of private parts. Using the same cloth repeatedly after washing during menstruation makes their problem even more severe,” notes Jairambhai Devabhai Savalia, the secretary of Narayanpura Cooperative Society at Patdi in Dasada taluka. Women work in salt pans for more than 10 hours a day. Those leasing salt pans enter into verbal agreements with ancestral producers, ensuring a share of salt revenue. Heenaben Jagabhai Khakariya (24) from Kesariya village of Lakhtar taluka in Surendranagar district claims that she has not been able to seek treatment for dysmenorrhea due to her demanding job. She tried traditional methods like carom seeds in lukewarm water to relieve pain, but without much effect.Pankti Jog talks about struggles of women (Photo - Amarendra Kishore, 101Reporters) Pankti Jog, an advocacy coordinator at JANPATH, a collaborative forum based in Ahmedabad, remarks that the struggles of women salt farmers in LRK does not end with water scarcity. “They have severe menstrual hygiene management challenges due to lack of hygiene resources such as clean water, soap, sanitary pads and toilets, leading to infections and waterborne diseases,” she says. No government medical facilities are available in LRK. However, there are primary health centres (PHCs) in Kutch, which function well. Even if they somehow get access to these PHCs, the women salt pan farmers will not make use of them, thanks to the stigma surrounding menstruation and unwillingness to consult male doctors.Bath place for the community (Photo - Amarendra Kishore, 101Reporters) A duty forgotten Dr Viren Dosi from Bhansali Trust has been serving the salt pan farmers of Santalpur in Patan district for two decades. He stresses that providing free water is the duty of state government. Yet, Agariyas are left parched in most areas of LRK. “In Surendranagar, water charges are based on salt production units (paatas), costing Rs 900 per month. Tankers deliver only 500 litres every five to seven days, forcing families to ration every drop. Women suffer the most, with inadequate water exacerbating menstrual hygiene struggles,” says Sahiya from Bhalot village of Kutch's Anjar taluka. “Bathing is a once-a-week affair; utensils are washed with the same water for days,” shares Ramaben from Patdi in Surendranagar. With no government water supply, the Agariya community is forced to rely on private tankers that charge Rs 1,200 to Rs 1,500 for 500 litres. Speaking to 101Reporters, Dr RB Singh, Taluka Health Officer, Santalpur, highlights state’s efforts to improve menstrual health in LRK, "where a mobile medical van visits salt pan farmers weekly". While sanitary pads are distributed, challenges like limited water availability and infrequent visits from health units remain. The health workers try to visit at least once in 10 days, but local weather, uncertain temperature and dusty winds pose problems.On menstrual health issues, the health department officials simply say that they are spreading awareness. When asked about the lag in capacity building, they outright refuse to acknowledge the truth. Limited water used for cleaning utensils (Photo - Amarendra Kishore, 101Reporters) The right approach The Menstrual Hygiene Scheme under the National Health Mission aims at improving menstrual hygiene, especially in rural areas, by providing free or affordable sanitary pads. Despite its goals, these provisions are absent in the LRK region. Awareness programmes and safe pad disposal initiatives are conducted, with training for anganwadi workers. However, questions remain about the state's commitment to these programmes, particularly in Agariya settlements. The scheme aims at reducing unhealthy practices, improving health and eliminating menstruation stigma, yet environmentalist Mudita Vidrohi highlights concerns over its execution. "A multi-dimensional approach is essential. It should include information and education to address gender equality standards and the stigma surrounding menstruation,” she says. “There must be an adequate number of safe and private toilets, easily accessible water facility for hygiene purposes, culturally appropriate menstrual products and materials [such as cloth, pads], socially and environmentally suitable methods for the disposal of used sanitary materials, private washing/drying facilities for clothes, practical information on maintaining hygiene during menstruation and supportive healthcare services," Harinesh Pandya of Agariya Heet Rakshak Manch tells 101Reporters. Ahmedabad-based writer Preeti Jain Agyat stresses the importance of linking anganwadi centres and midday meal workers to a system of providing sanitary napkins for women and girls. “Regular supply of sanitary pads is essential. Corporate Social Responsibility can play a crucial role in eliminating these issues in Kutch. Activating panchayats and involving non-governmental organisations in this campaign could also make a significant impact" says Jog. On dealing with water scarcity, Bharat Somera, a social activist based at Patdi in Surendranagar district, says, “During the British era, water was supplied through pipes over a limited distance of five to eight km in LRK. There is a need to revive and expand this pipeline. Additionally, the daily water supply needs to be ensured, and the amount of water per household should be increased.” Harinesh Pandya talks about water supply and health issues (Photo - Amarendra Kishore, 101Reporters) Asked if it is possible to effectively address the issues of water supply and women's health in Kutch, Pandya retorts, "Why not? If the vibrant Rann Utsav flourishes in the desert, surely this challenge is within reach. What is required is the resolve of our leaders and bureaucracy." Cover Image - Reproductive health issue begin in the early years of life (Photo - Amarendra Kishore, 101Reporters)
A picture of contrast: Allehpur block scores both high and low in rural sanitation
While women workers strive to keep Tibri village spic and span, there are other places like Ditanpur where garbage mounds and foul smell are the order of the dayDhampur, Uttar Pradesh: Sitting in the middle of a mound of garbage, Hanso Devi (38) is sorting dry waste from wet waste. There is an overpowering smell of decomposing waste, but Hanso’s hands are working tirelessly. “This is where my money is,” she says wryly. “We will earn by selling iron and plastic items in the waste people throw away. The panchayat secretary will pay us at the end of the month,” she says. Hanso is among the seven women hired by the panchayat office of Tibri village in Allehpur (Dhampur) block of Uttar Pradesh’s Bijnor district to maintain manure and compost pits as part of the Swachh Bharat Mission-Grameen (SBM-G), panchayat secretary Himanshu Chauhan tells 101Reporters.“They segregate waste and play a crucial part in maintaining cleanliness in the village. They sell to scrap dealer whatever scrap metal or plastic they find in the garbage. These women receive 60% of the proceeds from selling reclaimed metal items, while the remaining 40% is deposited in the panchayat’s account,” Chauhan details.The condition of the roads in the village (Photo - Shahbaz Anwar, 101Reporters)A plus pointWaste disposal initiatives were launched in the villages included in the Open Defecation Free (ODF) Plus scheme launched last year. “In the first phase of the scheme, 49 of the 1,124 panchayats in Bijnor districts were selected, including Dhampur and Tibri in Allehpur block,” Allehpur’s Assistant Development Officer Naseem Ahmed tells 101Reporters.Naseem says the first phase (2022-23) of ODF Plus scheme covered gram panchayats with a population of over 5,000. In the second phase, 84 villages in the block are slated for inclusion. Chauhan informs that the Uttar Pradesh government designated a 15 x 8 m sq plot of land provided by the revenue department and located within the village for the initiative. “A budget of Rs 13,82,000 was sanctioned for various activities. The allocated land now hosts a waste disposal centre comprising nine sections, facilitating segregation of various types of waste such as glass, cardboard, plastic, iron and more.”Vegetables and fruit peels are composted at the community compost pit set up on this land. Other wet waste gets buried in the ground.According to Chauhan, every woman is estimated to get Rs 5,000 to 6,500 after the sale of scrap. “When I heard about this job, I signed up as my husband’s income is not sufficient to meet our household expenses. This work helps in managing our household expenses,” says Rajwati Devi (42), one of the seven women workers. A garbage dump site in Ditanpur village (Photo - Shahbaz Anwar, 101Reporters)Holistic approach The commencement of ODF Plus scheme marks a holistic approach to cleanliness. This includes diverse initiatives such as door-to-door garbage collection, setting up of garbage disposal centres and establishment of manure and compost pits. Traditionally, each village appoints a sanitation worker responsible for upholding cleanliness. “Additional workers can be enlisted with the approval of the village head and panchayat secretary in villages with large populations, if the sanitation worker finds it challenging to handle the workload alone,” Naseem says.Under ODF Plus, the number of sanitation workers is higher. "This is because they not only collect garbage from every household, but also play a crucial role in segregating dry and wet waste,” he adds.According to Ditanpur village head Nafees Ahmed, three sanitation workers cater to a population of 5,000 in his village. “Considering the presence of two gram panchayats in my area and its considerable geographical expanse, the number of sanitation workers is more. They work from 7 am to 2 pm during summers and from 8 am to 3 pm in winters,” Nafees says.Talking about the