'Migrants' and 'Medical Refugees': A short report
Item
- Title
- 'Migrants' and 'Medical Refugees': A short report
- Creator
- Anurag Bhargava
- Date
- 2009
- extracted text
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‘Migranls’and ’Medical Refugees’: A short report
draft for discussion
Anurag Bhargava.Jan Swasthya Sahyng. village and PO.Ganiyari.district Bilaspnr
‘What is the “catchment" area of your hospital?’ The well-meaning person from the funding agency
asked. 1 responded with our oft-quoted figure of people from over 1500 villages coming to us for
healthcare, including many from the adjoining parts of Madhya Pradesh. But what I did not tell him then
were the life experiences of some people from these villages, in an era where all aspects of rural life seem
to be in a crisis. As the harvest season of the single rain-fed crop draws to a close and no other
employment is in sight, an annual exodus begins, all loo visible at bus stops, railway platforms, and in the
general compartments of trains bound for Delhi, Punjab, Gujarat, Bihar, and U.P. The ‘migration’, which
according to some administrators the people of these parts are ‘habituated’ to, has begun. And as the
monsoons draw closer, the return journey home begins, for many, however, the work so far away is
interrupted by what is unexpected for the well to do, but always close at hand for the poor— illness; and
again more often for only the poor—a serious illness.
A person blinded while making India Shine
This is one patient that I am unlikely to forget, even hardened as I am by the exposure, day after day, to
a level of deprivation and misery that has parallels only in the mid-nineteenth century descriptions of
Dickens’ England. The OPD was closing as a man came in carrying in his arms one of the thinnest
women I have ever seen, and lay her down on the bed. They had come straight from Delhi, he said—-from
Gurgaon, one of the symbols of India Shining, where they lived on the construction site of a shopping
complex. Geeta had become unwell only two weeks earlier, when she developed a boil around the nose.
Within a span of 2-3 days this spread to involve both the eyes, which became swollen, and then later to
the right leg. In a matter of days she lost sight in both eyes. They had sought therapy from a local doctor,
and in the process spent their entire savings (about Rs. 3500), which had been accumulated over many
months of labor. I hey realized then that there was just enough money left to go back home. Geeta
weighed 22 kg at around 30 years of age, her right eye had been reduced to a mess, and the left eye was
opaque but recognizable. Her right leg had a large abscess. Given her state of nutrition, a simple bacterial
infection had spread extensively, causing so much damage. What was completely unsettling for us was
her composure as she lay, without a murmur of complaint, responding to any questions with a calm, “ I
am better”, in a situation which would have driven any other person insane. Geeta’s right eye had to be
enucleated at the Medical College Hospital in Bilaspnr.
The couple was from a village about 10 km away, and this had been their first experience as migrant
labourers. The husband later told us that she had been carrying loads of about 25 kg on her head till a few
days before her illness, that she had been earning Rs. 50 per day. Il had been difficult to get leave to get
her treated properly. Not that they knew where to go, anyway. . . .
Working for the Army, till the very end....
Ajit staggered into the OPD, in a disheveled state, gasping for breath, his face completely pale, his feet
swollen with edema, the neck veins engorged in a tell-tale sign of heart failure. 1 le had come back home
just a few days ago, and a lower respiratory infection had made matters worse. He had come from Chinta,
a town 150 km from Jammu, where he and his brother had been involved in constructing homes for the
army, earning Rs. 75 per day. I le had rheumatic heart disease (a form of heart disease that damages the
cardiac valves, and is especially common among the poor), and a hemoglobin of only 6 gni/100 ml, yet he
denied having any symptoms for a long time. It was inconceivable for me how he could have worked with
heart disease as well as anemia of that severity. There was a local hospital in his place of work, but that
was onl\ foi auny men. not lor the likes of Ajil. I le hail to come back home, nearly two
thousand km and many days ol travel away. lor treatment.
I le had to be relerred to the local Medical College lor admission in the IC’D. where he later
died
al the age of?. I years, leaving a young widow and a child behind.
.1 slory from Mahoroshtra which ended we//....
Meerabai worked at a construction site in Aundh (Pune), where she and her husband had
been going for the past three years, leaving their children in the care of grandparents. She
developed a cough and fever, lost weight, and spat out a small amount ol blood one day.
Alarmed, they went to a clinic in Aundh where an x-ray was taken and tuberculosis was
diagnosed. The very next day, she coaxed her husband to accompany her back home. I ler
sister had been treated by us for IB successfully, so she too came to us for treatment. 1 tried
to suggest that I could give her a letter of referral to the local Medical College. But she would
have none of it, and went back only after completing her course of anti-tubercular treatment.
. Ind one closer home whii h dido 'I
Shravan hails from a village It) km from our centre, but had been living and working for the
past six years in Satna (MP) with his father. fen months ago. he developed symptoms of
tuberculosis. Instead of going to quacks or private practitioners like many other people, he
visited the government hospital where he was diagnosed as having sputum smear-positive
tuberculosis. I lis could have been one of the success stories of the RN'.I CP. But they lacked a
ration card, and hence proof of local residence, so the district TB officer did not register him
under DOI S. (I was told by the DDG ( I B) Dr. L.S. Chauhan. when I narrated this case study
in a presentation, that the card was not really required). He was advised to go back to his
village in Bilaspur district and register at the nearest treatment centre. The same doctor,
however, had no problems in calling Shravan over to his private clinic and writing a
prescription which cost him Rs. I 800. Within the very first month, this exhausted all their
resources, and it was hardly surprising then that he discontinued the treatment, bought drugs
only once more for a few' weeks, and then did nothing... Six months later, when the disease
progressed, he finally came back to his village. Despite a few visits; the local Cl IC failed to
provide him with I B treatment. 1 le then came to us. every inch ol his lungs affected with the
disease. I le was started on treatment, but a few weeks later he did not turn up on the
appointed date. Our field coordinator made a home visit, during which his father related
tearfully that Shravan had become very depressed, left home without notice one day, and was
still missing.
