“When my father walks on the road, people call out to him saying, ‘Doctor sahib ke babuji‘ [the doctor’s father].”
Vijay (name changed) is a jhola chaap – an unlicensed medical practitioner – often dismissed as quacks in both government and academic reports. “What people from outside call me doesn’t matter,” says the 30-year-old from Malkharoda block in Chhattisgarh, brushing off any slurs.
The moniker jhola chaap ‘doctor’ is said to refer to the ‘jhola’ or bag of remedies that give the ‘chaap’ or (unofficial) licence to be considered a medical professional in the eyes of the people he treats. Vijay says he worked closely with a MBBS qualified doctor for seven years. That close proximity to a licensed practitioner, along with a bachelor’s degree in Science (Biology), was enough for him to get going with his practice as a jhola chaap ‘doctor’.
According to the Medial Council of India (MCI), only a licensed doctor with a qualification recognised by the MCI – is allowed to practise medicine. So running an illegal operation does have its occupational hazards. Jhola chaaps like Vijay say they need to stay one step ahead of the law and they have a contingency plan: “We can dispose off our bag of remedies quite easily so it’s hard to prosecute us [for offering illegal services],” he says.
But none of this fazes Vijay who says he enjoys what he does and believes he is providing a service. “If someone fell sick in my village, we had to travel 25 kilometres to the block headquarters to find a doctor. I grew up seeing this and decided I would serve the [medical needs of the] people of my village,” he says. Dismissing any criticism that he is neither qualified, licensed nor legal, he chooses to focus on the respect he gets from the people he lives among and who swear by his remedies, mostly over-the-counter allopathic drugs like ibuprofen, antibiotics and even injections of paracetamol. Almost half the population of Malkharoda block is made up of Scheduled Caste and Scheduled Tribe communities.
Even today, Vijay and others here in Malkharoda block of Janjgir Champa district, need to travel to access the public health system – sometimes upto five kilometres on dirt roads through forests. “I can save people time and money while providing immediate relief,” he points out. Around 27,218 rural people in Chhattisgarh are served by one primary health centre, says the Rural Health Statistics 2019-2020 report published by the Union Ministry of Health and Family Welfare. The state has a shortfall of 404 doctors in primary health centres; in tribal areas, even health assistants are in short supply – a shortfall of 1,393 as of March 31, 2020.
When he was finishing school two decades ago, Vijay had his sights on a medical degree but couldn’t afford it. “Doing a BSc itself was a big achievement for someone like me who had to cycle 50 kilometres a day to continue my schooling from Class 9 to 12.” He recalls that many of his friends dropped out of school and were unaware of options or guidance for further studies and careers.
Where is the doctor?
“Biology graduates are stepping into the gap left by the unavailability of MBBS doctors in rural areas,” points out Ranjeet Ajgalle, 46, a former MLA of Malkharoda block. His observation is supported by a 2010 report that states “…acute shortage of physicians in rural areas has led to non-physician clinicians becoming the main providers of primary health care.” The report, titled ‘Which Doctor for Primary Health Care,’ was jointly published by the National Rural Health Mission and the Public Health Foundation of India.
The shortage of qualified health professionals, poor road connectivity, dense jungles and the ever-present fear of violence arising from State-Maoist conflict, discourages people from leaving the security of their villages. The familiar face and proximity of the jhola chaap who lives nearby, wins each time. The fact that he diagnoses illnesses and prescribes medicines without a licensed degree, putting a patient at risk each time, is not a deterrent. Overall, there is a general sympathy to their role, as long as the patient’s condition does not deteriorate.
Landless agricultural worker Rathbai (also known as Siriyagadhin in her village in Malkharoda block) is very clear that when someone in her family falls ill, they will first look for the jhola chaap. “We don’t own a motorbike, so how would we take anyone who is ill to the [public] hospital?,” she asks. “Moreover, if we don’t have the money, credit works with jhola chaap. If we go to hospital, most of the medicine they write [prescribe], needs to be bought in a medical shop and they don’t give us credit,” adds the 33-year-old.
Malkharoda block has a population of 140,175 across 108 villages (Census 2011). The people here are served by a grand total of four allopathic doctors who function across one hospital and dispensary, five primary health centres and 23 sub health centres, according to the District Statistics Report of 2014-15. “Government [healthcare] facilities in rural areas are exhausted due to lack of manpower and infrastructure,” says Dr. Ravindra Sidar, the block medical officer (BMO) of Malkharoda. “The number of jhola chaaps is definitely increasing and their number could be two to three per village here,” he adds.
Rathbai (left) sitting with her five year-old daughter Bhavishya outside their home. Right: Ranjeet Ajgalle (right), a former MLA representative of the block with retired tailor, Kondu (left) at Gaura chowk in Malkharoda village. Ranjeet says, “Biology graduates are stepping into the gap left by the unavailability of MBBS doctors in rural areas.” Photos by Ayush Mangal
The rise in the number of jhola chaaps is matched by their readiness to jump in. “We are available all the time, especially at odd hours like late night and early morning. So they [patients] are assured of our visit. This is not available in [government or private] hospitals,” says Rajesh (name changed), a jhola chaap in a neighbouring village.
