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LIFELINE EXPRESS

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INTRO

In India, inequities in wealth and health are deeply intertwined.
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The Lifeline Express, or Jeevan Rekha in Hindi, travels across rural and remote parts of India, providing free medical services to the poor.

Over the past 25 years, the Lifeline Express has treated over a million patients in rural India & over 80,000 surgeries have been conducted on-board.
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LIFELINE EXPRESS

The train was launched in 1991 by the Impact India Foundation.

The Impact India Foundation is an International Initiative Against Avoidable Disablement, promoted by the UNDP, UNICEF and WHO, in partnership with national governments.
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India has one of the most extensive railway networks in the world, covering over 85,000 kilometers of tracks.

It is this extensive reach of the railway network that gave birth to the idea of a hospital train. The Impact India Foundation now works in close partnership with the Indian Railways, who provide and help maintain the coaches.
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Despite India’s impressive economic growth rates in the previous decade, progress in public health remains glacially slow. Public health expenditure in India is abysmally low at 1.4% of GDP compared to a world average of 6%.

The Lifeline Express was intended to be a temporary measure to build awareness, but growing gaps in India’s public health system have necessitated the continuation of the project.
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In rural India, people often have to travel many miles, often by foot, to access reliable health facilities. Many patients have not seen a doctor for years, despite serious health conditions.

Government hospitals are often under-staffed and under-resourced and private hospitals are unaffordable for most.
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“All we wanted was that people should not, through neglect or ignorance, become disabled or crippled, and thus robbed of health, productivity and joy, and that disabled persons especially in rural India should have access to medical services wherever they be.”

Impact India Foundation
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Over the years, the train has grown from 3 to 7 coaches. It is equipped with state-of-the-art medical facilities, including 2 surgical operation theaters, sterilization rooms, mammography and x-ray machines and a dedicated area for dental treatment and lectures on health.
  
The staff work tirelessly to maintain the highest standards on the train, as seen here.

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Doctors also conduct awareness workshops, on topics ranging from dental hygiene to breast cancer. As religion is a big part of daily life in India, these workshops often take place in local temples, mosques and churches. This helps the doctors reach a large cross-section of people.

Here, a medical practitioner from the Lifeline express is holding an awareness workshop at a local Jain temple. The children come to the temple every other evening for classes on the scriptures.
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TEAM

Many local people help out at the train – from patient registration to supplying food and water for patients.

Some people volunteer to help – motivated by sense of duty or ‘seva’; for others it is an opportunity to experience something outside of their everyday life while earning some extra money as well.
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At any given moment, a 20-person medical team is on the train, working 15 hours a day.

They are supported by an extensive technical support system - from electricians that help link the train to the local electricity supply line to local water tanker suppliers.
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The technician is a core member of the Lifeline Express team.

He is responsible for maintaining the equipment necessary to run the train as a hospital– from the generators that keep the air conditioning working to the medical machinery.
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Most of the regular staff lives on the train – they sleep, eat, and relax in the train’s remodeled compartments.

Thanks to the technician, life on the train is comfortable for everyone – from watching television after a long days work to finding respite from the heat under the air conditioning.
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A dedicated medical professional trained to identify symptoms of oral, breast and cervical cancers is also part of the Lifeline Express team.

“I was supposed to go to Canada to study medicine, but I wanted to be here, in India…and I can’t work a 9-5 to job in a clinic…I have so much energy to share…and I feel a sense of duty, to help others."

“I wanted to see the world…have some adventure”, says a 22-year-old nurse from Madhya Pradesh who completes this team and will go to John Hopkins University for a nursing residency next year.

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Every year, over 7oo,ooo patients are diagnosed with cancer. But the number of cancer patients is probably a lot more - most people in rural India do not have access to cancer screening services.

The Lifeline Express recently included cancer services – a dedicated doctor, a mammography room, and awareness workshops – to facilitate prevention and early diagnosis.
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The train has 5 permanent Operating Theater Technicians. All of them have been with the train for over 10 years. This typically means that they only see their family occasionally, but their dedication to the train’s mission and purpose makes this a worthwhile sacrifice.