expenditure, Nafees explains, "A designated percentage of the funds allocated for developmental projects in the village is specifically earmarked for the cleanliness system. Over a five-year period, our gram panchayat covering Jeetanpur and Alawalpur has been granted approximately Rs 1 crore. As a result, an annual allocation of about Rs 6 lakh is directed towards cleanliness in our gram panchayat."In contrast, Anil Kumar, a former Assistant Development Officer, observes that the standard annual development budget for a gram panchayat falls within the range of Rs 20 to 25 lakh. Typically, 30% of the amount is designated for cleanliness, with specific allocations varying among different villages.Panchayat officials having a discussion in Tibri village (Photo - Shahbaz Anwar, 101Reporters)RoadblocksThough on the right track, SBM-G faces several roadblocks ahead. A part of Allehpur block manages its waste under ODF Plus scheme, while the other areas still grapple with the problem of garbage accumulation along the highways.According to Monu Kumar, a resident of Ditanpur, the garbage crisis in his village is only increasing. “I am deeply troubled by this garbage pile. Villagers dispose of their household waste here, making it unbearable to stay indoors due to the foul smell. Recently, we found a snake in our house, which might have landed here from the garbage heap. Despite multiple complaints to the authorities, no action has been taken."Continuing along the same route, approximately 200 m away, another sizeable garbage mound poses a potential health hazard near a settlement. While the authorities say lime and pesticides are regularly sprayed in such areas, doctors argue that the accumulation of waste encourages breeding of mosquitoes and other insects, which are carriers of diseases.“The presence of garbage and filth poses a significant risk of cholera, jaundice and other potentially life-threatening illnesses,” says BK Snehi, in-charge medical officer, Seohara Community Health Centre. Allehpur Block Development Officer Trilokchand tells 101Reporters that the initiatives to establish garbage disposal centres are going on in different villages. “Comprehensive efforts are being made to address this issue promptly. When complaints about garbage heaps are received, additional cleaning staff are deployed and measures are implemented to ensure cleanliness," he claims.Edited by Tanya ShrivastavaCover Photo - Woman worker striving to keep the village clean (Photo - Shahbaz Anwar, 101Reporters)
Diseases waiting to strike as biomedical waste dumped in fields of Supaul
Indiscriminate burning of biomedical waste along with other garbage points to a lack of awareness in villages around managing this hazardous waste Supaul, Bihar: A resident of Babhangama village in Bihar's Supaul district, Asha Devi (80) was diagnosed with a liver infection in 2013. “The doctor we consulted in Patna told us that the infection came either from filth or from stepping onto animal excreta. That is when we realised how harmful the garbage dump near our house was,” said Bipul Jha, Asha Devi's grandson. Until 2013, the empty government land next to Bipul's house served as a garbage dump for the 100 households of the locality. “We would just burn the wastes once a week. But after my grandmother fell ill, we stopped people from dumping garbage here. Now, everybody digs a pit in their own fields for waste disposal,” said Bipul.Asha Devi (extreme right), resident of Babhangama village in Supaul district of Bihar (Photo - Rahul Kumar Gaurav, 101Reporters)Babhangama has four chemist stores. Apart from selling medicines, people are treated for ailments there. “We have kept a dustbin near the shop. Every two to three days, when it fills up with used syringes, needles, gloves and masks, we throw it in a pit dug in a field,” said Raju Mandal, the owner of one of the stores. In Bihar, low awareness about disposal of biomedical waste in rural and semi-urban areas has led to the disposal of hazardous material in agricultural fields. “Hospital waste can be dangerous. It is not just being dumped in villages, even scrap dealers in towns are recycling and selling off biomedical waste, which poses a high risk of infection. Cattle and stray animals are more prone to diseases as they feed on littered garbage that has biomedical waste mixed in it,” Dr Om Prakash Jha, a practising doctor from neighbouring Saharsa district, told 101Reporters. Shankar Mandal (65) of Bina village panchayat in Supaul has given away his land for dumping of waste from about 200 houses. This includes waste from two chemist stores. “That piece of land has a depression. Anyway, nothing much can grow there, so I thought of serving a social purpose by allowing people to dump waste there,” he said.“Unlike cities, villages do not suffer from land scarcity. Some farmers have too much land, while others are landless. People with large tracts of land usually allow dumping in a portion... However, we try to prevent them from throwing needles because they are sharp. Otherwise, it is difficult to distinguish biomedical waste from the rest,” Shankar said.In villages closer to towns and cities, urban local bodies do send a vehicle for garbage collection. For instance, this happens in Malhad and Karanpur villages near Supaul and in Bangaon and Mahishi near Saharsa city. But there is no segregation of biomedical waste from other garbage.“In the last two years, a government vehicle has been coming to collect waste. Before that, we used to throw garbage in the fields only. Now that we are on the periphery of the city, population is increasing and farm lands are decreasing,” said Rajesh Jha, a resident of Bangaon.According to World Health Organisation (WHO), only 15% of the healthcare waste generated is considered hazardous. It may be infectious — like the waste contaminated with blood or other body fluids (test samples), toxic heavy metals like mercury in thermometer or chemical solvents or radioactive diagnostic materials. The WHO data claim that about 16 billion injections are administered worldwide every year, but not all of the needles and syringes are disposed of properly. Open burning and incineration of biomedical waste emits toxins such as dioxins and furans and particulate matter in the air.Garbage being thrown near the railway line in Supaul (Photo - Rahul Kumar Gaurav, 101Reporters)What the law saysAs per the Bio-Medical Waste Management Rules, 2016, hospital and medical waste cannot be disposed of along with municipal solid waste. The rules divide biomedical waste into categories such as anatomical waste, discarded medicines and chemicals, and specifies how each of them should be disposed of, the responsibility of which lies with the hospital administration itself.As per the 2020 report of the Central Pollution Control Board (CPCB) on biomedical waste management, Bihar generated 27,846 kg of biomedical waste per day, of which only 10,201 kg was getting treated, which means 17,644 kg was being disposed of unofficially, a gap second only to Karnataka. The state has about 25,000 healthcare facilities, out of which 15,027 are yet to be authorised by the Bihar State Pollution Control Board (BSPCB) under the 2016 Rules. As per the Central Pollution Control Board, authorisation is a tool to capture the information regarding waste management by healthcare facilities as well as the common biomedical waste treatment facilities. The report said the gaps in implementation of 2016 Rules exist because of a lack of awareness at the district level, lack of segregation of waste within the healthcare facility and non-segregation of household waste from biomedical waste by local bodies.Manish Kumar, media in-charge, state environment department, told 101Reporters that the department has been regularly spreading awareness about biomedical waste. "I cannot do anything more than this," he asserted. Last November, the BSPCB sent closure notices to 1,800 health centres that failed to follow the prescribed standards under the 2016 Rules. 101Reporters asked more than 30 chemist shops in Bina, Ekma and Laukaha panchayats of Supaul about the rules, but only three were aware of them. "A municipality vehicle comes and takes away the garbage from our place. Many doctors also pay money for this," informed Pawan Kumar Jha, a compounder at the clinic of Dr DK Yadav in Supaul. A medical representative in Supaul, on condition of anonymity, said that biomedical waste generated in Supaul was mostly thrown on a private plot located near the railway station. “Vehicles for waste collection are sent only to registered doctors. All others just throw it anywhere. Since the municipal solid waste is mostly thrown near the railway lines, biomedical waste also ends up going there. However, there is still a little awareness in cities. In villages, people do not even consider biomedical waste any different from municipal waste,” he said.However, the local civic body denied that biomedical waste was ending up near the railway station. “Only regular garbage of the town is thrown near the railway line as of now. Biomedical waste is picked up in a separate vehicle and incinerated. We have already raised a requirement to higher authorities for setting up a waste processing unit. The unit will come up as soon as land is made available. And even municipal waste will not be thrown there then,” Krishna Swaroop, Executive Officer, Supaul Municipal Council, told 101Reporters. Edited by Ravleen KaurCover Photo - Disposal of garbage in Malhad village located near Supaul (Photo - Rahul Kumar Gaurav, 101Reporters)
All work, less pay push ASHAs in Kashmir into protest mode
