In their lifetime, Chingmak Kejong, a former pastor turned social reformer, and his wife, Phutoli Shikhu, have done more for the people of Tuensang district in eastern Nagaland than politicians and bureaucrats.
Working hand-in-hand with tribal communities through their non-profit, the Eleutheros Christian Society (ECS), they have helped communities living in this remote and backward district bordering Myanmar successfully battle the HIV and heroin epidemic in the 1990s, help establish a functioning primary healthcare system and bring warring tribal communities together with their work in healthcare.
Districts like Tuensang are governed under special provisions of the Constitution, but its proximity to Myanmar and China, and a long-running insurgency has left this area mired in a state of conflict. Rampant underdevelopment and conflict offer perfect breeding grounds for these epidemics in the picturesque Naga Hills.
In battling these epidemics, Chingmak has also tragically lost two brothers. One can personally see how vested he is in ensuring his people overcome them. Beyond healthcare, ECS has significantly ventured into education, water sanitation and a myriad of livelihood projects as well in this economically backward district. “There has always been a systemic marginalization of this region which today encompasses Tuensang district,” says Chingmak.
From Pastor to Social Worker
As Nagaland entered the 1990s, Chingmak had studied to become a priest pursuing his Master’s in theology from the Union Biblical Seminary in Pune, a city where he also met Phutoli, who had found work in Hong Kong for an organisation rescuing and rehabilitating children forced into prostitution. Meanwhile, in Tuensang, Chingmak took up work as a priest, and vividly recalls how drugs suddenly took hold of families.
“All of a sudden, you had drugs like heroin flooding the streets of Tuensang. You would find elderly people saying if people took this drug all their joint pains would go away. Before you knew it, every third household had a drug addict,” recalls Chingmak.
It was in Hakchang (1991-92), a village 17 km away from Tuensang, where this pastor witnessed crushing poverty and rampant sickness for the first time in his life.
However, a series of events would drastically change the course of his life. First, two of his brothers fell into the throes of drug addiction, a fact Phutoli would constantly remind him about.
“My wife would always taunt me saying I was living in my comfort zone. Village residents respected, revered and listened to me in rapt attention for two hours every Sunday. She would repeatedly ask me ‘doesn’t it bother you that your brothers are in the streets chasing drugs?’ My ambition back then was that I would serve in the church of a small village, get promoted to a township and eventually attain a significant official position. But Phutoli kept nudging me to do something more meaningful for the community,” he says.
However, there was one particular incident that really shook his conscience during his years as a village pastor, when a young infant died of hunger after her mother set off to find food.
Allied with the realization of the growing drug epidemic and a shocking lack of basic healthcare facilities, Chingmak quit his role as pastor in 1993, set up his non-profit ECS and immersed himself fulltime in social work.
House of Hope
As per this policy document published by the Transnational Institute, an Amsterdam based global research and advocacy non-profit:
Production of heroin in the Golden Triangle – roughly the area that spans northern Burma, Thailand and Laos – started in the 1970s, and cheap high quality Burmese “no. 4 heroin” was abundantly available in Manipur and Nagaland. As a result, many users switched to smoking heroin, usually in cigarettes. When poppy cultivation in the Golden Triangle diminished in the early 1990s heroin became scarce and more expensive. Law enforcement by the Indian authorities further contributed to the price rise. As a result, many heroin users switched from smoking to injecting, to obtain a maximum effect from a relatively smaller dose. The high cost of needles and syringes, fear of being exposed as a user and ignorance of the danger of unsterile needles led many injecting drug users to share needles and to fashion makeshift needles and syringes made from ink droppers.
For the first few years of ECS, Chingmak and Phutoli sold their wedding gifts to fund their work rehabilitating addicts since no international funder would make the trip to a place caught in a raging insurgency located barely two hours away from Myanmar. Shootouts and ambushes were a regular feature of the conflict between Indian security forces and Naga insurgents. And everyone in this part of the world lived through that hellish experience.
