How did you keep your idealism alive for 40 years?”
Our question surprised Dr Sudarshan. Four decades of work would have been an event anticipated and elaborately publicized in many quarters. It hadn’t even crossed his mind. All the response that Dr Sudarshan had for us was “I graduated in 1973” and after a brief calculation, “Mmm….yes…its been 40 years”.
We weren’t letting it go so easily.
Medical Colleges, more than perhaps any other course, get a large number of students who join with an intention to genuinely help the poor and suffering. As they ripen, unnoticed, with the weight of added responsibilities or the gravitational pull of commerce, many drop away from the mother tree of idealism.
What made Dr Sudarshan stick to the idealistic path?
We were at his simple Jayanagar office. As we entered, we were scanning for at least a large corner room. No, he was sitting at a rather nondescript desk, pen held over a page, methodically going through the contents.
When we persisted with our question, he suggested we come to BR Hills, where it all started. Actually, as he later explained, it started much before that.
His motivation to serve as a doctor was derived from his first hand experience of absolute helplessness one could feel without proper medical support. He had seen his father, right before him, die due to lack of medical attention following a heart attack.
When he was in medical college, it was all about preparation for the mission, or even adventure, he had chalked out for himself. He was clear he was going to serve in some remote area. An area where there were no medical facilities at present. Vivekananda’s writings provided him the energy, as they would even after he graduated. He concentrated on equipping himself for his future role.
While the typical MBBS syllabus was important, he wanted to add some specific arrows to his quiver.
He was all attention during his posting in the dental department. Diligently hanging on to every instruction. At the end of it, he knew how to extract teeth, or do simple fillings. This was going to be helpful he knew, wherever he was going.
He focused and went after acquiring surgical skills way beyond what normally is picked by MBBS students. He knew this would come in very handy on his mission. He spent time, not just on opening abscesses, and suturing surgery, but also other procedures that he thought may come in handy like skin grafts, appendectomy, tracheostomies etc
Poring over Hamilton Bailey’s Emergency Surgery, he decided a low cost defibrillator would be handy, and figured out how to build it. You never know what you may require. Especially since you didn’t even know where you were headed !
And so it went on during his entire MBBS course. He was stocking himself up for the long and exciting journey ahead.
After graduation, his search began for a place worthy of all the preparation. He even toyed, very briefly, with the idea of becoming a monk at the Ramakrishna Mission. At the end of a journey that took him to remote parts of India, he chose Biligiri Ranga Betta (or BR Hills) – the forest area home to the Soliga tribe. There was no road back then; one could only trek through the jungle.
The Soligas had no medical facilities, and to make matters truly desperate, repressive laws had evicted them from their home, the forest. This was where Dr Sudarshan would serve. Devoting himself to the healthcare needs of the guileless Soligas.
As it often happens, things don’t always run according to the script. The Soligas would have none of it. All cures should involve local herbs and also invoke the supernatural to resolve any issues related to it. What was this strange system of tablets and solutions that are merely handed over being advocated by the newly arrived doctor? They fled.
In a pattern that was to repeat itself several times later, Dr Sudarshan was up for the challenge. His passion was strong enough not to be intimidated by a need to change attitudes. He would go to each settlement of the Soligas and convince them.
He set up base in BR Hills. His home being an 80sqfoot hut (shown alongside). It was built on top of a rock , the elevation meant that it would be unreachable to elephants, keeping him safe. Given that many of the patients he hoped to treat were those attacked by bears, boar, and other wild animals, it is debatable how safe one would be with protection just from elephants.
The first step in convincing the tribals about his allopathic approach would require him to meet them. They were scattered all across the forest, living in small groups. The forest department gave him a list of Soliga settlements, called podus.
Sure enough, the Soligas were not to be found there, as their practice of itinerant farming had seen them move with every harvest.
It was persistence that made him find them, and then a rare compassion that made him understand them, their problems and their fears. It was to be his trademark in dealing with other groups later in his journey.
