On the Brahmaputra, India

It had been raining all morning but Debika Mikum was still waiting. About a dozen women stood with her, huddled under their umbrellas.

Chacha had seen them from afar. He deftly brought the starboard parallel to the slippery bank, as Sanjay Pegu, the wiry deckhand, flung the anchor ashore. From the other end of the vessel, another rope flew out. It was quickly tied to the remains of a dead tree.

The boat secured, someone pushed out a thick wooden plank from the main deck and carefully wedged it into the slippery mud. Half-a-dozen crew members promptly marched out, hauling an assortment of poles, pegs, and a large tarpaulin sheet. In minutes, a tent was conjured up.

With two fat logbooks, two stethoscopes and a trusty old sphygmomanometer between them, Bhaben Chandra Bora and Juganta Kumar Deori were out next. The two doctors settled on a plastic table under the rickety tent. Back in the boat’s lower cabin, pharmacist Apul Das had already got his logbook and medicines in order. It was all clockwork.

MV Akha was ready for business at Aisung, the crew gestured. The women, many with young children, folded their umbrellas and headed into the tent.

For the 3,000-odd residents of Aisung, medical care or supplies don’t come easy.

“During my pregnancy, I got all my medicines from the boat,” said 20-year-old Mikum, her infant skillfully strapped to her side. “Otherwise, we have to go to Panitola for everything.” It is a two-hour-long journey, first by boat and then by rickshaw, to Panitola, the nearest town.

Devjyot Ghoshal Debika Mikum stands with her child on MV Akha.

It’s not very different in the other 2,500 saporis, or riverine islands, on the Brahmaputra, the world’s fourth-largest river in terms of total discharge. The river descends from Tibet, through the hills of Arunachal Pradesh, and meanders 891 kilometers across the length of Assam.

Over three million people, or about 10% of Assam’s total population, live on these saporis, which are ceaselessly manufactured, reshaped and destroyed by the powerful waters of the Brahmaputra. Typically connected to the large towns and cities on the banks by a few regular ferries and ramshackle country boats, their isolation means that most are devoid of electricity, clean drinking water and schools.

The lack of basic healthcare is a recurring nightmare. In a country where the availability of doctors is 0.7 per 1,000 persons, less than even South Africa (0.8) or Brazil (1.9), the crisis of healthcare in Assam’s saporis is extraordinary.

On these riverine islands, there are almost no permanent health centres. The scattered populations spread across remote saporis, the impermanence of their land mass, and the general reluctance of doctors to serve in these difficult conditions render such establishments nearly impossible.

“The islands are shifting,” explained PC Suarnakar, joint director of health services in upper Assam’s Dibrugarh district, “The government has tried to build sub-centres but the population is not steady. Sometimes it goes up, sometimes it goes down.”

Assam itself suffers from some of the worst health indicators in the country. In 2011, the state had an infant mortality rate of 58 per 1,000 live births. India’s national average is 47. The maternal mortality ratio of 390 per 1,00,000 live births is the worst in the country, significantly higher than the national average of 212. And within the state, the five districts of upper Assam—Tinsukia, Dibrugarh, Sibsagar, Golaghat and Jorhat—had an ever higher maternal mortality ratio of 430.

An idea that worked

In 1996, Sanjoy Hazarika, a soft-spoken academic and journalist, was working on a documentary film in Assam when he heard of a pregnant woman dying on a sapori. She tried to reach a medical facility but missed the ferry. There was no other way she could travel.

The story stayed with Hazarika.

By 2004, the bearded and bespectacled former New York Times reporter had tried to devise a solution: Boat clinics that would take doctors and basic healthcare to the saporis, instead of residents struggling to reach these services.

“A ship of hope in a valley of flood,” as he described it in a pitch to the World Bank for an innovation award. The Centre for North East Studies and Policy Research, or C-NES, a trust founded by Hazarika in 2000, won the prize—all of $20,000, about Rs13.5 lakh at today’s conversion rates.

Devjyot Ghoshal Bhaben Chandra Bora speaks to patients on Mohmora Sapori.

A year later, MV Akha, a wooden boat clinic made with that money, floated out of Dibrugarh, eastern Assam’s biggest city, for the saporis on the Brahmaputra. “Akha” is Assamese for hope.