The grassroots health workers do not get their meagre honorarium on time, while incentives for some services they render remain unpaidFahim Mattoo and Sadaf ShabirGanderbal, Jammu and Kashmir: Nine months ago, Shaheena Wani (29) from Chountpati Waliwar in Lar tehsil of Ganderbal district joined duty as an Accredited Social Health Activist (ASHA) in her locality. She chose this as her first job to serve the community and to help her family. However, to date, she has only received her first month’s honorarium (assured initiative) of Rs 2,000."I did not even get money for my uniform. I bought it myself and it cost me Rs 1,700. So far, my colleague and I have made 400 ABHA [Ayushman Bharat Health Account] cards, but we have not received a single penny," Wani tells 101Reporters. She was supposed to get Rs 10 for every card made.Administering vital vaccinations, guiding maternal and child health initiatives, and providing essential nutrition counselling are some of the key work areas of ASHAs in the rural landscape of Jammu and Kashmir. They work mostly three days a week, unless there is an emergency. Despite their valuable contributions, these grassroots health workers grapple with the weight of financial insecurity as their meagre incentives fluctuate with the number of patients they attend to and the services they offer. Apart from their honorariums, ASHAs get incentives for running government initiatives. Under the Janani Suraksha Yojana, they provide guidance to expectant mothers on antenatal care, birth preparedness and how to recognise danger signs during pregnancy. Following childbirth, they extend postnatal care for 42 days and initiate a two-year-long baby immunisation programme. “Despite our efforts, we are provided only Rs 600 per patient for this extensive service. Moreover, we often encounter significant delays in receiving these payments. It mostly takes five to six months to obtain what we rightfully deserve," Rubeena Showkat, an ASHA with 16 years of service in Chountpati Waliwar, tells 101Reporters. The National Female Health Workers (NFPHW), the backbone of Immunisation Day in Chountpati Waliwar, demonstrating unwavering commitment to community health, ensuring every child receives vital vaccinations with care and expertise (Photo - Fahim Mattoo, 101Reporters)The ASHAs conduct non-communicable disease screenings for individuals aged 15 and above. “These screenings encompass full body assessments, diabetes tests, blood pressure checks and weight monitoring. They are conducted every Saturday at our centre. We are also tasked with maintaining the Comprehensive Basic Assessment of Care records of it, both online and offline. For these efforts, we are supposed to receive Rs 1,000, but payments are consistently delayed,” she explains.Similarly, the incentive of Rs 250 per child for initial immunisations has been delayed. “We have expressed our concerns through protests, and assurances were given to resolve the issue. Regrettably, upon checking the data, we discovered that not even 40% of the promised compensation had been provided.”Articulating their concerns and advocating for a prompt enforcement of the Minimum Wages Act, 1948, ASHAs from several regions of Kashmir gathered at the Press Enclave in Srinagar and held a large-scale protest on September 17. In a stern declaration, the ASHAs made it unequivocally clear that they would go on strike if their demands were not swiftly met.They say instead of honorarium, they are requesting the government to provide them with a monthly salary of Rs 5,000. Even the sought amount is insufficient, considering the nature of their work in remote areas.Meanwhile, Lar Block Medical Officer Dr Ishtiyak Naik tells 101Reporters that the policies made at the Central level are implemented for all ASHAs, and the government is actively addressing the issues at the Central level.While claiming that the monthly honorariums are paid on time, Dr Naik admits that other incentives are currently pending. "When the budget allocations come in, the pending payments will be cleared," he says. About the delay in providing uniforms to ASHAs, he says funds are released once in a year for the purpose and that ASHAs would receive their uniforms at that time. Rubeena, the steadfast Asha worker from Chountpati Waliwar, extending a helping hand to the National Female Health Workers (Photo - Fahim Mattoo, 101Reporters)Dispelling myths at a difficult jobChountpati Waliwar comes under Chunt Waliwar village, which is home to 901 families. According to the 2011 Census, Chunt Waliwar has a total population of 5,950, comprising 3,003 males and 2,947 females.The village's literacy rate is lower (48.24%) than that of Jammu and Kashmir’s overall literacy rate (67.16%). The male literacy rate stands at 58.20%, while the female literacy rate is 38.31%. Furthermore, Scheduled Tribes account for a majority (45.01%) of its population. For ASHAs, going door-to-door motivating people about immunisation is an incredibly challenging task. Sometimes, people refuse to come out of their homes, and at times, they hesitate to give Aadhaar cards for generating ABHA IDs, fearing misuse.“I vividly recall an incident during the peak of the COVID-19 pandemic when we tirelessly went from door to door for vaccination. Some people would even attack us, and tragically, a woman with pre-existing health issues passed away after receiving the vaccine. Her family unjustly blamed me, alleging that the vaccine was the cause of her death,” Showkat says.“There was a prevailing myth at that time that we were injecting viruses through vaccines. Once I encountered a man who sternly warned me that if I ever visited his home, he would harm me with his axe. Despite enduring such challenges, the government has not paid adequate attention to our plight," laments Showkat, while collecting forms from the mothers of newborn babies at her centre.Recalling an incident when a woman in the seventh month of her pregnancy had to be hospitalised late in the evening due to bleeding, Wani says, “We quickly shifted her to the first sub-district hospital in Lar and then to LD Hospital in Srinagar. After she gave birth to a baby girl, I returned home at 2 am in the ambulance, and the driver dropped me midway. I had to call my husband, who then borrowed a motorcycle to pick me up. 'For just Rs 2000, you go through so much struggle. Even a labourer earns more than you,’ my husband used to tell me.”Wani is the designated ASHA of Parveena (20), who is three months pregnant. During her routine check-up, she warmly expresses: "It is Shaheena di who has been guiding me about antenatal care. These ASHAs are incredibly helpful. They dedicate their time to visit our homes and impart crucial knowledge about antenatal care and immunisation, ensuring the well-being of both mother and child."Sabreen, a dedicated NFPHW, stands at the forefront during Immunisation Day in Chountpati Waliwar (Photo - Fahim Mattoo, 101Reporters)Capacity building effortsLast year, a two-day capacity-building workshop was organised at Sher-i-Kashmir Institute of Medical Sciences (SKIMS), Soura, with an aim to minimise unnecessary interventions during childbirth, lowering caesarean rate, and reducing the workload for doctors. A new cadre of nurse practitioners and midwives was established to provide comprehensive assistance to women during pregnancy, childbirth and postpartum stages.Supported by the Government of India, the initiative was a collaborative effort between the Jammu and Kashmir National Health Mission, Postgraduate Institute of Medical Education and Research, Chandigarh, and United Nations Population Fund, New Delhi. "For getting trained as an ASHA for midwifery, all that is required is class 10 pass or seven years of experience in the field. However, the selection for the training lies with the higher authorities. Unfortunately, in Kashmir, no one from our region was chosen for this valuable training opportunity," Showkat notes, adding that her days of training had been in the range of five to 10 days. She suggests that training should continue in the village afterwards to facilitate continued learning. In this regard, Dr Naik explains that they conduct workshops periodically and are actively working on providing adequate training to all ASHAs.Meanwhile, Wani says ASHAs have repeatedly requested the Union Territory administration to provide them with tablets for official work since their phones struggle with the heavy online workload. “Our honorariums and incentives are not sufficient to purchase a smartphone,” she says.Highlighting the importance of door-to-door awareness campaigns, Sabreena Gul (32), a female multipurpose health worker at Chountpati Waliwar, says the unique local language complicates communication, making ASHAs indispensable for effective outreach. Despite their efforts, ASHAs still face challenges in mobilising the community. "Today is the immunisation day, and people were informed yesterday to bring their children for immunisation. It is already noon, and no one has turned up yet," Gul says disappointingly. Cover Photo - With determination Shaheen and Rubeena work in harmony with NFPHWs, making Immunisation Day in Chountpati Waliwar a resounding success (Photo - Fahim Mattoo, 101Reporters)
No doctors, equipment: Dhampur CHC in Bijnor district is almost a referral centre now
