When a group of residents in the Indian state of West Bengal recently insisted on praying at their local mosque, violating the rules of social distance amid the coronavirus pandemic, Mohammed Nizamuddin took action.
This helped the locals to trust Nizamuddin. They called their 54-year-old neighbor a “doctor” and visited him for treatment and medicine whenever he became ill.
Except that Mr. Nizamuddin is not a qualified doctor.
He is one of the state’s estimated 100,000 informal rural health service providers. These unqualified doctors provide the first line of medical assistance in tens of thousands of indigenous villages.
Often ironically described as “charlatans,” informal health care providers are usually male and in their forties, having spent a decade or more helping qualified doctors before starting their own rural clinics. They also outnumber qualified doctors in the heart of India, where health services are precarious.
With few surgical operations – although they offer jabs and sew wounds – they provide medical assistance and refer patients if they feel they need more care. Some states, like West Bengal, have taken steps to train thousands of these informal providers.
They operate like “non-doctors” in Africa – most rural health care in Kenya, for example, is provided by nurses and clinical staff. They can also prescribe a wide range of medications.
Back in his village in the Birbhum district, Nizamuddin dissuaded his neighbors from saying prayers inside the mosque.
“There was a lot of pressure. I explained why it was wrong for public health. They listened and finally decided to keep smaller congregations in various open places,” Mr. Nizamuddin told me.
When the blockade to prevent the spread of the infection began in late March, Nizamuddin closed his complicated clinic near his home in Birbhum district.
But he was forced to reopen it after three days, when he was surrounded by calls from dozens of residents seeking treatment and medication.
Residents often come to him with stomach problems, asthma, lung flu and minor injuries. To treat them, Nizamuddin maintains a stock of pills and basic injections, nebulizers, gauze and dressing.
Currently, he also checks all patients who seek treatment at his clinic for influenza and respiratory infections.
If a patient shows symptoms, he enters his details into a Coved-19 surveillance application on his cell phone. The information in the app is transmitted to the health authorities of the capital of Calcutta, about 200 km away.
Nizamuddin also asks all his patients, mainly rural workers, to wear masks and wash their hands regularly. “With the monsoon onset, I see a lot of flu patients anyway. So I have to be vigilant,” he told me.
Subrata Mandal, another informal supplier who lives a few kilometers away, is also at the forefront of surveillance against Covid-19 in a cluster of eight villages.
After a 35-year-old resident tested positive after returning from work in Mumbai, Mandal arranged for him to be quarantined. Together with 70 other similar practitioners, he went door to door in two dozen villages, handing out masks and disinfectants and telling people to be safe. They also recorded a cassette of information related to the coronavirus and played it loudly in mobile vans that traveled to all villages.
“We can’t let our guard down,” says Mondal, 49, who stopped studying after high school and worked with a doctor before starting his own clinic 12 years ago.
India spends 1.28% of GDP on public health, one of the lowest in the world. One reason these informal providers flourish in India is because there are very few qualified doctors working in the villages.
“They are not night operators, but reliable members of the community they serve,” says Jishnu Das, professor of economics at Georgetown University.
A recent study by Prof Das and a team of researchers from India and the USA found that 68% of all providers in an average village were informal, unqualified providers. But they also noted that the “key role” played by informal providers in rural India “needed recognition”.
In some states, the researchers found, they are actually “better educated” than qualified doctors, a reflection of uneven medical training across states in India.
“If informal providers are counted as primary care providers, there is really no shortage of human resources – India will actually have more health care providers per capita than in rural Europe or the USA,” says Prof Das.
After the outbreak of the pandemic, informal providers are playing a crucial role in community surveillance, reporting cases of fever and flu and even taking people to testing centers.
One way to make these providers more useful is to give them more training.
A 2016 study by a group of researchers, including Nobel Prize-winning economist Abhijit Banerjee, found that while qualified physicians are more likely to manage a case correctly than untrained informal providers, “training has filled half the gap in correct case management “. A national grouping of licensed doctors consistently maintains the work of informal practitioners is “illegal”.
Since 2008, a Calcutta-based non-profit organization called the Liver Foundation has been training these suppliers. Now, the West Bengal government also offers training at more than 30 centers. Abhijit Chowdhury, who runs the nonprofit organization, says in many ways that he owes his life to informal suppliers.
“About 45 years ago, I was bitten by a snake at my village house at night. The nearest town was 10 km (6.2 miles) away. There was only one phone in the village,” he told me.
“My family called the local quack. He came promptly, cleaned the wound, gave me an anti-allergic pill, called the ambulance and took me to the hospital.”
“In a way, he saved my life that night.”