The world's first hospital in a train has performed more than 81,000 surgeries since its launch in India. Those who benefit most are the poor and needy. Jerry Pinto reports. It's a hot afternoon in Udaipur, a small town in Rajasthan, best known for the Lake Palace Hotel that floats like a fevered dream in the middle of a rapidly drying lake. With temperatures reaching 40C in the shade, it's not the best time to be travelling 200km with a four-year-old child. But Rajan and his son Chander don't care. They've travelled for nine hours now, walking some of the way, taking a city bus for a while and then walking again from the bus depot until they've joined a line of people, waiting outside platform one of Udaipur City Station. They're powered by a dream.
Chander was born with a cleft lip. At the Lifeline Express, the world's first hospital in a train, a plastic surgeon will give him a new face. "It's not just a new face," says Zelma Lazarus, the chief executive officer of Impact India, the United Nations-affiliated non-governmental organisation that runs the train. "It's a new life." She's not exaggerating. In rural India, a child with a cleft lip is said to be possessed by the devil. "The boys become beggars; the girls go into prostitution," says Lazarus. "It's a terrible thing and it's easily avoided. Surgery takes about 30 to 45 minutes."
Chander's father knows this. "We showed him to many doctors," he says as the boy sits quietly in his lap. "They said, 'operation'. But it would cost 20,000 rupees." At about US$420 (Dh1,540), that might sound doable but Rajan is a subsistence farmer. He has only a small plot, barely a quarter of a hectare, and five other mouths to feed. "Someone told us, 'They do operations free'," he says. He does not sound convinced.
The story of the train begins with the UN Year of Disabled Persons in 1981. "That was the first time that the health ministers of the world got together and brought with them figures of the disabled," Lazarus says. "The figure was 500 million disabled people. Half of those disabilities could have been prevented. But what was even more shocking was that there were going to be one billion disabled people across the world by the year 2000. And so it was decided that governments would have to go into partnership with the private sector. They would have to forge real partnerships, not order people around."
Sir John Wilson, known for his work helping to prevent blindness in developing countries, was the man put in charge of the project. He was on his way to the Philippines, but Indira Gandhi was at the UN and she insisted he come to India. He did and met with officials from the Tata Group, a multinational conglomerate based in Mumbai that had a strong sense of corporate social responsibility long before the term became a buzzword. "Impact India was formed. I was working for one of the group companies at the time and I was handed over, lock, stock and barrel."
And so a couple of years later, Lazarus was on her way back to India from London, where she had gone to receive the gift of a diagnostic bus from the island of Jersey. Sitting next to her on the flight was a surgeon, Patrick Rozario, an avid rock climber who was returning to the Himalayas and to a promise he had made to villagers there the previous year. "When I heard that he was going back to try and help with their medical problems, I said, 'Take my bus'," Lazarus says.
The next morning, he was at her door and the bus set off across the dusty plains of India on its medical mission in the hills. "I was Mother Superior in charge of the log cabin," says Lazarus. "The doctors worked all day and then one evening as we sat around the campfire, we heard drums beating. Our guides told us that a very sick boy was being brought from a distant village. They had heard about the doctors and the bus."
The boy's appendix had burst nearly three days earlier. He was comatose and had begun to take on the colour of death. "We worked like mad to save him," says Lazarus. "I remember scooping snow up with my hands and boiling it in a kettle and handing it into the bus. I remember those doctors hunched over the boy. They snatched him from the jaws of death. In the morning, his eyelids flickered and we took him down to the mission hospital."
And that evening, as they again sat around the campfire, they heard the distant hoot of a mountain train. "Suddenly, I said, 'How wonderful it would be if a train could come to these children'." Later, she remembered it was not her idea. Jawaharlal Nehru, the visionary first prime minister of India, had suggested that the largest network of railways in the world (now covering 75,000km) could be used to help prevent disability.
"All night the idea thundered in my head. A train. A train that goes around India. A train that goes where it is needed. A train that prevents children from being crippled by polio. A train that prevents people from losing their sight to cataracts. A train." Dr Vijay Kumar, an associate professor in plastic surgery from Lucknow, has forgotten how many times he has been aboard the Lifeline Express. He is one of the many doctors who volunteer their services for free. "I think this is my 14th or 15th visit," he says. "I have told these people, 'If you don't get anybody, call me'."
He thinks Chander has a good chance of getting an operation. "He will be in good hands here. The facilities on the train compare favourably with those of most hospitals in India. But the problem is not with the train. It's often with the child. We don't work on cleft palates, for instance. There may be bleeding and we do not have a blood bank on board the train. And the child is very often undernourished."
That is not just because the cleft lip carries a social stigma. "A child with a cleft lip cannot suckle well, so the tendency is to spoon feed them," says Dr Shyam Sheth, another plastic surgeon who has come from the neighbouring state of Gujarat. "In areas such as Rajasthan [which is largely desert and often drought-prone], there is not enough water to keep things clean so there are infections. And much of the food that you put into the child's mouth comes out."
In the queue, Narang sits with little Chanda on his lap. Narang says she is four years old, but she looks much younger. She is quiet, sleepy in the heat. But when she begins to cry from hunger, the process of feeding her a banana turns into a performance only a dedicated parent would go through. She must sit up. Her head must be tilted. The banana must be mashed and then passed through the front of her mouth, through which two of her teeth have erupted. She must then be turned slightly so that the mash does not slip out of the side of her face.
Dr Kumar is not sure that Chanda can be treated on the train. "She has other congenital abnormalities and deformities." But he will try not to disappoint the parents. "They have to bring her to Lucknow. I will operate on her there." Impact India has a T-shirt with the neck of a giraffe that ends at the wearer's head. It says: "Stick Your Neck Out." It would not be a bad motto for Zelma Lazarus. Armed with only an idea, the UN tag, and the support of one of the largest corporate groups in India, she went straight to the then railway minister, George Fernandes.
