HEALTH PROBLEMS – Anthropology by K.V RAMESH

Introduction:

John S. Gaikwad (1970), D.P. Mukherji (1973), P.C. Malhotra (1967), P. Bhole (1986), S.L. Khatle (1986), R.K. Mutatkar (1986) World Health Organisation (1986) and several others studied the problem of health among the tribes in India. All these studies show that the health status of the tribal populations in India is very poor. They have pointed out that poverty illiteracy, malnutrition, absence of safe drinking water and sanitary living conditions, poor maternal and child health services, ineffective coverage of national health and nutritional services are the contributing factors for the poor health conditions among the tribal populations in India.

Health Problems.

The tribes in India understand their health problems according to the dictates of their culture. In this context, they classify their diseases into seasonal, incurable, curable, hereditary and women’s diseases.

The seasonal diseases are several Amoebic dysentery, malaria, chronic headaches, jaundice and bacillary dysentery occur in summer. Diarrhoea, cold and cough, fever, bronchitis and tonsils occur during
rainy season. Scabies, ring worm, chicken pox and fevers occur in writer season.
The curable diseases are common headache, hook worm infestation, round worm infestation, amoebic dysentery, blood dysentery, jaundice, cold and cough, ring worm, fevers and chicken pox.
The incurable diseases are yaws, tuberculosis, diabetes, epilepsy, syphilis and leprosy.
The hereditary diseases include diabetes, tuberculosis, epilepsy and filarial.
The disease of women includes infections of genital tract, the venereal diseases and irregular menses.

Distribution of diseases:

The seasonal diseases occur in all tribes in India. Likewise, the curable diseases occur in all the areas where the tribals live. The incurable and hereditary diseases occur in specific areas inhabited by the tribals.

Yaws is mostly found among the tribes living in the scheduled Areas of Orissa and Andhra Pradesh. Sporadic instanced occur in the tribals areas of Chhattisgarh, Madhya Pradesh and Tripura.
Tuberculosis occurs in different tribals tracts of Chhattisgarh, Madhya Pradesh, Maharashtra, Rajasthan and Tripura.
Incidence of leprosy is high among the tribes of Assam, Jharkhand, Chhattisgarh, Orissa, Uttar Pradesh, Tripura, Lakshadweep and Minicoy islands.
Venereal diseases occur among the Andamanese, Todas, Khasas of Jaunsar Bawar, Khonds of Orissa, and tribes of Chhattisgarh, Rajasthan, Karnataka, Lakshadweep and Islands. The high among the polyandrous tribals like the Todas and Khasas. It is also high among the Santhals of Mayurbhanj District of Orissa.
Infectious of genital tract are numerous and widespread among the tribal areas. such diseases are related to inappropriate care or poor hygiene in connection with child-birth, abortion or menstruation.
Respiratory infections, skin infections, gastroenteritis, helminthiasis, trachoma, fevers of unknown etiology are some of the communicable diseases which are also found among tribal groups.
Induced abortions, inbreeding, addiction to opium and disturbed sex ration leading to storage of women were some of the health problems indicated by investigations. The Singpho of Arunachal Pradesh are addicted to opium. On account of this their population came down from 40,000 in 1961 to 10,000 in 1991.

Special health problem:
The tribal populations have special health problems and genetic disorders like sickle cell anaemia, glucose-6- phosphate enzyme deficiency, thalassaemia, and haemoglobin-E, which occur in high frequencies.