The first thing Chingmak and Phutoli, who returned from Hong Kong, did was establish a small drug rehabilitation centre, which they called ‘House of Hope’ for recovering drug addicts in the Longpang village near Hakchang in 1993. The first batch of 33 addicts from Tuensang joined the House of Hope, including two of Chingmak’s brothers.
“We never knew about the nexus of drugs. Many of these insurgent Naga groups would shoot down drug peddlers and brutalise drug addicts. There were days when my wife and I would hide these boys above a false ceiling because they were scared that insurgent groups would catch them. My work was borne more out of pain than a passion to start a non-profit. We were just responding to immediate problems on our doorstep,” says Chingmak to TBI.
Speaking to The Indian Express, Senti Tzudir, a former drug addict who now works with the couple, talks about the House of Hope. “The first day was hard. The second, harder still…[But] We had our own routine, we would collect firewood, cook for ourselves, and focus on developing our own individual identity,” he says.
Senti has been sober for 20 years now.
Cocktail of Conflict, Drugs and HIV
According to Chingmak, the incidence of HIV among drug users in Tuensang was almost 47 per cent in the late 1990s. Also, the HIV-rate among antenatal mothers at the time was 8.1 per cent in Tuensang, which is just a few percentage points below Namakkal in Tamil Nadu, which is known to be the worst-affected district with 8.6 per cent.
Chingmak argues that the spike in HIV positive cases in Tuensang was a consequence of a misdiagnosis of the drug epidemic by the Church, an all-powerful institution in the State, and insurgent groups, particularly when it came to injection drug use (IDU). They didn’t see the conflict, mental health or underdevelopment as the root cause, but the needle.
“What insurgents and the church groups did was ban the needle. In fact, that created another serious problem. Say, there are 10 drug addicts and one boy has HIV. With needles banned, there is only one which is shared among the 10 addicts. What happens next? He infects all the 10 with HIV through just one needle. That really blew up the HIV epidemic in Nagaland since intravenous drug use and needle sharing was so rampant. Things were so bad that needles that were originally an inch long when first used would shrink to half a centimetre because of regular use. It was a very scary time,” he recalls.
However, the realization that HIV was a major public health crisis came only a few years after he had started work rehabilitating addicts. Towards the end of 1993, a team of researchers from Indian Council for Medical Research (ICMR) had visited the House of Hope to witness the couple’s work and also test the blood of addicts under their care.
“I wasn’t really sure why they had come. Back then, HIV hadn’t even registered on our radar. When we told our boys that these researchers wanted to test their blood, they happily agreed. At the time, all 33 boys got their blood tested,” says Chingmak.
What the couple didn’t know at the time was that they had conducted an ELISA test used to diagnose HIV. Nearly four years later around early 1997, by which time the couple had forgotten about the test, a doctor from the local Civil Hospital in Tuensang called Chingmak. The doctor asked him to send a member of his senior staff to pick up the results of this test in 1993, which had only recently arrived from Kolkata.
“Out of the 33 boys tested, 25 were found to be positive. If I had the resources, I would have sued the government back then for this level of shocking oversight. Out of the 25 who tested positive, only 18 were alive at that point. One of the boys tested at the time was my brother. I came to know that my brother was HIV positive after he died in 1995,” he recalls.
What followed was a rigorous contact tracing process for the 18 men still alive, asking them about their needle partners and sex partners. “We then asked their sex partners who they had intercourse with during this time. We ended up with around 299 names after the contact tracing process. We met all of them. That’s when we realised that it’s now pointless to conduct further contact tracing and that we had to reach everyone in Tuensang. In fact, we closed down our facility in Longpang for almost three years (1998-2000) and decided to really expand our grassroots work to address the HIV epidemic,” he says. The biggest issue they had to deal with was the stigma attached to drug addiction and HIV, particularly in homogeneous communities living in the Hills. Stigma thrives in this sort of a social setting.