Despite physically and mentally taxing efforts, progress was very slow. Passion and patience need to co-exist, and they did in Dr Sudarshan. Sure enough, word of one or two instances of dramatic interventions by him in snake bites and the like soon started going around. He supplemented his treatments over that of the traditional faith healers. Dr Sudarshan’s bond with the Soligas flowered, and they came a bit more readily for his treatments. All the trekking through the jungles , having several narrow escapes from wild animals began to slowly start paying off.
Even today, his efforts are to approach all systems of medicine with an open mind. He feels happy when the Soligas give the traditional cough syrups a go by, and are able to just as effectively get relief by boiling 2 or 3 leaves of a particular herb and drink it. Integration of different systems of medicine, including the Soliga herbs, was accomplished wherever they were found useful. As they had documented, several Soliga herbs were useful from bites and allergies to post-partum recoveries and fungal infections.
His clinic was the space on the rock outside of his hut, that is, when he wasn’t visting the Soligas in their podus. The Soligas had a literacy rate less than 3%. So, in the evenings, his hut doubled as a classroom for half a dozen Soliga children, increasing his involvement with their community.
Slowly, but surely, his contribution was going beyond just treating the Soligas to looking at their other important needs. The doctor was not just providing a service, but, was an important part of the community.He soon moved from just curing the patients who came to him, to searching out diseases that afflicted the tribals. His own “tribe” of followers was also now growing, and they fanned out on community surveys.
Innovation was always necessary at every bend in the road.
Dr Sudarshan found that a large number of the Soligas were suffering from Sickle Cell Anemia or Sickle Cell Trait. To bring them all the way to Bangalore for diagnsosis, where a medical college had an electrophoresis machine was prohibitively expensive. With his brother, an electronics engineer, Dr Sudarshan designed an electrophoresis machines, locating cheap sources for platinum wires, gel etc and put it all together, for around Rs 400 !
A small clinic was started in the foothills. To include even the surrounding villagers into the fold of Dr Sudarshan’s activities. The Karuna Trust (KT) was formed for rural development. This accelerated the move into Community Health projects.
The rural children would develop convulsions in the weekends. This mystifying behaviour was solved with great support from that “genius of clinical diagnosis” Dr K S Mani of NIMHANS. It was identified as Hot Water Epilepsy. Intravenous administration of Diazepam was too difficult for the minimally trained assistants of those days. Dr Sudarshan found that sublingual administration was effective enough. A pharmaceutical giant had offered free drugs for the epilepsy treatment, but, fearing that problems would arise whenever the plug was pulled by them, he and Dr Mani settled on two much cheaper substitutes, Phenolbarbitone and Phenytoin. Fortunately, even these were later donated to by the Indian Epilepsy Foundation, Bangalore.
Tuberculosis was also indentified as prevalent in the rural community. Again, a survey was done by the community as a starting point for the assault on Tuberculosis. The approach was again very resourceful. He had no X-Ray. Reliance again was on very good clinical diagnosis skills. Auscultation. Dr Sudarshan had already come prepared, and could collect the sputum and stain for the microscopic evaluation for diagnosing TB. The greater part of their effort was devoted to ensuring that each patient completed the full round of medication, as several tended to stop when they felt better.
The Soligas were in touch with some of the villagers at the edge of the forest. Leprosy was sometimes picked up because of that. Again, he involved the community to first survey, then disseminate information to ensure the affected were brought for treatment, and finally, tailor the treatment regimen so that it’s easy for the patient, and is effective.
It was realized soon enough that supply of qualified personnel was very limited for working in these conditions. Clarity on knowing the limitations and working well within them, and innovating on processes became the approach he followed. However, this level of healthcare was delivered in a highly competent manner, and consistently. Paramedical staff were used for meeting these limited goals. Great emphasis was placed on preventive aspects of medicine. This was a crucial step that allowed the model to be scaled up with ease. Dr Sudarshan is on the panel which is fixing the syllabus of the newly proposed 3 year BSc in Community medicine that will allow the support net to be cast wider.
Gradually, a 2 bed ward came up. The Vivekananda Girijana Kalyan Kendra (VGKK) was formed to promote the integrated development of tribals.
From Community Health, Dr Sudarshan took the next step towards Community Development. A free residential school for the tribal children , VGKK School was set up.
From the very outset it was clear that this was an uphill task. A great portion of the staff’s time was spent in searching for the students , who were not just unenthusiastic about the whole affair, but, were also natural experts at hiding in the surrounding forests.