Since then, the C-NES has commissioned another 14 boat clinics, which have provided basic health services to over 1.5 million people across 13 districts in Assam. In 2008, the National Health Mission, India’s flagship healthcare scheme, signed an agreement to run the project as a public-private partnership. The team at C-NES manages the boat clinic, while the entire funding for the service come from the government of Assam, through the National Health Mission.

Every month, these boat clinics together reach between 18,000 and 20,000 sapori residents who have little access to any other healthcare facility. It is, in other words, a working model for decentralised healthcare access for a part of India where doctors are few and far between.

“There is nothing more important to me than an idea that works,” said Hazarika.

But making it work isn’t easy.

The reluctant doctor

Bhaben Chandra Bora wanted to be an engineer. After his middle-class parents packed him off to Dibrugarh’s prestigious Assam Medical College, he went through the grind with little enthusiasm.

“It took me a few years to love this profession,” he admitted, sitting on the foredeck of MV Akha, as the boat travelled upriver on the Brahmaputra from Dibrugarh.

Bora didn’t try to become a specialist doctor after graduation, unlike much of his class. His family simply didn’t have the means. Instead, he went straight to work, at nursing homes in his hometown of Nagaon in central Assam and Guwahati, and then at a tea garden.

He came to the boat clinic at Dibrugarh because it was another job, but has stayed here for eight years because of the work he is able to do. “These people don’t get a single government facility, and there is no regular health facility apart from this boat clinic,” he said. “It’s a great satisfaction.”

Since 2008, Bora has helped create and implement the systems that underpin the boat clinic’s success. In a month, MV Akha typically spends between 15 and 18 days out on the river, covering a population of a little more than 8,000 people across a dozen inhabited saporis.

Devjyot Ghoshal MV Akha waits for patients at Dusti Bali Sapori.

The schedule is designed so that each community is served at least once every 28 days. That allows the boat clinic to run a closely-monitored immunisation programme, particularly for children and keep track of other regular patients including pregnant women. An established itinerary also helps sapori residents know when the boat clinic’s doctors and medicines will be available.

The most common ailments on the saporis are respiratory problems and fungal infections. Both are quite easily cured if they are diagnosed early and treated properly. But that doesn’t usually happen. “To buy medicines worth Rs200 or to see a doctor for Rs100, patients would have to pay over Rs1,000 to hire a boat,” Bora explained.

Sometimes, it costs a lot more.

Two years’ earnings

Seema Bhumij lives a short walk away from where the MV Akha usually docks at Polo Bhonga Sapori, an island with a population of about 240 people.

Her home is a dingy, ramshackle hut made of bamboo and thatch, which she shares with her husband and four children. Chickens, goats, and cows amble around the yard outside. It’s not much, but for a month in 2015, the young mother spent her nights in much worse conditions.

Everything on the boat is free.

It was about a year ago, she reckons, that her youngest son, then a three-year-old, suddenly fell sick. His stomach swelled up, and he stopped passing water. Panicking, Bhumij decided to find a doctor. It took her three hours and over Rs1,000 to reach Chabua, the nearest town that’s best known as an Indian Air Force base. The doctors at the government hospital there referred her to the Assam Medical College in Dibrugarh, about 30 kilometres away.

Although Bhumij, who is probably in her early 20s, can’t quite describe her son’s ailment, it was apparently serious enough for the child to be admitted to a hospital for a month. His mother stayed there with him the entire time. The entire episode cost the family Rs12,000, she estimated. That’s double of what they usually earn in a year, growing their vegetables and rearing cattle and poultry.

“We had sold a calf the same day we took him to (a) hospital,” she explained, sitting on her haunches, outside her house. Everything from that sale was spent on saving her child.

If she had had access to the MV Akha, which only began visiting Bhumij’s sapori six months ago, perhaps the crisis could have been averted. Regular monthly checkups at the boat clinic could have ensured an early diagnosis, and cost nothing. Everything on the boat is free.

Tyranny of distance

Often, the most difficult part of Bora and his team’s job is simply reaching the saporis.

The Brahmaputra is dangerous and fickle. No one knows that better than Kapila Chaudhury, MV Akha’s pilot, who is universally known as Chacha.

