Sunday, March 20, 2011

Dr Abhay Bang: the revolutionary paediatrician

Dr Abhay Bang does not look like a pioneer. He sits across the table in a London conference room, his posture slight and upright, his beard neatly trimmed. He is wearing a grey suit and tie, his hair brushed precisely to the right. And yet despite the conventional appearance, this is the man who has revolutionised healthcare for the poorest people in India and who has overseen a programme that has sent infant mortality rates plummeting in one of the most poverty-stricken areas of the world. Medical experts now believe that Dr Bang's radical beliefs hold the key to tackling the myriad endemic health problems that blight the developing word.

"I suppose my name might have something to do with the path I chose," he explains in rapid, accented English. "Abhay in Sanskrit means 'No fear.'" Dr Bang smiles. "'No fear of death.'"

It is a particularly fitting moniker for a man who has dedicated his life to turning medical orthodoxy on its head. Instead of accepting the traditional hospital-based treatment model, Dr Bang has spent the last 26 years training up local volunteers in Gadchiroli, one of the most deprived districts in the Indian state of Maharashtra, to treat simple maladies at home. The World Health Organisation and Unicef have recently endorsed his approach to treating newborn babies and the programme is currently being rolled out to parts of Africa.

But success has been a long time coming. When Dr Bang and his wife, Rani, set up the charity Search (Society for Education, Action and Research in Community Health) in Gadchiroli in 1985, their mission was simple. "We wanted to listen to the people," says Dr Bang. "What kind of healthcare did they want?"

Dr Bang, who had just graduated with a masters in public health at Johns Hopkins University in the US, started holding regular People's Health Assemblies were the local inhabitants could voice their concerns. Infant mortality emerged as one of the most pressing problems. In 1988, 121 newborn babies were dying out of every 1,000 births in the area. Dr Bang's solution was simple: he trained a group of local women in the basics of neonatal care.

They were taught how to diagnose pneumonia (using an abacus to count breaths), how to resuscitate children and how to administer some basic antibiotics. Instead of villagers having to walk for miles to get to the nearest hospital, these health visitors (called arogyadoots, which means "health messengers") went to where they were most needed, carrying a small health pack on their back. As more women were trained, they passed on their knowledge to others and, according to Dr Bang, entire communities became "empowered".

Anjana Uikey, 40, who was one of the first arogyadoots to be trained, says that the experience has been one of "enormous [personal] growth". "I'm being useful to the village and on a daily basis I have people who are grateful to me," she explains. "Now I get a lot of respect. Earlier, I was nobody and today the whole village knows my name."

The newborn death rate in Gadchiroli has now fallen to 30 per 1,000 live births. In 1988, the death rate here among children who developed pneumonia was 13%. With Dr Bang's intervention, it has come down to 0.8%. The figures have had an extraordinary impact on ordinary women such as Meena Dhit, 28, who delivered her second child – a daughter – at home with the help of health visitors. "It was very well done," says Meena. "These women handled it so well. There is a lot of difference from the old days. Now I feel there is the support for young mothers that my mother did not have. There is someone to take care of me. I have more confidence now and less to worry about."

"We are very MUCH part of the community," says Dr Bang, when we meet in London at the launch of No Child Born to Die, a global initiative by Save the Children to achieve a two-thirds reduction in child mortality. "I really can't say where the line of separation is between them and me. It is research with the people, not on the people."

As an idea, it might sound obvious, but for decades well-intentioned non-governmental organisations from the developed world had attempted to impose the western model of healthcare on rural India. In Dr Bang's eyes, that clearly wasn't working. "The villagers said they were scared to go to hospital," he says. "When we asked why, they told us something fascinating. They said: 'Your doctors and nurses drape themselves in white clothes. We wrap dead bodies in white shawls. How can you save lives if you are dressed like a dead person?' They said: 'When they admit a patient, we can only visit between 3pm and 6pm and we don't have wristwatches. We don't have anywhere to stay in town, so we go back to the village. The patient doesn't want to stay on their own."

