Giving infants the gift of life

N Madhavan | Updated on September 14, 2018

Abhay and Rani Bang   -  Ramesh Sharma

Dr Rani and Dr Abhay Bang’s success in Gadchiroli has transformed the way India and the world tackle high infant mortality

Gadchiroli district is as backward as it can get. Located in Western Maharashtra, some 1,000 kilometres from Mumbai and bordering Chhattisgarh, 60 per cent of its land mass is covered by forests and 80 per cent of the people live below the poverty line. Indigenous people account for 40 per cent of the district’s population and primitive beliefs and age-old traditions, such as resorting to witchcraft to treat diseases, govern everyday life.

In 1988, the district’s infant mortality rate (IMR) stood at 121 per 1,000 births, among the highest in the country. But what happened in the next decade-and-a-half surprised policymakers both in India and abroad. The IMR in the district saw a steep fall to 30 – equal to the rate in large cities with state-of-the-art medical facilities. This change came about not because the Government suddenly chose to invest heavily in the district’s medical infrastructure but due to the work of the doctor couple Rani and Abhay Bang. Their home-based newborn care (HBNC) model revolutionised the way infant mortality is approached in rural areas.

Today, based on their success, the Government of India is training 8.19 lakh village health workers under its Asha programme. HBNC has reached 11 million newborns across six lakh villages. And the results are beginning to show. According to a 2016 study by Prabhat Jha of the Centre for Global Health Research, India prevented about one million child deaths between 2005 and 2015. HBNC has played a key role in this. Six African countries embraced this model in 2005-06.

Influenced by the Mahatma

Born in 1950, Dr Abhay Bang (68) spent much of his childhood in Mahatma Gandhi’s Sevagram Ashram in Wardha, Maharashtra (his father was a Gandhian). Gandhi’s teachings left a strong impression on him, so much so, that at the age of 13, he had decided to pursue medicine and serve the people.

He entered medical college when he was 17 and there he met Rani Chari, his future wife, who, despite coming from a wealthy family, chose a simple way of life and wanted to serve the people. “Our dreams and aspirations matched,” says Dr Abhay. He completed his MD in Internal Medicine and she in Obstetrics & Gynaecology.

Both topped their respective classes and could have had a lucrative practice in Mumbai or Nagpur. Instead they began working in Kanhapur, a village near Wardha. Soon they realised that merely running a clinic was inadequate to improve the health of people in the villages and their focus shifted to public health.

But most research in India on diseases such as malaria or cholera is done by foreigners. Not much information was available on how to carry out public health research in India. Their search to understand it took them to Johns Hopkins University in the US, where they completed their Masters in Public Health. On their return they chose Gadchiroli as their base and started SEARCH (Society for Education Action and Research in Community Health) in 1986.

“We chose to go where the problems are and not operate out of cities where infrastructure such as electricity and office facilities existed but were far removed from the challenges plaguing rural India,” says Dr Abhay Bang. Gadchiroli had other advantages too. “It had a unique rural and tribal population mix and offered us an ideal test-bed to research diseases affecting both tribal and rural people,” explains Dr Rani Bang (67), who began her work by focussing first on ‘sickle cell’ disease, which is common among the tribal population, and then on women’s reproductive health (this has now become a global policy replacing the earlier focus on just birth control).

The turning point

One rainy evening in the late 1980s, two women rushed into the Bang’s home at Shodhagram, 15 kilometres from Gadchiroli town, where SEARCH’s 40-acre campus is located, with a very sick infant. Even as Dr Abhay Bang began evaluation, the baby stopped breathing. “It died on my bed while I helplessly watched,” he recalls. He deduced that the child could have died from 18 different causes.

The child’s death affected them badly and their focus turned to infant mortality. About 100-odd villages in the district became their laboratory and they began to record every childbirth and death. To their shock they found that 121 infants died within one year of birth and the major cause (40 percent) was pneumonia. While pneumonia could be treated with antibiotics, diagnosing it required x-ray machines, which were scarce in the district.

They began to look for a simple but effective way to identify pneumonia and arrived at a method based on the child’s breath rate. With no medical facilities worth the name, they also had to find a way to reach the cure for pneumonia to the people. Midwives or traditional birth attendants (TBAs) in every village were seen as a possible solution. After all, of the 26 million babies born in India, 75 per cent are in villages and of this, 84 percent are delivered at home, mostly by TBAs. Dr Abhay Bang designed a simple breath counter instrument to enable them to count. Once they diagnosed pneumonia, the infants were given antibiotics.

The solution worked and within two years (by 1990) the IMR in the district began to decline and fell to 75-80 per 1,000 as the death rate among infants due to pneumonia declined to just 0.5 percent. This simple method to cure pneumonia among infants not only proved to be crucial in India, where a million infants died every year from the disease, but is also in use in over 77 countries.

The IMR level remained at 75-80 per 1,000 for the next five years (1990-1995). A closer look revealed that the bulk of the remaining deaths occurred among newborn infants within four weeks of birth. Initial research by SEARCH revealed that 42 percent of the newborns were malnourished at birth and were easy prey to diseases; 54 percent required medical treatment at birth.

World Health Organization norms clearly specified that ill-born infants should be rushed to a hospital but in Gadchiroli district, hospitals were far and few. Also, local custom mandated that a newborn and mother should not leave their home for a certain length of time after the birth. This situation called for an innovative solution — healthcare had to be provided at their home. Thus was born HBNC.

Building on the success of using TBAs to fight pneumonia among infants, SEARCH identified one woman from each village and trained her as a village health worker. Their training included checking the newborn’s weight, temperature and breathing, maintaining hygiene, giving injections/antibiotics (if needed) and maintaining a complete record.

Overcoming challenges

There were objections from many quarters saying it was ill-advised to get uneducated people to provide such services. Dr Abhay Bang got a team of ten leading paediatricians from all over the country to check if the trained village health workers were competent to treat the newborns.

The team of doctors gave the green signal and HBNC was rolled out. The results were stunning. By the year 2000 the IMR had fallen to 30 per 1,000 births.

IMR has remained at this level since and SEARCH is working on a new intervention: home-based intensive newborn care. “We hope to reduce IMR to 25 per 1,000 by this initiative,” he says, adding, “further reduction would require hospitalisation facilities as this involves heavily pre-term and underweight babies.”

Drs Rani and Abhay Bang have also started new initiatives that focus on non-communicable diseases such as hypertension/stroke and alcohol addictions in the district. Dr Rani Bang points out that it was the villagers who forced them to take up the issue of alcohol and tobacco addiction. “A study in 2015-16 revealed that the 1.2 million people in the district spent ₹350 crore a year on alcohol and tobacco. This was way above the ₹157 crore the Government spent as part of the district’s development plan,” she adds. Today, the duo have successfully managed to bring total prohibition in the district.

They have also started NIRMAN, an initiative to create changemakers. “We have trained over 1,000 youngsters and 200 of them are already out in the field working on social issues,” says Amrut Bang, the couple’s younger son, who manages the programme.

Both Dr Abhay Bang and Dr Rani Bang, who were awarded the Padma Shri in 2018 in recognition of their work, were offered attractive posts by the Government and other organisations over the years. But they chose to stay back and restrict their work to Gadchiroli. “Without Gadchiroli, Rani and I are zero. This is our lab, where we see a problem, measure it, develop solutions, field-test them ... and when we succeed, we try to bring about a policy change that benefits people across the country,” explains Dr Abhay Bang.

He signs off with his favourite quote: “One accurate measurement is infinitely superior to a thousand intelligent opinions.

Published on March 16, 2018

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