To me, Ulhas is an unusual character, a doctor brave enough to think out of box, bold enough to practise what he believes, and determined enough to translate his ideas into reality.
The father of our nation, Mahatma Gandhi, had envisioned his list of priorities in almost all walks of life. Just two months before independence, Gandhi wrote (June 15, 1947) about his perception and vision for the medical profession. “I would like to know what the medical men and scientists are doing for our country. One finds them readily going to foreign lands to learn new modes of treating special diseases.
I suggest that they should turn their attention towards the seven lakhs of villages of India. They would immediately discover that all the qualified men and women are required for village service, not after the manner of the West, but after the manner of the East.” Everybody believed that our medical schools will design doctor who will meet these expectations. Unfortunately, as in several other fields, the medical profession also paid little attention to Gandhiji’s thoughts.
Ulhas, born in post-independence era, is also a product of the very system that trains and produces thousands of doctors every year. Then what inspired and motivated him to take a path less traveled by? What provides the inner strength of his convictions? If I may be permitted to use the scientific language, he probably got it in his genes. Soon after independence, Ulhas’s grandfather Shrikrishnsdas Jajoo rejected Sardar Patel’s invitation to become India’s first finance minister and continued to work in the distant Harijan villages of Bihar, ravaged by communal violence. Of course earlier, he had also refused to be the chief minister of Central Provinces. Probably the gene of selfless service may account for his incessant zeal to improve the healthcare facilities in villages around Sevagram. All those who have addressed these issues would understand the challenges and difficulties of working in rural areas -we at Kasturba Health Society are certainly proud of him. Ulhas joined MGIMS in 1977, and began teaching medical students and treating patients in the hospital wards, tasks that he did with exemplary zeal and enthusiasm. But he also wanted to reach the unreached. MGIMS offered him autonomy and opportunity to figure out what ails the healthcare delivery system in villages around Sevagram and to design interventions that would fill those critical gaps. Supported by a bunch of like-minded medical students who were fired by his idealism, he carefully crafted a system that linked primary healthcare with a hospital-based tertiary care. He began to learn that rural people do not put health very high in the list of pressing issues that they have to cope with. He started spending his evenings, and weekends with the villagers, discussing, debating and arguing with them to know how to design a system that is responsive to their felt needs. He began to realise that he must design his community based interventions on a premise that when communities receive access to reliable curative services, they are also then open to the idea of prevention. Therefore, an affordable and approachable hospital must ensure good curative services along with prevention of entire spectrum of medical disorders. bedside medicine He redefined the role, rights and responsibilities of village health workers; gave them enough powers and brought healthcare at the doorsteps of villagers. He inspired and motivated them to creatively engage in issues related to health and illness in rural communities. The cadre of trained village workers and midwives -and strong referral support system they use -has seamlessly bonded the hospital with the nearby villages. He joined hands with obstetricians and pediatricians to ensure that no mother or child in the villages enveloping his medical school dies from a preventable death. In 1982, he replaced door-to-door vaccination strategy with cluster immunization and was able to achieve almost 100% vaccination coverage. And to minimise pregnancy - associated deaths, he identified, trained and posted village health workers who would pick up high risk pregnancies and arrange for their institutional delivery. According to Ulhas, the top-down approach for delivering healthcare to the villagers is improper.
He believes in participatory democracy at the grassroots level and encouraged women and other weaker sections of the society to participate in decision making, and take an active part in local governance. Ulhas also introduced the Gandhian concept of self-governance and began several programmes that would create a republican village - self-sufficient and self-reliant in respect of necessities like food, cloth, shelter, employment, education, health, knowledge and skills. Because the village owned the natural and other resources, it also had power to decide who gets what and how much and how often. He might not have fully succeeded in creating the Gandhian utopia of , but he did instill the importance of self-sufficient villages with local administrative structures, planning and catering to the local needs.
Amartya Sen, an “argumentative Indian” himself, argues that India had a long history of governance by discussions, in which group of people sharing common interests made decisions on matters that affected their lives through debates and consultation, and arrived at solutions by consensus. The concept of local self-governance is indigenous to the Indian soil and has helped to preserve the democratic traditions in social, cultural, economic and political life. Over the last three decades of his rural work, Ulhas fully subscribed to, and implemented this philosophy in his work. He enthused and motivated local communities and developmental agencies to work together in planning, implementing, and monitoring of programmes at the grass root level. He re-designed home grown systems instead of transplanting best practices from other contexts. He respected the wisdom of local communities in deciding what is good for them, and encouraged the villagers to innovate and experiment rather than being pushed to adapt to pre-selected modules.
