In his address to the nation on Independence Day, Prime Minister Narendra Modi spoke about inclusive development, with food security, safe housing and sanitation being the rights of every citizen. Health is intimately linked to these essentials of living. The health status of India’s tribal communities is in need of special attention. Being among the poorest and most marginalised groups in India, tribals experience extreme levels of health deprivation. The tribal community lags behind the national average on several vital public health indicators, with women and children being the most vulnerable.
Several studies on maternal health show poorer nutritional status, higher levels of morbidity and mortality, and lower utilisation of antenatal and postnatal services among tribals. Under-five mortality rates among rural tribal children remain startlingly high, at 95 deaths per 1,000 live births in 2006 compared with 70 among all children. A recent study in Melghat area of Maharashtra revealed that 80 per cent of tribal women weighed under 50 kg and 74 per cent of under-five children were malnourished. “Starvation deaths” continue to be reported from tribal areas, including from advanced States like Kerala.
Health problems prevalent in tribal areas include endemic infectious diseases like malaria, tuberculosis, and diarrhoeal diseases, apart from malnutrition and anaemia. What is worrying is that the prevalence of chronic diseases such as hypertension and diabetes mellitus, hitherto rare in these populations, is rising, and stroke and heart disease are now the leading causes of death. Some of the highest rates of tuberculosis in the country have been reported from the Sahariya tribe of Madhya Pradesh. Similarly, deaths due to malaria occur disproportionately among tribals.
Reasons for poor health Research has shown that 75 per cent of India’s tribal population defecates in the open and 33 per cent does not have access to a clean source of drinking water. Insanitary conditions, ignorance, lack of health education and poor access to healthcare facilities are the main factors responsible for the poor health of tribals. Further, displacement from their traditional forest homes and natural source of food and lack of livelihoods makes them dependent on the public distribution system (PDS) and other government handouts for survival. Most tribal groups are traditionally hunter-gatherers and not accustomed to agriculture — their diets, therefore, are now severely limited in fruits and vegetables as well as good sources of protein (including fish and meat). Polished rice and cereals available through the PDS have replaced diverse dietary food baskets.
Although the government has provided for the establishment of Primary Health Centres (PHCs) in tribal areas for every 20,000 population and sub-centres for every 3,000 population, quality healthcare is not available to the majority of tribals. Posts of doctors and paramedicals are often vacant. Additionally, the non-availability of essential drugs and equipment, inadequate infrastructure, difficult terrain and constraints of distance and time (one Auxiliary Nurse Midwife is responsible for 15-20 scattered villages), and the lack of transport and communication facilities further hinder healthcare delivery. The geographical and infrastructural challenges to public health and the lack of health-related knowledge among tribals are exploited by quacks (unqualified medical practitioners), who are often available at the doorstep. Though some traditional practices and superstitions persist, acceptance of modern medicine has increased in recent years, but access to good care is the major issue. Levels of illiteracy are high, with 47 per cent in rural areas and 21.8 per cent in urban areas being unable to read and write. Better educated tribal communities will be better aware of their healthcare needs (and rights) as well as of better care-seeking practices.
Though successive Five Year Plans have provided for the needs of tribal populations within different schemes, and a large amount of funds are allocated, little improvement has been noted on the ground. The poor health of tribal populations cannot be overcome by mere establishment of more PHCs and sub-centres. Scarcity of trained manpower for health is a major problem and an obstacle to the extension of health services to rural and tribal areas. Traditional healers, who are often the first point of care, can be sensitised and trained to deliver simple interventions like ORS for diarrhoea and anti-malarials as well as to refer patients to the PHC in a timely manner. Tribal boys and girls (who complete school but often have no further opportunities) could be trained as community health workers or nurses and incentivised to stay and work in their own communities. A successful example is the ASHWINI Gudalur Adivasi hospital in the Nilgiris, where the management and most staff (except the doctors) are tribal. Nutritional counselling and education, establishment of kitchen gardens and provision of a more diverse range of food items through the PDS would help in curtailing macro and micronutrient deficiencies. More research needs to be done on the traditional herbal medicines used by tribal people and their use encouraged, wherever beneficial.
Scaling up models The theme of this year’s International Day of the World’s Indigenous Peoples was “Bridging the gap — implementing the rights of indigenous people.” Tribals’ right to good healthcare must be addressed using modern technology and innovative approaches and most importantly, by involving the community in developing solutions for their problems. Health is intimately linked to food and nutrition security, safe housing and availability of sanitation and clean drinking water. There are many successful examples of good healthcare delivery in remote tribal areas in our country (almost all involving dedicated NGOs working with the people). These models need to be scaled up in order to improve the lives of the most vulnerable and marginalised citizens of our country.
(Soumya Swaminathan is director, National Institute for Research in Tuberculosis, Chennai.)
Correction
>>In the Comment page article, “Taking healthcare to India’s remote tribes” (Sept. 2, 2014), there was a reference to a study in Melghat district of Maharashtra. It should have been Melghat area .
