Jai Bhim, Kajubai!

Aashish and I recently visited SEARCH at Gadchiroli. There we met Kajubai, who showed us how healthcare can be democratised. We wrote a small article about her, which was published by scroll.in. I am posting the original here.

Democratizing health, one hand-wash at a time

When it was time to leave, we said namaste to Kajubai. She returned the greeting without much emotion. We then asked her, “aap kya bolte hain?” (how do you greet one another?). To this, she enthusiastically replied, “Jai Bhim!”

Kajubai turned 64 this 1st July. She remembers her age well, which is rare for older people in rural India. For the last 21 years, Kajubai Undirwade has been successfully saving babies from suffocation, bacterial infections and fevers. As some girls walked by her house, she proudly pointed out the one she resuscitated just after her birth. This girl is eighteen years old now.

Kajubai is not a doctor or a nurse. She did not even complete eight years of schooling. But in 1994, she trained to be an Arogyadoot (Health Ambassador) with the Society for Education, Action and Research in Community Health (SEARCH), a pioneering rural health organisation set up in 1986 in Gadchiroli.

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The basic features of SEARCH’s Home Based New-born Care (HBNC) model are well known and have been widely reported, in both scientific journals and popular media. SEARCH’s interventions helped bring the Infant Mortality Rate down from 76 deaths of babies aged less than one year per 1,000 live births in 1993-95 to 31 deaths per 1,000 live births in 2001-03. In control areas, this IMR remained essentially unchanged: IMR was 77.1 infant deaths per 1,000 live births in 1993-95, and 75.8 in 2001-03 in control areas where Arogyadoots were not functioning. After the publication of these results, SEARCH’s Arogyadoots transitioned from a research to a service orientation, continuing to bring child mortality down.

Arogyadoots are trained to provide care for low birth-weight babies, babies with birth asphyxia and those with infectious diseases such as sepsis and pneumonia. According to the Million Deaths Study conducted by the Registrar General of India, these four causes together account for 78% of total neonatal mortality or the deaths of infants younger than 1 month. It is in the neonatal period that babies are the weakest, and most vulnerable to diseases and death. Often, these conditions occur together.

Using her simple and localised medical kit, Kajubai showed us how to detect these conditions and what to do about them. As soon as a baby is born, she checks if the baby is crying, breathing, and not gasping. If any of this doesn’t happen, she starts what the World Health Organisation calls bag-and-mask ventilation, after clearing the airways in the baby’s mouth, ears and nostrils. She makes sure that, following WHO guidelines, she starts this process within the first minute of the birth. Until she can see that the baby is breathing without difficulty, Kajubai continues to ventilate.

Kajubai took us to Laksh’s house, who was born on 1st June in a nearby sub-centre. After saying hello to the mother, she proceeded to wash her hands after removing her bangles. Every time she is seeing a baby, Kajubai removes her bangles, washes her hands thoroughly, and then holds them out, so as to air-dry them completely. She joked that if she is ever seen without her bangles on the village road, people ask her, “Who just delivered?”

“Information asymmetry” is the polite term used by economists to describe massive hierarchies in knowledge between providers and recipients that characterise fields such as medicine and law. These inequalities of information, along with an unresponsive health system in a society riddled with hierarchies of gender, caste, wealth, age and education present particularly insurmountable challenges for improvements in well-being in India.

Because of her demonstrations over and over again, and quiet insistence on following guidelines, the logic behind these simple methods has percolated into wider village consciousness. By following the exact same set of procedures for all babies in the village, Kajubai is also able to keep other forces of inequality, such as those of gender and caste, at bay.

For all babies, Kajubai has simple and easy to understand recommendations: wrapping the baby in a warm cloth, keeping it warm by giving the baby body heat through their parents’ bodies, adequate and exclusive breastfeeding, and avoiding infections by washing hands and maintaining hygienic conditions. These help improve health and survival of all babies, but are especially useful for babies who are born before the completion of 38 weeks of pregnancy, and those with birthweights less than 2.5 kilograms at birth. These are both common occurrences in India.

Another intervention that Kajubai excels at is giving Vitamin K injections to the babies in her village within the first hour of their birth. Her track-record with these inoculations, as well as of all the other Arogyadoots, is flawless. So much so that a new doctor in a nearby health centre brought his own daughter to Kajubai, just to make sure that everything was done as it should be done.

In all this, Arogyadoots like Kajubai and SEARCH have demystified a jargon-ridden profession while also using medical advances to save local lives. Kajubai’s skills and her explanations are remarkable, but even more remarkable is the way Arogyadoots have democratised the technical field of medicine.

In these interventions, and as a Dalit woman, Kajubai understood the importance of Dr. B.R. Ambedkar’s words to the Constituent Assembly: “On the 26th of January 1950, we are going to enter into a life of contradictions. In politics we will have equality and in social and economic life we will have inequality.” In her life and her work, Kajubai continues to defy precisely these disparities.

Jai Bhim to her!