"The minister had five minutes to spare in his busy schedule. 'What do you want?' he asked me. 'I want a train,' I said. He looked a little stunned." But he heard her out and the railway ministry came up with a solution. Three old coaches were sanctioned. "When I climbed into one, my foot went through the floor. I staggered a little as I dragged my foot out and reached out for support and the side of the coach shuddered a bit," remembers Lazarus. "I met the minister in Delhi and he looked at me with a twinkle in his eye and said, 'Have you seen the coaches?' 'Yes,' I said. 'Do you know how much you will need to refurbish them?' he asked. 'No,' I said. 'You'll need a crore (Dh740,000),' he said. 'I'll find it,' I said. 'Just let me take them where they're needed.'"
When Lazarus got back to Mumbai, she noticed that the Rotary Club had a new president. He was a doctor. "So I called up Dr Jayanti C Kothari and he got together a group of surgeons and they sat down to design the hospital on a train. There are international rules and standards for how many feet you have to have around an operating table. I had no idea of any of these. Then they gave us a list of the machines they would need. But they didn't stop there. They called up their contacts in the medical supply companies and said, 'These are good people, doing good work. Give them a good discount.' And what do you know? They sent us the machines, top-class machines, free. You just have to stick your neck out."
Today, the hospital does not work in old coaches. Sonia Gandhi, the president of the ruling Indian National Congress, was impressed by its work. A spanking new train was commissioned and handed over to Impact India in 2007. Back on the train, people are lining up for dental treatment. Many of them are obviously from the target group, the poor who have never seen the inside of a dental clinic. Some of them do not seem to be in much pain but just want a tooth removed.
Colonel Randhir Singh Vishwan is used to this kind of thing. He is in charge of the 10-member team that operates the train. "In the villages, there is no dentistry. There is only someone who will pull out the offending tooth. And once he's started pulling it out, there's no going back. He can't leave it half in and half out. So if a tooth is shaking but not hurting, they want it out before it hurts."
Quite a few look like they belong to the middle class and have come along for a free ride. Colonel Vishwan is used to this kind of thing, too. "We cannot turn anyone away," he says. "If you have a camp and you say it is free, you cannot turn anyone away." A retired army man, the Colonel has fought in two wars and perhaps his close encounters with death have given him an unflappable air. In 2008, during the making of the BBC documentary, India's Hospital Train: The Lifeline Express, public demonstrations in Rajasthan turned violent. Agitators stopped the trains, some of which were supposed to bring anaesthesiologists and surgeons to the Lifeline Express. As the tension mounts, you see Colonel Vishwan walking the platform and working his phone, summoning people, rerouting them, sorting it all out.
"It's because you can see the end product," he says. "You see someone go away with eyesight. You see a child walk. You can do anything for that." Cleft-lip surgeries will take only the first week of the train's caseload. In the second week they will work on hearing problems and those afflicted by polio. The last week is dedicated to cataract surgery. Then the train moves on to its next destination.
"I know where the train is going for the next two years," says Colonel Vishwan. Chander goes under smoothly. "This is an operation that can be done with local anaesthetic," says Dr Kumar. "But the patient has to cooperate. Children don't. So we put them under." About 45 minutes later, his small body is lifted off the table and carried into another compartment, where he flops down and sleeps it off.
"There will be some speech impairment because we caught him a bit late," he says. "If we get them before they are one or one-and-a-half, we can restore full speech. But after that, speech has begun to develop and the child will slur unless he goes through speech therapy. It seems unlikely that Rajan will have the time or the resources to bring Chander to Udaipur twice a week for speech therapy. "But at least people will not shun him," Dr Kumar says. "And he can take part in village festivals."
And he might even find a suitable wife. One of the train's great stories - and it abounds in them - is the young woman whose cleft lip was operated on. She wrote in to say that she was going to get married. And so she did. On the train. It's an idea that has caught on internationally now that 81,000 surgeries have been performed on the train and 200,000 lives have been touched in one way or another in the 100-plus stops it has made. China has three trains. In April 1999, the floating riverboat hospital "Jibon Tori" was launched in Dhaka, by Impact Bangladesh. There is a riverboat hospital that operates in Cambodia as well.
"They weep when we leave," says Neelam Kshirsagar, the deputy general manager of special projects at Impact India. "They lie on the tracks. They point and say, 'If you go, who will look after him? If you go, how will she get better?'" So why aren't there more trains? "Because the train is not the answer," says Lazarus. "One of the corporate guys came up to me and said, 'I want my own train'. I said, 'You can have it but where will you run it?' The Indian Railways are already overcrowded. And they are divided into four administrative zones. We trundle up to the end of one and then we have to begin negotiating with the authorities of another zone. It's not a sustainable model. It's not replicable."
Lazarus says the answer is to take preventive health to the villages, the schools. "Our community health initiative in Maharashtra [the Indian state whose capital is Mumbai] is an exciting one. We've started kitchen gardens to augment the nutritional needs of the children. We have health monitors chosen from among the children who will keep an eye on the children's general health." A fount of stories, she offers this one.
"A little girl. About nine years old. She couldn't hear anything so the teacher sent her home. She dropped out of school. She was going to end up illiterate. Luckily for her, she was brought to our diagnostic bus. We found that the problem was impacted wax. We syringed her ears and in a few minutes, her hearing was restored. And she went on to stand first in the district." For more about the Lifeline Express or to donate to Impact India, go to www.impactindia.org
