The Pharmaceutical Journal Vol 264 No 7101 p923-925
June 17, 2000 Articles

Out of Gujarat

By Leslie Robertson, MRPharmS

This article is based on a diary kept by the author while he worked in Western India on a polio immunisation campaign

My visit to Bhavnagar last year had originally been planned to coincide with the completion of this project, but a number of factors meant that the project would not be finished until spring, 2000. However, I was able to discuss a number of local issues and investigate some ideas for future co-operation. The Sunday of my visit happily coincided with one of the polio national immunisation days that were being held in towns and cities all over India. I travelled with my host - by scooter, with no helmet - to the control centre at the local town hall where I was introduced to the organisers and health director. It seemed as if everyone in the town remotely connected with Rotary or with the local health services had been asked to help. Rotarians at the town hall were co-ordinating the operation, linking the 260 booths located around the city. Each booth was manned throughout the day by four volunteers, two male and two female, in the hope that the great majority of children under five years of age would be brought for polio immunisation. However, it had been recognised that many babies and small children, particularly those from the poorest areas and the migrant population, would not be brought to the booths. Seven vehicles, equipped with loudspeakers, were therefore provided for use as mobile units. Local council workers manned four of these and Rotary manned the other three. I was allocated to one of these vehicles as part of a team, which consisted of my host and two women Rotarians, one of whom was a doctor. There was also a driver. By this time, having seen - and avoided - many slums throughout India, I was feeling some trepidation about my role. After an initial briefing we went to the first of our dozen or so designated slum areas. This was a group of rough shelters around the edge of an open space, partly in use for a circus and fairground. Our job was to try to make sure that all the children were immunised, calling for them to be brought out, asking older children where the younger ones lived and persuading and cajoling the adults to allow their little ones to be given the drops. Searching in and around the hovels - flies were everywhere - while carefully watching where we put our feet, we found as many children as possible.	Slum dwellings in Bhavnagar
	By early afternoon, about 300 children had been immunised
	Mobile units were staffed by local council workers or Rotary members

"Strange foreign devil"

One of the team administered the oral drops, one marked the child's left little finger with blue dye, and a third person kept a record of everything, while I took a few photographs and tried to keep track of what was going on. Feeling a bit superfluous to start with, I suggested that I might be a liability. However, the team pointed out that I was in effect the bait to get the children to "come out and see this strange foreign devil in a funny hat, who will take your photo if you're good!" And, by having my own left little finger painted blue and showing it prominently, I was also used to convince mothers that their children would come to no harm. A couple of times, when that failed to work, I was asked to greet the mother, and my best Hindi "Namaste" seemed to do the trick, as the children were handed over for immunisation without more ado, and I quickly began to share the work of handling the children and giving the drops, snatching a photograph when I had the opportunity.
That first slum was not very large, perhaps 60 or 70 dwellings - makeshift shelters of sticks, sacks, old rugs, anything which could be used to provide a bit of shade - all huddled together in the lee of a low embankment. It goes without saying that there was no sanitation or rubbish disposal, although there was water for half an hour a day, and some simple cooking was going on over tiny fires on the ground.
Most of the shelters had a quota of children, many of them very young. Most of the mothers seemed scarcely more than children themselves and some of the babies were cared for by siblings of perhaps six or seven years of age. Ragged and dirty scraps of clothing or sometimes none at all, thickly matted hair and running noses were the order of the day, but there was no sense of hostility or despondency. On the contrary, most of the children were smiling and happy, jostling to squeeze into a photograph and rushing forward as I stepped back to get them all in the picture. The men mostly kept out of the way and left the negotiations to the women who seemed, in the main, rather dispirited.
To our relief, this first slum turned out to be the most unpleasant one of our quota as we continued our search for children without little fingers painted blue. We saw Nepalese traders selling beautiful woollens, and a travelling circus - where we sat taking tea in the boss's tent while all the children were rounded up and brought to us. After moving through a variety of street settlements and a kind of housing estate with small blocks of flats, we ended up in an extensive village of huts and shanties on some waste ground near a stadium.
There were a few occasions when we suspected that children were being hidden, but it is impossible to know for sure. But it did highlight the difficulty of delivering mass immunisation, and confirmed the need for a mobile unit to cover the rural areas. By early afternoon we had covered the areas we had been allocated, and our records indicated that we had immunised about 300 children. If the other mobile units had been similarly successful and each booth had provided vaccine for the expected 150 to 200 children, the city's entire population of under 5s - about 45,000 - would have been covered in a single day.
This represents a tremendous voluntary achievement, repeated that day all over India, and which is happening regularly throughout Asia and Africa. When our ambulance takes to the road it will be operational 365 days a year, reducing and eliminating new cases of poliomyelitis. The problem remains of supporting those already crippled - another project for the future.
Other ongoing Rotary projects in Bhavnagar include a literacy and numeracy scheme for street children, health education for women and a tuberculosis screening project, but I was particularly interested in ideas for a clinic to screen for AIDS and sexually transmitted diseases at the Alang ship breaking beach. Despite the official closure of the entire Alang area to all foreigners following some recent bad international publicity, I was given permission to visit - regrettably without a camera - and escorted by one of the ship breakers, who explained the background as well as current practice and the political situation.
Alang is unique. Developing from nothing in the early 1980s, it is one of the largest ship breaking operations in the world, and the only one operated entirely manually. About 170 adjoining "yards" of 50 or 100 metres width spread out along more than 17km of shoreline in that part of the Gulf of Cambay where exceptionally high tides every two weeks or so enable up to 300 ships - often as large as giant super tankers - to be driven and stranded high on the beach. Here they are cut up with oxygen/LPG torches by gangs of men without goggles, gloves or any protective clothing.