The lack of healthcare options is reflected in the alarming health indicators for the state: at 8.6 per 1,000 population, the rural death rate here is the highest in the country and infant mortality at 42 is higher than the national average of 36 per 1,000 live births, according to the health ministry’s May 2021 report on rural health statistics. In 2020, Chhattisgarh recorded 18 deaths from malaria – the highest in the country.
A 20-kilometre journey on kuccha roads through the jungle brings us to the ‘clinic’ set up in the front room of a single-storey pucca home. The monsoons have made the mud roads even more slippery and we are in danger of falling off our two-wheeler, so we park the bike and finish the journey on foot.
This ‘clinic’ is run by Rajesh who applied and was admitted for a bachelor’s in science after school but could not complete it. “The financial condition of my family was not good, and I was expected to start earning. I began working as a medical compounder with a doctor,” he says. Later, when he could afford the college fees, he felt, “I was already learning the practice [of medical treatments] so going to college didn’t seem useful.” He says he earns around Rs. 12,000 – 18,000 a month and adds that “expenses are low here so I am able to save most of it. In a city I could earn around 25,000 rupees but the expenses there are much higher.”
Rajesh’s workstation is equipped with a sphygmomanometer (machine to measure blood pressure), an udhari (borrowings) register, a shelf of medicines, injections, a weighing scale and more. Photos by Ayush Mangal
Rajesh is attending to a patient; neatly dressed, he is seated at a table, and the patient, on a stool. The room has a few extra chairs for relatives of the patient, a wooden bed on which to administer injections or an intravenous drip, and a weighing scale. On the table is a sphygmomanometer (instrument that measures blood pressure), a box of medicines and injections. There’s a pile of books that includes a desk calendar and an annual diary, in which he says, “I note down the credit details.” Many of his patients, he adds, cannot afford to pay him immediately. “They may have to wait till market day or harvest,” he explains.
In the ‘business’ of jhola chaaps, offering credit is critical to retaining patients. Vijay says, “If I refuse to work on credit, I might go out of business. When I ask for my fees of say 300 rupees, the family will usually just hand me a hundred rupees and say they will pay the rest after they earn it.” Vijay estimates that he is due Rs. 2.5 lakh in fees, but he says, “only 50,000 rupees will likely come back. The rest is already a bad debt.” To recover the money he is owed, he ends up charging high fees and high prices for medicines.
The few MBBS qualified doctors on the ground here, prefer urban postings. “If not for the rural work bond with the government, I probably would have not served for two years in a rural area,” says Dr. Nalini Singh Chandra, a doctor who has spent two years at the community health centre (CHC) in Malkharoda block. “Rural areas lack both the social and the economic incentives for an MBBS doctor. A bachelor life here is still possible, but if you wish to start a family, it is not ideal,” she adds.
Adding to this is the comparison in the eyes of locals between state-appointed medical practitioners like Chandra and the intensely popular and almost familial jhola chaaps. The doctor recalls one of her expeditions to confront a jhola chaap in a neighbouring village. People in the village berated her and the investigating team saying. “Look, they have shut down the good medical service we were getting. Now we will have to go running 20 kilometres to Malkharoda when we fall ill. These MBBS people will not come to check on us, the jhola chaaps will.”
The jhola chaaps are sympathetic to their patients – such as the sick daily wage worker who is losing precious earning time and tells him, ‘Doctor, I need to get well as quickly as possible; I have to get back to work soon.)’ Vijay says only an injection will satisfy them of his care and expertise, and he quickly pulls out the syringe to oblige.
That treatment draws the wrath of qualified doctors. “Most of the patients I see as out-patients have come after getting an injection. They say “our bodies will only get rid of the disease if we get an injection,” says Dr. Chandra. “This mindset among villagers is the result of the practice of these jhola chaaps who rely on injections to treat the patients. It has become a habit,” she adds, unhappy at the trend.
Honour among jhola chaaps
“There are certain diseases that we call ‘sarkari case’ [government hospital case], which we don’t treat at all, such as leprosy, tuberculosis, cholera, diarrhoea, malaria, dengue, pregnancy and childbirth,” says Vijay explaining the unwritten code among the jhola chaap doctors about the ailments they can and cannot treat and those they do not touch. “We send these cases to government hospitals only. The government is also strict about getting these cases and no amount of bribe will work if a person is caught treating these cases,” he adds, speaking practically.
In the last two years, Vijay has been sending anyone with a persistent cold and cough to get a Covid test at the block’s community health centre in Malkharoda. If they test positive, jhola chaaps withdraw and the hospital takes over. With Covid cases increasing, Vijay was worried about his family: “My wife was pregnant and I was anxious for her. I quarantined myself to rule out the possibility of passing the virus to our newborn. I looked at her only from a distance when she was born.”
Despite the close relationship with their patients, not receiving official recognition for their work rankles. “Unlike registered doctors, there is no recognition of our work. If something happens to a doctor, the government provides compensation, and they become celebrities in the eyes of the society. Such is not the case with us. If something happened to me, my family would be forced to do wage labour. But, we keep working,” says Vijay.
Ayush Mangal is in the final year of a MA in Economics at the Azim Premji University, Bengaluru. He was a PARI intern in the summer of 2021. Located in Chhattisgarh, he wanted to research jhola chaaps. He says, “I have witnessed the tangled relationship between jhola chaap doctors, the community they serve and public health services in rural areas. Any policy to improve healthcare in these areas will need to understand these complexities.”