The short, stout man is the third generation of the Chaudhury clan to pilot boats on Assam’s rivers. Chacha was born in Uttar Pradesh’s Ballia district, but, like his grandfather and his father, has spent almost his entire life on the Brahmaputra.

“It’s not a job for everyone,” he said, sitting on the bank beside a docked MV Akha one evening.

In his six decades on the river, he has seen the Brahmaputra change its course more than once. Entire saporis have disappeared, steadily eroded by the river’s swirling waters. Many more have dramatically shrunk, forcing its residents to go elsewhere. The new islands that the river is carving out can’t sustain people yet.

That is why, Chacha explained, the mixed population of ethnic tribals, Hindi-speaking herders from Bihar and Uttar Pradesh and the native Assamese who have lived on these islands is slowly moving out. Only a few large, heavily populated saporis now remain on this stretch of the Brahmaputra.

An unceasingly changing river is also a constant challenge for Chacha because channels deep enough to accommodate a boat like MV Akha keep shifting. From his small cabin, the veteran pilot keeps a close watch on the waters ahead, gauging the depth by monitoring the flow of water. One wrong turn of the wheel and the boat could run aground.

“Only the pilot knows the real risk,” he said, as a couple of fighter jets from Chabua’s air force base roared by above.

Devjyot Ghoshal Chacha is a third generation boat pilot on the Brahmaputra.

The river also has a seasonal rhythm. The monsoon rains wreck havoc almost every year, swelling the river manifold, swallowing up saporis, and spawning whirlpools and strong currents. In the winter, as the Himalayan glaciers that feed the Brahmaputra freeze up, the water levels drop dramatically, exposing kilometres of sandy river bed.

In either situation, the MV Akha and its crew must reach their patients on time, every 28 days.

Last winter, the routine got too much for Rijumoni Deka. MV Akha’s 25-year-old nurse broke down after trudging for long distances, equipment in tow, to access the saporis. “In January, I cried because I had to walk so much,” she recalled, smiling sheepishly.

When she accepted the job at the boat clinic after graduating from nursing school last December, Deka had some doubts. “I wasn’t sure if I’d be able to do it, or not,” she admitted. It only took her a few weeks to discover the difficulty of living on a boat, and the stamina required for the job.

It is Deka’s duty, along with another senior nurse, to vaccinate children, update the Mother and Child Protection Cards that are issued to pregnant women, and examine expectant mothers on a small bed in the boat’s engine room.

Despite the challenges, her service is vital, and she knows it. “The PHCs [primary health centres] are far away,” Deka explained, “If the service wasn’t there, then the vaccinations wouldn’t happen.”

All about the money

After watching the boat clinics in operation for over a decade, government officials like Dibrugarh’s joint director of health services Suarnakar have little doubt over the model’s effectiveness.

The rough math comes to a little over Rs480 per person per year for delivering basic healthcare in an incredibly challenging environment.

In fact, Suarnakar argued that the frequency of existing services of monthly camps at the saporis was not enough. “I feel that it should be at least once a week, and they should stay for two days,” he said.

“But finance is a problem,” he quickly added. “It is up to the government.”

In the 2014-2015 financial year, the Assam government gave Rs7.24 crore to C-NES, via the National Health Mission, to run the boat clinics on the Brahmaputra. That amount covers everything—salaries, supplies, fuel and the maintenance cost of the boats—for a service that currently reaches about 150,000 people every year.

The rough math comes to a little over Rs480 per person per year for delivering basic healthcare in an incredibly challenging environment, even by Indian standards.

Still, the money doesn’t always come on time, mostly because of bureaucratic logjams. When such delays happen, it isn’t just the staff and crew of the boat clinics that suffer, although they sometimes go for a month or two without salaries.

Instead, it is the hundreds, if not thousands, of isolated patients on Assam’s saporis who are deprived of the only regular health care service that reaches them. Especially for expectant mothers and young children, the inability to receive medication, or vaccines, on time can be dangerous. The state’s dreadful maternal mortality ratio is proof.

That is perhaps why, as the MV Akha reached Aisung, Mikum and her companions waited patiently, with their children strapped to their back—despite the blinding rain.

A spot of bad weather is hardly a factor when it comes to matters of life and death.

We welcome your comments at ideas.india@qz.com.