The sun took a long time to shine on March 31. By afternoon, the slowly warming rays melted the remnants of the hailstorm that blew away swathes of towns and villages across Barak Valley the night before, revealing a transformed landscape.

The Barak Valley region of Assam consists of three districts: Cachar, Hailakandi and Karimganj. This region has 98 tea estates and other small, unregistered gardens. The tea estates in Barak Valley employ around 60,000 permanent and 50,000 casual labourers, according to Rajdeep Goala, chairman of Assam Tea Corporation Limited and general secretary of the Barak Cha Shramik Union (the Barak tea workers’ union).

There are 75 primary healthcare centres across this region, with 593 sub-centres. Each district has a civil hospital, but only one government medical college, Silchar Medical College and Hospital.

Raja Ram Rabidas, the president of the estate panchayat, is a labourer who works in the Rosekandy tea estate in Cachar district, 31 km from Silchar town. He is the sole earner for his family of four. Parbati, Rabidas’s wife, was admitted to the estate hospital during the birth of their youngest daughter, Preeti, who is three months old. Rabidas says, “We did not have to worry about the expenses, and it took us only five minutes to reach there.”

The estate hospital is part of the Assam government’s Private Public Partnership with Tea Garden Hospitals to strengthen healthcare services and increase access to primary healthcare. The scheme was launched in 2007-’08. The Memorandum of Understanding with Tea Garden Hospitals is aimed at offering reasonably priced healthcare, including providing doctors, ANMs, or auxiliary nurse midwives, doctors’ assistants and Accredited Social Health Activists, or ASHAs.

But there is a lack of specialised doctors and tertiary care services, our reporting found. Workers have to travel to nearby towns and villages for better hospitals, and remote locations of the tea estates, inadequate infrastructure to and from nearby towns, and socioeconomic conditions of the workers act as barriers to healthcare access.

“If serious health issues arise, we have to go to Silchar Medical College, which is more than 30 minutes away, and the roads are pretty much inaccessible during the monsoon,” says Rabidas. “Blood tests, CT scans and basic services are often unaffordable for most of us.”

Maternal care in tea estates

A study by the United Nations’ Children Education Fund and the sociology department of Tezpur University in Barak Valley noted that safe deliveries in the region were a challenge. In 2009, the study found that 40% of deliveries were attended by trained attendants in tea garden areas, compared to the then-all-India average of 52.7%.

Maternal healthcare access has since improved in the Barak Valley districts. But it still lags behind the Assam average and the national average.

In 2023-’24, Cachar’s National Health Mission reported 773 normal deliveries, 513 pregnant women who registered for ante-natal and postnatal checks, and 757 women who had a postpartum visit within 48 hours of giving birth, at tea garden hospitals run under the public-private-partnership model.

Like Rabidas, Sumit Chasha is the sole earning member of his family. He is a labourer in the Vernerpur tea estate in Hailakandi district. His daughter, Susma, was born less than a year ago in a government hospital in Lalamukh, a small town located a few kilometres from the estate. Himani Karmakar, an ASHA, assisted Sumit’s wife Joba during her pregnancy, including routine vaccination, and antenatal and postnatal care.

Suma Saha, an auxiliary midwife and nurse, says most child deliveries in the gardens happen at home, depriving women of government health schemes such as the Janani Suraksha Yojana, the safe motherhood scheme, which provides a financial incentive for mothers who give birth in government health facilities or certified private hospitals.

The most significant blind spot in Assam’s maternal health is the neglect of women working in its tea estates – 803 spread across 27 districts – that report a disproportionately high number of maternal deaths, IndiaSpend reported in June 2019. We had reported in April 2017 that in the tea gardens of Assam, anaemia among women was almost universal.

Inadequate, limited infrastructure

Ram Lakhan is a registered medical practitioner who manages the South Cachar tea estate dispensary. He is responsible for treating workers and locals for various conditions, including fever, anaemia and gastric issues. His duty starts at 7 am and ends around 7 pm, during which he gets an hour-long lunch break.

Ram Lakhan, a registered medical practitioner, manages the South Cachar Tea Estate dispensary.

“Small tea estates usually don’t want to hire a government doctor because they can’t afford to pay them and provide them with other benefits,” Lakhan, who has been working at the tea estate since 2001, says. “I do preliminary treatment and send them to a PHC [Primary Healthcare Centre] or other places according to the healthcare needs of the patients.”

Lakhan prepares a list of medicines needed for the dispensary every week or so. Once the estate manager approves the list, he collects the medicines from the nearest National Rural Health Mission facility in Lala, 45 minutes away.