Emergency cases transferred to district hospital as six out of the seven medical posts remain vacant in the community health centre Dhampur, Uttar Pradesh: When Shakeel Ahmad (52) of Sherkot in Bijnor district felt chest pain over two years ago, his family rushed him to the Community Health Centre (CHC) in Dhampur, located almost eight km away. “There was no one in the hospital. So we decided to take him to Moradabad, located 50 km away. But he died on the way,” said Shakeel’s brother Vakil Ahmad.Sharad Kumar (46) died in the same manner in 2017. “He suddenly got a chest pain, and his body started convulsing. Even though Dhampur CHC was nearby, I had to take him to a private hospital,” said Sharad's neighbour Manoj Kumar, a resident of Teachers’ Colony in Dhampur.Manoj claimed that Sharad died due to lack of timely medical attention. “Had there been a cardiologist in the government hospital, we would have got medical attention sooner, and maybe his life could have been saved,” he said.Bijnor Additional Chief Medical Officer Dr PK Gupta told 101Reporters that Haldaur, Chandpur, Anku, Dhampur (Allahpur), Afzalgarh, Budhanpur Seohara, Najibabad and Nagina blocks have 11 CHCs, each catering to a population of over one lakh.However, inadequate facilities have always been an issue everywhere. “There are many problems in Dhampur CHC. Some doctors prescribe medicines that are only available in private medical stores. There is a shortage of doctors and lack of facilities as well. We had staged a demonstration to bring the matter to the attention of the authorities,” said farmer leader Dushyant Kumar Rana, a resident of Jaitra village in Dhampur.Duty chart at community health centre (Photo - Shahbaz Anwar, 101Reporters)Key posts vacantDhampur CHC Superintendent Dr Manas Chauhan told 101Reporters that as per rules, there should be seven doctors, including an in-charge medical officer, an orthopaedic surgeon, a general surgeon, an anaesthetist, an ENT specialist, a skin specialist and a pathologist, in the CHC. “If you do not take contract workers into account, I am the only one posted here. One doctor was transferred recently, while another retired,” he said.According to him, 200 to 250 patients visit Dhampur CHC every day. “There is an operation theatre here. If there are doctors, operations can be done. As of now, serious cases are referred to district hospitals,” he said.There are vacancies at Nagina CHC as well. “We have only three doctors posted here. We need at least a child specialist and a gynaecologist, but we do not have any of them,” said Nagina CHC in-charge medical officer Dr Naveen Chauhan. According to the doctors, the CHCs in the district see two to four emergency cases a day. “We refer two to three patients to the district hospital every day. Ahead of the referral, we give the best primary treatment we can, given the facilities we have, but there is always a risk as patients need to be transferred over long distances to other centres within a short time,” Dr Naveen said. “In emergency situations, say head or internal injuries, we need specialist doctors and medical equipment like CT scan, ultrasound and X-ray machines. But in our health centre, even accessing an X-ray film is difficult,” Seohara Main CHC in-charge Dr Vishal Divankar told 101Reporters.The population residing in these blocks is mostly rural. “Women and child health is a major concern due to lack of awareness. To compound this, most CHCs are running without gynaecologists and child specialists,” Divankar added.According to Dr Naveen, the CHCs are trying to provide services of a gynaecologist by contracting it to other doctors. “A doctor has been assigned the responsibility to see women patients at Nagina. We still need a child specialist, but have not been able to find a suitable person,” he said.Queue of people for the check-up at CHC Dhampur (Photo - Shahbaz Anwar, 101Reporters)What the officials sayBijnor Chief Medical Officer Dr Vijay Kumar Goyal admitted that there was a shortage of doctors in the entire district. “Dhampur CHC has only one doctor, while two doctors are posted at the Trauma Centre located in Nagina Road area of Dhampur," Dr Goyal told 101Reporters.According to senior officials, fresh medical graduates from state-run institutions opt out of the compulsory rural service by paying the bond amount, which further exacerbates the shortage of doctors. “We do inform the top officials about the shortage of doctors and we try to get recruits from government colleges. The new generation of doctors, however, is not much interested in rendering their services to rural government hospitals,” said Dr Gupta.Dr Manas said doctors also have to do administrative work in government hospitals. “The youth may feel that the salary is less and this may be the reason for the low number of new recruits in the CHCs,” he said.District Panchayat member Vivek Sen said he has raised the issue of shortage of doctors with the higher officials multiple times. “These hospitals have become referral centres. I do not understand how such a large population is being treated in a hospital with no facilities. A few months ago, I attended a district planning meeting, where I raised this problem in the presence of top officials,” he said. Edited by Tanya ShrivastavaCover Photo - Community Health Centre in Dhampur (Photo - Shahbaz Anwar, 101Reporters)
Fighting in the dark: How ASHAs in Bihar strive to keep kala-azar at bay
Overworked and underpaid, grassroots health workers continue to go door to door, persist in screening of people with symptoms, and constantly monitor them for years together in their bid to eliminate the diseaseMumbai, Maharashtra: Ashima Kumari* has run away. The rumour reached Richa* as she stepped into Salha, around 40 km from Bihar’s capital Patna. Wearing her custom uniform — a pink and purple saree with letters ‘ASHA’ stitched on the border — Richa had started out from her home in Ward 15 by foot at 7 am to make her rounds of the area with over 1,000 people in 248 houses.Ashima’s (17) home was the last stop on her route before lunch. An Accredited Social Health Activist (ASHA) for 18 years now, Richa has been looking after Ashima for the last 14 years (since 2009) after the district hospital diagnosed her with Visceral leishmaniasis, also known as kala-azar. Though Ashima recovered, she contracted Post Kala-azar Dermal leishmaniasis (PKDL) in 2016, which relapsed twice later. The girl now has brown and red patches on her face, a sign of PKDL relapse.The PKDL patients are reservoirs for the leishmaniasis parasite, which enters the body through the bite of minute sand flies and causes kala-azar. India accounts for over 80% of kala-azar cases globally, with Bihar reporting about 90% of them. It can be fatal in 95% of cases if left untreated, and is the second deadliest parasitic disease, next only to malaria.India accounts for over 80% of kala-azar cases globally, with Bihar reporting about 90% of them. ASHAs are the first line of defence against the disease (Photo courtesy of DNDi)About five to 10% of kala-azar cases develop PKDL, although some do not have such prior history. The lesions develop anywhere between six months and five years. However, lesions were reported within two months in Chapra in Saran district and some villages, local healthworkers said. Despite strong surveillance, early diagnosis, and new treatment regimes, India failed to meet the deadline thrice before — in 2015, 2017 and 2020. If untreated, even one PKDL case can trigger a kala-azar outbreak — a tripwire India wants to avoid by adopting best practices to eliminate the disease by this year. Even people successfully treated for kala-azar can infect others if they develop PKDL, a 2019 study found, implying that even when kala-azar is controlled, the transmission of PKDL continues unchecked.ASHAs are charged with the task of solving a central piece of the puzzle: rigorously screening and managing PKDL cases. In fact, Kala-azar presents a unique challenge as illness lingers even after recuperation. The ASHAs’ ‘cure’ is then disguised as care, as they straddle the limits of medicine.The first line of defenceThe first PKDL case that Richa saw was within her family, when her nephew developed skin lesions. The endemic districts in Bihar are warm and sticky; vegetation and poor housing create the perfect environment for sandflies to breed. Kala-azar is termed as the disease of the poor, who have no clothes and shelter.Jharkhand, Uttar Pradesh and West Bengal also witnessed a high Kala-azar caseload until 2017, when India ramped up screening and vector-control initiatives. The PKDL cases have hovered in the range of 600-800 since 2020 (across the four states where it’s prevalent and cases are notified). Healthcare workers, however, hint at an unfavourable trend: old cases relapsing and new ones rising.ASHA workers in Dariyapur village, Bihar (Photo courtesy of DNDi)The ASHAs have internalised the gold standard of defence: door-to-door screening and surveillance. First comes fever, often accompanied by loss of weight and appetite, anaemia, and enlargement of the spleen and liver. They are told to watch out for extended stomachs. Skin lesions develop months or even years later.If the fever persists for more than 15 days, the ASHA concerned will persuade the patient to visit the nearest Primary Health Centre (PHC). Once tested and confirmed, the ASHA will pay fortnightly/monthly visits to check the patient’s symptoms and to take him/her to the PHC if needed. Follow-up check-ups are held in one, three, six, nine, 12, 15 and 18 months.A 2014 study showed that training ASHAs on managing kala-azar increased the referral rate from less than 10% to over 27%. If not for them, the symptoms are missed or ignored.Meena Devi (48) of Anandpur Kharauni in Muzaffarpur district has scaly patches on her upper arm, an early sign of PKDL. She visited Paro PHC, some 10 km away, when kala-azar manifested with a fever. She did not visit the PHC immediately during the second bout thinking that farm labour caused fever. Now, focusing on relatively painless marks from PKDL feels like a luxury for her.