The 20th anniversary of India's Lifeline Express - in pictures

Patients desperate for simple prescriptions and medicines as basic as paracetamol fight for attention at a registration session following the arrival of the Lifeline Express in Umaria, a small town in Madhya Pradesh. The train is usually based at a given location for about four weeks Photograph: Marc Sethi/LLE

A boy with orthopaedic problems is examined to gauge his suitability for surgery. Possible operations are determined by the suitability of the train’s facilities and the available post-operative care Photograph: Marc Sethi/LLE

Prospective patients are screened and assessed. Here, a case of suspected skeletal fluorosis, caused by too much fluoride added to the water supply, proved unsuitable for treatment on the train Photograph: Marc Sethi/LLE

On the train's second morning in Umaria, children selected for surgery are carried on to the train by their mothers. Since the project began, 600,000 people have received treatment and approximately 85,000 operations have been performed. The train visits locations with limited access to doctors, and patients are invited on-board for orthopaedic surgery, treatment for hearing and visual impairments, cleft lip repairs and, more recently, for counselling on epilepsy, neurological and cardiac disorders, dental and gynaecological problems Photograph: Marc Sethi/LLE

Two operations are performed in a carriage adjacent to a live running railway track. The Lifeline Express has inspired similar models of healthcare in China and central Africa and riverboat hospitals in Bangladesh and Cambodia Photograph: Marc Sethi/LLE

Volunteer orthopaedic surgeons prepare a child for surgery to shorten the tendons in both legs. The World Health Organisation estimates that India's spending on health stands at less than 4% of its total budget. Zelma Lazarus, of Impact India, the NGO behind the project, had hoped that the train would be defunct by now. It was not set up to plug the gaps in India’s public health system, but to bring about change and educate the poor about their rights and medical needs, so they could make informed demands to the government Photograph: Marc Sethi/LLE

The arrival of a neurologist at the district hospital prompts a heated scramble for attention among people who normally have little chance to receive medical care. The train usually stops in areas that have some sort of post-operative care. If a district hospital is available, patients will be treated on the train and then sent to the hospital to recuperate Photograph: Marc Sethi/LLE

In two days Dr Mamta Bhushan Singh consults 203 epileptic patients, providing them with medication and education on managing a disease that mostly goes unrecognised and untreated in poor areas of India. If there is no suitable place for post-operative care, makeshift recovery areas are set up around the train Photograph: Marc Sethi/LLE

Consultants have modified cleft palate surgery so that it can be performed under local anaesthetic on the train, maximising the number of patients while minimising post-operative care Photograph: Marc Sethi/LLE

Post-operative cleft palate patients assemble at the district hospital in Umaria. The hospital only has beds, so has no facilities for counselling or surgery, which is why the train was needed in that area Photograph: Marc Sethi/LLE

A 55-year-old woman is selected to undergo surgery for her cleft lip. In rural India this disfigurement often goes untreated due to religious beliefs Photograph: Marc Sethi/LLE

A day later, following treatment, the woman has had her dressing removed Photograph: Marc Sethi/LLE

A three-year-old girl recovers after surgery for polio on the train. Her parents are thrilled she will now be able to marry Photograph: Marc Sethi/LLE