Choosing Allyship over Saviourship !

Dear readers, I am Priyansh Nathani, a medical graduate with a passion for global health and surgery, resource-limited settings, and equity. When I am not working, you can find me indulging in my hobbies of gardening, cooking or perhaps playing football. I am sharing my experience and learnings from working in the field of Jashpur for improving maternity care with a focus on caesarean delivery in Jashpur district of Chhattisgarh, India. It is a district with a total population of 9,50,000 and an area of around 6000 square kilometres located in the northeast corner of Chattisgarh- a scenic beauty with stunning landscapes and beautiful flora and fauna.

Differentiating between volun’tour’ism and volunteerism- Limitation of personal experience

While travelling through various forests, rivers, and visiting remote hilltop villages and health centres, it was crucial to distinguish between volunteerism and volun’tour’ism during our work in these areas. This experience is just on the basis of 1 month’s stint, however, the local team has been engaged in the same work and much beyond since decades!

My experience hereby was just a small part of the entire experience of a local person working in Jashpur for years and can in no way reflect all of the difficulties faced by the local healthcare providers, administration, or the community in general on a daily basis. In full disclosure, this experience helped me more than me helping the community. Once I feel like a know-it-all person, I realise that it is a fraction of what the community has to offer. I faced this issue yet again in my life as I share my experience here. And trust me, I still have a lot to learn, unlearn and relearn!

To Save or to Ally? That is the Dilemma

Let me address the elephant in the room as I am still figuring it out- Who am I in this blog? Definitely not a hero, do not worry, it is not always a black and white view, so I am not a villain either. What is it? The dilemma of saviourship vs allyship is difficult to resolve in my mind. In parallel, I also believe it is all about our mindset and organisation of thoughts, how we take any experience in our lives- a digression from our conventional life goals or a unique learning opportunity to enhance life and define our positions in various scenarios.

Unsung Healthcare Heroes: Not Just in the Movies Anymore- Collaboration over individual heroism.

I have come to realise that the idea of me being here solely to serve the people is not appropriate. Rather, adopting a mindset of helping myself while empathising with the beneficiaries allows me to do more for them and myself. With a sense of solidarity and collaboration, useful outcomes can come to life. Single or a team of 2-10 heroes concept are for the movies who win the battle at the end of 2 hours and gets the public applause and box-office success. I am not looking at these ‘conventionally’ celebrated ‘celebrities’ in a condescending way, I relax on several days through movies in theatres and weekends with Netflix, they are phenomenal, influential and integral part of my memories and my life. But I just identify the disparity and there are several ‘champions/celebrities’ who are inspiring and unsung heroes who are ‘unconventionally’ ‘not’ celebrated from the grassroots serving thousands and millions of people as healthcare professionals or otherwise.

Unpacking the Health Puzzle: When the pieces initially do not fit!

Before my visit, I had to don my detective hat and bridge my knowledge gap with local data and learning materials. Of course, working out the logistics such as travel and food with the team was also on the to-do list. Understanding the local context was key, as well as global health understandings – I did not want to be the health equivalent of a tourist with a fanny pack and a camera. And let us not forget about setting expectations – because disappointment is not a souvenir anyone wants to bring home. Every person’s experience is unique, and expectations cannot be the same for everyone but we also cannot expect all the facilities we get in privileged settings. As I started delving into the district’s health puzzle, I thought I only had to solve one piece – the mystery of low rates of caesarean sections. But as any good detective knows, one clue leads to another and soon enough, I was facing a whole Pandora’s box of interconnected issues – it was like a spider’s web. Navigating through all those interrelated problems without getting overwhelmed was a challenge, but prioritising and avoiding deep dives into too many issues was crucial. After all, too many priorities equals having no priorities, and that leads to no outcomes except maybe ‘anxiety of no performance’ as an outcome.