“I come from a small village, so I understand the needs. I am happy to be here.”

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The OTT staff oversees the maintenance of medical equipment and supplies, and help doctors with the surgeries. Permanently posted on the train, they are an essential support system for the visiting surgeons and doctors.

There is a great deal of camaraderie that characterizes interactions across staff and volunteers on the train, much of which is a related to the experience, knowledge, and humor of the technical staff on-board the train.
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A three-person team oversees the administration of the train. They come from various parts of India – of course, it is job for them, but they also convey a deep sense of commitment to the train’s mission and the possible impact they can make.

“I used to work at a local hospital earlier, but now with Lifeline Express I can leave a larger footprint.”

Deputy Director, Lifeline Express

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A different donor typically sponsors each project. The administrative team liaisons with donors, conducts the necessary needs assessment in identified districts and villages, and establishes the network of doctors and local hospitals.

The administrative team is the glue that binds the Lifeline Express together.
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Over 80,000 doctors from some of the best hospitals in the country have volunteered on the train. All are motivated by a sense of duty and service.

“As a doctor, it is my duty to help. Once I heard about the Lifeline Express, I knew I wanted to be part of it….I wish we could do even more.”
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Doctors visit the train for 2-3 days at a time to conduct specialist consultations and surgeries. Major surgeries have been performed on the train to restore movement, hearing, sight and correction of clefts, among others.

Over the course of one train-stop, as many 40-50 doctors work on the train.
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Two cooks travel with the train, preparing elaborate and nutritious meals for doctors and volunteers. At each stop, cooks and helpers from the town come on-board the train to help out in the kitchen.
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Doctors, Nurses, Technicians, OTT staff and volunteers all eat together. Meal times are a time for sharing, learning, and laughing.
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Nurses from hospitals across the country come to volunteer on the train. Often, they a help out at the local hospital as well, where nurses are often in short supply.
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“This is a chance for us to learn about the hardships experienced by people in rural India as well as the different kinds of medical conditions… This is important for us to be good nurses…But it is also sad and draining – so many people desperately need help.”
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ASHOKNAGAR

We met the train in Ashoknagar, a small town in Madhya Pradesh. Madhya Pradesh is one of the poorest states in India – over 40 percent of children under the age of 5 are underweight and undernourished.

Here, a middle-aged man, unable to walk on his own, is being carried by his mother to the patient consultation. They have walked many miles like this, in the scorching heat, desperate to receive medical attention.
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The train arrives in Ashoknagar 10 days before the start of doctor consultations. Local politicians and community leaders help spread the word and encourage people to visit the train.

The Lifeline Express also publishes its schedule of medical services in the local newspaper and puts up posters in and around the town. Local political leaders sometime use association with the train to win political favor among local constituencies. But perhaps this is a small price to pay when the medical needs are so great.

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The train parks for 3 weeks at a time, during which time there is a rotation of specialists and doctors.

People come from far and wide to meet the doctors; many are desperate to receive some kind of medical attention, even if only a strip of multi-vitamins. Some patients are treated right away with medicines, others are scheduled for surgery, and a few referred to local hospitals for consultation.
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But the doctors are unable to help everyone. Reasons vary – from unavailability of doctors for specific medical conditions to patients being too weak or unwell to be put under general anesthesia.

People are disappointed, sad, and angry, having walked many miles and waited many months…But the doctors have no option either.
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Oral cancer is the most common cancer in India amongst men. In 2015, over 50,000 men lost their lives to oral cancer. Around 80% or oral cancers are directly attributable to tobacco use.

As a young woman in this profession, it is often difficult for her to make sure her advice is being taken seriously - but she is gentle and patient, combining humor and compassion in her interactions with patients.
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Breast cancer is the most common cancer among women in India and accounts for 27% of all cancers in women. One woman dies of cervical cancer every 8 minutes in India. But, cancer treatment is expensive and for many women it is unaffordable.

A young doctor from the Lifeline Express has been trying to raise money through the local women groups and temples to support their surgeries. In the mean time, all she can do is provide advice and support – but even this is a lot more attention and care than many of these women have ever received.
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The cancer team talk to a gynecology patient and her husband about a medical issue which the woman suffers from since many months.