(i) Sickle cell disorder is prevalent among tribes of Mahapatra, Pardhan, Pawara, Madia, Gond, Bhil, Halbi, Malhar Koli, RajGond, Koruku, Tandvi, Kolam, Warli, Katkari, Kokana, Andha, Mahadeo, Koli, Thakur. The same tribal population groups residing in the neighbouring states of Gujarat, Madhya Pradesh and Andhra Pradesh have a similar prevalence.
(ii) Thalassaemia is another type of disorder among the tribes in India. It pertains to haemoglobin synthesis. The production of normal haemoglobin (HbA) is inhibited due to anomaly in the orderly synthesis of one or the other polypeptide chain of haemoglobin molecule.
(iii) Sickle cell Haemoglobin (HbS) is prevalent in Central, Western and Southern India. There were more than 35 tribal population groups showing a frequency of 19%. According to the DST report 1990 approximately 50 lakh individuals were carriers (Heterozygous) among the tribals. In some South Indian tribes like Mullukurumba, Paniyan, Pradhan, Irula, Adiyans, Konds Kamara the percentage of Haemoglobins or Sickle cell Haemoglobin is prevalent up to 40%. It has been observed that Sickle cell trait(HbAS), in heterozygous condition confers protection against Falciparum Malaria. Tribals carrying Sickle cell trait (HbAS) are more prone to certain diseases like Pulmonary disorders, Haemolytic crisis, Mild jaundice, Infections and Kidney disorders. About 1.6 lakh tribal individual suffer from Homozygous (HbSS). These Homozygous individual with few exceptions do not survive up to adulthood.
(iv) Glucose –6- Phosphate enzyme deficiency (G-6-PD) of the red blood cell is inherited as an X-linked recessive trait. Males are affected by this deficiency. About 13 lakhs G-6- Pd deficient were present in tribal population (DST 1990). This deficiency diseases were prevalent among the tribes of Madhya Pradesh, Maharasthra, Tamil Nadu, Orissa and Assam. Glouse-6-Phospate dehydrogenase enzyme deficiency is one of the most common defects of inherited red cell enzyme which prevalent among tribes from South-North, North-East through Western and central India (Das 1985). Among the Naik-Lambadi and Koya Southern tribes the frequency of G-6-PD is below 5% while among the Western tribes like the Khatari, Bhil, Dhodia and Konkana the percentage vary between 5-10%. Central tribes like Gond exhibited high frequency (19%) whereas among the Angami Nagas the frequency is higher (26.06%).
(v) Haemoglobin E (HbE) occurs among the Totos of North-East. The tribes of North-East show HBE gene in high frequency among the Mikir tribe (0.198) and the Kachari tribe (0.549).
(vi) Infant mortality rate is one of the indicators of the health status of a society. Valuable information of infant mortality rates of tribal population of different states of India shows that it is minimum in some states and very in some other states. The tribal populations belonging to the states of Andhra Pradesh, Gujarat, Madhya Pradesh have high infant mortality rate (140/1000).
(vii) Nutritional problems are also common among the tribes in India. Malnutrition is common among tribes and affects the general physique of the tribals and lowers the ability to resist infections and leads to chronic illness. In the post-weaning period if leads to permanent brain impairment. Among most of the tribal population the staple diet is rice. Occasionally they also consume birds, fish and other meat products. Their nutritional status depends on the capability of the tribal group to procure and consume food of their choice. Tribals largely depend on the forest produce, which is easily available for consumption. Tribal diets are deficient in calcium, Vitamin-a, Vitamin-c, Riboflavin and animal protein. In some South Indian tribes, the diet is deficient in Calories and protein. The studies on dietary status and health of tribals of Bihar, Maharasthra, Andhra Pradesh, Madhya Pradesh observed deficiency of Proteins, Calories and Amino acids. In some primitive tribes of Phulbani, Koraput, Sundergarh district in Orissa, Bill, Garasia of Rajasthan, Padar, Rabri and Charan of Gujarat and Bonda of Orissa, high incidence of malnutrition were observed.
Deficiency disease like Anaemia, Kwashiorkor, Marasmus and vitamin deficiency signs like Bitot’s spot and angular stomatitis were prevalent among tribal population. Nutritional anaemia, which lowers resistance to fatigue, and increases susceptibility to other disease is common among tribal women. Maternal mortality was reported to be high among tribes in India. The chief causes for maternal morality were unhygienic conditions and primitive practices for parturition.