From Mangoes to Coconuts: A SMART Approach to Work

To make the most of my one-month visit, I decided to categorise my work into two types of fruits – low-hanging and high-hanging. The low-hanging fruits were tasks that could be achieved quickly, like picking ripe mangoes off a tree. On the other hand, the high-hanging fruits required more time and effort, like trying to reach a juicy coconut at the top of a tall palm tree. Working in rural regions is no walk in the park, but a SMART approach can help make things more manageable. To achieve our set goals and expectations, our team had to be Specific, Measurable, Achievable, Relevant, and Time-bound. It is like following a recipe for success – you do not want to end up with a half-baked cake.

From Tetris to Marathons: Tackling tough terrains of Jashpur

Healthcare is like oxygen, a basic need for survival, and just like oxygen, it should be available to everyone. Our team wanted to make a meaningful impact just like any other person coming to serve in an austere setting, so we decided to have a pragmatic approach and focus on three locations to operationalize caesarean sections that had a high number of pregnancies and institutional deliveries, and were also located in distant and challenging geographic areas. One of these locations, Bagicha, was so tough for a fellow like me, that even Bear Grylls would have to think twice before venturing in some of its remote locations where the community resided! It is important to remember that what may be seen as an adventure to some can be a daily challenge for the locals, and it is essential to approach these experiences with sensitivity and respect for the local community. Additionally, it was an area with more of tribal population (Particularly Vulnerable Tribal Groups (PVTGs)) having low health seeking behaviour. While opening the pandora’s box here, we opted for a brownfield approach in its community health centre- means working with the existing infrastructure and making necessary changes in a cost-effective manner. We observed a scarcity of both specialists and paramedical staff not only in this specific area but throughout Jashpur district, of which this location was just a small fraction. We worked closely with the local team to ensure that all necessary equipment and consumables were made available and that the arrangement of equipment in the operating theatre was improved. It was like playing a game of Tetris, but with real-life equipment!

Careful planning, coordination, and consideration of all relevant factors, helped us overcome significant challenges like the remote location and road conditions while planning out the visits. It was like running a marathon, but with extra hurdles along the way. But, with the help of the local team and our own determination, we were enabled to successfully achieve our mutually set goals with relative ease.

In the end, it was not just about improving healthcare facilities, but also about motivating the local team to take ownership of their work and strive for excellence and most importantly, learning ourselves in the process.

Dismantling the ‘God-Like’ perceptions and pedestals

As healthcare providers, we may also be considered as beings with some god-like powers, but let us not get too carried away. We are not omnipotent, and we certainly cannot cure everything with the snap of our fingers. I realise that it is essential to remove any cultural, social, or language barriers that may exist and not to misuse the honorifics like “G sahab” or “G madam”. Recognizing the significance of adopting a “explain it to me like I am in sixth grade” mentality to uncover gaps in our comprehension is essential. To effectively communicate complex concepts, it is important to use simple language that can be understood by everyone. We need to simplify our learnings and avoid using jargon that may not be understood by the local community. We are not here to impress, baffle and confuse. With simplifying language, this involves gauging the person’s comfort level. When visiting a new place, it is important to introduce oneself in a non-threatening way, establish rapport with locals and have relaxed conversations in their interest areas. This approach helped me as an outsider to make it easy for people to open up and express their complete issues while appreciating the ongoing efforts. Attending meetings, observing and hearing more than speaking, obtaining statistics, and conducting facility visits were additionally essential to understanding the local community’s priority areas.

To improve healthcare in such a remote area, we took a systematic approach – no fastest finger-pointing and assigning blame which may be faster but provides self satisfaction. Instead to be problem-solving which takes slightly more time consuming and is mutually beneficial and positive. Recognizing the importance of understanding the local context, managing logistics, having realistic expectations, being flexible, and prioritizing tasks effectively is prudent in order to have a successful and impactful project.

In conducting the facility assessment, a prioritised checklist of available equipment, in-person facility assessment, and qualitative notes of interactions with local health staff should be prepared. We first identified the equipment needed and ensured that the healthcare workers knew their way around them. Ensuring the availability of equipments and supplies, we did not want to leave any stone unturned (or any scalpel missing, for that matter) when it came to patient care. To apply the 5S health system model in Jashpur, we need to consider the five elements: staff (skills), stuff, space, systems, and social support.  Understanding these aspects can help in identifying and addressing issues specific to that particular healthcare setting.