Dr Bang's solution was to build a hospital consisting of a series of huts that looked like a tribal village so that patients could stay with their relatives. "To me, with my modern education, it looked old-fashioned," he admits. "But the people said: 'This hospital belongs to us.'"

For Dr Bang, it was the culmination of a lifelong dream. His father, a supporter of the Indian independence movement, was a devoted follower of Mahatma Gandhi and both Dr Bang and his brother Ashok grew up in Gandhi's ashram in Sabarmarti.

Dr Bang was heavily influenced by Gandhi's philosophy of "self-rule". "Gandhi had a vision of how society should be, of how India should be self-ruled," he says now. "But it was not only India that should be allowed to self-rule, it was every human being as well… I took inspiration from that and asked myself, 'How can individuals and communities become autonomous and independent with their own healthcare?'"

He remembers walking past a rural village at the age of 13 with his brother and seeing that the inhabitants didn't have enough food and were sick. "My brother said: 'I will improve agriculture when I'm older,' and I said: 'OK, I have no option but to improve their health.'" He emits a high-pitched giggle. Both brothers kept their promise – Ashok now works with farmers in central India while Dr Bang's wife, Rani, a contemporary from medical school, was swiftly co-opted to the healthcare cause.

"Her name in the Indian language means 'the Queen'," he says, eyes twinkling. "So I am an ex-officio king." Given that they live and work together under such intense conditions, do they ever argue? "Ooh don't ask me this! Now, at the age of 60, it has reduced. But when we were in our 30s, we were constantly arguing about the best way to do things."

Still, in spite of Search's impressive statistical results, the Bangs have been criticised in the past for allowing uneducated women to administer complex medical drugs. In response, Dr Bang insists that, so far, "our workers have given 15,000 injections. The rate of complication has been zero." The insistence that patients must be treated in "techno- centric" hospitals by western-trained physicians is, to his mind, simply not viable in rural India, where lack of transport and an inability to pay for treatment often mean that sick people stay away. "I think this view is, to say it mildly, impractical and to say it forcefully, it's an imperialistic way of thinking. What is do-able in Boston is not do-able in Gadchiroli… Needs are different in different societies."

But although he has saved countless lives, Dr Bang remains plagued by the memory of a single baby he could not help. "It was one of the turning points, before the hospital we constructed had been built," he recalls. "One rainy season, it was pouring outside and it was dark. I was relaxing in the evening after a day's work. Suddenly somebody knocked on my door. It was a young woman carrying a tiny child. The child was skin and bones. I held the baby up as there was no examination table and started examining him. He was malnourished and had severe dehydration and pneumonia. Within minutes of arriving at that diagnosis, the baby stopped breathing. I couldn't do anything.

"The woman had come from a village 4km away. I asked her: 'Why didn't you come earlier?'"

She replied by telling Dr Bang her story: her husband was an alcoholic and spent all his earnings on drink. During pregnancy, she had not eaten because of an ingrained tribal belief that if she did, it would make the baby too heavy to deliver. She developed malaria while pregnant, but there was no money to buy drugs to treat her. When the baby was born, she fed him diluted milk. Then when the baby fell sick, she took him to a witch doctor who sacrificed a chicken for 200 rupees. When that didn't work, she started walking to Dr Bang but a river that lay across her path had swollen and burst its banks. She could not cross because there was no bridge: the government had promised to build one, but it had been lying incomplete for months. So the woman slept rough overnight before resuming her journey the next day, when the water levels had fallen.

"I felt very miserable when she told me this story," says Dr Bang. "That baby died because of many factors: poverty, a wrong belief system, an alcoholic husband and corruption, because the bridge had not been constructed [by the government]. I felt terribly hopeless.

"But then I looked at the whole situation and asked myself: 'Do I really need to solve all the problems, all the links in the chain of this cause of death?' I started to think: 'Where is the weakest link I can attack?' and that was access to healthcare." He falls silent for a moment. "It was practical compassion, not a flash of genius."

And in a world where eight million children a year continue to die before they reach their fifth birthday, perhaps it is Dr Bang's practical compassion that offers the best hope of some kind of solution. Until then, the memory of that woman and her baby haunts him still.