“During our HIV campaign, we heavily emphasized on testing. This is because we found that if a boy or girl tested positive, they would invariably tell an aunt, uncle, a close sibling or friend about their condition, which increased the circle of concerned persons. At ECS, we must have tested about 40% of Tuensang’s population. Until HIV strikes close to home, people don’t care. When it affects one of your close ones, you develop concern and empathy. Testing really addressed the stigma attached to HIV,” he says.
Chingmak goes on to say that ECS was fortunate to work with some ‘very good officers’ in the Nagaland State Aids Control Organisation. With these officers, ECS formulated the idea of a link workers programme, where there would be volunteers in a village. Anyone with high risk of HIV or showing symptoms would be referred to ECS by these volunteers.
At ECS, they had a mobile testing unit, and volunteers would also enact village plays of why people should test themselves. They had a network of core volunteer groups in schools, colleges and churches identified as link workers, who would refer people for testing. For the first five years, they were running the testing facilities in Tuensang.
“We even went to remote villages crossing into Myanmar. In remote places like Tuensang, where the primary healthcare system is non-existent, greater testing ensures more caution. However, the biggest source of success was getting the church involved,” he says.
The biggest public platform in Nagaland is the church. Every hamlet has a church. A lot of stigma came from them because a church tends to be very moralistic. What ECS wanted was to ensure that this platform spoke differently. This is what happened next.
In the later 90s, NACO (National AIDS Control Organisation) offered a massive grant to ECS in their battle against HIV/AIDS. They had asked ECS to take the money since Tuensang was heavily hit with HIV. However, the couple told NACO that they would take the money only if tribal leaders, village heads and the church joined their efforts. After prolonged discussions and debates with the church over months, particularly against a faction deeply opposed to their work, the church finally asked ECS to take the money.
Various churches came together under the umbrella of the ‘Churches Alliance for Community Support’ (CACS) in 2000. Given the prevalence of stigma, ECS negotiated with the Church to work on extending care and support to people living with HIV.
ECS claims the outcome has been overwhelming. In 2001, the prevalence of HIV among Injecting Drug Users (IDUs) was 34.6% but today it is below 1.8%. Among ANCs (antenatal care) the district had the highest prevalence rate at 8%, which is now below 2% and the response to HIV education has been relatively positive.
“On Sundays, a pastor would stand on a pulpit and talk about a parishioner who had HIV without naming them, saying that he/she might die any day so let’s pray together for them. The whole congregation would pray for an HIV positive person. This act of praying together in some way internalized a sense of empathy amongst the larger community for the person afflicted by HIV. In addressing the stigma, we also got rid of the uninformed fear and paranoia surrounding it. Things started to normalise and hospitals started opening testing centres, supplying antiretrovirals. Without any fear people just approached them and took their ART medicines with little trouble. It became normal to say, ‘I’m HIV positive’,” he says.
Once people started doing this more regularly, ECS began winding up some of their work in HIV to focus on other issues. From 2000 onwards, their focus shifted away from addressing HIV and drug rehabilitation to larger mitigating factors surrounding primary healthcare, livelihood generation, education and sanitation. They handed over the drug and HIV-related work to an offshoot of ECS and nonprofit called the Integrated Development Society.
Establishing Primary Healthcare
Sometime in 2007, there was a cluster of around 8 villages in Tuensang district, where 40 children died in one week because of water-borne diseases like diarrhoea, cholera, etc. Naturally, there was a lot of panic and the eight villages got together.
“From the very beginning, we believed that unless communities own the process, there is little impact. We spoke to village elders and told them that the government will take its own time to come, so why don’t we do our own thing? Given the circumstances, ECS converted the ‘House of Hope’ into a community care centre (CCC) in 2007, starting with two nurses and a visiting doctor. When the community started showing initiative, the government came to us and said they would like to work with us,” notes Chingmak.
Although the government wanted to work with these village communities to establish a primary healthcare centre, there was one bone of contention. During one such meeting, which was attended by the State health secretary, the village elders issued their demand that they would appoint the doctor, nurses, janitor and ambulance drivers, while the government would pay their salaries. The health secretary initially rejected the demand.