“Rural access to medical care and general awareness are different from that in urban areas. Commuting is a challenge. Health workers play an important role in ensuring that the patients reach the health centre,” said Dr Kavita Singh, Director-South Asia, Drugs for Neglected Diseases initiative (DNDi).Meena Devi sits on her charpai, pointing at the mosquito net above (Photo – Saumya Kalia)Fending off trust deficit, stigmaASHAs create awareness on kala-azar, its symptoms, the need to maintain cleanliness and use mosquito nets at baithaks (small gatherings) organised every month. “People did not understand hygiene or cleanliness earlier, but now they do. Everyone has become samajhdaar [sensible],” said Richa.The PKDL scars are non-fatal, but they evoke shame. Could that be the reason for Ashima’s disappearance? “Her face is the colour of sindoor and her body has black spots,” Richa murmured.Gender norms further exacerbate the situation. Families understand that daag (scar) and dhabba (patch on skin) may obstruct the marriage prospects of girls and augur abandonment of married women. Some families thus chose not to engage with ASHAs or report symptoms.Kala-azar can overlap with other conditions. For instance, HIV patients are at risk of developing it. Sometimes, PKDL scars are mistaken for leprosy in rural areas. Stigma takes on a life of its own, sustained by misinformation floated by local quacks who claim to offer ‘quick fixes.’ASHAs respond to such cultural anxieties and help people understand all aspects of PKDL, including disability and violence. Their role extends far beyond case detection and management as both diseases morph into social malaises.However, social support for women who face abandonment and violence remains a gap still. A 2018 study published in PLOS attributed the delay in PKDL treatments to a lack of knowledge and perceived stigma, which “interferes with the therapeutic outcome of the disease through its effects on treatment-seeking behaviour and drug compliance”. “ASHAs are the messengers. People will not know if ASHAs do not carry information to them,” said Shishu Kumari (38), an ASHA coordinator in Dariapur, from where kala-azar was eliminated in 2017. The custom saree of an ASHA worker in Dariyapur (Photo courtesy of DNDi)Neeta Kumari (32) joined the ASHA workforce in Gaighat block of Muzaffarpur district last year. “Darr lagta hai. Bahut darr lagta hai [It is scary, very scary]… My husband encourages me to work safely, but kaam toh karna hi hain [I have to do the work],” she said about her initial days at the job.In Baniapur of Saran district, an ASHA facilitator was diagnosed with kala-azar in 2018. But ASHAs like Kumari have overcome their fear, armed with the knowledge that kala-azar is not a communicable disease. Looking on the bright side, she added, “These are our people. I like to work with them and walk around my ward.”No incentivesThe nearest PHC for Richa is at least five km away and takes about Rs 100 both ways via auto. People often refuse to travel citing cash shortage. “We make sure we take them on the same day… Sometimes we pay from our pockets,” Richa said. The state government gives each house is an incentive of Rs 7,000 to report cases, and buy medicines and mosquito nets.ASHAs are volunteers with a fixed monthly wage (Rs 2,000 to 4,000 depending on the state) and receive incentives for case-specific tasks, including organising family planning meetings, advising on immunisation drives for newborns and taking pregnant women to hospitals.For every kala-azar or PKDL patient they bring to the hospital, they get only a one-time incentive of Rs 300-500 by the state, though they follow-up with patients for months, if not years. In some cases, these payments are delayed.Shishu has been awaiting her kala-azar incentive since 2017. Richa has not received the incentive for Ashima’s case yet. “We have tried raising the issue in meetings, but no one hears us,” said Richa, who earns only Rs 3,000 per month.An ASHA worker cycling to work in Dariyapur (Photo courtesy of DNDi)The lack of incentives is not an invisible deficit. Meena Devi says no ASHA visited her. “There is very little incentive for kala-azar and PKDL. ASHAs already look after a lot of people, and maternal and child care take priority,” says Prakash, who works at Chapra PHC. Public health is a leaking pipe, and ASHAs can plug only a few holes.Expensive drugs with side effectsGovernment-mandated VL drug regimes — Miltefosine and AmBisome (single liposomal Amphotericin B) — are administered for PKDL as a 12-week oral regimen. The national guidelines for treating PKDL recommend Miltefosine as a “preferred” first-line drug, and Amphotericin B for patients who have liver or kidney complications, or if they don’t respond to Miltefosine. The cost of the drugs (Miltefosine is Rs 2,500 to 5,000 depending on dosage and AmBisome costs Rs 75,000 to Rs one lakh per treatment with people usually needing 3-4 depending on weight profile) is a barrier to mass treatment. There are also concerns about efficacy and side effects — fever, nausea, eye complications and stomach pain. Stomach pain has forced PKDL patient Chanani Kumar* (17) of Anandpur in Bihta block of Patna district to skip medicine for the last six months, besides check-ups.Clinical trials by different organisations, including the DNDi, are progressing to develop a safe, affordable, accessible and sustainable treatment regime. But even as kala-azar demands tight surveillance, along the lines of COVID-19 drive, ASHAs operate from a blind spot. They go about their work much like the way stones are laid one on one, on a long road that may never be finished.Rita Mishra, an ASHA worker in Salha village (Photo courtesy of DNDi)The health card of Nandlal in Paro district (Photo – Saumya Kalia)The home of Meena Devi (Photo – Saumya Kalia)Meena Devi has already relapsed twice (Photo – Saumya Kalia)*Name changed to protect identityThis story was originally published under Rukhmabai InitiativesCover Photo - ASHA workers of Dariyapur village (Photo courtesy of DNDi)
Death and debt: The two shadows that never leave Jodhpur sandstone workers, families
Silicosis shortens the lives of mine workers, but families continue to push more members into the profession as they have to repay loans taken from mine owners for medical treatment Jodhpur, Rajasthan: A resident of Gandero ki Dhani near Jodhpur city, Dhalki Devi Kadela (60) spends her days gazing at the photographs of her late husband and son. In 2017, she lost her husband to silicosis, a disease caused by sandstone mining. Her son Ramesh (34) succumbed to the same illness last December. Now, another son Dungarram (36) has been diagnosed. He experiences shortness of breath on climbing just four stairs."Ramesh toiled in the mines for 13 years. We never thought he would leave us so soon. His son Manish is only eight. The weight of debt looms over us. I do not know how we will manage household expenses," Dhalki says tearfully.Jodhpur is home to 5,900 sandstone quarries across several villages, including Soorsagar, Fidusar, Balsamand, Mandore, Keru, Badli, Ghoda Ghati and Bhuri Beri. As highlighted in the research paper titled Jodhpur Sandstone: An Architectonic Heritage Stone from India, the stone with its characteristic reddish brown/maroon tint has been in use for over 1,500 years, which stands as a testament to its durability, timeless appeal and high demand.Quarrying and extraction of sandstone in and around Jodhpur have increased significantly, as indicated by Google Maps for the years 2008, 2013 and 2018, says the research paper. Due to the small size of quarries and their close proximity to each other, simultaneous mining operations lead to pervasive clouding of the entire area with dust. The workers inhale silica-laden dust all the time, which leads to silicosis, a debilitating condition that damages the lungs, causes respiratory distress and eventually death.(Left) Shanti Devi with her husband's picture (Right) Dhalki Devi with the photos of her husband and son (Photo - Dinesh Bothra, 101Reporters)Shanti Devi Kadela (61) of Gandero ki Dhani faces the same fate as Dhalki. Her husband Binjaram died of silicosis in 2013. Three of her daughters are now married, while sons, Sundar and Magaraj, work in the mines. Another son Bhanwarlal succumbed at the age of 35."We do not know if Bhanwarlal also had silicosis. The cause of his death could not be determined as medical facilities were not accessible due to the COVID-19 outbreak. The other two work in the mines as repaying money borrowed from the mine owner is a big challenge. I am well aware of the risks, but we do not have an option," laments Shanti.Ironically, there are no facilities to test or certify silicosis in the mining area. Workers have to travel 15 km to reach the Kamla Nehru Chest Hospital in Jodhpur city for even preliminary check-ups.There are only 35 houses at Bheel Basti in Sodhon ki Dhani village, but it has at least 25 ‘silicosis widows’. Sharing her story, Puppu Devi Bheel (45) says, "When my husband Pancharam died in 2016, I had no option but to work in the mines to raise our six children. Two of my daughters and one son are married now. We received the government aid upon my husband's death, but it was spent on marriages of my daughters."After the death of her husband from silicosis, Pappu Devi goes to the mine to work every day (Photo - Dinesh Bothra, 101Reporters)She adds that several residents of the colony died while working in the mines. “Many of them were not officially tested for silicosis, but we know all of them had difficulty in breathing," she reveals. Streamlining the systemIn his research paper titled Silicosis — An Ancient Disease: Providing Succour to Silicosis Victims, Lessons from Rajasthan Model, Prahlad K Sishodiya, a former director of the National Institute of Miners' Health (NIMH), Nagpur, says, “It was series of reports on detection of silicosis among sandstone mine and stone carving workers in Karauli, Dausa and Dhaulpur districts based on medical records of workers, by National Institute of Miners’ Health, Nagpur, under Ministry