Can Trains-turned-hospitals Cure Rural India's Health Care Woes?

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Apr 1, 2010, 11:54:26 PM4/1/10
to SAFE - Social Action Foundation for Equity
Can Trains-turned-hospitals Cure Rural India's Health Care Woes?
http://online.wsj.com/article/SB127009776884170663.html?mod=WSJ_latestheadlines

INDIA NEWSAPRIL 1, 2010, 1:04 A.M. ET

Grateful patients bearing small bags of fruit and vegetables are
common along the railway platforms where Lifeline Express -- the
world's first hospital on rails -- halts for three-week camps across
rural India. So when a distraught parent dropped a bundle into Zelma
Lazarus's lap at one of the stations and begged her to help his son
who had lost his arms in a threshing machine accident, the CEO of
Impact India, the foundation that created Lifeline, took it in stride
-- until she opened the bag and found the severed limbs.

"The rural poor often slip through the gaps in the public health
system," Lazarus says. "Lifeline Express is like a magic train to
them, and they expect us to perform miracles." In this particular
case, the "magic train" couldn't help, but Impact India could: The
foundation brought the boy to Mumbai, where he was fitted with a pair
of artificial limbs.

The mission of Lifeline Express is to vanquish avoidable blindness,
deafness and physical handicaps. After 19 years and nearly 600,000
surgeries, the train and its 100,000 volunteers have not even
scratched the surface of disability in India. Impact India's chairman,
A. H. Tobaccowala, estimates that the train has reached less than 10%
of the population in need of medical attention.

When the Impact Foundation was set up in 1981 by Sir John Wilson -- a
prominent British supporter of the disabled who himself was blinded in
a laboratory accident at school -- three United Nations agencies threw
their weight behind the organization, with the understanding that it
would be run as a public-private partnership. Accordingly, Impact
India was founded in 1983 with managerial and technical support from
the Tata Group conglomerate. Tobaccowala and Lazarus, who were
respectively chairman and general manager of corporate affairs at a
Tata Group company called Voltas, were seconded to the new foundation
and have been there since.

Making Tracks

Impact India initially focused on immunization and prevention of
diseases such as polio and malaria. In 1989, it started "Cure on
Wheels," a van that traveled around the hinterland, dispensing medical
and surgical treatment to people beyond the reach of the state-funded
basic health service. But the care the van was able to provide was
still too little and, often, too late. Impact wanted to extend medical
services to larger numbers of people in even more remote parts of the
country. The challenge, however, was that sterile facilities for the
surgeries and post-operating recovery were needed, while procedures
had to be consistently replicable across the country. This was clearly
a task beyond what a van could do. So Impact turned to India's railway
system -- all 109,000 kilometers (68,000 miles) of it.

Three old, wooden carriages were donated by Indian Railways and
renovated to the foundation's specifications. An air-conditioned
operating theater with three adjustable tables, a diagnostic center, a
sterilization chamber and a post-operative recovery room were
installed in one carriage. The other two contained the living
quarters, pantry, office and pathology lab. Funding for the overhaul
came from international charities, such as the Ford Foundation, USAID
and Impact UK. On July 16, 1991, Lifeline Express rolled away from
Mumbai to Khalari in Bihar state, then the smallest railway station in
India.

The present Lifeline Express has five customized carriages that were
unveiled in 2007. Indian Railways once again provided the carriages,
and Impact UK funded their overhaul. The new train has state-of-the-
art facilities, including an auditorium, public announcement system
and closed-circuit cameras. There is also a second, self-contained,
two-table operating theater, which can be detached from the rest of
the train and function as a standalone unit in the event of a
disaster.

The train may be new, but the procedures have remained much the same
since the early days. Lasting three to four weeks, each project serves
nearly 5,000 people and relies on community participation. At every
stop, local villages and non-governmental organizations offer various
assistance, from food and laundry services to crowd control (polite
patients waiting in line and disorderly mobs are equally common) to
finding accommodations for post-operative patients and family who
accompany them.

The train has only a few permanent staffers, such as the cook, a
technician in charge of maintaining the pathology lab and computers,
an operating theater assistant and a driver. All medical specialists
-- surgeons, doctors, nurses, anesthetists -- are volunteers,
providing the equivalent of US$80,000 of donated time for every
project. At any given moment, a 20-person medical team is on the
train, working 15 hours a day.

