Tribal hospital in Sittilingi valley in Dharmapuri district. Photo courtesy: N. Bashkaran
On Monday’s misty morning in the Sittilingi valley, located between the Kalvarayan and Sitheri hills in western Tamil Nadu, people entered a stone complex of single-tier structures made of dry bricks, Mangalore-tiled roofs and arched windows.
The earthen structure, resembling a village shelter, is a tribal hospital that provides secondary health facilities in one of the most remote parts of Tamil Nadu, about 45 km from the block headquarters of Harur at Dharmapuri.
Revati was also among the visitors that day. She brought her mother from Navakollai, 20 km away, as she has been doing for the past 10 years, bypassing the primary health center just 5 km away from her village.
She says, “I haven’t seen such a place anywhere else. They take women’s problems seriously. Doctors take time to listen and explain, spending at least 15 to 20 minutes with a patient. Even in private hospitals, doctors don’t listen to our complaints.”
Sometime in 1993, a young couple in their 30s, both physicians from Gandhigram, arrived in the tribal valley of Sittilingi with a dream: to become doctors in a place where they were needed, where no other doctor had yet gone.
This dream would take shape as a 35-bed tribal hospital and give birth to the Tribal Health Initiative (THI), a Community Health Program (CHP) that would reverse Sittilingi’s extremely low infant mortality rate within a decade, and radically redefine the scope of health beyond the clinical, expanding it to the social and economic determinants of well-being over three decades.
Gynecologist Lalita Regi and anesthetist Reggie George chose Sittilingi because of its geographical isolation, where like all tribal areas access to care is limited, and its appalling infant mortality rate (IMR) – 147 children per 1,000 live births – at the time.
If the couple conceives with CHP, the level of morbidity and mortality requires a different course of action.“There was so much morbidity that we needed to address that first,” says Dr. Lalita. She took over a Porambok land, where local people helped build a one-room structure of mud and grass. “For three years, deliveries and some surgeries took place on a bench, under a 100-watt bulb.”
Dr. Reggie George and Dr. Lalita Reggie, Founders of Tribal Health Initiative. Photo courtesy: N. Bashkaran
Then, through ActionAid, came a hospital with 10 beds and a center to train local people to take care of themselves. Dr. Lalita adds, “Then, as now, the belief was that any planning and resources should come from within, not from outside.”
Earlier in November this year, the McGill School of Population and Global Health named Regis a co-recipient of the prestigious Paul Farmer Award for Global Health Equity. The citation describes his achievements as “combating the failures of imagination” and “living a life of togetherness”.
ground up construction
The couple’s first health worker was Rajamma, an eighth-grade pass, who joined the hospital as an intern in 1994. “We went to villages and asked educated girls to help us in the hospital,” says Dr. Lalita.
But the state’s curriculum up to class eight meant that young girls like Rajamma could read letters, but not words or entire Tamil sentences. Therefore, their training began with basic language and arithmetic before moving on to anatomy, physiology, pharmacology, diagnosis and treatment.
“Diagnosis is focused on the prevalent diseases in the area, nothing extra. What they’ll see, how they’ll diagnose and treat…” said Dr. Reggie. “That’s why we called them health workers, because they were more than nurses.” Similarly, he trained laboratory technicians and an accounting team. Due to lack of money, many things had to be improved. The hospital’s first autoclave was a pressure cooker. “We had to make do with what we had for all kinds of emergencies, because people couldn’t go anywhere,” says Dr. Reggie.
health assistant
“We were seeing people only when they came to the hospital. There was no one in the village to see what was happening. So, we asked each village to choose one person free from child care responsibilities.” Twenty-one villages had sent 25 women, who would become trained health assistants and form the backbone of the community health program.
The first goal was to tackle infant mortality. Since under-five deaths in most places include malnutrition, respiratory diseases and diarrheal diseases, health assistants were trained to focus only on these through nutrition management, prevention of malnutrition, early detection and treatment of respiratory diseases, recognizing symptoms of pneumonia and safe delivery practices.
“In villages, skilled mothers would deliver at home. Health assistants would monitor home deliveries and bring them to hospitals in case of emergencies,” says Dr Lalita.
Women preparing garments in Sittilingi Valley under Tribal Health Initiative. Photo courtesy: N. Bashkaran
By 2003, the IMR had fallen to 60, and further dropped to 20 by 2008, when Tamil Nadu’s average was 35 and the national average was 53. Today, the IMR of Sittilingi is 8.
Madeshwari’s life changed after one such village meeting in 1998. He studied only till eighth grade. When the hospital arrived, she knew she wanted to do something there. “Looking at my teachers and Dr. Lalita, I also wanted to be like them and achieve something in life.”
She took her SSLC examinations and joined the hospital as a health worker trainee. He was trained in delivery, surgery, out-patient and operation theatre. “In the beginning, one of us (trainees) would faint at the sight of blood. But, Dr. Lalita and Dr. Reggie trained us patiently, and showed us every step – from the mother’s arrival to delivery and beyond.”