Causes of disease:
The tribes in India attribute the causes of disease to environmental, social, supernatural and acculturative factors.

(i) Environmental factors: Tribal people living in forest and hilly areas depends on perennial hills streams for their water requirement. The streams are used for bathing of humans and livestock. Dirty clothes are cleaned in the stream water directly. Men and women defecate on either side of the stream and wash directly in the stream water. The stream water carries decomposed leaves and other vegetative matter that provides a breeding ground for various kinds of parasites. The water used for domestic purposes is released into small pit outside the house. Physical or environmental causes, include accidents, venomous snake bite or insect-bite, attack by ferocious animals, eating if inappropriate food, contact with poisonous insects and plants, effect of changing weather and environmental factors.
(ii) Social factors: They include (a) Non-fulfilment of obligations towards relatives, to neighbours and to friends (b) Social factors treatment status, role and rules pertaining to treatment of patients (c) Allowing a large number of relatives or visitors to see the patients, (d) Mingling of patients with people. (e) Entering the task of child care to the victims of leprosy or other diseases.
(iii) Supernatural factors: The attitudes of tribals towards health and diseases are superstitious and unscientific. The concept of etiology illness, of diagnosis and treatment and ideas of prophylaxis were developed and preserved as the traditional lore of tribal society. In many tribal cultures ideas and practices relating to illness are inseparable from the domain of religious beliefs and practices. The relationship with the Gods and ancestral spirits plays a decisive role in the occurrence of diseases in society. Tribals believes that “diseases are caused by supernatural powers and the wrath of their deities and ancestral spirits and therefore they can be cured by propitiation of the enraged supernatural powers by sacrifices of animals, religious rituals, sorcery and witchcraft”. They believe that a harmonic relationship with the supernatural ensure protection from diseases and other calamities. Hence, they make periodical offerings to them and worship them.
(iv) Culture context: Though culture contact tribals contracted venereal diseases and tuberculosis.

Treatment of diseases:

The tribal specialists, who treat the disease are: Shamans, divinators, sorcerers and doctors. The tribals they some home remedies for treating some diseases before they procure the services of specialists. Shamans have many functions. Their activities include omen-reading, sooth-saying, divination for detection of the cause of suffering, exorcism, removal of the harmful effect of evil-eye, nullification of the influence of witchcraft or sorcery, propitiation of deities and manes, control or appeasement of malevolent spirits, preparation of magico-religious charms for clients, prescription and administration of herbal medicines, cure of snakebites. All their actives centre around cure of diseases, amelioration of sufferings and removal of socio-personal maladies. Shamans in tribals societies are respected and have high esteem. In the tribal society the medicine men and Shamans have comprehensive knowledge about of medical plants, roots, tubers seeds, flowers, barks, fruits, leaves, birds, reptiles, animals from which they extract medicines.

Government initiatives:

(i) The National Health Policy 1982 and the new revised 20-point programme of government of India stressed the need for improving the health status of the tribal population. The Central Ministry of health and family welfare, Government to India in order to reach the tribal population has relaxed the
norms for establishment of Primary Health Centres (PHC’s) and sub centres in tribal areas. In a tribal/hilly area Primary Health Centre can be established to cover a population of 20,000 as against 30,000 in other areas. Similarly, a sub-centre can be established for a population of 3000 in tribal/hilly areas as against 5000 in other areas. A separate sub centres.

(ii) Out every 4 PHCs one is to be upgraded to a community health centre with 30 beds and 4 specialities of Gynaecology, Paediatrics Surgery and Medicine. Villages having more than 1500 population two or more village heath guides are to selected and one of them should belong to scheduled tribe community.
(iii) The Ministry of Health and Family Welfare provide centrally sponsored schemes for control of Malaria, Filaria, tuberculosis, Leprosy and Blindness.

