When I first heard the words ‘rural bond’ I had unfairly attributed to it a certain amount of negativity. This was much before I had met any of my seniors too be influenced by their ideas and I was far too young and immature to have personal notions about it. I guess I always associated the word bond to depressing things like bonded labor or it was possibly because I was holding a somber official looking document in my hand that had all sorts of legal jargon and said something about a few lakhs ,while waiting outside the Director’s office. That was frankly the first time I entertained thoughts about the rural bond wondering why there was such a big deal about something that was 5 or 6 years away.
I will not proceed to recount my experiences as a student with reference to community medicine as that would be a book in itself but will mention the few defining moments that influenced my decision to pursue the rural bond.
I guess the climate at Johns was a little odd while I was studying (probably a reflection of the turmoil between two polar philosophies) and I was thoroughly confused as to what I had to ‘do with my life’ by the time I was in internship. I had received much contradictory advice from faculty, seniors, well and not so well wishers about the decisions I had to make regarding the bond and studying for entrance exams.
[In general DON’T DO THE BOND! The oh lord if you do- piece of advice-‘ chill’ centre-entails few working hours, weekends off for coaching, no Obstetric work, no night calls and those other irritating things that doctors are sometimes called to do and more along those lines, with a personal recommendation to the nun at the ‘chill’ centre bestowed upon you and much talk about ‘settling’ soon]
Now there are some who know for certain and plan their lives according to what they want to do, where they want to do it, how much they would like to earn, when they want to get hitched, have kids, and where they would like their retirement home to be etc. I am not one of those persons so decisions other than when my next drink would be, were quite hard to make at that time.
If I use general altruistic terms and talk about rural healthcare and the ‘far flung rustic lands’ where ‘need is most’ etc. and quote them as reasons for having decided to do the rural bond It would defeat the purpose of me writing this . I write to express my personal opinions and share a few experiences that I feel were unique to my rural work. These are my thoughts and by no means an expression of any other bonder/non bonder/johnites views. I also do not pretend to stand on a pretentious moral higher ground by employing general ‘philanthropic’ terms. I would just like people to read it without judging and try to understand me and my ideas a little better. So-NO OFFENCE!
I had the good kismet of meeting Dr.Ravi Narayan –SOCHARA who told me about ‘Tribal Health Initiative’(henceforth referred to as THI)- the hospital where his son Lalit (batch 02) did his rural bond and put me in touch with Dr.Seshadri( who was then in General Surgery at St.Johns) who had volunteered there for 6 months.
I was quite sure that I did not envision myself working under a schizoaffective nun who orders you to overprescribe and admit patients unnecessarily and serve you dollops of judgement for breakfast due to your agnostic leanings.
My interest piqued ,I did a little research and decided to visit THI along with a friend the following week and met with Dr.Regi whose post would be difficult to describe (if you could find a term for anaesthetist ,surgeon, sonologist, managing trustee, organic farmer , voluntary wildlife warden, ornithologist combined- that word would just about describe him). Little did I know that this was an informal interview. Regi is an affable man aged about 50, dressed in kadhi homespun who greeted me with a disarming smile and a reassuring handshake. What was supposed to be a brief meeting turned out to be a long conversation about healthcare, St.Johns, the history of THI , his experiences, metaphysics ,his Buddhist philosophies, the fall of the Ottoman empire and other such matters of great consequence .With both of us being gassers of the first order ,we got along famously. When we finally realized the time, it was 3:30 in the afternoon and poor Manu was probably cursing the day he agreed to come with me. After a tour around the place and a look at my future cottage, I was hooked.
A LITTLE HISTORY
THI was started by Dr.Regi George and his wife Dr.Lalitha in 1992 in the Sittilingi valley. The Sittilingi Valley is nestled between the Kalryan and the Sittheri hill ranges, surrounded completely by deciduous forest and comes under the Dharmapuri district of Tamil Nadu though the closest urban centre is Salem. At the time of its inception there was no electricity, pucca road or public transport to the hospital much of which has changed now.
This remarkable Doctor couple met and fancied each other while in Med School in Kerala and decided to take the plunge. Having been inspired by the life and works of Albert Schwietzer they always had a yearning to make a difference in an area of need. They worked a few years at the Kasturba hospital for the poor at the Gandhigram trust –Dindugal for a few years and then Regi went on to specialze in Anaesthesia and Lalitha in OB/GYN. In order to find out where their services would be needed the most they went on a road trip to many preselected areas all over India for over a year and decided to dedicate their services and build a hospital in the Sittilingi valley after extensive research .
At that point of time the Valley composed predominantly of tribal people and had one of the highest MMR and IMR in India with deaths due to preventable illness very common place.