Then came another big step.
focus on farming
At Sittilingi Organic Farmers Association (SOFA), one of the 700 organic farmers registered with the THI Partners branch in a laptop camera. “This seeding of biometric data is for authentication of organic produce from a particular farmer’s land,” says Manjunath, coordinator of SOFA and one of the initial community members of THI.
“In 2003, we conducted an external evaluation of THI,” says Dr. Lalitha. “One of the observations was that if what we want to achieve with IMR is that other social, economic and political determinants of health, such as food, employment and income (we must consider). Unless you address people’s economy, you cannot tell them what they should eat.”
“There were many complaints – schools not functioning, bad roads, transport and water. But a consistent issue was that farming was loss-making, yet that was all they knew,” explains Dr.Reg.
Farmers were initially resistant to organic farming due to fear of losses. But after two years of negotiations, four farmers took it on board and the initiative soon spread. SOFA was formed, which today represents 700 organic farmers in the Sittlingi Valley. Organic products from Sittilingi, including millets, turmeric, pulses and a variety of millet-based products such as biscuits and namkeen, are now a regular feature in organic shops.
Reviving a lost art
In subsequent years, THI’s focus on the local economy deepened. Sittilingi Panchayat also includes two Lambadi villages and one Dalit village. “I noticed that the rich art of Lambadi embroidery had vanished because no one wore that dress anymore,” said Dr. Lalita.
A little research led her to Neela and Gummi, two women in their seventies who had learned the art from their grandmothers. “They used to wear sarees, and their mothers used to wear sarees, but their grandmother was the last woman to wear the Lambadi dress,” he said.
He remembered this art and in 2006, 10 youth came forward to learn it. Thus Tamil Nadu Lambadi embroidery was revived. Porgai (which means pride and dignity in the Lambadi language), an organization of artisans formed in 2009, has been registered as a producer company this year with 70 shareholders.
“It’s an unfair market for crafts in India, and artisans don’t earn much. So we thought we’d do something different: create art that is seen and valued differently. They organized artist residencies at the home for 10 artisans, where artists come to live and learn for four months.”
This year, 20-year-old Sindhu graduated from NIFT, becoming the first design graduate from the Lambadi community. Similarly, women wanted continuous work, as agricultural opportunities were limited on marginal land holdings. Vanaville, a tailoring service society for brands, was born out of that demand.
THI’s high notes came in 2019, when it radically pushed the CHP’s boundaries in local self-governance. Health worker Madeshwari contested the panchayat elections and won by a margin of 500 votes. Madagapadi, a village with 50 houses located 55 km away, got many things for the first time during his tenure, including electricity, houses, water supply through over-head tanks. “At first, our friends thought we were crazy for doing this. But Madeshwari won and did a fantastic job,” says Dr Reggie.
Sittilingi Model
“We function as a secondary care hospital,” said Dr Ravi, one of the first doctors to join the hospital after a similar rural stint in Odisha. “In any population, out of 100 patients, 50 may be seen by a regular medical officer, another 30 will need a specialist, and the remaining 20 will need higher-level hospitals. A normal delivery should be managed by a good primary or secondary level health facility. That’s what we are trying to do. We are not trying to replace the government system, but trying to provide an alternative secondary care that may not be available.”
In 2018, a rural sensitization program was launched for 35 medical students and some doctors who came to stay in Sittilingi for three days to see how a secondary care hospital in a tribal area could match private hospitals in the city, but in a much more affordable and meaningful way.
“They go to villages, see villagers in their homes, see their lives and problems, and understand their access to health. They come back and discuss, and return changed and question why this is not part of the medical curriculum,” says Dr Reggie.
But doctors wanted more than just three days to make a life-threatening decision. So this year, a traveling fellowship for doctors was conceived. Dr Reggie says, “We spoke to organizations working in rural areas, slums and tribal areas. The traveling doctor would visit these places for two to three months and see how these organizations are dealing with the problems. With changing geographical conditions, diseases vary, and they get to see the real India. By the end of it, they are completely changed.”
Can the Sittilingi model be replicated everywhere? “The state can do this if it wants,” says Dr. Lalitha. “It has the infrastructure. But success comes from community participation. What is relevant for a tribal area like Sittilingi, which has a homogeneous tribal community, is not necessarily relevant for a taluk like Harur. People are different, and they have different perspectives. First of all, you have to sit and listen to the people. All our programs are run by local people, which is what makes them successful.”
According to Dr. Reggie, the Sittlingi model, as we now describe it, was a series of intuitive interventions that are now understood, leading to a certain level of health. “This is to show doctors that there is another way to deal with health. We have planted a seed; that seed should be taken and planted elsewhere.”
At the heart of the conversation was a single underlying thread: respect. Patients wanted respect, and so did the community. Clearly, this is where meaningful and sustainable change begins.