A specific provision is made to carryout research into disease to which scheduled tribes are prone. Towards the end of Second Five Year Plan the Government of India launched a National Goitre Control Programme (NGCP) to control Goitre among tribal population. Indian Council of Medical Research (ICMR), (Ministry of Health and Family Welfare, Government of India) set up regional centres at Jabalpur, Bhubaneshwar and Port Blair to study the health problems of tribal population. Integrated Child Development services provided supplementary nutrition, immunisation, health check-up and referral services to children in age group of 0-6 years and also to pregnant and nursing mothers. In the tribal areas with a population of 700 persons an Anganwadi can be set up.

A number of MCH Schemes have been initiated by Government of India to provide maternal and child health care to reduce mortality and morbidity among the tribal population. The schemes are
1. Health education
2. Prophylaxis against nutritional anaemia
3. Prophylaxis against blindness due to Vitamin-A deficiency
4. Medical Termination of Pregnancy (MTP)
5. Universal Immunisation
6. Oral Rehydration Therapy (ORT)
7. Acute Respiratory Infection control
8. Minimum Needs Programme (MNP)

(iv) On the eve of the Fifth Year Plan Period a detailed of the tribal problem was taken up and the tribal sub-plan strategy was evolved. The objectives of the sub-plan are: socio-economic development scheduled tribes and protection of tribals against exploitation. The Integrate Tribal Development projects
(ITDPs)/ ITDAs were conceived during the Fifth Plan for the implementation of sub-plan strategy. Modified area development approach (MAD) was adopted to cover smaller areas of tribal concentration having 10,000 population of which 50% or more were weak tribals. The tribal subplan strategy was extended to all tribal in country in the Seventh Plan Period.

Voluntary Organisation

There are many voluntary organisations working for the development and health care pf tribal people. They are:

1) Action for welfare and awakening in rural environment (AWARE). This is a private voluntary organisation set up in 1975 working in Khammam district and also 9 district Andhra Pradesh. It has extended its activity to some pockets of Orissa, Karnataka and Tamil Nadu. In 1984 a project entitled “Floating Health Centres for Inaccessible tribal people” was initiated in the Khammam district with USAID assisted PVOH scheme. The project covered 38,000 population spread over 80 villages.
2) Sevadham is another voluntary organisation, which was set up in 1978 and is operational Ander Maval area in Puna district, which is inhabited by tribal people.

Remedial measures:

The remedial measures for solving the health problem of the tribal people in India.

(i) Efforts may be made to train local people at least as health care workers if not at higher levels.
(ii) Encouragement of indigenous system of medicine
(iii) Involvement of many voluntary agencies in health education.
(iv) Motivating the doctors and paramedical staff to work in tribal areas.
(v) Taking care of the physical comfort of doctors (housing etc) and medical staff working in tribal areas at least with regard to housing.

Xaxa committee on Health

The diseases prevalent in tribal areas can be broadly classified into following categories:

Diseases of underdevelopment

1. Malnutrition – Low birth weight, under-nutrition of children, lower body size of adults, anaemia, iron and vitamin A and B deficiency.
2. Maternal and child health problems – higher IMR, U5MR, neonatal mortality, acute respiratory infections, and diarrhoea.
3. Communicable diseases – malaria, filaria, tuberculosis, leprosy, skin infections, sexually transmitted diseases, HIV, typhoid, cholera, diarrheal diseases, hepatitis, and viral fevers.

Diseases common in scheduled tribes

1. Accidents and injuries – including the burns, falls, animal bites, snakebites, violence due to conflicts, and more recently, motor cycle accidents.
2. Hereditary diseases such as the Hemoglobinopathies (Sickle Cell) and G-6 PD deficiency.
3. Speciality problems – especially the orthopaedic and surgical problems, gynaecological problems, oro-dental problems and eye problems.

Diseases of modernity

1. High consumption of alcohol and tobacco in most areas and of drugs in the Northeast region.
2. Mental health problems – especially in the areas affected by conflicts.
3. Non-communicable illnesses – hypertension, stroke, diabetes, and cancers.

