Impact India Foundation is a global initiative supported by UNDF, Unicef and WHO, to assist in the prevention of disablement around the world. London practice Barbican Dental Care teamed up with the Foundation to provide essential equipment, and dentist Neil Sikka joined the team on board the Lifeline Express hospital train to provide free treatment to those in need in remote parts of India. This article is an account of his travels.
India is a vast and varied country, with a population of 1 billion, of which 70 million are disabled – more than the total population of the UK. I was looking forward to returning to my homeland and to working alongside those on the Lifeline Express. While the word 'Delhi' may conjure up images of crowding, poverty and sickness, Delhi domestic terminal was like any other European airport – all Jasper Conran-designed hotels, five star cuisine, designer shops and even a place to catch a coffee and a chocolate muffin. It seems Delhi has changed incredibly since my last visit three years ago.
After an evening of a good meal (where I choked over the wine list as luxury items costs three times as much as London but everyday living costs less than one third), I caught the red-eye flight from Delhi to Jabalpur in Madya Pradesh. Touching down in Jabalpur was a complete contrast. A solitary, simple, small plain concrete terminus greeted us surrounded by a barren, dusty landscape. Jabalpur is just like many other small towns in India. Low rise, an army presence and an air of tolerance from all those who go about their daily routine, especially when it comes to the traffic! Most importantly, it has a railway station.
Neelam Kshirsagar, the General Manager of Special Projects for Impact India, met me and took me immediately to the Lifeline Express. The train was parked in the sidings where a platform had been specially built, and consisted of six or seven brightly painted wagons. There were families milling around, waiting for their turn for treatment, not worried about the baking platform and 45 degree oven-like heat. A quick tour revealed two operating theatres with three beds in each, with waiting and recovery areas, three large, gleaming, industrial autoclaves, a lecture room, stores, office, changing, staff room and finally the dental room, all wonderfully air conditioned.
I was introduced to Zelma Lazarus, the charismatic CEO of Impact India. She explained that the Lifeline Express was here to provide free treatment for all but it could only be successful with the support and co-operation of the local community. Local hospitals had been contacted many months prior to arrival and teams of local orthopaedic, eye, cleft lip and ENT surgeons agreed to 'donate' their time. The local Hitkarni Dental College was also supporting the project. Led by the director Dr Dhiranwani and his team, they would be assisting me for the duration of my visit.
As only certain types of operations could be performed on the train, all patients had to be screened prior to commencement. The orthopaedic team alone saw over 3,000 patients to find 200 suitable cases! Zelma explained that the only way to really 'get things moving' was to go straight to the 'District Collector'. He is the area head of local government and in India holds a position of considerable power and influence. He agreed to mobilise his network of officials to ensure that all the town and outlying villages would be aware of the visit. The Collector also wanted to meet 'the dentist from London' and so at the duly appointed time he arrived for the inaugural ceremony for the dental suite. He assured me that he was committed to spreading the word and promised me many patients for the next day. To prove his point he brought along the local television station to do an interview with me, which was shown that night.
The following morning I was raring to go – I had not been this excited about going to work for years. So at 0900 hours on the dot I arrived at the platform ready, willing and able, only to find the place virtually deserted. Colonel Vishwen, who runs the The Lifeline Express, invited me into his office for a cup of tea. In the nicest possible way he explained that in India, when a doctor says he starts at 9am he never arrives before 10! As a result patients never turn up before 1015.
The team from the dental college arrived at 0930. I had thought they would send a dental nurse to assist me but to my surprise, two dentists, Dr Mangesh Ghate and the newly-qualified Dr Pratiba Patel; a hygienist – Amos; and our nurse, Reena, welcomed me. Dr Ghate explained that as it was my first day they wanted to ensure I was fully supported! He proposed that as it was likely to be very busy we should concentrate on those most in need. Dr Patel and he would initially screen the patients and any non-urgent cases would be asked to return at a later date. Anyone else would be given a written prescription for treatment. This was of enormous assistance as my Hindi is terrible and most patients were speaking a local dialect (one of the 1,500 in India).
True to the Colonel's word, at 1015 the first patients arrived and by 1100 we had a queue of 20 people. We turned the lecture facility into a waiting and post-op room. Extractions and scaling were the order of the day. Many patients had never visited a dentist in their life and most had travelled enormous distances to be treated. By lunchtime I had removed more teeth than I had in the past ten years. I was thankful for the pristine ultrasonic scaler, which enabled me to provide some first time scaling. All those I treated were incredibly grateful and remained stoic despite the considerable pain they had been in (probably for some years).
Some of those I examined had difficulty in opening their mouths and, on further investigation, I noticed clinical changes on the buccal mucosae consistent with chewing tobacco and betel nut. Dr Ghate later confirmed that they see many cases of submucous fibrosis at the dental clinic. I remained on the train for the next two days, after which it was time to hand over to Dr Ghate and his team who would be continuing the service for three weeks.
By the end of my two days, we had seen and treated 62 patients for dental problems, a number which rose to an impressive 334 at the end of the three-week clinic. The medical teams on the Lifeline Express also treated 405 patients with eye problems, over 100 for cleft lips, 83 patients with ear problems, and 211 sufferers of polio; in total a staggering 1,134 patients were treated.
Impact India's ultimate aim is to raise awareness in communities about the benefits available to them by encouraging them to demand treatment at local and regional health centres. Most poor Indians are illiterate and unaware of their right to treatment. For instance, in Madya Pradesh, those below the poverty line are entitled to £300 of treatment a year, paid for by the state. While funds are available to treat those below the poverty line, less than 10% of allocated finance reaches those in need.
On my final day I asked Zelma what her ultimate dream for the Lifeline Express would be. She replied, 'Neil, I hope that one day the train becomes defunct. If we can educate and inform people of their rights, treatment will be fully provided locally and our train will be surplus to requirements.' Here's hoping!
The Lifeline Express is the world's first hospital train. To date over 500,000 patients, living in the remote rural interiors of India where medical facilities are scarce, have been treated. Last year Impact India introduced dental services as a trial measure on the Lifeline Express at Mandsaur, Madhya Pradesh State. Patients received free treatment for scaling, fillings, extractions and minor surgeries and biopsies of a few patients were taken for diagnosis. This trial project showed that there was an urgent need for dental healthcare and so Neil Sikka has donated funds to cover the costs of items such as a hydraulic chair, an oil-free compressor, a scaler with handpiece and other essential equipment. For his next trip, Neil already has a list of further equipment needed, including more syringes and cartridges, sprays for disinfection and tissues, and sharps bins. His thanks go to Claudius Ash for donating 500 much needed toothbrushes, all gratefully distributed. For further information on Impact India, visit http://www.impactindia.org.
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The benefits of international volunteering in a low-resource setting: development of a core outcome set
Human Resources for Health (2018)