of Mines, which drew attention of the state government and media... The reports indicated high prevalence of silicosis varying from 38.4% to 78.5% in Karauli district among sandstone mine workers and 100% prevalence among [those] who worked for more than 20 years in stone mines.” The reports prompted the Rajasthan State Human Rights Commission (RSHRC) to take suo moto action, following which the government formulated the Rajasthan Policy on Pneumoconiosis including Silicosis Detection, Prevention, Control and Rehabilitation-2019, which made silicosis grant disbursement a flagship scheme. The Building and Other Construction Workers' Welfare Board and Mines Department also initiated relief programmes for silicosis patients and dependents.Before 2019, based on the NHRC recommendations, the state government made an ex-gratia payment of Rs 1 lakh to silicosis/asbestosis patients and Rs 3 lakh to the dependents of the deceased from the Rajasthan Environment Health Cess Fund. Starting 2019, ex-gratia to the patients/dependents are disbursed from the District Mineral Foundation Trust (DMFT) fund.In 2021-22, Jodhpur district managed to collect Rs 1,907.17 lakh under the DMFT fund. However, only Rs 222.57 lakh could be utilised to improve the conditions in mining areas in that fiscal. Shyam Kapri, a mining engineer in Jodhpur, acknowledges that a significant portion of the DMFT fund is allocated towards ex-gratia payments. "At times, additional funds have to be sourced from the state to pay ex-gratia. As a result, the allocation of funds for other priority sectors under the DMFT becomes less apparent and visible."According to the silicosis portal, 31,419 certified silicosis patients in Rajasthan have received ex-gratia, including 7,526 in Jodhpur district. However, 477 certified patients in the state, including 52 from Jodhpur, are yet to receive the payments. As for dependents, ex-gratia have been disbursed to 6,353 in the state, including 1,482 in the district.Conversations with mine workers and dependents throw light on how they resort to borrowing money from either the mine owner or moneylenders by using their movable and immovable property as collateral. “My husband's treatment lasted seven years, which forced me to turn to moneylenders. I still have Rs 80,000 to pay, but work at the mine earns me only Rs 250 a day. Both my sons attend government school, and I aspire to provide a good education so that they do not have to work in the mines," says Pushpa Kataria (36), who lost her husband Shrawan Kumar Kataria to silicosis last November.Explaining the procedures to get silicosis aid, State Nodal Officer for Silicosis Control Programme Ashok Jangid tells 101Reporters that the government launched a web portal in 2019 to ensure transparent disbursement of assistance. “After applying, the patient has to undergo primary check-up, screening and examination by the medical board. Once a patient gets silicosis certification, Rs 3 lakh will be provided as assistance. The dependents are eligible for Rs 2 lakh in case of a patient’s death,” he explains. Ghewar Bhati, an e-Mitra kiosk operator in Gandero ki Dhani, says the applicants have to register for financial aid using their Jan Aadhaar card. "The process of allotting the amount to a dependent starts as soon as the application is made, as the silicosis victim's death certificate would already be linked with Jan Aadhaar. Who is to blame?The Directorate of Mines and Geology estimates the number of mine workers in the state to be around 25 lakh. In Jodhpur district, nearly 12,000 quarry licences for sandstone mining have been issued, with 5,900 located close to Jodhpur city.Estimating the number of mine workers in the unorganised sector is a big challenge. “Four to five workers are employed in every quarry surrounding Jodhpur, which means at least 25,000 unorganised labourers. They mostly reside in temporary settlements near the mines as it offers convenient access to employment opportunities,” Rana Sengupta, the managing trustee of Mine Labour Protection Campaign Trust, tells 101Reporters.Dr MK Devarajan, a former member of the RSHRC, tells 101Reporters that the disease could have been contained to a great extent if the mine owners and government officials had implemented the provisions of the Mines Act, 1952, the Mines Rules, 1955, and Metalliferous Mines Regulations, 1961. “Knowingly or unknowingly, the government officials have abetted the criminal negligence of mine owners.”"The state government has issued leases to several small mines. For example, sandstone mines with 30 m x 60 m lease size function in Jodhpur district, while Makrana has marble mines of 15 m x 20 m. While this promotes equitable distribution of leases, it poses a herculean task for regulatory agencies such as the Directorate General of Mines Safety to enforce safety provisions effectively," says Devarajan, who had submitted the 2014 special report on silicosis.Devarajan thinks providing biometric identity cards with details of the mine workers’ employment record and medical history is of utmost importance. “Mandatory medical examinations at the time of employment and periodical follow-ups, as prescribed by the Mines Act and the Factories Act, should be extended to contract and casual labour in hazardous occupations."At present, the absence of employment records prevents most of the sandstone workers from filing for compensation before the labour courts. “Even if mandatory legal provisions are fully enforced on mine owners, it is unlikely that most workers, who often work as contract or casual labourers and move between mines for employment, will be able to seek compensation. Mine owners frequently resort to 'outsourcing' to evade legal liability," he points out. Undoubtedly, unorganised workers suffer as they do not have an alternative before them. As Bheel Basti-based Vimla Bheel (34), whose husband died two years ago, puts it, "No one willingly chooses this job, given the looming threat of death." Edited by Rekha PulinnoliCover photo - Vimla, the widow of a silicosis victim, devotes time to household chores apart from working at the mines (Photo - Dinesh Bothra, 101Reporters)
Lumpy Skin Disease returns as social, infrastructural factors dampen Uttarakhand’s vaccination drive
The issue of information not reaching marginalised communities, lack of roads in difficult terrains and official apathy during last year’s drive lead to a second wave of the viral infection Almora, Uttarakhand: "One of my cows has not stood up for the last 24 days. When the first one got sick, we could not separate it due to lack of space. Now both are sick, and we have no milk to consume. We are forced to buy powdered milk for my four-year-old grandson," says Kaushaliya Devi, a Dalit farmer from Dhudholi village in Almora. Kaushaliya’s cows are among the thousands infected with Lumpy Skin Disease (LSD) in the second wave of the viral infection to hit the state since last year. In a reply to a question in the Lok Sabha on February 7, Union Minister for Fisheries, Animal Husbandry and Dairying Parshottam Rupala said 921 cattle died in the state till then and 6,96,811 cattle received vaccine against the disease.Caused by Lumpy Skin Disease Virus (LSDV), the condition is characterised by fever, skin nodules, enlarged lymph nodes, skin oedema, and sometimes death. It can cause a temporary reduction in milk production, temporary or permanent sterility in bulls and damage to hides. The World Organisation for Animal Health categorises the LSD as a notifiable disease, which means it must be reported to an appropriate authority if suspected or confirmed."There are many animals that cannot get up and many that cannot sit down for days because their feet are swollen.... others have swollen udders or briskets. Some will develop nodules, while others will not," Dr Surbhi*, a government veterinary doctor in Champawat district, tells 101Reporters.The LSD has no antiviral treatment yet, so supportive care, which includes antibiotics and painkillers, is only possible. However, the cost of treatment has been burning holes in the pockets of dairy farmers. "When cows are ill, milk production drops. We dairy farmers have spent twice as much on treatment as we make from milk sales. We are completely dependent on farming and dairying, so it has been difficult,” says Bhuvan Purohit from Dhudholi.Purohit claims he did not even make enough money this year to buy feed for his cows. “We have had a rough time for the last couple of months. I have spent Rs 25,000 on my cows so far. Medicines are very expensive, and minerals and other supplements should also be given." Accessibility an issueThe Central government’s action plan has mentioned a vaccination target of 9,10,000 out of the total 18,52,123 cattle in Uttarakhand. According to Uttarakhand Livestock Development Board, 2,92,748 cattle have been vaccinated so far. While the action plan to control the spread and severity of the disease involves vaccination push, many villagers in Almora have claimed that lack of accessibility prevented them from benefitting from such drives."So far, a calf and cow of mine have died. Last time, the vaccination drives were held near places connected by roads. But my home is quite far away. I was aware that a vaccination drive would take place, but had no information on the dates," says Mohan Singh Adhikari, a dairy farmer in Dhudholi. The pradhan (village chief) coordinated the drive through a WhatsApp group. However, since all farmers, especially those from marginalised communities, may not have access to smartphones, the project did not succeed fully. Due to the presence of so many unvaccinated cattle, the risk of a fresh bout of infection was always there.Kaushaliya Devi's cow affected by LSD could not stand up for 24 days (Photo - Swati Thapa, 