Remote Control

Each project costs the foundation about $65,000. Typically, the
sponsor -- generally companies such as Tata and Mahindra & Mahindra or
state governments -- decides the location of the camp. Impact India's
only condition is that it must be in a suitably remote location.
Project work starts a month before the train reaches the station. The
Lifeline team liaises with the district administration to make sure
all the red tape -- permits and so forth -- and publicity are dealt
with before the train arrives. Town criers, flyers, clowns on stilts
and poster-draped elephants spread the news about the train and urge
people to register at the nearest community welfare center or primary
health center. Once selected, patients are called to a local school or
marriage hall, which serves as a makeshift waiting room.

The train treats "avoidable disabilities," which means the focus is on
ear and eye ailments, as well as orthopedic and facial handicaps, such
as illnesses caused by polio and cleft palates. Typically, each
specialty is run as a week-long camp. Other ailments are also
examined. Last year, a British clinic sponsored a dental unit on the
train and volunteered its services. Neurosurgeons have begun treating
epilepsy, while counseling superstitious, often illiterate villagers
about why the afflicted are not cursed or possessed by evil spirits.

Perhaps the greatest advantage Lifeline Express has over other health
services for the poor is its ability to reach "the doorstep of the
patient," says G. Chandrasekhar, medical director of K.B.H. Bachooali
Charitable Ophthalmic & ENT Hospital in Mumbai. "My hospital also
performs free surgeries, but patients have to reach here. Lifeline
Express takes me to the patient." Chandrasekhar has volunteered as an
ophthalmic surgeon for the train in 2005 and 2007, and says he's
waiting to be called again.

Three Lifeline Express trains now operate in China and Zimbabwe, while
hospital river boats based on the India model have been set up to tend
to patients in Bangladesh and Cambodia. Lifeline has inspired other
projects in India, too. In 2007, the government launched Red Ribbon
Express to increase awareness of HIV and AIDS, and Science Express to
promote science among students.

Tobaccowala may regret the large numbers that remain untreated, but
there is a consolation: The country's government wouldn't have reached
even a small fraction of the people helped by Lifeline Express.
India's public health system is dangerously overstretched and large
parts of the country have limited or no access to basic medical care.
Government spending on health, at 3% of total its budget, is among the
lowest in the world. There is one doctor to every 870 people.

A recent government report notes that the low number of trained
medical professionals in India has led to a shortage of one million
nurses, 600,000 doctors and 200,000 oral surgeons. The scarcity is
especially pronounced in rural areas. "Many of the people we treat
have never been to a doctor before," Lazarus says. "People are so
desperate for medical treatment they lie on the tracks to stop the
train from leaving."

Seeking Sustainability

Despite all this, Lazarus says she wishes that the train would become
defunct. Why? "The train arrives at the platform, treats as many
people as it can and then leaves. It is not a sustainable solution for
these people's health care needs. Once that is attained, there will be
no need for a Lifeline Express." To address health care needs over the
longer term, Impact India started an initiative in 2005 in Maharashtra
state. The grassroots program aims to reduce disability by improving
community health and neonatal and maternal care by focusing on
malnutrition, sanitation, hygiene and family planning. To get the
message across, mobile clinics are equipped with LCD screens showing
film clips about health-related issues, while a local art form called
Warli painting is used on posters, clothing, walls and even water pots
to spread the word.

"Hospitals are already overworked treating patients. They can't focus
on prevention and awareness," says G.V. Rao, country director of Orbis
India, a blindness-prevention nonprofit. "That can be done by trains
and planes to draw attention to these preventable and easily treated
ailments." Orbis's Flying Eye Hospital travels the world with
volunteer surgeons, who treat patients and train local specialists in
eye care. In India, Rao says, Orbis has screened more than 3.5 million
children over the past eight years, treated nearly 600,000 people and
performed more than 60,000 surgeries. "Policy-level changes are
needed," Rao says. "Children should be screened for basic health
issues during school enrollment. Diet and nutrition issues should also
be tackled at the primary level."

For India's rural poor, prevention is essential because the chance for
a cure may never arrive. More than budgetary support, it requires an
approach to rural health care emphasizing nutrition and immunization.
Until that happens, there will always be offerings of fruit and
flowers for the doctors on board Lifeline Express.

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