Prevailing patriarchal attitudes make this a sensitive issue – most women are often embarrassed to ask for help. For many, this is the first time they have spoken about such issues to anyone at all – hugs and tears regularly accompany these interactions.
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The day starts with registration procedures. Often this takes a long time, and people wait at the platform, in the heat, for many hours.

Local businesses help out, providing food and water, along with chairs and pedestal fans.
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Nurses prepare patients for surgery, checking their previous medical history and performing the necessary tests.

Most patients are scared and nervous, at least partly because their previous experiences at government hospitals and private clinics has been either poor or expensive. Many said they find it hard to trust doctors. Hearing this, the nurses go out of their way to reassure and comfort them.
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Doctors conduct eye, ear, orthopedic and plastic surgeries through the day. On some days, the doctors conduct as many as 50 surgeries a day.

Some of the surgeries are quite routine, while others are less common in the urban hospitals in which these doctors typically operate.
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Certain parts of the train's coaches are designated as the recovery area. Patients wait here till they are transported to the local hospital.

Here, a young girl is joined by her mother in the recovery room – both were scared and unsure of what to expect, but are hopeful and happy as the doctors have assured them that the surgery went well.
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Cleft lip is the second most common embryonic deformity in India. Sometimes the trouble is only aesthetic - for children, it is often embarrassing to look different from their friends and this simple surgery restores confidence and self-esteem.

But often cleft lip causes much more serious problems – like difficulty in eating and breathing.
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There are an estimated 250,000 children and people in India with cerebral palsy, making it the most common cause of disability.

Caused by abnormal development or damage to the parts of the brain that control movement, balance, and posture, cerebral palsy causes permanent and severe movement disorders, making it almost impossible to have a normal life.
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Many surgeries require patients to be put on general anesthesia. There is a huge shortage of anesthesiologists in India, particularly in smaller towns and villages. Often, this rules out any possibility of surgery for people in need in rural India.

Here, we see a doctor administrating a form of spinal anesthesia, a complex and potentially dangerous procedure. As the only anesthesiologist on the train, he has an incredibly tough and demanding job.
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The doctors perform from 10 – 50 surgeries a day, often working over 10 hours a day. Teamwork, dedication, and a sense of duty make this possible.

The doctors are notably impressed by the quality of services on the train. “The sterilization facilities here are better than most hospitals in New Delhi.”
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Depending on the surgery, some patients go home right after, while others are taken to the nearby local hospitals for recovery. All expenses at the local hospital are paid for by the Lifeline Express.

Here, a girl with severe cerebral palsy is being taken to the local hospital after surgery – the doctors are hopeful for a full recovery, but this will also depend on the availability of post-operative care, particularly physiotherapists. Unfortunately, such care is expensive and local hospitals are not adequately equipped.
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For most, this is a very emotional time. Despite being sick and in pain for many years, they have been unable to access or afford reliable medical services.

For many, the Lifeline Express might be the beginning of a new lease on life. For others, while full recovery might not be possible, there is at least some improvement and therefore hope.
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After a few days, patients leave the local hospital and go home. But doctors remained concerned whether they will have access to continued medical services to help with their recovery.

This is perhaps the biggest challenge faced by the Lifeline Express - unless their work is supported by the local hospitals and medical practitioners, particularly in the recovery stage, many patients will not be able to make a full recovery.
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After a hard days work, the Lifeline Express team finally gets a chance to put up their feet up and relax. Tired as they are, they also know there is a lot of work still to do – so many places to go, so many more people to help.

But, as the Lifeline Express Team are themselves painfully aware, theirs is only a temporary 'seva' or service - more permanent solutions supported by the Indian state are urgently needed to address India's growing health inequities.

Maybe one day, each Indian state will have its own Lifeline Express...But for the time being this is just a distant dream.


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Idea and concept: Enrico Fabian
Text: Urvashi Aneja
Photo and video: Enrico Fabian
Editing: Enrico Fabian and Urvashi Aneja
Photo and video editing: Enrico Fabian
Pageflow implementation: Enrico Fabian

© Goethe-Institut
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