Frightening statistics

After every recyclable item has been removed, the final lorry-sized sheets of steel, many of them well over an inch in thickness, are carried and loaded by hand by small teams of men. The statistics are frightening. Thirty thousand tonnes of metal - the equivalent of a complete ship - leave the beach every day in 2,000 heavily loaded lorries for destinations all over India. Four hundred lorry loads of oxygen are needed daily in addition to LPG. Thirty five thousand itinerant men from distant states, like Bihar and Orissa, where there is no employment, work and live in Alang in shanty towns behind the beach, without any family life, and another 10,000 local workers provide services and commute daily from up to 50km away.
With the sea, and a tidal lagoon behind the beach, sanitation is deemed unnecessary. But the statistics cannot begin to convey the assault on the senses of this nightmarish scene - the smoke, the noise, the smell, the heat, the glare, even the sheer size of the dismembered ships - which made me feel like an ant in a dinosaur graveyard. But it is not all bad, and some of the adverse publicity seems undeserved. The housing is not as grim or as overcrowded as the slums in most Indian towns - certainly not as bad as Delhi, Calcutta or Bombay - if only because of the tidal removal of effluent. The men are reasonably paid by Indian standards and are able to send money home to families who might otherwise starve. The local economy is buoyant and at least some of the breakers are trying to improve the lot of their workers.
But there are a multitude of health problems. There is the significant risk of accidental injury and lung damage from smoke and fumes. There are environmental health risks from the living conditions. There are social health risks for the workers, the local service population and, through the multitude of lorry drivers, potentially for the whole population of India. Hence the local Rotary club has proposals for a screening and health education centre for AIDS and sexually transmitted diseases, which in my view would need to be mobile to cover the widespread working areas.*
Tuberculsosis also appears to be increasing again, and it would seem sensible to include TB screening with the others. Because of the TB implications, I was able to arrange a visit to a dedicated TB hospital and research centre at Amargadh. About an hour's drive away from Alang, the hospital has two mobile X-ray units and organises its own TB screening days, funding permitting. Founded over 50 years ago, and expanded to its present size of 747 beds, the hospital has many buildings in a poor state, and almost all of the facilities were pretty basic.
Simple wire spring beds with thin mattresses and little bedding lined the wards. Cooks squatting on the kitchen floor prepared the evening meal. The operating theatre looked to have changed little since 1948, and even the relatively well equipped laboratory and research facilities were starved of funds and materials. What was not in any doubt was the standard of care of the patients and the dedication of the staff.
Most of the wards were for men, who make up over 80 per cent of the occupants, but there were women's wards and also a separate one for young children with their mothers and families. Stick-thin men sitting cross-legged on their beds with tubes from their chest walls draining pus into quart jars appeared horrific enough, but the suffering seemed so much worse when it affected babies and young mothers who were having their lives snatched away.

Humbling and moving

It was a humbling and moving visit, and it is so difficult to know how to help. Money is always needed as the government's contribution to costs is constantly falling. Drawn from all over western and central India, almost all the patients are treated free of charge, and 120,000 inpatients and almost a million outpatients have been treated in just over 50 years.
Individual costs are remarkably low in western terms, confirming that TB is not an expensive illness to treat and control. The two or three months from admission to discharge cost only about £90 per patient. A community screening day with one of their mobile units costs just over £100. It is possible to sponsor both patients and screening, but it seems to me that the day-to-day costs are only the tip of the iceberg. Some modernisation, renovation and support for the research is desperately needed if the increasing risk of an epidemic of tuberculosis is to be averted.
This is simply not the time for the largest TB facility in India to be allowed to fall apart, and I am now beginning work on a project to combine the facilities of this hospital with the screening work needed at Alang. Preliminary costs for the basic clinic at Alang, without any TB screening, appear to be about $20,000, excluding the premises. A properly constructed and supervised project should attract 50 per cent support from the Rotary Foundation. However, most of the balance would have to be raised in the UK. British pharmacists, with or without family roots in India, may be interested in supporting this or a variety of other projects, especially where there is reliable local control, and no administrative cost.

Leslie Robertson, a pharmacist since 1959, has spent most of his working life as a community pharmacist in Luton. Currently he is secretary of Bedfordshire local pharmaceutical committee (e-mail leslie.robertson@dtn.ntl.com)

*Since the author's diary was written, the proposals for a screening programme at Alang have moved on. The author is in discussion, via the local Rotary club in Bhavnagar, with the TB hospital and the Red Cross of India about his proposals to enlist the help of two ship breakers to allow screening of all their workers as a pilot scheme of 500 to 600 men (1 to 2 per cent of the total) using mobile units from the hospital. Workers would be screened for TB (active and latent) and HIV and some health education would be available. The object of the pilot would be to quantify the extent of health problems and the cost and manpower implications in respect of treatment. Currently, the author is awaiting firm responses to his proposals.