Conclusions

Examination of the available facts about health of Scheduled Tribe population in India reveals that:

1. Population size: Total fertility rate in Scheduled Tribe population, though reduced to 3.12, is still above the replacement level. During 2001 to 2011, theScheduled Tribes population in India has annually increased by 2.12 percent, constituting 8.6 percent of the total population of India in 2011, amounting to
about 10 crores in absolute number. Health of the ten crores vulnerable people should become an important national concern. At the same time negative Scheduled Tribe population growth in Nagaland and in the Great Andamanese tribe in Andaman & Nicobar is a concern.

2. The mortality indicators of Scheduled Tribe population have certainly improved during the past decades. However, these are significantly worse than of the general population. A comparison on a few important child mortality indicators is as follows: The infant and child mortality rates (most likely to be underestimates) in the Scheduled Tribes have shown improvement but slower than in the total population, 123 with the result that these rates in Scheduled Tribes are higher by about one third than in the other population. Moreover, these show a huge variation between the states, and are particularly high in 7 states.

3. The life expectancy at birth in the Scheduled Tribe population was 61 years, several years less than in the general population in 2001.124 It is a commentary on the national data systems that updated information on life expectancy in tribal population is not available.

4. The nutritional status of Scheduled Tribe children as well as of adults reveals a sad picture.

i) 53 percent boys and 50 percent girls in preschool age were underweight, and 57 percent boys and 52 percent girls were stunted in height.
ii) 49 percent of Scheduled Tribe women had a body mass index less than 18.5 indicating chronic energy deficiency.
iii) 40.2 percent of Scheduled Tribe men had a body mass index of less than 18.5 including chronic energy deficiency.
iv) Dietary intake of tribal households showed large deficiencies in protein, energy, fats, iron, calcium, vitamin A and riboflavin.

The under-nutrition in children and adults in Scheduled Tribe population has certainly decreased over a time period (from 1985-87 to 2007-08), yet the present levels of deficient food intake and under-nutrition are unacceptably high, almost always higher than in the non ST counterparts.

5. The social determinants of health are heavily pitted against the health of the Scheduled Tribe population. For example, the following differences are noted among Scheduled Tribes in comparison to the general population.

6. The sex ratio (number of females per 1000 males) in ST population at 990 as compared to 938 in non-Scheduled Tribes stands out as the best in India (2011). That speaks about an egalitarian social norm towards women. Unfortunately, with the exposure to the outside world, the sex ratio in tribal population is recently showing a decline.

7. Tribal people carry a traditional worldview with large number of beliefs and practices which affect their health, sometimes favorably, but sometimes unfavorably. There exists a severe gap of scientific knowledge about why diseases are caused and how to prevent them. This offers a great opportunity for improvement by way of spreading health literacy.

8. Tribal cultures have carried a heritage of traditional healing methods through the use of medicinal herbs, which address both mind and body. These traditional beliefs and methods are different from the modern scientific worldview and emerge from their living in forests rich with medicinal plants. This belief and healing system has a strong influence on the health practices and health seeking behavior and choices of tribal people. In order to study these systems in a holistic manner, there is a need to distinguish harmful and beneficial practices.