Because accessing nearby towns is difficult, locals come to Lakhan for preliminary diagnosis and treatment at the estate dispensary. The doctor who used to visit the estate dispensary once a week died about three years ago, and no one has been engaged to replace him since, Lakhan said. We have reached out to South Cachar Tea Estate about the lack of a doctor and will update the story when we receive a response.

The Indian government approved Rs 1,700 lakh – Rs 10 lakh per hospital – for tea garden hospitals in Cachar district in fiscal year 2023-’24. The other two districts in the Barak Valley region do not have operational tea garden hospitals.

Dr Ashutosh Barman, Joint Director of the National Health Mission, Cachar, said, “The funds are given to tea garden administration for the recruitment and hiring of physicians and paramedics in tea garden hospitals. Financial aid can also be utilised to renovate existing hospital infrastructure and purchase equipment for PPP hospitals to improve facility service delivery. “

This report by the National Health Mission, Cachar shows that of the 19 operational tea garden hospitals functioning under the public-private -partnership model in the Barak Valley, 12 have MBBS medical officers, while two have Ayurvedic medical officers. There are Community Health Officers in 11 hospitals, ANMs at 18 hospitals and only seven have staff nurses. Fifteen hospitals have lab technicians and 17 have pharmacists. In 2023-’24, an estimagted 305,230 patients visited the outpatient departments and 5,835 patients were admitted to the 19 hospitals, while there were 28,231 laboratory tests.

A 2021 study, covering 300 tea garden workers across three tea estates in Assam, found that two in three workers utilised government facilities, while 29% used tea garden hospitals.

Saha, who is an auxiliary nurse and midwife for a mobile medical unit visits tea gardens for a preliminary check-up of labourers and workers. There are 18 mobile medical units currently operating in Barak Valley. Saha works with Mahi Das, a pharmacist, and Prajit Deb, an ophthalmic technician. They work for 25 days every month for six hours. When labourers or their family members visit, they check their weight and blood pressure. Some are referred to a local primary healthcare centte or to sub-centres on a case-by-case basis.

“Most of the labourers that come to us suffer from hypertension issues, and it is either because they are drinking too much tea with salt in it or because of alcohol consumption,” says Saha. “Alcohol and tobacco consumption are prevalent in tea gardens and surrounding areas.”

A Mobile Medical Unit at Bidyanagar Tea Estate

The absence of specialised doctors and diagnostic facilities in the estate hospitals forces the workers to seek treatment in faraway towns. Chasha, the labourer in the Vernerpur tea estate in Hailakandi, said it was difficult to access advanced treatment in Silchar: The journey to the medical college takes around two hours.

Forty-six-year-old Manju Bhar is a seasonal plucker and cleaner at Rosekandy tea estate. Her husband lost most of his eyesight and hearing after working in the garden for most of his life. She started experiencing persistent gastric and stomach aches in January this year, which led her to a private clinic a few kilometres away in Natun-Bazar, where a sonogram cost her Rs 3,000.

The doctor there referred her to Guwahati Medical College. “Guwahati is a big city, and I can’t afford to go there, so I asked the manager here, and he sent me to a doctor he knows in Cachar Cancer Hospital,” Bhar says. Her struggle for healthcare continues, as she has to visit the cancer hospital with an income certificate, after which further testing and treatment can resume in Guwahati.

Manju Bhar, a seasonal plucker at a tea estate in Assam says she finds it hard to fund her cancer treatment. Pictured, Bhar, with her son, Babul, outside their hut.

Rabidas said that some workers have used a government fund to access financial help for cancer treatment. The government set up a Health Minister’s Cancer Patient Fund in 2009 with a corpus of Rs 100 crore. To get financial support under fund, a patient must submit a form, signed by the treating doctor and countersigned by the Medical Superintendent of the Government Hospital/Institute/Regional Cancer Centre, along with a copy of the income certificate and ration card. This fund is used at 27 Regional Cancer Centres, of which the Dr BB Cancer Institute in Guwahati is one. Bhar did not specify if she was using this fund.

Occupational hazard

As the time for plucking commences, labourers, especially women, are exposed to extreme weather events and snake bites, which increase their vulnerability to disease. Other common conditions such as diarrhoea, skin rashes, fever and malaria, tend to spike during the summer and monsoon seasons, health workers said.

Apart from this, locals say, extreme erratic weather events, such as intense rainfall, thunderstorms and hail storms, such as the one just before this reporter visited Cachar, also impact workers’ health as they have to work in waterlogged plantations.

The Rosekandy Tea Plantation Health and Wellness Centre, under the National Health Mission.

