Occupational Therapy: Going Beyond Boundaries Kulkarni C Occupational Therapy: Going Beyond Boundaries: A Case Series Chaitrali Kulkarni Abstract India, once called the land of villages, has developed not only in its urban but also rural sector. An Indian village community is a political, economic, and a cultural system. While geography is only one of many factors that contribute to health inequities, access to health-care services has been cited as disproportionately poorer for rural residents. With various organizations working hard toward improving the quality of life in these areas; community education, empowerment, good local governance, and preventive occupational therapy are found to be important steps in rural rehabilitation. Therapists have to have understanding of rural life, people, their beliefs, culture, and how this affects health. The Madia-Gond tribal, who have inhabited Gadchiroli for decades, are an extremely remarkable race, affected by chronic poverty, adverse incorporation, a decline in employment opportunities, and the neglect of rural development. This article reports experiences of an occupational therapist working in the tribal areas for the tribal people, who were utterly ignorant, and ages and centuries behind time. Key Words: Occupational Therapy, Quality of Life, Rural Rehabilitation, Tribal INTRODUCTION A dream came true when I got a call from Dr. Anagha Amte about acceptance of my application to serve at their non-governmental organization (NGO). The journey commenced with lots of plans and expectations, but in no time the ground reality struck. This paper describes my experience of working in an NGO for tribal people in the neglected area of Bhamragad, Maharashtra. Community-based rehabilitation (CBR) is an approach that has been used primarily in developing countries to facilitate the provision of rehabilitation services to rural and remote areas, where the number of people with disabilities is numerous but where the resources are few.1 CBR is implemented through the combined efforts of people with disabilities, their families and communities, local governance, rehab workers, occupational therapy, and social services. Occupational therapy service becomes more potent with the existence of CBR structure. Assistant Professor, School of The field of rehabilitation is very underdeveloped in India. As a general rule for developing Occupational Therapy, D.Y. countries, the World Health Organization estimates that only 1-2% of patients who need Patil University, D.Y. Patil rehabilitation actually have access to it.2 College, Navi Mumbai, While geography is only one of many factors that contribute to health inequities, access to Maharashtra, India healthcare services has been cited as disproportionately poorer for rural residents.3 With various Place of Study organizations working hard toward improving the quality of life in these areas; community Lok Biradari Hospital, education, empowerment, good local governance, and preventive occupational therapy are found Hemalkasa, Bhamragad, to be important steps in rural rehabilitation.4 Gadchiroli, Maharashtra, India Period of Study BACKGROUND OF LOK BIRADARI PRAKALP (LBP) February, 2015 - July, 2015 It all started as an adventurous family trip. When Baba Amte’s two sons returned home after Correspondence answering their final M.B.B.S. papers for a vacation, he took them on a trip to Bhamragad. Chaitrali Kulkarni, B-6, They were extremely moved to see the condition of the tribals. Baba felt a strong urge himself nd 2 Floor, Gharonda CHS, to start reformative activities and vowed to start a new project here. Baba’s younger son Shastri nagar, Dombivali West, Thane - 421 202, Dr. Prakash promised to join him. Thus, Dr. Prakash Amte and his wife Dr. Mandakini Amte Mumbai, Maharashtra, India. began a new chapter in the history of selfless and courageous social service. Prakash’s sister Tel.: +02512484443, Renuka and four educated inspired young men from different parts of Maharashtra joined Mobile: +91-9769131626, him.5 Email: [email protected] LBP is a social project of the Maharogi Sewa Samiti, Warora involving a hospital, a school, and an animal orphanage. It was started on December 23, 1973 by the social worker Baba Amte for Paper was presented in OTICON’2016: The 53rd integrated development of Madia-Gond. It is in Hemalkasa, Bhamragad taluka in Gadchiroli Annual National Conference district of Maharashtra, India. of AIOTA at Chennai in January, 2016 in Non- The Madia-Gond is a primitive tribe inhabiting the Dandakaranya forests in the Central Eastern Competitive Category. part of Gadchiroli district of Maharashtra. A phenomenal race, the tribes have been in existence 3 | Indian J. Occup. Ther. | Volume 49 | Issue 1 | Jan - Mar 2017 | Page 3-7 Occupational Therapy: Going Beyond Boundaries Kulkarni C for centuries. However, this gentle race was completely cutoff Accessibility from civilization, knowing no clothing, education, or health Accessibility is one of the major concerns that limit patient care until LBP was established.6 compliance. Inadequate