This is the zero sum game being played out in the lives of thousands of poor ‘migrants’.
Chhattisgarhi men and women often go to work in brick kilns which arc predominantly rural
or peri-urban in location. I hey get paid about Rs. 150 for preparing 1000 bricks, and live
largely confined to these kilns. They get some payment up front which goes towards settling
previous debts. For much of the duration of their stay they receive a subsistence dole for
buying food, and then a lump-sum payment of dues at the end in which many get cheated.
Life at construction sites is no better. One of our patients went to Delhi when his brother died
from a fall while working for a construction company. The compensation to the family was a
mere Rs. 1000. Who would have registered a case against the company', and what could this
man have done? I Ic had no alternative but to return with his brother’s widow.
Issues such as children's education come second to the issue of survival. Another generation
is destined, then, to live in poverty, but will perhaps wage its own struggles when the time
comes.
These migrant workers arc involved in the enterprise of‘Bharat Nirman’. but are truly
stateless individuals, absent from their states of origin and not recognized officially by their
stales of temporary residence. I he notion of citizenship and its entitlements, especially for the
poor, is confined to whatever social services a BPI. card can confer—be it lower cost food,
healthcare, or even a house or toilet. . But what of the poor Chhattisgarhi who is fortunate
enough to have a BPI, card, but works in Delhi? I Ic cannot access lower-cost food but will
buy rice at what will seem to him an astronomical price in the local market. We have
discovered that for many, the possibility of getting this magically enabling card disappears
due to the migration itself. It has been lite experience of a large number of people that when
the last poverty survey was conducted, they were away in another state.
If accessing food is a problem, accessing healthcare is even more difficult. I feci that there is
nothing more miserable in this world than to be poor and ill—and realize that to ‘purchase’
healthcare and thereby buy back your ’health' is beyond your reach. And what if you are poor
and ill and away from home? Your knowledge of the local area is often scanty. The Bl’I, card,
which can provide access to healthcare at public health facilities, again has a limited statewide
currency. People invariably go to quacks or private doctors, and lose a large portion of their
resources by spending on irrational therapy. They are unable to access or negotiate their
healthcare needs in the alien and forbidding environments of the local medical colleges, and
they arc hardly the sluff‘medical tourists' are made of. Rather, they arc ‘medical refugees'
who often head back home in desperation, although eventually even that may not assure
proper healthcare.
Migrants are not only not anybody's concern, they are often unpopular in public health terms.
They push down public health indicators and arc often seen as one of the pools and vectors of
many communicable diseases. Delhi has apparently failed to eradicate leprosy because many
of the patients arc ‘migrants’ from other states. When there was an outbreak of falciparum
malaria in Vellore a decade ago involving predominantly migrant workers, the contractors
sent the affected workers back with unseemly hurry. The linkage in the public mind between
migrants and HIV disease is now common, even if HIV is now an indigenous infection all
over India. When the RN'I'CP programme in Bangalore showed default rates of 24% and
40% in a cohort of new and retreatmenl patients respectively, it was later discovered that
these were largely poor migrants working in Bangalore who had gone back to their villages
after developing the disease. This is a logical course of action for the patient but anathema for
the programme, which could have anticipated this turn of events and arranged for a transfer of
treating centres. In all these scenarios, a convenient label is stuck on people, and victims
become villains...
1 may have digressed from the theme of this meeting, which is the issue of forced
displacement and health. Can these people be classified as ‘internally displaced persons'? If
one’s migration is driven by hunger, is it voluntary? Can we not describe them as ‘forced
migrants’ if a daily wage of Rs. 25 rupees and uncertain employment at home has forced the
move ? There arc people who are affected by ‘development induced displacement', but what
about those affected by a ‘lack of development induced displacement"? Are victims of
structural violence really different from those of ethnic or communal violence? Do they not
suffer a destruction of their present and their future, their way of life, and their dignity? Arc
discussions of migrants’ health not ultimately a matter of semantics, because in the final
analysis it is only the poor who are invariably involved?
To some these case studies may seem as depicting extreme situations, but to many these
would be situations they can relate to. Even people who are otherwise settled in a rural area
have no assurance in terms of access to healthcare. Their numerous attempts to seek a solution
to their problems - with the village quack, the private doctor, the public health system in the
rural areas, and ultimately, with our medical colleges, or even AllMS (while squatting on the
pavements outside them) are the actions of ‘medical refugees'. I he neat boundaries of stales
on our country’s map mean little to those whose lives do not follow a neat pattern, and whose
movements across boundaries do not register on the maps ol our healthcare system and public
health programmes.
Acknowlegements: Many thanks to Yogesh .lain, for numerous discussions on such issues.
My thanks also to my fellow ’voluntary migrants' in Chhattisgarh my wife Madhavi, and my
friends: Madhuri and Biswaroop Chatterjee. Rachna .lain, Anju and Raman Kataria . Ramani
Atkuri and Ravi D’souza. 1 have merely reported what has been our common experience.
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