What started at a single thatched roof hut in 1992 is now a 30 bedded hospital with 2 operating rooms , a well equipped lab ,nursery, endoscopy, pharmacy and other trappings of a self sufficient secondary hospital. There are also organic farming initiatives and tribal embroidery units that have been started to help augment incomes in lean periods of the year and also revive the dying designs of Lambadi embroidery.
THE REST OF THE TEAM
I also had the privilege of working with Ravi who after his MBBS volunteered at Sittilingi and then went on to do his Masters in Public Health from the London School of Tropical Medicine and Hygiene . Soon after he worked a few years at the Christian Hospital Bissamcuttack, Orissa in the community health program and the Department of Surgery where he realized his forte was Surgery and then went on to specialize in surgery. It was In Bissamcuttack that he met his lady love Prema who was in charge of the nursing school who then went on to finish her Msc Nursing from CMC Vellore and the rest is history with them joining THI in 2012.
The nurses are all local tribal women selected from the community for their diligence, intelligence and empathy and have been trained over the years by Lalitha. It was nearly impossible to get Nurses to work here so they managed to strike two birds with one stone. By generating local employment, training staff that the community already trusts, raising their standard of living and dissemination of health practices its actually more than two birds it’s almost a flock. They are currently the backbone of the hospital.
With Prema having joined there is now a nursing course in place and we train 8 students per year with plans for a Tribal College of Nursing on the table.
THI has seen quite a few of Johnites in the past-
Emily –batch of 2000
Lalit-Batch of 2002
Sheshadri-Pg Johnite –somewhere around there
Randall –Batch of 2005
Me ,myself and I -2006
Pravin- Batch of 2007
I will not share any personal ‘heroic’ stories or recount instances of medical bravado as every single doctor has loads of those to share, but I hope to share a few changes that I have seen in myself and a few observations that I have made during my two years of service hopefully without boring the readers to death or being too preachy.
From collecting reports and writing discharge summaries I was suddenly a few days later in an Out patient with two or three other doctors and close to 250 patients all of whom have to be seen before 5 pm (that’s the last bus out). Being called in-between for other emergencies and surgery if necessary has taught me how to multitask. During the first few weeks I oft wondered if I could ever cope with this breakneck pace and then I found myself learning how to prioritize and make best use of available time.
Language always seems to be a big barrier and my English or broken Kannda was of little help in Tamil heartland. With wonderful guides all around and plenty of teachers I picked up medical tamil quite soon and though my atrocious conversational tamil still brings tears to a few eyes (mirth and grief), I think Ive managed to glean a decent amount of Tamil. I was also very touched as during my whole two years not a single person be it a patient or their family, nurses or general public ever dismissed or ignored me for not knowing tamil nor was it an impediment to build relationships. The respect that tribals have for each other and which they accord to you when they identify with you are truly unique and flattering.
From studying in atmosphere where the hierarchy is so rigid to working for bosses who believe that you should do as much work you feel like. If for some reason, I have not written a discharge summary Regi would have no qualms to sit and write it, which was a foolproof way of ensuring that I never left things undone. The rest of the hospital, patients and me always referred to Regi as Gi and Lalitha as Tha, no sirs and ma’ms and your excellencies. It was hard the first two weeks as I would say Sir or Ma’m by default and would be gently reminded that its Gi or Tha and refrain from using officious titles. They also firmly believed that the work you do speaks for itself and there was no dress code, after observing my initial attire of pressed formals Regi told me that I would probably be more comfy in slacks and t- shirts. I also learnt that no work is beneath you – we started the day with 5 minutes of silent meditation followed by communal cleaning of the campus , some days cleaning of the toilets led by Lalitha and some days firing the incinerator by turn- everyone was expected to do these jobs. In patient care –starting an Iv , helping patients to the toilet or with a bed pan administering drugs if needed .You feel odd for not doing it when someone older and more senior than you does it with no misgivings and soon learn to love it.
Some days you would be woken up to problems like ‘Anna(term of endearment) the borewell motor isn’t working” or “Anna the Autoclave isnt running and today is Theater “. The hospital being partly solar, AC current and diesel generator hardly helped matters (The entire circuitry was designed by a group of students from IIT Chennai as a summer project so it was complicated as hell! )as we had to shift between each depending on the voltage and where the maximum use was at that time. Basic knowledge of the circuits and strong eardrums to withstand the ancient generators’ protests were necessary.
