I arrived last week in Gudulur, in the Nilgiri Hills of Tamil Nadu, India.

The district is home to around 28,000 adivasi or indiginous tribal people, who populated the area's forests as hunter gathers long before the British arrived to plant tea in the days of the Raj. Many were displaced from their original areas by settlers and government leglislation and are among the poorest groups in this state.

ASHWINI (www.ashwini.org) was set up in the late 1980s as a health care system for the adivasi population, which is made up of diverse ethnic groups. The programme consists of 8 rural centres and one 20 bed hospital which is staffed mainly by adivasi staff who have been trained as nurses, accountants, administrators and health 'guides' working in the villages.

The main problems we see here are infectious diseases. TB is a common problem as well as a high incidence of sickle cell anaemia. Interestingly the largest causes of death here are suicide and cancer, particularly of the oesophagus, probably due to the amount of betel nut chewing that goes on.

The health programme is managed by the adivasis and is partly financed by a community health insurance programme. Each member contributes from 10 to 35 rupees (20 - 50pence) per year which covers costs of admissions and medicines and out patient treatment.

I'm starting a study this week of the factors affecting whether people pay the premium and attempt to explain why the rate of thos paying has remained steady at around 40-50%.

I'm also working in the hospital and visiting the rural centres. Medicine here is understandably very different from the UK and the health programme is only a small part of a larger development effort including education, legal support and economic efforts including tea cooperatives.

Last week, to give a flavour we saw stroke patients, cancer, sickle cell crises, septic miscarriage, PID, trauma (a lot of falling out of trees goes on here) severe bronchopneumonia in a 1 year old, severe malnutrition, rhematic fever and numerous signs I have only read about in textbooks. There is also a growing incidence of diabetes, incongrously in a malnourished population.

For more information on electives / development and health training see Ashwini's website.

Rebecca Hope