On August 10, the rain-fed Baradaha River began to swell. Earlier that month, heavy rains had lashed several parts of Uttar Pradesh, particularly eastern UP and Bundelkhand. Water-levels in the Yamuna, Ken and Mandakini neared the danger mark. Giduraha village, situated beyond the Baradaha in a remote, dacoit-infested corner of Chitrakoot district, Bundelkhand, was cut-off. Low lying bridges called raptas, which connect the village to the rest of the district, were submerged, swiftly turning Giduraha into an island. The lone auto, which plied twice every day, stopped its service. For the next four weeks, the village was inaccessible.

Among the first casualties of the floods was this year’s sesame crop. Between consecutive droughts and, now, floods, Bundelkhand farmers were seeing yet another failed crop season. However, undocumented by the state’s flood bulletins, a bigger, more debilitating crisis was unfolding in primary and community health centres and district hospitals. The creaking rural health system collapsed in the face of a medical emergency.

Chitrakoot district, for instance, saw a sudden outbreak of water-borne diseases such as cholera, malaria, typhoid and dengue in a month when the district’s pharmacists and accredited social health activist or ASHA workers were on strike. The district’s only blood bank, in the district hospital, was out of order. For a population of nearly 10 lakh, there are only 14 qualified doctors. The requirement for the entire district is 98 doctors so, Chitrakoot has an 86% shortage. For nursing staff, the shortage climbs up to 90%. The district has no pathologists, radiologists, cardiologists and female gynecologists.

“We faced a severe crunch at the time of the floods,” said the district’s Chief Medical Officer Ramji Pandey. “We have enough ANMs [auxiliary nurse midwives], pharmacists and health centres. But the top of the health pyramid is entirely empty, no doctors, no nurses.”

Further into the district, to Manikpur, which is considered the most backward block, the health pyramid ceases to exist. For a population of over two lakh persons in the block, there is only one government doctor who sits at the Manikpur community health centre. Nationwide, the average ratio of doctors to patients is a low at one doctor for every 1,674 patients. Manikpur’s ratio is downright alarming. On August 10, Giduraha, which falls in Manikpur and was one of the six marooned villages in the district, lost access to the block’s only certified doctor.

Pregnant in a boat

Giduraha, a small village of about 150 Kol Adivasi households, lags considerably behind on development indicators – landlessness is high, ration cards are few, malnutrition and tuberculosis run rampant, and there is no provision for a primary health or even a sub-centre. The only health facility is a small dispensary run by Christian missionaries. In August and September, Sister Satyavati, 69, tells us that she treated “nearly 100 children for malaria, typhoid, diarrhea and fevers”. Almost every house had turned into an OPD ward. Medical supplies were limited; there were few malaria kits and even fewer injections.

The outbreak was so widespread that even the dacoits of the region were not spared. According to a villager who didn’t want to be identified, members of the dreaded Babli Kol gang on which there is a Rs 5 lakh bounty, marched to the dispensary, held the sisters at gunpoint and asked for malaria medicine.

That month, Giduraha made headlines. The district administration’s biggest success story came from the village when the National Disaster Response Force made a daring rescue of a pregnant woman using an inflatable dinghy to cross an angry river. “It was a successful rescue and we managed to get her to the hospital safely,” said Rajesh Vishwakarma, the upper-tehsildar of Manikpur. “Our response was immediate.”

Rapta on the Baradaha river that was submerged during the floods. Photo: Pavithra Chandrasekar.
Rapta on the Baradaha river that was submerged during the floods. Photo: Pavithra Chandrasekar.

Even the district magistrate Monika Rani was pleased with the promptness of the rescue. But Sushila Pintu, the 26-year-old pregnant woman in the story, remembers it all too differently.

Before dawn on August 24, Pintu began to experience labour pains. Over the course of the day, Pintu would take an uncomfortable bike ride, squeezed between her husband and mother-in-law, through the jungles of Ranipur, sit through a harrowing boat ride across the Baradaha, climb into a van and finally into an ambulance, before reaching the Manikpur community health centre. The pain was excruciating and she had begun to bleed.

Labours of a doctor

The Manikpur community health centre is a two-storey building and a 30-bed hospital. Two ambulances, 108 and 102, stand by in the courtyard, ready to fly at a distress call. On the ground floor are chambers for doctors and counselors, which lie vacant. Brand new equipment occupies the X-Ray room, but there is no technician to operate it. The dimly-lit operation theatre is only used for conducting tubectomies and vasectomies. The hospital’s two nurses sit on the first floor, alongside the maternity and general wards. A long corridor opens out to a terrace, which serves as a waiting room.

The only government doctor in these parts, Dr Rajesh Kumar Singh, said, “I came here a year ago and I can’t wait to leave. We see an average of 200 cases in the OPD every day, we are on call 24x7…I’m sure to have a breakdown soon.”