“But both I and the village elders convinced him otherwise. They told the health secretary that if the government brought in doctors and nurses, they would not stay in the village since it had no electricity or other modern amenities. If the community appoints its own doctors and nurses, they would stay. He eventually agreed to our demands,” he says.
In 2009, ECS finally signed an MOU with the government of Nagaland to run the first PPP mode Primary Health Centre (PHC) in the state. The House of Hope was chosen as the site of this PHC. This was essentially a 6-bedded hospital at first but the community has increased the same to 35 beds.
Though in a remote setting, the centre today is equipped with ultrasound machine, x-ray and basic lab facilities. This may be among the very rare PHCs in India, where the doctors and nurses are appointed by villagers.
Two years later, the Primary Health Centre was empanelled as a unit to manage the Rashtriya Swasthya Bima Yojana (RSBY) insurance programme. The insurance coverage was Rs 30,000 for a premium of just Rs 30 for BPL families. Free medicine and treatment was provided to those who come to the centre with the RSBY card.
This PHC has also catered to HIV positive patients as well. In the past five years, the centre has treated 656 HIV positive patients and continues to render services to them.
“Today, we have expanded to 7 PHCs where doctors and nurses are appointed by the respective villages. We have around 18 sub-centres. In total, we cover around 73 villages in Tuensang, Mon and Longleng districts, giving them access to primary healthcare. But what you’re seeing today is a culmination of a myriad of efforts. We live in a community where superstition is rampant, and traditional medicine and quack doctors took precedence over modern medicine. A lot of work had to be done at the village level to get them to accept modern medicine. We organised mothers in these villages into Mothers Clubs, operationalised anganwadi centres, ensured complementary feeding for them and organised regular camps to raise awareness about pre- and post-natal care,” he recalls.
All these PHCs have been empanelled under the Ayushman Bharat insurance scheme. None of the villagers come to these centres with cash. They bring their insurance cards and reimbursement happens within two weeks. However, in the verdant and uneven terrain of the Naga Hills, road connectivity is still a major concern. For better access to these PHCs, Chingmak worked together with villages to construct three wooden bridges to improve access to these centres.
“We built these bridges out of utter frustration with government apathy. Before the first bridge, there were 8 villages, whose residents would have to take a 60 km round trip to reach our PHC in Longpang. If there was a functional bridge, it would take them 5 km one way. Instead of waiting for the government, we got together in 2014 with the respective village residents, while someone donated a JCB and an engineer came to design the bridge. We built the bridge in just four months in 2014,” says Chingmak.
Last December, ECS helped locals build a 50-foot bridge that connected five villages to district headquarters — a demand pending for over 70 years. This 17-km bridge took two years to make and it connects six villages to a PHC adopted by ECS in Noksen village.
“This year, we are constructing a 19 km road which will connect around 20 villages. We are raising money to buy steel girders since a bridge this wide (70 feet) cannot be supported by wood. All the funding for these bridges is community-generated. When we opened the bridge last December, all the village heads arrived in their traditional gear. We decided not to call ministers or anyone else from the government to inaugurate the bridge,” he adds.
“ECS [also] caters to unmet secondary and tertiary care needs of the community through surgery camps conducted once or twice a year…For the week-long surgery camps, eminent surgeons visit the centre and perform about 80 general as well as specialised surgeries,” notes Social Work India. Similarly, they have run successful immunisation programmes.
Besides their incredible work in healthcare, they have launched a myriad of educational initiatives, built infrastructure, introduced farming and piggery initiatives and instituted water and sanitation projects. Many of these initiatives are in partnership with the government, while they have received grants from companies like Tata, Wipro, HCL and Kissan.
“It’s better to make government schemes and programmes functional. We may have to push this idea further, but five years down the line you may see me growing pumpkin and engaging in a piggery in my backyard,” he laughs.
(If you want to contribute to ECS’ work in Eastern Nagaland, you can click here.)
(Edited by Gayatri Mishra)