9. Public Health Service to Scheduled Tribe population is one of the weakest links. It suffers from several handicaps.

i) It is often inappropriate for the needs in the Scheduled Areas, being a rubber stamp version of the national model primarily designed for the non-tribal areas. It does not take into account the different belief system, different disease burden and health care needs as well as the difficulties in delivering health care in a geographically scattered, culturally different population surrounded by forests and other natural forces. It is surprising that no serious thought was earlier given to design a public health care plan for Scheduled Areas.
ii) The other major difficulty in delivering public health care to tribal population is the lack of health care human resource that is willing, trained and equipped to work in Scheduled Areas. There is a shortage, – vacancy, absenteeism or half-heartedness of doctors, nurses, technicians and managers in public health care system in Scheduled Areas.
iii) Though buildings are built and health care institutions created in the form of health sub-centers, PHCs and CHCs, they often remain dysfunctional resulting in poor delivery of health care. This is further compounded by inadequate monitoring, poor quality of reporting, and accountability.
iv) Factors such as unfriendly behavior of the staff, language barrier, large distances, poor transport, low literacy and low health care seeking, lead to lower utilization of the existing health care institutions in Scheduled Areas.
v) Access to hospital care for all ailments remains very low in tribal areas. Thus, the public health care system in Scheduled Areas is characterized by low output, low quality and low outcome delivery system often targeting wrong priorities. Restructuring and strengthening this should be one of the highest priorities for the Ministries of Health and Family Welfare in states and at the Centre.

10. A reason for the inappropriately designed and poorly managed health care in Scheduled Areas is the near complete absence of participation of Scheduled Tribes people or their representatives in shaping policies, making plans or implementing services in the health sector. This is true from the village level to the national level. Even though the PESA gives Gram Sabhas the right and the role of influencing social sector schemes, which include health, there are no mechanisms in place for such participation or oversight at the village level. Similar situation is observed at the ITDP, district and the state levels. At the
Central level, the Ministry of Health and Family Welfare has no separate body to shape policies or monitor programs in Scheduled Areas. This is in complete disregard to the promise of the Constitution and the Panchsheel guidelines.

11. In addition to the various weaknesses listed above, there is a common perception and complaint that funds for health care in tribal areas are underutilized, diverted to other areas, or utilized inefficiently, and worst, siphoned off by way of corruption.

12. Coverage with medical insurance including the Rashtriya Swasthya Bima Yojana (RSBY) remains extremely low in the Scheduled Areas. Thus the Scheduled Tribes populations are almost completely without financial protection against acute and catastrophic illnesses.

13. From the pre-independence period to the present day, voluntary organizations including the missionary or religious or the non-government organizations (NGOs), have made laudable attempts to provide health care to tribal people. They have often reached out to underserved areas or pioneered
better ways of delivering health care. However, such efforts remain localized and predominantly curative.

14. There is a near complete absence of basic data required to make situational diagnosis of health and health care in Scheduled Areas. The Sample Registration System, the NFHS, DLHS, AHS, NSSO – none are designed to give reliable, robust, timely and segregated estimates of health outcomes in Scheduled
Tribes populations. Such data are completely subsumed in the data for the whole population making any assessment of the health of Scheduled Tribes populations very difficult if not impossible. In the absence of such quantitative estimates, the evidence-based insights and professionally sound efforts for correction have been missing.

Recommendations

1. The first principle of any policy or program for tribal people is participation. Tribal people as a population segment are not politically very vocal. However, they have different geographical, social, economic and cultural environments, different kind of health cultures and health care needs. Hence their views and priorities must get due place in any health care program, meant for them. We suggest making use of three types of existing institutional mechanisms to improve the programs.

Tribal Health Assembly: From the Gram Sabhas at village level, upto the national level, Tribal Health Assemblies should be annually organized in which the people (at the level of village) or their representatives (at the higher levels) participate. For instance, such a ‘Tribal Health Assembly’ is annually organized for the past 15 years by an NGO, SEARCH, in Gadchiroli district (Maharashtra) for three purposes, a) to listen to the health problems and priorities of the people, b) to get approval for the proposed health solutions and activities, c) to get their feedback on ongoing activities. This can serve as a model at the local level in other Scheduled Areas. At least one Gram Sabha meeting annually should be
exclusively dedicated to the purpose of health and related subjects.

Tribal Health Councils: These should be constituted by including elected representatives, NGOs, experts and government officers for the purpose of planning and monitoring of programs. Such councils should be constituted at the block or ITDP level, district, state and national level. These should be empowered
to shape the health plans and monitor implementation. These sub-committees of Panchayat level, district level and Zilla Parishad could function as Tribal Health Councils.