transportation, poor condition of roads, and frequent floods during monsoons are some of the The tribes are skilled craftsmen and hunters. Their language, factors that reduce the patient’s willingness to seek quality Madia, is one of the many Indian tribal languages with no script medical and other therapies. In addition, commute to the and limited set of words. They do not follow any of India’s hospital from their remotely located homes is time consuming major religions but continue worshipping their local deities and cumbersome. Hence, a trip to the hospital is an entire day’s and forces of nature. Being very closely associated with nature, affair. Subsequently, this leads to loss of work hours and lower these tribes eat “anything that moves” ranging from squirrels to pay which demotivate them furthermore (Figure 1). snakes and crocodiles. They even brew their own liquor. Their existence is completely dependent on the forests they live in. Madia society is based on cooperation and mutual coexistence, with females enjoying a social status equal to that of males.6 In 1973, when LBP was established here at Hemalkasa, modern medicine and health care was unknown. When ill, tribals took the patient to local witchcraft, which of course often proved fatal. The very first challenge in front of Dr. Prakash et al. was to show the tribals that illness and diseases had to be dealt differently.7 After immense struggle of 40 years, Lok Biradari Hospital is widely accepted today from the initially suspicious tribals and serves around 45,000 patients a year from 1000 villages in a 250 km radius, including people from Chhattisgarh and Andhra Pradesh. Figure 1: Bridge Submerged Under Water Breaking Access to Ten Villages The hospital has both outpatient department (OPD) and Personal Factors inpatient department (IPD) services. After the initial medical Peoples’ Attitude and surgical treatment, patients are referred for therapeutic Even in the 21st century, the tribe of Madia believes in witchcraft intervention if required. The hospital also provides its patients to alleviate their illnesses. In spite of Dr. Amte’s in numerous and their relatives with two meals. It provides 24 h care to efforts to reform this belief, medical treatment at the hospital patients who may land up at any time of the day.8 continues to be their last resort. A classic example to the above Occupational Therapy Perspective scenario is 50-year-old patient, who suffered from leg cellulitis. He resorted to “mantrik” measures initially by performing It is essential for a therapist to have thorough understanding various superstitious rituals. Only when these measures failed, of rural life, people, their beliefs, culture, and how this affects he sought medical treatment. However, due to lack of timely health. In the rural setting, majority are living closer to the clinical measures, his condition worsened, and a below knee poverty line. This larger perspective of health requires therapist amputation surgery became essential. to reach outside their prior norms and concepts of practice, or what their professional training had prepared them for. In Patient noncompliance is another major limitation that affects particular, it requires them to adapt their service provision the quality of treatment. It is challenging to convince the (treatment protocols, clinical practice guidelines, other patient to adhere to the home exercise program prescribed by evidence-based approaches, or health service delivery models) the therapist that would help to mitigate the pain and improve to a larger definition of health.9 their health. Factors Affecting Rural Practice Furthermore, the tribals did not prefer to be admitted to the ward; this reduced the efficiency of clinical care. Contextual Factors Limited Resources Culture Lok Biradari Hospital caters to patients living within a 250 km Work is very important for them. The livelihood of the tribals radius, including the village of Bhamragad. Since there are not is mainly dependent on farming and gathering different products many general physicians available at the primary health-care from forests. Since this is their only source of income, they prefer centers (PHCs), the hospital is the only option for medical needs. to choose work over their treatment time at the hospital. The Furthermore, there is a scarcity of medical and rehab stores that weekly market (where they sell their goods) is the only conducive provide assistive devices such as braces and walker. Lack of a factor to attend their follow-up sessions at hospital which is near fully functioning rehab unit at this hospital and lack of necessary the market. The last week of May is their prime work season, and adaptive devices/equipment add to the woes of the patients. hence a steep decline in their hospital visits was observed. 4 | Indian J. Occup. Ther. | Volume 49 | Issue 1 | Jan - Mar 2017 | Page 3-7 Occupational Therapy: Going Beyond Boundaries Kulkarni C Poverty/Economy and reduced work performance due to knee pain and limited As established by the previous statements, their seasonal nature ROM.