101Reporters)With new cases surfacing since March this year, the state animal husbandry department launched a doorstep vaccination drive using animal ambulances. On getting a request from helpline number 1962, a medical team would visit the village to vaccinate the animals. However, Purohit claims many families, including his one, could not make use of the facility due to a lack of road connectivity. "No one came to our village. We contacted the authorities, but they said they were understaffed. This is a large area. As many as 116 villages constitute the development block of Dwarahat, but there were not enough people to serve everyone," he adds. In several villages, the Dalit hamlets are located far away from the village epicentre, due to which information also escapes them. To this effect, Dalit dairy farmer Prema Devi mentions how she never got to know about the vaccination drive as her house is in the village outskirts."The ambulance service came once when I called them. But the second time, the staff concerned told me that they would come tomorrow as it was raining then. But they have not reached out so far," says Adhikari.In many families, male members migrate for work. Hence, the burden of duties weighs heavily on women. As such, in Uttarakhand, women are mostly the caretakers of cattle. During last year’s drive, many could not get their animals vaccinated due to daily domestic chores. They mostly do not have access to smartphones either. Under-reporting of deaths"A majority of bovines have not been vaccinated. The number is huge and we did ask them [the animal husbandry department] to provide preventive vaccination to the healthy ones right now. However, the doctor said it will be done after the cases and spread came down. I do not know when that will be. I feel vaccination will not happen," says Adhikari. The LSD deaths have also been under-reported due to lack of a proper documentation system. "We are not told to follow any procedure to report cattle death. So, all we do is bury them in the soil. There is no reporting of any kind. At least 15 cattle deaths would have taken place in this village alone, so definitely the death toll would be much higher in Almora district," he avers. An email sent to the animal husbandry department on whether they have raised awareness on how to deal with animal deaths did not elicit a reply. Many farmers are hesitant to mention the actual cause of death, fearing they would not receive the insurance money. The state government is not providing any separate compensation for LSD deaths, but it is covered under its Livestock Insurance Scheme. Yet, farmers are not keen on applying as red tape deters them. Moreover, a postmortem report from a doctor is required for applying. *Name changed to protect identityEdited by Rekha PulinnoliCover photo - Lumpy Skin Disease is characterised by fever, skin nodules, enlarged lymph nodes, skin oedema, and sometimes death (Photo - Swati Thapa, 101Reporters)
No care, no medicines: Koiripur PHC reroutes patients to private facilities
With ceilings that may collapse at any time, admitting patients is a strict no; even pills that are given free of cost at PHCs have to be bought from outside pharmacies Sultanpur, Uttar Pradesh: “He won the election and disappeared. We never saw him in our village, leave alone doing something for our betterment.” A resident of Koiripur nagar panchayat in Sultanpur district of Uttar Pradesh, Rauchi Devi (42) did not mince words when narrating the tale of neglect that haunted a local primary health centre (PHC). Her anger was directed against former nagar panchayat chairman Sudhir Sahu, whose tenure ended recently. Rauchi’s daughter-in-law Zriya Devi (19) recently faced a pregnancy-related complication, and lack of facilities at the PHC exacerbated the ordeal. She had to be rushed to the community health centre (CHC) in Chanda, located eight km away. Though Zriya delivered a baby boy there, further issues made them visit a private hospital. “The doctors in the CHC said the newborn had water in the belly. The CHC was not equipped to treat the condition, so we had no choice but to rely on a private hospital in Chanda,” said Rauchi, whose husband and son work as labourers.Entrance to the Primary Health Centre which serves the Koiripur Nagar Panchayat (Photo - Bilal Khan, 101Reporters) A poll plankAccording to the 2011 Census, Koiripur nagar panchayat has a population of 8,927. Sahu, who once again stood for the chairman’s post in the election held on May 10 and 11, said the electoral rolls had 7,800 voters this time. His contender and newly elected chairman Kasim Raeen told 101Reporters that the majority of the population in Koiripur town lived below the poverty line. “They are the ones who have been suffering badly due to the poor state of affairs at the PHC for over a decade now,” he said.No wonder why the issue played out during the nagar panchayat polls this time. “We were all fed up with the PHC issue. Since we realised that Sahu will not do anything, we ditched him. What is the point in giving vote to a person who does not care for the people,” Rauchi asked. Ideally, a PHC should have one MBBS doctor, two to three female staff to treat women, especially those pregnant, hospital beds, facilities for basic check-up and an out-patient department. As per the Indian Public Health Standards (IPHS) guidelines, a PHC caters to a population of 20,000 in hilly, tribal or difficult areas and 30,000 in plain areas. One MBBS medical officer and six indoor/observation beds are required. It acts as a referral unit to the CHC for six sub-centres also. In Koiripur, however, the PHC building is so shabby that doctors are scared of working there. Portions of the ceiling may come off any time. “We have medicines for basic issues, say cold, cough and wounds. Equipment for medical check-ups are not available,” Dr Sunil Kumar, the medical officer at the facility since September 2022, told 101Reporters.Crumbling ceilings, broken windows, lack of drinking water, dysfunctional toilets and missing medical equipment are some of the issues plaguing Koiripur PHC (Photos - Bilal Khan, 101Reporters)The PHC has a large room with a few beds to admit patients, but there is no facility for treatment. “Even if things were in place, no patient would be admitted here because of the ramshackle building. Parts of the ceiling fall off quite often,” added Dr Kumar, a Bahraich native.He claimed lack of amenities affected the doctors equally and that he had written to the competent authorities about the issues. “There is no drinking water facility. We buy it on our own. The toilet is in such a bad condition that we cannot use it.” Along with Dr Kumar, a homeopathic doctor also works there. “Healthcare is a big issue here and people have been demanding that the PHC be equipped. But I do not think that was the reason for my defeat,” said Sahu, when asked whether he lost the election due to the poor condition of the PHC.Elaborating further, he said the PHC building was a private property with a monthly rent of Rs 1. Consequently, even the government could not do anything to improve its condition. It took me almost a year to make it a non-rental property and hand it over to the government.”Sahu informed that the health department was in the process of initiating repair works. “I have been in contact with the authorities concerned earlier. Though I am not the chairman now, I am from the Bharatiya Janata Party, which is in power in the state. I will continue to make efforts to make the PHC facilities better," he said.District Chief Medical Officer Dr DK Tripathi was aware of the condition of Koiripur PHC, but did not comment on the timeframe for repairs or the expenses involved. “The building needs reconstruction. We have asked the junior engineer concerned to make an estimate. I cannot say how long it will take to resolve the issue,” Tripathi said. Meanwhile, Sahu estimated that around Rs 1 crore would be required to repair and equip the PHC with necessary medical facilities. Few and far At present, people of Koiripur have no choice but to visit Chanda CHC for medical care. Many try to avoid treatment as expenses are high. Mithailal has been facing respiratory issues for the last three years, but has visited the CHC only twice. Neither did he think about getting a better treatment elsewhere as he could not afford the medical expenses. “The doctor at the CHC suggested medicines for 10 days. It should be given free of cost to the patients, but there was no stock. When I went to a private pharmacy, I found the medicine would cost Rs 3,000 for 10 days. It was not at all affordable. So, I ended up consulting a local doctor (quack), who suggested a medicine costing Rs 500 to 700 a month,” he said. Mithailal does not breathe normally and cannot stand for 10 to 15 minutes as his legs shake. “I have not been working for the last three years. My sons are in their early twenties; they do earn a little through construction labour. Both could study only up to class 8,” he lamented. (Above) Saroj Kumari has been unable to get her son Tirbahavan Kumar the required medicines for his respiratory condition because their local Community Health Centre doesn't stock them; (below) Mithailal resorted to medicines given to him by a local quack after finding that he couldn't afford them at the private pharmacy (Photos - Bilal Khan, 101Reporters)Saroj Kumari did not follow the treatment suggested by the doctor at the CHC when she learnt that the medicine would cost Rs 700 a week. “My son had mucus build-up in throat. The PHC doctor referred us to the CHC, where medicines were not available at the pharmacy. Since I did not have Rs 700 to buy medicine from outside, we avoided treatment.”“We are seven members in the family and there is only one breadwinner,” added Saroj, whose son Tirbahavan Kumar (21) seemed weak and malnourished.If private pharmacies are not affordable, how can private hospitals be? Rauchi claimed her grandson was admitted in the private hospital in Chanda for three days, and the bill came to Rs 16,000. “For us, having this much money at once is a luxury in itself. What my husband and son earn is barely sufficient to put food on the table for all seven in our family. We had no option but to borrow money. We do not know when we will repay it,” exclaimed Rauchi. Asked why they did not visit the district hospital in Sultanpur, she said it was 40 km away and would involve similar expenses. “Admitting the baby in the district hospital means we have to arrange accommodation for three to four days. We also have to buy food thrice a day. We have children at home too.” Pinning hopes on the new chairman Raeen, Rauchi said, “We have high expectations from him. He was once in that post and he did a lot for us.” Meanwhile, Raeen said he had raised the PHC issue during the poll campaign. “Now that people have elected me, my foremost priority will be to get the PHC fully functional. I will talk to the authorities concerned and request them to expedite the process.” Edited by Rekha PulinnoliCover photo - Dr Sunil Kumar, the medical officer at the Koiripur PHC, hands over medicines to a patient (Photo - Bilal Khan, 101Reporters)