Unique problems were again met with innovative solutions.
Every single one of the students was a first generation one. The parents were not sure if this was such an important activity for their children to be engaged in. The genius of the management lay in recognizing that in several areas the tribals could be right, and that they, the teachers, could be wrong. The disruptive risks this education posed were identified, and suitable solutions found.
As Mr Sundaresh, the HM of the school earnestly explained, the sensitization of the teachers was heightened by running a tailor-made course for them in NIMHANS. Teaching methods were looked into and modified. Study materials were re-written, with the government’s permission. Everyday objects like a ball or a chair that find mention in textbooks were alien to many of the children. This is perhaps one of the only schools in the world where the sciences are taught through lessons in animal tracking! Firewood gathering is part of the duties. Activities like growing vegetables and maintaining the 20 cow diary were introduced, and handed over, to the children. Instead of pure Kannada, words from Soliganudi, their language, were used. Soon enough, there was a dramatic turnaround in the environment of the school, and the tribal’s embrace of its education.
Over 800 students have been turned out till date. Its SSLC results place the school in the top 3% in the State. There are several who went on to do their MSc, PhD etc. (One of the first PhDs , is an alumni of the first batch of 6 taught outside Dr Sudarshan’s hut). Not bad for a “tribal” school, providing free education !
Not surprisingly, most of the boys want to be in the Forest Service when they grow up. The school respects all traditional Soliga knowledge. Dr Sudarshan was also clear that the school would lay special emphasis on civics, exploitation and teach the children the meaning of rights ,the and the process of governance. It was interesting to know that the great majority of the students come back to live in the hills. While in the rest of India, graduates take flight out of their own communities, perhaps because quite often their own culture, language and traditions do not form part of what they learn in schools.
Dr Sudarshan could see in the surrounding villages, the rural (as against the tribal) population struggling to get their healthcare needs met. Often being driven to penury by having to pay the private practicioner’s fees. The government clinics were so unresponsive, ill-staffed, and had no stock of drugs that they were not an option.
The solution was historic.
He proposed to the Karnataka Government to hand over the running of one of their Primary Health Centres (PHC) , the smallest unit of the whole healthcare apparatus, to him to run. After all, he said, there was more to be gained for all in the efficient running of the existing investment , rather than pouring in more money and set up a parallel structure . In a decision that was equally radical ,and commendable, the Karnataka Government agreed to do so for the Gumballi PHC. Before taking the PHC under his wing, Dr Sudarshan discussed various issues at length with the village and zilla panchayats. He wanted the PHC to play a pivotal role in the community, not just to cure those who came to its doors. At the same time, the villagers would take responsibility for their own health.
So far so good. Then came the realization that in addition to what had been identified above, another reason keeping the poor away was that they could not afford to lose even a day’s wages.
When in a bind, innovate !
Dr Sudarshan espoused an insurance scheme where for a premium of Rs 30 or so, the patient would get reimbursement of wages , and a small amount paid to the PHC (which was used for drugs purchase). UNDP funded it for 2 years. When the UNDP withdrew, the village panchayaths, since they had been involved at inception decided it was too good a scheme to abandon, began to contribute from their end. This became a template for several State-sponsored Insurance schemes for the poor, like the Yashasvini Insurance scheme etc.
So, now you had the PHC running with a surge of patients coming for treatment, at a cost much lower than when under government custody. But its contributions were just beginning.
Dr Sudarshan has made the PHC step out into the community, and by involving the villagers, to address Mental Health, Epilepsy etc . Diseases that were otherwise suppressed for social reasons , or, the hurdle of having to travel all the way to Bangalore etc. They have sought to, and greatly succeeded in changing attitudes towards these diseases. With outstanding assistance from NIMHANS, they have built up, would you believe it, meticulous case records for nearly 3000 cases each of Mental Health and Epilepsy. A weekly outpatient department treatment of for 50 of the current 200+ cases is carried out with the assistance of the willing experts from NIMHANS. We have to remind you, once again, that this is a PHC we are talking about here. The social agony would have been immense, if the stigma related to these diseases had not been perceptibly removed, and the families persuaded to bring the sufferers for treatment . A treatment that had now been brought to their doorstep.