Rajesh Kumar Singh, one doctor for a population of two lakh people. Photo: Pavithra Chandrasekar.
Rajesh Kumar Singh, one doctor for a population of two lakh people. Photo: Pavithra Chandrasekar.

Singh was not joking given the enormous pressure on the Manikpur community health centre. As per the National Health Mission norms, there must be one sub-centre for every 3,000 to 5,000 people, one primary health centre for every 20,000 to 30,000 people and one community health centre for every 80,000 to 120,000 people. Each primary health centre ought to have at least one doctor and a community health centre must have four doctors, including specialists. All the centres should have pharmacists, technicians and nursing staff.

The Manikpur hospital has one doctor for two lakh people and no permanent nurses. There is no technician and no specialist.

Data from the Rural Health Statistics 2014-’15 reveals that Uttar Pradesh is easily one of the worst performers in delivering healthcare. More than 55% of the nursing staff positions are vacant, there is a 77% shortfall in lab technicians at primary health centres and community health centres, and the shortage of doctors, gynecologists, pediatricians, surgeons and obstetricians is more than 80%. This, the district magistrate Monika Rani, said, “is the massive human resource problem Uttar Pradesh faces. Positions lie vacant for years. We have to try to find creative ways to attract nurses and doctors.”

In August, the hospital saw a staggering 260 deliveries. Twenty three-year-old sister Suman, who is on her first rural assignment, said, “Sometimes, we end up doing 10-12 deliveries in one night. We are not equipped and without a gynecologist we certainly can’t deal with complicated cases.”

Between two nurses, there is a single pair of gloves that is washed and reused. They have no aprons. Stained sheets cover the beds in the wards, and rubber sheets are few. Surprisingly, the stores at the chief pharmacist’s office are flush with fresh supplies. “We have 7,000 pairs of gloves, 128 new bed sheets, 1000 metres of rubber sheets and 100 plastic aprons ready to be issued,” said JP Singh, the chief pharmacist. “But we haven’t received any requests.”

Manikpur's maternity ward. Photo: Pavithra Chandrasekar.
Manikpur's maternity ward. Photo: Pavithra Chandrasekar.

The hospital also has a list of Dos and Donts. “We don’t do deliveries for women with diabetes, HIV or hypertension,” said Suman. “We don’t do cesarean operations, we don’t do any surgeries.” The list goes on.

“We can’t diagnose dengue or chikungunya, we don’t look at cardiac problems,” Singh added. “Anything complicated, we just refer.” Every day, the community health centre refers around six cases to the district hospital or Allahabad. This is strange behaviour for a centre that will soon be given the status of a First Referral Unit. As an FRU, the centre should be able to carry out obstetric surgeries, blood transfusions and provide specialised pediatric care. In its current state, Manikpur community health centre is the most unlikely candidate to be referral unit for the block.

Waiting room in Manikpur. Photo: Pavithra Chandrasekar.
Waiting room in Manikpur. Photo: Pavithra Chandrasekar.

In August, three newborn infants, delivered at the CHC, died. They had all been referred at the last minute to better hospitals. “Last-minute referrals can be dangerous but what can we do?” asked Suman. She described a recent case, where a 21-year-old woman, pregnant with her first child, had to be referred at the very last minute. “She had gone into labour, but she was very nervous,” Suman said. “She kept sitting up, even with four people holding her down. We could see the baby coming out of the womb, but she would sit up, scream and push the baby back into the uterus. We couldn’t calm her down, we had to refer her. We don’t know what happened to her.”

Long way home

Sushila Pintu, who was rescued in Giduraha, was also one of the patients the centre referred to the district hospital in Chitrakoot. “She was in unbearable pain,” Munni Devi, Pintu’s mother-in law said. “The nurses pressed her stomach and inserted a tablet in her womb to ease the passage of the baby. But she was too anemic.”

The district hospital too could not handle her case. Pintu had travelled the whole day from her village to Manikpur, which is the block headquarters, and then to Chitrakoot, which is the district headquarters on bikes, boats and vans for medical attention. She was referred once by the community health centre and again by the district hospital. “I just couldn’t make the journey to Satna or Allahabad,” she said.

Giduraha's lone dispensary. Photo: Pavithra Chandrasekar
Giduraha's lone dispensary. Photo: Pavithra Chandrasekar

On August 26, two days after her labour pains began, she came back to the Manikpur centre. The delivery was a messy, bloody affair. Sister Mamata delivered her baby, cut her umbilical cord and then performed a Postpartum Intrauterine Contraceptive Device operation. The baby survived for just 15 minutes, said Munni Devi. At the centre, however, the nurse says the child died in the womb.

An ambulance dropped Pintu and her family on the main road to Giduraha. “I walked back through the jungle, crossing the river in pouring rain. I was drenched, in pain and completely scared,” said Pintu. Her rescue had made headlines, but nobody in the administration had a clue what happened to her and the child after. “This would have been my third child,” she said.