On the outskirts of Tarwadih vil-lage in Jharkhand’s Latehardistrict, a path winds throughpaddy fi��elds and leads to

Bhuiantola, a hamlet where Bhuian Da-lit families live. That month, four resi-dents of Bhuiantola hamlet were beingtreated for tuberculosis (TB), a bacterialinfection that mostly aff��ects the lungs.

Radha Devi, the village sahiya or fron-tline health worker, an Accredited So-cial Health Activist (ASHA), was walkingdown the village path and hollered outto Ramavtar Ram, a farmer in his 50s,who was working in the fi��elds. “Ninenumber medicine course is over foryou,” she said. “You will now be on CP.”Ram had contracted TB six months agoand looked emaciated from theinfection.

Stepping in Devi, who has been supervising Ram’streatment for the past six months, is nota trained doctor or nurse. She has stu-died only till Class IV and is one of theover 1,325 health activists appointed un-der the National Health Mission’s com-munity health programme in Latehar. “Iam not fully literate, but I recognisemedicines through a number or an al-phabet in the drug’s name,” Devi said,explaining how she had memorised 13long and complicated names of TBdrugs.

TB can be fully cured with a six-month antibiotics course. But India ac-counts for a fi��fth of TB-related deathsworldwide. In Jharkhand alone, nearly40 people die of the disease every day.The government has recognised that pe-ople in remote tribal districts, with pooraccess to nutrition and medicine, are apriority group.

Jharkhand’s Adivasi villages lack criti-cal healthcare infrastructure. RajabauYole, a World Health Organization TBconsultant working in Jharkhand, saidthat although every community healthcentre is supposed to have an X-ray ma-chine and a courier service to transportsputum samples for testing, these aremissing in most districts.

Then there is also the major shortfallof doctors. Raksh Dayal, Jharkhand’sState TB offi��cer, said the State has only2,200 doctors (of 3,400 posts) and onlyhalf the required contractual healthstaff�� for the treatment programme. InLatehar, one of the poorest Adivasi re-gions in Jharkhand, 13 of 23 posts in thedistrict TB hospital have been vacant for

fi��ve years, including the post of TB med-ical offi��cer.

It is here that health workers like Rad-ha Devi step in to fi��ll a critical gap.

Deadly smoke Latehar families are especially vulnera-ble to TB because of their work. Whenthe season’s paddy harvesting is done,they migrate for work to the brick kilnsin Benaras in Uttar Pradesh and Auran-gabad in Maharashtra. Here they are ex-posed to smoke that damages lungs andreduces immunity to many infections,particularly TB.

In fact, before Devi was chosen as the

sahiya in 2007, she too worked in brickkilns. The contractors off��er ₹��10,000 to₹��12,000 as an ‘advance’, but there areno regular wages. “At the kiln sites,away from towns, there are no health fa-cilities,” said Devi. “Besides, many peo-ple do not complete the treatmentcourse. Some don’t like the taste of themedicines, others worry about theside-eff��ects.”

In Tarwadih, Devi met Bartu Oraon,who has had a relapse. Then she coun-selled Neetu Devi, a young farm workerand patient, who had recently delivereda baby boy. Devi advised her to coverher mouth while breastfeeding to pre-vent the infection from spreading to herbaby.

Teaching precautionsDevi has been trained by the TB hospitalin Latehar. “I ask patients to take pre-cautions, to use ash to cover their spit,or cough only into a gamchha and boil itin water to prevent the infection fromspreading.” And to cover the after-taste

of drugs, she even buys them packets ofnamkeen, she said, showing me a smallpacket of snacks she was carrying for apatient.

Among the more serious patients,Mohan Bhuian, also a brick kiln worker,developed multi-drug resistant tubercu-losis, a more deadly form of the diseasethat develops when a patient gets in-complete or inadequate treatment. Thismakes the most powerful TB drugs inef-fective, and it needs a protracted two-

year treatment with highly toxic drugs.This deadly strain can be passed to oth-ers through close contact via air dro-plets in much the same way as regularTB.

Always there“The sahiya has been coming home togive him medicines every day,” said Sita,Bhuian’s wife. Devi travelled twice withher husband to Itki, 110 km away, wherethe government runs a sanatorium. Af-

ter nine months of treatment, Bhuiannow had enough strength to walk andhad taken the cattle out to graze. But hisfamily was anxious: one of the medi-cines had impaired his hearing.

The medicine can also make patientsdepressed, paralysed, or completelydeaf. “Sadly, I have seen Mohan gothrough all these stages this year,” saidDevi.

When he started to display theseside-eff��ects, Devi went to Itki a secondtime to act as his counsellor. “Mohancalled me and said he feared he was go-ing to go mad,” she said. “I felt he waslike my son; I was worried.” The govern-ment staff�� did not pay her anything butBhuian later reimbursed her the ₹��400she had spent on travel.

As a sahiya, Devi is supposed to get₹��100 as ‘incentive’ for each TB case shereports. She has heard that the govern-ment has promised to double the incen-tive and the honorarium this year. Butnothing has happened yet. “I have notbeen paid anything for more than ayear,” said Devi. But she was soon upagain, ready to see a new patient.

The writer received the REACH fellowshipon TB.

FIELD NOTES

Interpreter of a maladyIn one of Jharkhand’s poorest districts, a village health workeris the only one watching over TB patients BY ANUMEHA YADAV

Critical gaps (Clockwise from above) Villagers in Latehar line up to cast votes;students cross a makeshift bamboo bridge on their way to school; Radha Devi(centre) with a patient’s family. Manob chowdhury

<>‘Mohan called me andsaid he feared he wasgoing to go mad,’ saidDevi. ‘I felt he was likemy son; I was worried’

<>To cover the after-tasteof drugs, she even buyspatients packets ofnamkeen, Devi said,showing me a smallpacket of snacks