Astonishingly , the Gumballi PHC has even been NABH accredited ! When most of the private institutes in the country are not. The enthusiasm of the staff , and commitment to processes is quite remarkable.
Not surprisingly, the Karuna Trust now runs over 70 PHCs across the country right from Arunachal Pradesh to Karnataka.
But we digress. We have to backtrack to yet another activity that Dr Sudarshan was simultaneously pursuing.
Dr Sudarshan’s attachment to the Soligas also exposed him to their miserable plight. Forest Laws deprived them of their livelihood, their rights, their culture and their future. The forests they had inhabited for millennia was now banned for them.
Uneducated, meek and helpless. They had survived for millennia in the forests by helping each other by sharing, whether it be food , land or any other possessions. An individual’s problem was the community’s problem. Their system of Justice or Nyaya, held men and women to be equal. They now found themselves resettled on small plots whose barren emptiness bewildered them, in a land where the women were disempowered, and that was creeping back into their own community. And there was nothing to share. There was no Nyaya for the community.
Dr Sudarshan was soon plunging headlong into launching agitations to fight for their rights. He escalated the agitation in stages, taking recourse to every avenue of persuasion and discussion before proceeding to the next levels of confrontation. It was inevitable that it would finally lead to his arrest, as government attitudes cannot be easily changed , especially when the aggrieved are helpless, powerless and have already shown they can be easily exploited.
He did not fear arrest, and the collapse of all that he had built up . For him , the reversal of the draconian laws was something that had to be done; it wasn’t a matter of choice, whatever the costs.Not yielding even when incarcerated, he went on a fast. He was eventually released. After decades of such agitations, the Soligas have now won land rights and also the right to their traditional livelihood of harvesting minor forest produce. A large role in facilitating this was also played by the Asst Commissioner at that time, Mr M Madan Gopal.
Not many people have lived within the bandit Veerappan’s territory, repeatedly called him a psychopath in several interviews, and then refused police protection. It didn’t seem foolhardy , but, as the only logical thing to do so for Dr Sudarshan ! Like many others, he was horrified at Veerappan’s cold-blooded brutality . Dr Sudarshan was also seething at the harassment , and many murders of the tribals by Veerappan. Keeping diplomatically silent , as chosen by others, was not for him. At the same time, there were several instances where Dr Sudarshan had to also intervene to stop the police from brutalizing the tribals to extract information about Veerappan or even exploit them for their own interests. He felt the tribals would have run away from him if he were to always move with these very same policemen as escorts. He did not budge even when it was confirmed by the police that he was one of the 4 persons on Veerappan’s “to-do” list. Famously, he sent word to Veerappan that he would himself come to him, but would not pay a single paisa as ransom. It is rumoured that Veerappan realized the support Dr Sudarshan had and backed off.
He has been plied with awards. We saw them compactly arranged in a room, because the room would have to also serve other, very important , purposes. Democratically arranged and in no particular order, we discerned even the original Padmashree award, and the Right To Livelihood Award, the latter being often referred to as the alternate Nobel Prize for Social Causes.
Progress was always reined in by the availability of funds.The The Rs 23 lakhs from the Right to Livelihood Award was poured completely into building the Vivekananda Tribal Health Centre (VTHC) at BR Hills.
The task of attitude change that Dr Sudarshan has undertaken to confront is monumental, and on-going even after 4 decades.
But he was ready for it.
We saw , for example , Dr Manu, the Asst Medical Officer at the VTHC is struggling to convince a Soliga patient who had come with severe shoulder injuries after a mauling from a bear. He had earlier refused to be an inpatient , and they had to treat him twice a day either at his podu or the hospital. Today, the patient was saying he was fully healed, because the tribal healer had assured him it was so. Dr Manu can clearly see from the X-ray that this is not so.
Most of the deliveries in the Tribal hospitals are done in their traditional squatting positions. This is because the Auxiliary Nurse Midwives (ANMs) , who are now mostly tribal women insist on it. Primarly because its much more comfortable for the women. The caregiver has to take the more uncomfortable position ! Dr Sudarshan has, however, been successful in getting them to agree to tie the umbilical cord. The ANMs are very skilled in their traditional ways, and knowledge of herbs, time etc. Dr Sudarshan quietly weaved programmes of immunizations , antenatal care with these practices to bring about radically improved outcomes.