The campus being Gandhian the meals were frugal and intoxicants were really not encouraged though no one would stop you if you did really bring in something for the rare relaxing Sunday afternoon at the stream nearby. I realized that I didn’t really have that craving for hangovers and haze that I had pretty much drowned myself in while at Johns. The meals though basic were made with love and we had to eat under the watchful eyes of Big Mama(Davaminamma) who always knew exactly how many dosais you’ve eaten and would try to trick you into eating more by telling you she would put one more on your plate while holding five! The trick to enjoying every meal was to stay hungry, then everything tastes amazing …. And the occasional PPI.
Its easy to sit in an OPD and chide someone for not coming earlier or for delaying your lunch break but its only when you really see how far away people live that you truly empathize. By visiting villages on weekly visits for the ANCs and the under fives , sometimes on foot for miles beyond where the Jeep wouldn’t go I had a real insight into how far people really live and how poor the connectivity really was. Its also because of these observations that you appreciate the smaller things in life like electricity, running water, and a seat on an extremely crowded bus or a hot home cooked meal that are considered a luxury by some.
In my first week Regi had told me that there was one skill that I should master before I leave, I thought he would say something like Caesareans or hernias or something, but he said that all junior doctors should learn to catch snakes! Killing of snakes was prohibited on campus unless poisonous and imminent danger was likely. So any snake spotted had to be caught without harming it and transported in a gunny sack to the forest where it was released. I managed to catch a small non poisonous wolf snake once though I never had the chance to do so again.
We had an active field program where we trained health workers who lived in the villages to be a first contact for any person requiring medical assistance and also to function as advocates of family planning immunization nutrition etc. they were pretty much hybrids between an ANM and an Anganwadi worker. These workers required monthly classes and updated us on deaths births in the villages etc to help keep an accurate census. Bi weekly classes by each doctor for the nursing students also helped improve my teaching skills.
Having enjoyed a great relationship with the nurses along with the wealth of knowledge I gained from them makes me respect workers at every level and has made me more open to taking inputs. My complete practical obstetric knowledge of differentiating all the aspects of the Bishop’s score to dosing the oxytocin to applying an outlet forceps are skills that were imparted to me by the nurses in the labour room .
All the above are things which I felt made THI very different from other hospitals and I haven’t emphasized on the usual surgical work caesareans , hernias ,hydrocoeles ,appendectomies , perfs etc . Regi and Ravi have held my hand while operating ,made me practice knots, bellowed at me enough and have taught me all the basic surgery I know- skills that are invaluable to me as I hope to be a surgeon. Medical emergencies-poisonings, MIs, Status many things, CVAs and all nighters for critical patients or while transporting patients with basic infrastructure has taught me to be quite self reliant .
I would be partisan if I said that everything was Hunky Dory. Since St Johns pretty much disowns you after start the bond you are on your own for the two years. Though Regi and Ravi were always around to help it is impossible to expect someone to be around all the time as sometimes its you running the show with no option of referral. Simple problems about loading doses, drugs of choice or investigations of choice did not occur to me initially as they do now(was also unable to get the free Epocrates to work for more than a month). Inspiring though they may be, sometimes doctors at the periphery who may not necessarily be teaching regularly find it tricky job telling you exactly what to do. Their experience gives them wisdom and confidence but sometimes you need clear cut guidelines and protocols when you are green behind the ears which they oft cannot to verbalize due to lack of practice of structured methods of imparting knowledge. My friend Manu had told me about the distance education family medicine course offered by CMC Vellore and 6 of us from the batch of 2006 had signed up for it though only two of us continued for the whole course . It was exactly what we needed ,with manuals and protocols and contact programs every six months for two years, regular exams and tests and even research projects all oriented towards secondary hospital care. We realized a perceptible change in our confidence levels after each completed manual and contact program.
I could keep going on and on as lessons over two years cannot be conveyed over a few pages, so I will stop. I don’t presume to recommend or advise anyone on what steps they should take professionally or give random life advice. I can only say this- if you don’t feel like doing the same thing everyday, and feel like challenging your boundaries and have completely new experiences and get a fuller control over your consciousness, you could maybe consider working in a completely different atmosphere. I often used reasons like its far from Bangalore, I don’t know the language, the food is not good or excuses like that which were security blanket never allowing me to grow out of my comfort zone all of which changed. So maybe if someone does feel the same way it might be nice to grow out of the blanket sometime.
I would like to thank you immensely for having read this long winded soliloquy of mine and would request you to please visit the site www.tribalhealth.org or visit Sittilingi if you have the time.
You could also join the facebook group ‘Friends of Sittilingi’ and like our page ‘Tribal Health Initiative’. It would be great if other Johnites who share the same philosophy could volunteer at THI.
If someone is interested in specific details or incidents or just feels chatty in general please mail me at