Tribes Advisory Councils at the state level: These Councils should approve the health plans prepared by the Tribal Health Councils, and to review the performance of implementation.

2. In view of the enormous diversity among nearly 700 tribes in India, the second principle to be followed is of area specific and tribe-sensitive local planning. The PESA provides an institutional basis for this. The three institutional mechanisms suggested above, when created and made operational at the block,
district and state level, will allow local planning.

3. Social determinants of health – literacy, income, water, sanitation, fuel, food security and dietary diversity, gender sensitivity, transport and connectivity – play very important role in determining the health outcomes. Hence, intersectoral coordination for improvement in other sectors is as important, if not more, as health care. Some specific suggestions for improving health are:

a) The construction of drainage system, village sanitation infrastructure, personal toilets and the environmental measures to control mosquito-breeding can be included in the MGNREGA scheme and completed on priority basis in Scheduled Areas.
b) To reduce the household use of unclean fuels and biomass burning, the solar energy, especially the solar cooker, water heaters and lights be promoted in Scheduled Areas. This will also help save trees.
c) Improving nutrition of children, adolescents and pregnant and lactating women is critical for the Scheduled Tribes population. The nutrition awareness and feeding programs in the Scheduled Areas can be better implemented in collaboration with the National Rural Livelihood Mission and the women’s saving groups in the villages.
d) Health and income available for family will show improvement by controlling alcohol and tobacco.

4. Empowerment of the Scheduled Tribe people is another cardinal principle. Building their capabilities to care for their health is the long term solution far superior to a perpetual dependence. This however does not mean that the government or the rest of the society can abdicate their responsibility towards tribal people. But this responsibility can be better served in long run by building local capacity. In other words, instead of ‘giving’ health care, the policy should be to build ‘capacity to care for health’. This principle should guide in planning health care – especially in the choice of who will provide health care, where,
when and how.

5. To bridge the scientific knowledge gap of centuries, health care for Scheduled Areas should give paramount importance to spreading ‘health literacy’ by way of mass educational methods, folk media, modern media and school curriculum. Enormous scope exists for communication in local dialects and for
the use of technology.

6. A large number of Scheduled Tribe children and youth – more than one crore – are currently in schools. This provides a great opportunity – both for improving their health and for imparting health related knowledge and practices. Schools, including the primary schools, middle schools, high schools, ashram shalas and also the Anganwadis should become the Primary Health Knowledge Centers.
7. Special attention should be given to women, children, old and disabled people in the Scheduled Tribe population as these are the most vulnerable.

8. Traditional healers and Dais play an important role in the indigenous health care. Instead of alienating or rejecting them, a sensitive way of including them or getting their cooperation in health care, must be explored. Traditional herbal medicines should be protected through community ownership. The ownership and intellectual property rights of tribal community over their own herbal medicines and practices should be ensured.

9. Apart from the physical distance, a huge cultural distance separates the tribal population from others. Health care delivery to the Scheduled Tribe population should be culture-sensitive and in the local language in order to overcome this distance.

10. Health care delivery system for Scheduled Areas must keep as its guiding principle the Chinese axiom – How far can a mother walk on foot with a sick baby? Health care must be available within that distance. This, for the tribal communities living in forests, means health care must be available in their village/hamlet. Sixty years of failure should teach us that health care from outside is not a feasible solution. The design of health care in Scheduled Areas should be such that major share of health promotion and prevention and a sizable proportion of curative care is generated and provided within the village or hamlet.

11. In light of these principles and in view of the common disease pattern and needs listed earlier in the conclusions section, we recommend that the Ministry of Health and Family Welfare should redesign the primary and secondary health care services in Scheduled Areas. The new pattern should not be enforced as a top-down, vertical, uniform national program, but should provide a framework for local planning with local participation. Thus, the ‘Tribal Health Plan’ will have three feature: one, a process framework about ‘how’ to prepare the local plan, which will be in the form of guidelines on mechanisms; second, a series of locally developed need-based contents of the plan and third, a design or structure of the health care system to deliver such services in all Scheduled Areas. This ‘Tribal Health Plan’ should become an essential feature of the National Health Mission and of the Tribal Sub Plan. The goals and monitoring indicators of this plan will be different than the regular MIS of the NHM.

