Dr Roshine Mary Koshy in the Makunda Hospital: ‘Serving the poor is like swimming upstream. You have got to keep going’
Dr ROSHINE MARY KOSHY | Makunda Hospital
Civil Society News
WHEN you are a highly qualified doctor who lives and works in a remote corner of northeastern India, chances are that you have gone a long distance in life. It is so with Dr Roshine Mary Koshy. She grew up in Kerala, studied at the Christian Medical College in Vellore, spent a year in Jharkhand and now heads the Makunda Hospital at Bazaricherra in the district of Karimganj in Assam.
Dr Koshy is 38 years old and an MD in internal medicine. Hers has been a restless search to find meaning in her career as a physician by serving the poor. If she weren’t a doctor, she would like to be a teacher or a nurse, she says.
But being a doctor has been exceptionally fulfilling. It has meant being able to save lives in difficult conditions with often very little to fall back on. It has enabled her to live among tea plantation workers and tribal people and discover what it means to be like them, on the periphery of a nation.
She has also come across medical conditions which she might not otherwise have. For instance at Makunda she has found a widespread thiamine deficiency caused by diet. Her life as a doctor has taken her into different cultures at the grassroots. She has had to overcome language barriers though she has a good knowledge of Hindi, which she learnt in Kerala.
At the Makunda Hospital, she takes over from Vijay Anand Ismavel and his wife, Ann, both doctors, who have spent 30 years of their lives turning a derelict hospital into a modern and affordable facility. Dr Koshy has spent six years in Makunda and she has pledged at least 10 years of her life to the hospital as its chief executive officer.
Q With all your degrees from CMC Vellore, why have you chosen to work in rural hospitals?
I always wanted to work with the poor but not necessarily as a doctor. There were three professions that I looked up to: doctor, nurse and teacher. In my mind these were the ones that could really change people’s lives. It was just natural for me to go to a rural area after I graduated in 2013.
I approached Emmanuel Hospital Association to work for three years in the neediest parts of the country. I spent the first year in the 75-bed Nav Jivan Hospital in Palamau district of Jharkhand. After that I was transferred to Makunda Hospital in Karimganj district of Assam where I am currently working.
Q Jharkhand must have been a big surprise for you. Was it tough?
I don’t come from a medical background so, yes, it was a surprise. I had read about the dire situation of health services in rural India but actually witnessing it was overwhelming. We would see a lot of patients, especially children, with snakebite. The krait would have bitten the child at night and they would come with the child, already dead, in the morning. It shook me. We were the only hospital in the area equipped with a ventilator. I thought our medical system was so complacent and unjust.
Q Do you remember your first patient?
No. I just remember this one patient, an eight-year-old girl with seizures. She was very sick and I advised her family to take her to Ranchi for treatment. My colleague told me a while later, ‘Why did you say that, this tribal family will just go home. They won’t go all the way to the city. They will go home and let the child die.’ I felt terrible. Life had no value here. This was a huge shift from the training I had received in Vellore. The challenges of working for the poor really struck me then.
Children used to come to the hospital in their school uniforms. I thought the child must have fallen sick in school. The truth was that those were the best clothes they had. I used to get angry with them because they would come for treatment to the hospital only when they were really, really sick. But when I went to their villages I realized why. They lived in such remote locations. If I was in their place and fell ill, I would also think twice.
The community here didn’t know anything about the human body. I still remember a man who brought his 22-year-old son to the hospital. The boy was very seriously ill, on ventilator and support systems. I explained to the father that his son’s heart was not working, neither was his brain, his kidneys had collapsed. He replied: “Lekin baaki sab toh theek hai, sir” (But everything else is okay, sir).
Q What was the disease burden there?
People basically came with a lot of preventable illnesses. Children suffered from diarrhoea and had dehydration. Whatever I saw while practising in CMC, Vellore I saw in Jharkhand. Except that you don’t have any back-ups or any resources in Palamau.
Q And then a year later you came to work at the Makunda Hospital?
In 2016 I joined the Makunda Hospital. I felt it was the right place for me. Dr Vijay’s Makunda model is one of the best solutions to equitable healthcare in rural India. I never wanted to do pioneering work. I wanted to continue someone else’s work because I’d read biographies of people who started such work with great commitment. But there was no one to take it further. I wanted to be that bridge person. Makunda’s philosophy was very similar to mine.
Q And the Makunda model. What does it mean?
The Makunda Hospital did not just focus on the poor and the marginalized, they actually had a bias for them. The management put it into practice. The hospital has only general wards and no private wards. All patients, whether they are rich or poor, get the same treatment, irrespective of their capacity to pay. I feel that gives dignity to the poor. They stand in the same line as the rich, get the same treatment and see the same doctor. In Jharkhand that was not the case. In most mission hospitals, private wards subsidize the general wards.
