Economic and Political Weekly October 7, 2000 3688 T he health status or sickness of a community especially within a modern nation state requires to be understood according to the social condi- tions mentioned here. The social condi- tions include access to the basic needs and amenities like food, drinking water, hous- ing, education, employment, transport, communication, etc. Within traditional anthropology, people’s perceptions, cul- ture, history would matter much but in- creasingly the all encompassing state that is the nation state and the internal indi- vidual and group competition for the scarce resources tend to determine the situation. Hence political forces play a dominant role in not only shaping health services but also determining the health status of a commu- nity. Secondly, the critical gap between availability and accessibility health ser- vices has been instrumental in excluding a large proportion of the rural population in India from leading a normal healthy life, as has been well documented [Goran Djurfeldt and Staffan Lindberg 1975; Frankenberg 1981; Banerjee 1984; Antia 1985; Jeffery 1988; Duggal 1996; Narayan 1999]. Both the private and public sectors have been contributing to this process in their own ways, depriving majority of the marginal communities, particularly the low caste and tribal groups. Hence, achieving better health care invariably involves a struggle for democratisation, just social relations, etc. These larger issues of health are examined through a study of the lep- tospirosis epidemic in Surat district. Surat district is located in the southern region of Gujarat. It is predominantly agricultural, though there is substantial industrial development in and around the urban centres of Surat, Navsari, Valsad, Billimora and Vapi in south Gujarat. The sources of health services are: (a) govern- ment run – primary health centres (PHCs), community health centres (CHCs), New Civil Hospital, Surat (NCHS); (b) private sources particularly rural private practitio- ners (RPP); 1 (c) indigenous healers in- cluding traditional healers (bhagats and bhuvas), elders of the community, dais, etc. Rural health care by the state has been mainly provided by PHCs, PHC sub- centres, and CHCs. Each PHC is expected to cover a population of 20,000 in case of tribals whereas 30,000 in case of non- tribal population while each sub-centre covers 5,000 population. Most of the PHCs and its sub-centres are under-utilised and inaccessible in Surat district due to several reasons: unavailability of service provid- ers and its paraphernalia; inaccessibility of services particularly for women and chil- dren due to transport and communication especially in the tribal areas; competitive fee by the RPPs; lack of provision for injections, etc. CHCs are expected to serve one lakh population covering four to five PHCs. CHCs are relatively popular com- pared to PHCs because of hospital facili- ties (specialist doctors, laboratory, ambu- lance, etc) and unaffordability of private hospital services but have problems like long waiting time, services provided by the doctors in restricted time and so on. NCHS is not considered an option by the majority of the rural population except for compli- cated cases referred by CHCs and for those residing closer to the city centre (for in- stance, coastal villages in Surat district) because of its distance, large institutional structure and related problems. In brief, though a vast infrastructure has been built, teams of trained health personnel have been provided to serve rural communities, issues of equity and access continue to rock the government health institutions. Although those persons who have under- gone five years university medical degree are supposed to be the only professionally qualified ones to practice allopathy in reality private practitioners comprise a mix of qualified (MBBS, MD) and unqualified (RMPs and other indigenous practitioners) personnel providing allopathic and other services in rural Surat. Most of the RPPs have dispensaries in the nearest urban centres while a few of them either run mobile clinics or have clinics in the villages. The problems identified with RPPs are :overuse of injections, multiple drugs (either sub-therapeutic or overdosing), extremely short duration of treatment, lack of accountability in terms of case follow- up and case reporting to any public agen- cies, etc. In brief, though RPPs are popular and the source of treatment for the majority in rural Surat, they are unable to deliver to the clients needs, which is apparent with many of them consulting minimum two RPPs for each sickness episode. Traditional practitioners comprise – midwife or dai, herbalist, faith healers (bhagat/bhuva) and a few elders of the community. Among the herbalists, there are generalists and specialists who treat exclusively certain sicknesses like jaun- Health Care Access and Marginalised Social Spaces Leptospirosis in South Gujarat Most rural poor have problems in accessing health care services not because they lack trust on biomedicine as is usually thought but because of the failure of the state to take cognisance of social spaces in health care policies. Secondly, the biomedical approach to human suffering is clearly inadequate especially in developing countries. Findings of a study of the leptospirosis epidemic in Gujarat show that the quick supply of drugs, opening of special wards in the hospitals, increased allocation of equipment, doctors, health workers, during the 1997-99 epidemics failed to save lives. The improvement of services and equipment temporarily during epidemics at PHCs and community health centres did not help change the reputation of these institutions overnight. PURENDRA PRASAD