Even leaving aside the outstanding work on the social side, like human rights , education or empowering an entire community , the results on the medical side alone are stunning. To mention just a few, we repeat, just a few…..
• Infant Mortality has been brought down from 75.7 to 11 per 10,000 (vs around 43+ for the State, and country)
• Maternal Mortality is down to 40 per 100,000 (vs around 200 for the country)
• Institutional deliveries now stand at 98% of all deliveries
• Deliveries by trained birth attendants is 100%
• Leprosy prevalence has come down from 21.4 to 0.46
• The results on TB, Immunization programmes, etc are equally remarkable.
• Bringing even Mental Healthcare, Epilepsy, Communication Disorders counselling , Cataract Surgery to a PHC . There are also fortnightly clinics to treat hypertension and diabetes.
• Not just using low-cost generic drugs , but, using computerization and mobile for their supply chain management !
Relating Dr Sudarshan’s story has been like taking a frisky dog for a walk. You think you will do the leading, but soon , it is you who are led . You have to go forward, backwards, left , right, as the pattern is not simple. There are so many spots and paths , in so many different directions , to touch, and so little time. Our interest has been solely to unravel what kept his idealism alive for four decades, and has been uni-dimensional on that account.
Were we any better at understanding how he remained idealistic, while so many well-intentioned ones drop out ? We think so.
The first was that he prepared for it . He didn’t think his job ended by just “being idealistic” and then expect some magic to do the rest just because of this. He actively focussed on preparation, using his own imagination. He equipped himself in small and big ways, much in the manner of someone going on a long, exploratory journey into the unknown. This may have also helped keep his dream alive.
Next, he was prepared for that most frustrating of tasks, changing other people’s attitudes. He combined persistence with empathy for the other side of the story. When you are ready to do this, Dr Sudarshan has shown that you often end up with a better, and not just a more sustainable solution than you planned originally.
Inspiration sustains idealism. It could be the teachers who, through personal example or guidance can help resolve any conflict between values and interests encourage students to speak and stand by unpopular positions, support them from being overwhelmed by the enormity of the task ahead, and make them more persistent and creative. Or, it could come from a book, as Vivekananda’s writings were for Dr Sudarshan. It remained like a flywheel that would get him going whenever problems sapped his energy.
It’s not said in jest, but, necessity is truly the mother of innovation. He started practicing this early too. He applied it to products, and processes.
What sets Dr Sudarshan apart is that he also had an obstinate courage and a soft compassion that has been the fortune of the Soligas, and later to the more than 1 million people now served by his healthcare, education and other initiatives.
It’s true that but for regular support from many quarters , like friends , family, the Government of Karnataka, and several others , his idealism would not have yielded much. The counter point is that his initial actions themselves showed that he was worthy of support.
For him, there was no other way visible. He is the first to concede that it is not an easy path, and is not disappointed that only an infinitesimal proportion of doctor will tread this path. But, such is the invigorating nature of the accomplishments that he finds it difficult to understand why more don’t do so. Even if it is only for short spells, after all the commercial appetites are met.
This exercise, has, for us, been as much an investigation as a privilege. We are all well equipped, at home and all around us, with cynicism to be able to face the “real” world we see around us. Fortunately, there still exist people like Dr Sudarshan who demonstrate that we need not be constrained by only what reality shows us.
__________________________________________________________________________________As we said, our account is uni-dimensional. More rounded accounts of Dr Sudarshan’s exploits have been recounted in several publications, particularly in the excellent ones of the Voluntary Health Association of India. The websites of his trusts too have information on their activities. Vivekananda Girijana Kalyan Trust (http://www.vgkk.org/) and Karuna Trust (http://www.karunatrust.com/) The contact details for VGKK and Karuna Trust are : At Bangalore : #686, 16th Main, 4th T – Block Jayanagar Bangalore – 560011 , Karnataka Phone : 91-80-22447612 Email :firstname.lastname@example.org