Mine contractors throw caution to wind, make villagers of rural Bhopal gasp for every breath
Lung diseases, allergies, eye and skin infections and anaemia are quite common, but no strict action has been taken against mine operators for flouting normsBhopal, Madhya Pradesh: “A strange sound comes out whenever I breathe,” says Kulwant Bai (40) of Acharpura village, located about 20 km from Bhopal.“I always have a sore throat. The local doctor could not help much. Therefore, I visited the Government Community Health Centre (CHC) in Bhopal’s Gandhinagar. The doctor told me I had throat and lung infection, and advised me to stay away from dusty environments, but I did not know how.” Kulwant and her family of four have been living in Acharpura for 26 years, where stone, ballast and murram mining is commonplace. A powdery film — a mixture of dust and other fine particles — covers the houses. Dust clouds hang around constantly. The farmlands look grey and dull from a distance itself. Nothing much grows here and whatever does is not good for consumption.Residents of many other areas of Bhopal — Neelbad-Ratibad, Balampur, Kolar Kajlikheda, Nipania Jat, Kurana, Chandpur, Nazirabad Gram Dhamantodi and Baroda — have similar stories to tell.Stone mining involves extraction of granite, limestone or marble from quarries or mines. Ballast, a type of gravel or crushed rock, is also extracted from some mines. On the other hand, the ground is excavated to extract murram, a mixture of soil and small stones.The air that killsSushila Bai (30) of Mastipura, located 10 minutes from Acharpura, understands what Kulwant is going through. “I came here after my marriage in October 2020. After a few months, I was expecting my first child… and all of us — my husband, mother-in-law, brother-in-law and sister-in-law — were happy. But one day, I fainted and was taken to the doctor, who told me I have anaemia. Pollution was cited as the reason.” “I used to wrap a cloth around the face, what else to do? The baby weighed less than normal at birth… and doctors said he had a lung condition as well. Anyway, he did not survive for more than a few days,” she cries bitterly.Long-term exposure to air pollution and fine particles (PM2.5 and PM10) increases the risk of anaemia, a 2022 study from the Indian Institute of Technology, Delhi, has found (Photos sourced by Sanavver Shafi, 101Reporters)Anaemia is prevalent in women in the area. “Exposure to particulate matter [PM2.5] for long periods can lead to oxidative stress, which impairs the circulation and absorption of iron in the body. Iron deficiency reduces the formation of haemoglobin in the body,” Dr Hansmukh Jain of Bhopal tells 101Reporters.Long-term exposure to air pollution and fine particles (PM2.5 and PM10) increases the risk of anaemia, a 2022 study from the Indian Institute of Technology, Delhi, has found.Other than pollution, the most obvious reason for anaemia is malnutrition. “Needless to say, if the mother is unhealthy, the child will also be. If we examine the National Family Health Survey (NFHS)-5, 53.5% of women (15 to 49 years) in Bhopal district are anaemic. About 68.5% of children under the age of five are anaemic, while 18% of the children aged under five are stunted and 19% are underweight,” cites Ravi Pathak, who works for Hidayat, a social organisation dealing with malnutrition in Bhopal rural.Meanwhile, a doctor at Gandhi Nagar CHC tells 101Reporters that four out of 10 people visiting the outpatient department suffer from lung and respiratory diseases. “Allergies and eye and skin infections are also going up. If the condition is serious, I refer the patient to Government Hamidia Hospital in Bhopal,” he says, on condition of anonymity.The villagers are susceptible to incurable diseases such as silicosis, an interstitial lung disease caused by inhaling of tiny silica particles found in rocks and soil. This causes permanent lung scarring over time. “However, they cannot afford to stop working in the mines because they do not receive pensions or other financial assistance,” Pathak says.Rules on holdThings could have been far better if the mines followed the guidelines related to air quality, says social worker and environment activist Rashid Noor Khan.As per the guidelines issued by the Madhya Pradesh Pollution Control Board (MPPCB), stone crushers should be covered with a tin sheet to prevent the dust from escaping. Labourers should be given “telescopic suits” for protection against dust and dirt. Additionally, water sprinklers to settle dust should be in place.But none of the mines, and definitely not the illegal ones, in Acharpura, Neelbad, Ratibad, Mastipura and Kaliyasot follow the rules, alleges Khan. “The worst part is there is no way to check pollution levels in these places. I believe the Air Quality Index may be at dangerous levels here,” he adds.Despite orders from four District Collectors in the past, the mine demarcation work to record and limit the area where operations are allowed has not been completed (Photos sourced by Sanavver Shafi, 101Reporters)MPPCB Regional Officer Brajesh Sharma tells 101Reporters that equipment to measure air quality is not located near the mining spots. “They are installed in the city, so we cannot measure the pollution from mines. However, we take speedy action whenever we get complaints. Acting on one such complaint, our team recently investigated and submitted a report regarding an illegal mine in Mastipura. Subsequently, the mine was shut,” he says.Khan, however, alleges that he has complained about air pollution in several places located near Bhopal to the PCB many times in the last three years, yet no action has followed. “And even if they do, it is often too late. In Mastipura, that was the case.”He also says that despite the orders from four district Collectors in the past, the mine demarcation work to record and limit the area where operations are allowed has not been completed.Acting on complaints, Nikunj Srivastava, the then district Collector, had first issued directions to demarcate all mines in 2013. In 2015, Nishant Warwade launched an investigation and gave instructions to make security arrangements to prevent illegal activities in mines. This stopped as soon as he was transferred. Dr Sudam Khade in 2018 and Avinash Lavania in 2023 gave instructions to fence the mines, but things remain the same. Lavania is no longer posted in Bhopal.“Demarcation would prevent illegal mining in areas where no permission has been given for excavation, while fencing will prevent accidents… There is a flurry of activity only when an unfortunate child drowns in an open mine pit. Otherwise, the administration hardly cares,” rues Khan.Mining beyond the legally allotted areas is quite common in Acharpura, Mastipura, Binapur, Khajuri and Ratatal. “Before issuing permission, the revenue officer of the mineral department and an official of the forest department will demarcate the area, but the contractors give it a pass. Action taken on our complaints is nominal,” says Jitendra Meena, a social worker from Mastipura.Refuting Meena’s allegations, Bhopal district Mineral Officer SS Baghel tells 101Reporters that the mineral department is quick to take action over complaints. “Recently, we got a complaint regarding a mine allotted to one Punit Jain in Mastipura. Our investigations revealed that Jain had mined from the area where he had no permission to operate. A case was registered in the Collector’s court and a fine of Rs 5 lakh was imposed.” “In 2022-2023, the department had filed 15 cases of illegal mining in Bhopal district and seized 17,379 cubic metres of minerals in all. In three cases, 18 cubic metres of sand and two tractors were seized. Also, 17,186 cubic meters of murram in seven cases and 134 cubic meters of boulder in five cases were impounded. Similarly, 41 cubic meters of soil and one dumper were seized in two cases. As many as 67 cases of illegal storage and 14 cases of illegal transportation have also been registered,” Baghel claims. In Bhopal division, the mineral department has allotted 140 stone quarries, 27 murram mines and one gravel mine each in Manpur-Gopalpur mines through e-tender. The department has earned a revenue of Rs 83.74 crore in the last five years, while Rs 17.13 crore was the revenue in 2021-22.Edited by Tanya ShrivastavaCover photo sourced by Sanavver Shafi, 101Reporters
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