Additionally, a team exercise was implemented after discovering the problem of workplace management while uncovering the interconnected issues within Jashpur’s healthcare system, which was akin to opening Pandora’s box. Participating teams of field workers were able to improve their warehouse and workplace organisation and management to better access and distribute the equipments, diagnostic kits and other consumables. And guess what? They could do it without pointing fingers or placing blame – talk about a productive and positive environment! Disorganised equipment arrangement was making it hard for them to do their job effectively. But by implementing a standardised 5S (sort set, shine, standardise and sustain) model and reorganising the workspace in a cheap and time-effective manner, they achieved small wins that contributed to a positive attitude for achieving bigger successes and a more collaborative team. Sustainability is also key. By making small improvements with long-term benefits, organisations can create a culture of continuous improvement that leads to greater productivity and success. Plus, why reinvent the wheel? Utilising existing tools and techniques can make a huge difference in the long run. As we know that by keeping it collaborative, sustainable, and using what works, we could build a team that is ready to take on anything!

Rolling Up Our Sleeves: A Key to Integration and Avoiding Alienation

As I delved deeper into our work, I came to the realisation that it was not just a one-and-done checklist. We cannot just check off the boxes and leave like we were at a grocery store and feeling all gratified. Trying to save the world in a rural healthcare setting may sound heroic, but it is not all sunshine and rainbows. I realised that it demands a lot of consistent coordination, effort, sensitivity to local needs, appreciation for cultural nuances, willingness to learn and adapt to the local community’s needs. However, if approached with the right mindset and attitude, it can be a valuable and fulfilling experience that teaches us invaluable lessons for life and enables us to do more. Local champions show that long-term commitment and sustainability are essential to provide meaningful and effective healthcare to rural communities.

Getting our hands dirty does not mean we have to wear gloves all the time. Sometimes it is better to roll up our sleeves and get down to business. And if we do get a little dirty (with good intentions), that is okay – it is all part of the job. It is crucial to think in terms of the person standing last in line, to try and understand the needs of everyone from a pregnant woman from a particularly vulnerable tribal group in the most isolated part of the region to the most senior government officer of the region in the most accessible part of the region. Understanding the big picture and getting into the details is essential to make a difference. I believe we must not forget to be grateful for what we have – after all, there are always people out there who would break boundaries for our problems!

Identifying the issues and learning from past incidents is vital. The goal is to improve and to focus on what we can do from here on because there is a lot to do, not to award a contestant who can spot the most number of mistakes.

Communication, Collaboration, and Cricket Jerseys Can Make a Difference!

This experience as mentioned taught me the importance of communication, empathy, and understanding the needs of the local community. We must be mindful of the cultural, social, and language barriers that may exist and approach our work with humility and a willingness to learn. Our project in Jashpur was just the beginning, which motivates me to continue bringing quality healthcare to people who need it the most.

My trip to Jashpur was a wild ride, and not just because of the bike ambulances I hopped on! The real gem of the experience was the people (virtually and in-person) I met along the way, from team members on zoom calls to new friends in broken trains to the district administration and community striving hard in healing health systems. It was a reminder that collaboration is key to success, but also that I must never stop learning from the world. Moving forward, there is a perennial need to document our strategies and resources to avoid reinventing the wheel and transfer the learnings across. We can also continue offering support, borrowing strategies from other success stories and to build on the progress. In the end, this journey taught me to appreciate the beauty around us and I am excited to see where it takes me next!

Coming to where we began. Who am I here? Well again, I would not say I am the hero or villain of this story. I am just a small piece of the puzzle trying to make a difference. But I do believe that every little effort counts, and sometimes, it is the small things like wearing a cricket jersey in Jashpur’s cricket match, that can break down barriers and bring people together. There are many nuts to be fixed. We can start by fixing one at a time and hand over the wrench when needed while making sure the usage method is shared.

Can I be just an ally? In this journey, I realise, I am perhaps a catalyst ally, just trying to fast track and stabilise the already ongoing reactions by bits. The reactions shall continue regardless….

-Dr. Priyansh Nathani,

MBBS, WHO-CC Global Surgery Fellow.