India has a large and heterogeneous tribal population of approximately 104 million. This accounts for 8.6 per cent of the total population and it is spread over a vast area. Apart from the States of the northeastern region, Madhya Pradesh, Chhattisgarh, Jharkand, Maharashtra, Orissa and Gujarat have large tribal populations. Physical remoteness, high rates of malnutrition and poor living conditions contribute to the vulnerability of tribal people to TB and other infectious diseases. Ignorance, misconceptions and variable access to quality healthcare make them vulnerable to exploitation by quacks, leading to poor health outcomes. In a way, the health problems of tribal groups are similar to those of the urban poor, though solutions will have to be differently designed.
A systematic review of Indian studies estimated that pulmonary TB prevalence among tribal people was 703 per 100,000, which is almost three times that in the general population (256 per 100,000). There was a lot of variability among the tribal groups, with the Saharia tribe in Madhya Pradesh showing the highest rates of up to 3,000 per 100,000. Further, a social assessment study commissioned by the Central Tuberculosis Division of the Union Ministry of Health, and conducted in 2005 and repeated in 2011, identified various gaps in service delivery to tribal populations. The first study led to the development of the tribal action plan: it outlined differential strategies and packages for the tribal population under the Revised National Tuberculosis Control Programme (RNTCP). However, the follow-up in 2011 revealed limited improvement in terms of two key parameters: access to services and awareness among the community. Insufficient community engagement, non-involvement of traditional healers, distance of the tribal populations from government health centres, and lack of appropriate awareness-building measures were some of the other issues identified. These resulted in significant delays and under-utilisation of programmatic services by the tribal population.
Clearly, these vulnerable populations need special attention, and bold initiatives are needed to reach out to them. The Indian Council of Medical Research (ICMR), in collaboration with the Central Tuberculosis Division of the Ministry of Health and Family Welfare, is planning an innovative project in certain hard-to-reach tribal areas in central and western India. It will be implemented initially in Gujarat, Rajasthan, Madhya Pradesh, Jharkhand and Chhattisgarh (19 districts and 17,000 villages) covering a population of approximately 18 million. A clearly defined implementation plan and strategies to engage the community to improve their awareness about TB and other diseases that affect them, and involve traditional healers in aiding earlydetection and referral, have been designed.
A mobile diagnostic van equipped with digital X-ray and sputum microscopy services will go to identified villages at regular intervals and offer services at the doorstep. Sputum will be collected from those with symptoms and brought to the nearest testing centre and the results conveyed the next day. Where possible, the latest diagnostic techniques such as Gene Xpert will be used. Individuals identified to have TB will be linked with the nearest treatment centre and treatment initiated quickly.
Through the involvement of local community members and traditional healers (in terms of sensitising and training them and providing incentives), levels of community awareness will be increased and their participation in health programmes strengthened. These efforts should lead to people seeking care early, reduction in delays in diagnosis and treatment initiation and lower out-of- pocket expenditure.
Patients need emotional and social support during treatment to ensure regular and complete therapy.
It is to be hoped that corporates and others will come forward to provide nutritional and other kinds of support, as patients need good nutrition to recover rapidly. This kind of implementation research will provide the needed evidence to scale up such strategies in other areas.
India having committed to the “End TB strategy” that calls for a 75 per cent reduction in deaths and 50 per cent reduction in incidence by 2025, it must take on tuberculosis in mission mode.
(Dr. Soumya Swaminathan is Secretary, Department of Health Research, and Director-General of the ICMR)