Dr Vijay told me that when they first talked about having only general wards, they were ridiculed. They were struggling financially at that time so to take that decision, not to have a cross-subsidy between general wards and private wards, was a very radical decision.
There were two reasons they decided to go ahead. One was Mohammad Yunus’ book, A Banker to the Poor. After a lot of research, the book concludes that when NGOs in Bangladesh introduced facilities for the rich then down the line, unknowingly, the poor were edged out. So, having the same facility for two sub-populations is not a great idea.
Secondly, when I used to treat my patients in the general ward in Jharkhand, there would be this one patient who would say, Give me the medicine that you’re giving the person in the private ward. He thought he was being given substandard care because he had paid less and his medicines must be of substandard value.
In the Makunda Hospital the poor feel welcome because they are not treated differently and they don’t have a problem paying the bills. What is interesting is that this is a financially viable model. All our income comes from patient revenue. It’s the large volumes that really help us. Our donor dependency rate is less than one percent. The fact that it’s sustainable is a real plus point.
Q Which poor communities come to the Makunda Hospital?
In Jharkhand just one tribal population would approach us but in Makunda the patient population is very heterogeneous. You have Muslims, Khasis from Shillong, Manipuris and the tea garden people. It took me a year to understand the different communities. Each has their own way of expressing themselves and their perception of illness differs.
I have a soft corner for the tea garden community. I see them as my Jharkhand patients who were brought from UP and Bihar to work in the tea gardens because the local Assamese people didn’t want those jobs. They spend their whole lives in the tea gardens, it’s like modern slavery. Locals don’t care for them and the tea garden managers exploit them. I felt God has given me a small Jharkhand to take care of. When they tell me they get good treatment here, I feel happy.
Q Are there any illnesses specific to this region?
A lot of people, especially pregnant women and breastfeeding mothers, have been coming to the hospital with peripheral neuropathy. They have weakness of the limbs and they come in wheelchairs. Over the years people postulated various theories. In 2014 or so, collating inputs from clinicians, we suspected it was due to thiamine deficiency.
I’ve studied thiamine deficiency in books, but I had never seen it. When we started treating patients with thiamine supplements, they improved quite rapidly. We collected data and showed it to the government. It’s a preventable illness, easily treatable, mostly seen in refugee camps or war camps but not in the general population.
We didn’t have a paediatric doctor for eight months. I was taking care of that department. Babies, two or three months old, seemingly healthy, would be admitted to the ICU and die in a matter of days, no matter what you did. We started giving them thiamine and they got well almost miraculously. We were able to identify a preventable cause of death in children and save them.
There is great evidence to show that if you tackle thiamine deficiency in a population, your infant mortality rates will go down dramatically.
I felt we should inform people quickly. It must impact our nutrition policy. But here things are moving so slowly. If this had happened in the city people would have acted swiftly. Our hospital is treating patients with thiamine deficiency but I fear other hospitals are not. Mothers in most rural areas wait for one or two days to see if the child will recover before approaching the hospital. By then the child may die. We are seeing only the babies who manage to reach the hospital.
Q This deficiency is due to nutrition. Can’t it be corrected with the right information going to the community?
It is due to nutrition—the large amounts of rice they eat and fermented dry fish. Both are supposed to contain thiamine inhibitors. The government said they need to see a study carried out in the community. Our studies are all hospital-based. We are partnering the National Institute of Nutrition (NIN) in Hyderabad for a study but the funding has not yet come. Research in rural areas is not a priority at all. We will do a study in the community with them to create scientific evidence, but, meanwhile, we can just start educating and creating awareness. I went to attend a meeting with the district administration. I told them we are seeing thiamine deficiency. No one believed me.
Q But couldn’t this deficiency be prevented if the community knew what foods they should eat and what they should not eat?
Changing the food habits of the community, whether tribal or otherwise, is very difficult. I do tell them. But unless the government agrees that there is a problem, people are not really going to listen or think about it.
Q Tell us about your family.
My dad is a priest of the Marthoma Church. My mom is a teacher and we are three sisters. My inspiration is my granddad, also a priest. I was inspired by his simple life. He was always there for people. I grew up reading biographies. I was most inspired by Mother Teresa’s biography. My work and experiences have changed me. You know life is not in your hands. You see so much suffering around and you realize it could happen to you too. It’s very humbling. And I don’t like people romanticizing poverty. It’s just a brutal fact. Working for the poor is like swimming upstream, but you have to keep going.
Q What are your priorities right now in the hospital?
We need consultants to stay on so that departments can grow. Obstetrics and pediatrics has grown. I want to improve ICU care. That needs some investment. I also want to ensure research questions on thiamine deficiency are all answered. Third is a question I’ve not been able to answer: how do you ensure commitment and hard work are values that are passed on?