The paucity of clean water sources is yet another issue. Many of the garden population drink water from unprotected ponds and water bodies that they also use for cleaning utensils and other day-to-day activities, leading to stomach pain, skin disease, etc. The tea garden hospital management committee's tasks include preventing and controlling malaria, tuberculosis, diarrhoea and Japanese encephalitis.

The 2021 study of 300 garden workers found that 47% and 15% of tea garden workers reported having non-communicable and communicable illnesses, respectively, which may necessitate frequent visits to a healthcare institution.

For this workers would want close access to health facilities. Rabidas says “Most of us workers prefer a quick remedy as we have to resume working to earn money as quickly as possible.”.

The hospital at Rosekandy tea estate, run as part of a public-private partnership.

Low awareness

Pradip Chakraborty, General Manager of the Vernerpur tea estate, explains that labourers often don’t use protective gear such as aprons, masks and goggles issued to them, which may expose them to hazardous chemicals. Factory workers are also advised to take all preventive measures, but non-compliance leads to injuries and accidents.

While gardens like Rosekandy and Vernepur can organise awareness camps about factory safety hazards and chemical exposure in the gardens, small gardens seldom have the financial capacity.

The 2009 Unicef study found that many of the complications for pregnant women in the tea estates could be avoided with better awareness and timely interventions. Nearly 67% of women surveyed had said they were not aware of danger signs during pregnancy such as fever, pain for 12 hours, premature rupture of members, bleeding, fainting, anaemia etc.

Awareness programmes in nearby government schools (where Ravidas’ children and those of many tea plantation workers study) distribute folic acid tablets and deworming tablets, locals say.

Parvati Rabidas, and Raja Ram Rabidas with their three children. Many tea plantation workers, like Rabidas, do not have health insurance.

The 2021 study mentioned above also found that about 63% of workers had health insurance, however, the vast majority (79%) had never used it. As many as 16% had no idea if they were covered by any form of health insurance policy, such as the central government’s Ayushman Bharat or the state government’s Atal Amrit Abhiyan, to which they are entitled because of their poor economic circumstances.

For instance, Rabidas says he is not covered under any insurance plan currently, “ I used to have an insurance policy from a private company but I closed that plan around eight years ago as I could not afford to pay the premium regularly.”

Economic conditions of tea estates

Rosekandy and Vernerpur are better off than other tea estates in Barak Valley. Many small, loss-making tea gardens are in fact closing down gradually. According to the Comptroller and Auditor General’s 2023 audit report, productivity in Assam, which produces nearly 50% of total tea in India, has gradually decreased from 2,330 kilograms per hectare (kg/ha) in 2016-’17 to 1,854 kg/ha in 2020-’21. Across India, productivity fell 7% from 2,165 kg/ha in 2016-’17 to 2,016 kg/ha in 2020-’21, even as the area under cultivation grew by 10%.

Global tea prices have fluctuated, production costs have risen, and labour issues have taken their toll. For instance, production costs for Darjeeling tea have increased, while the price has not increased enough, putting the industry at risk, IndiaSpend reported in January 2023. The crisis is exacerbated by climate change, with unpredictable weather patterns hurting tea harvests and quality, we had reported.

In 2022, the Assam government decided to lease 12 out of its 15 loss-making gardens to private companies for 30 years. As of January 2023, it had leased out three gardens and finalised lease deeds with two other gardens.

The loss of a steady source of income has led the labourers to look for work elsewhere.

When Chandan Prasad Kurmi took charge of the Bidyanagar tea estate, under the Assam Tea Corporation Limited in 2023, it was on the verge of shutting down. Although he is trying to redeem the potential of that estate through organic cultivation practices, he says it is a challenge to match industry standards and provide for labourers’ needs.

Currently, the Plantation Labour Act regulates healthcare and welfare, sanitation facilities, hours of work, leave and wages for the workers. It asks that plantation management provide medical facilities, recreational and educational opportunities, and housing for workers and their families.

According to Goala of the Barak Cha Shramik Union, workers should be paid at least the minimum wage of Rs 228 but that is not the case in 70%-80% of tea gardens in Assam. The workers also do not receive benefits, such as wages, ration and provident funds. Tripartite meetings between the union, management, and state labour departments seldom translate into real change, Goala said.

Also, some workers’ grievances have to be resolved through the state government, while the tea estate management can directly take care of some grievances, making the process confusing and cumbersome. For instance, Goala said, though the management has to take care of worker housing repair, in the tea gardens that are in poor financial condition, it needs state government or union intervention to get work done.

Goala said that workers’ unions are monitoring the situation to ensure that the management and government honour promises made for the welfare of these workers.

This article first appeared on IndiaSpend, a data-driven and public-interest journalism non-profit.