In the villages, he developed non-profit, nonpolitical, non-religious structure. He laid emphasis on income generating programmes and social upliftment of the women in rural areas. He organized and trained rural communities to critically plan and undertake developmental activities. He ensured that the leaders of the local communities are honest, sincere, committed and agree to collective decision making. Ulhas’ stories of diligence, determination and ingenuity take us to the households of villages around Sevagram- many of them did not have a toilet. Determined to get the rural landscape free from early morning squatters, and moved by the embarrassment created by the sight of men and women openly defecating in the fields, he invited villagers to join hands with a NGO to build a toilet in their household- an activity Ulhas is justifiably proud of.
Ulhas tells us the methods he employed to help each household in his intervention area to acquire a toilet. He also discusses how he made villagers aware of the advantages of lift irrigation system. He also encouraged them to participate in each and every stage of implementation of lift irrigation programme in the villages. He describes how the residents of villages enthusiastically carved channels in the unflinching hard soil, laid pipes and leveled the sloping land. The lift irrigation– a part of the participatory watershed development strategy– is helping the villagers develop, conserve and manage land and water resources in this area and battle the tyranny of seasons.
Affordable, appropriate, accessible – are the words health economists often use to describe a good health system. These words would sound hollow if a woman with an obstructed labour dies in the village- unwept and unsung. Healthcare costs, and those for in-patient care in particular, pose a barrier to seeking healthcare, and is a major cause of indebtedness and impoverishment, particularly among the poor. Community-Based Health Insurance (CBHI), a concept deeply rooted in the soil of Sevagram began to flourish under Ulhas’s leadership. He showed that pooling of resources can cover the costs of future, unpredictable, health-related events and can protect individuals and households against the uncertain risk of catastrophic medical expenses. Unlike schemes, run by profit making private agencies, in this scheme he involved the targeted community in defining the contribution level and collecting mechanisms, the content of
the benefit package, and allocating the scheme’s financial resources No wonder, in 2011, about 58000 villagers, 55000 members of the self-help groups, and 1500 village- based small organizations enrolled themselves in this scheme. Ulhas has also been conscious of the fact that women in rural households often have neither voice nor power. He launched women-led micro-finance programmes (Self Help Groups) with the explicit goal of empowering them. The women in the village began to participate in decision making both within and outside the households and also started challenging the existing norms and culture.
Rated by the alumni of this institute as a superb teacher, an empathetic physician, and an amazing human being, Ulhas creates an environment in which his charisma, words, personality and vision make him the most sought-after person on the campus. He wears so many hats with an exemplary ease- that of a physician, teacher, researcher, community health worker, and a friend, philosopher and guide to villagers. He is as comfortable talking to a villager as much as with an articulate and suave scientist- strongly believing in what he does and what he stands for. Not too long ago, an alumnus in his batch reunion succinctly described his tryst with Ulhas.
“For those of us lucky enough to get to work with him in his villages, rubbing shoulders with villagers – sitting in their huts and walking along with them in their fields, it was a great honour. Ulhas helped us understand the divide between the classroom medicine and the issues peculiar to the rural health. He inculcated in our minds the concepts that could close these gaps: low-cost medicine, for example. We began to understand why he questions unnecessary tests, needless surgeries and technology-triggered interventions.
We were sensitized to the unvoiced needs of a common man and learnt how a medical system should address- and be responsive- to those needs. After coming out of the portals of the medical school, do we realise how much we miss those days?” True, among the large number of doctors practicing medicine during the last three decades, only a handful have been able to blend internal medicine with public health with such a remarkable ease. I have known Ulhas for almost five decades and have been touched by his simplicity and diversity. Readers will discover plenty of these virtues in this book. I would recommend that those who shape the medical education in the country–the Medical Council of India, the Health Ministry and the Medical Universities, must make this book as a part of their curriculum. These experiential stories would help medical students to understand the rural healthcare much better than the dry textbooks they read to pass their examinations.
Shri Dhiru S. Mehta
President, Kasturba Health Society, Sevagram
Director- Mahatma Gandhi Institute of Medical Sciences, Sevagram.