12. Human Resource for Health: The well-known difficulties in deploying doctors, nurses and other technical personnel from outside into Scheduled Areas have made the problem of human resources the Achilles’ heel of health care in Scheduled Areas. We recommend that, instead of making futile efforts to import unwilling and unstable personnel from outside, the most feasible and effective long term solution will be to select, train and deploy local Scheduled Tribe candidates. This should be done at the following levels:
The Accredited Social Health Activists (ASHAs) and Anganwadi workers – from the same village or the hamlet. The ANMs and paramedic workers – from the same block. The doctors and public health program managers – to a large extent, from the same district. The candidates must be local, belong to Scheduled Tribes, be fluent in local tribal dialects, be selected on merit and should be committed to serve in the local Scheduled Area for at least ten years. The ASHA workers, Anganwadi workers and ANMs will continue to be the mainstay of health care in rural and tribal areas. Due to the physical isolation of tribal communities, compounded by a lack of doctors, it will be pragmatic to train, equip and empower the three ‘As’ – ASHA workers, Anganwadi workers and ANMs – in tribal areas to a higher level. Since the selection for medical education is through a statewide and all India competitive process, the local Scheduled Tribe candidates may not get selected.

Hence, we recommend that separate Medical Colleges for Tribal Areas be opened in selected scheduled districts, one college per three million Scheduled Tribe population in the state. All seats are to be reserved for such committed Scheduled Tribe candidates, to be selected from the respective Scheduled Areas, depending on the population and need for doctors in each Scheduled Area. The aim should
be to provide, in ten years, the required number of appropriately trained doctors to serve in these areas. The High Level Expert Group (HLEG) on Universal Health Care, appointed by the Planning Commission, in its report (2011), has recommended that the District Knowledge and Training Centers be developed
and made into medical colleges attached to district hospitals, and nearly new medical colleges should be opened in the country, especially in undeveloped regions. These recommendations can be used to open Medical Colleges for Tribal Areas. Approximately 30 new medical colleges for tribal areas, each with 60 seats per year, will be able to produce nationally about 1800 new doctors per year, selected from, trained and legally committed to work in the Scheduled Area of their origin.
The Medical Education for Tribal Areas (META) should be, to some extent, different from the regular MBBS, and hence, should not entirely follow the curriculum of the Medical Council of India. Besides the regular medical curriculum, some modifications are necessary such as: i) knowledge of and sensitivity towards tribal culture and language, ii) methods of communication iii) training and management of a health team, iv) competencies in preventing and managing health problems common among the Scheduled Tribe population by way of clinical, outreach and public health approaches, v) collaboration with other sectors of development affecting health, eg. sanitation, nutrition, education, forestry. If necessary, the MCI recognition for this degree may not be sought, or a new degree different than MBBS be created, with legal permission to function as a doctor in Scheduled Areas.

13. Addiction has serious effects on the socio-economic fabric of tribal society. It affects not only health but also productivity, family economy, social harmony and ultimately, development. Hence, i) the Excise Policy for Scheduled Areas, approved by the Ministry of Home Affairs, Government of India, in 1976 and accepted by the states, should be implemented effectively, ii) the availability and consumption of tobacco and drugs should be severely controlled and iii) the availability and use of alcohol and tobacco products among the Scheduled Tribe population, and the implementation of control policies by the states, should be monitored on selected indicators. These efforts should become a critical part of the Tribal Sub-Plan.

14. The TSP budget, in proportion to the Scheduled Tribe population, should be an additional input and not a substitute to the regular budget for routine activities of the Health Department in Scheduled Areas. At least ten percent of the total TSP budget should be committed to the health sector, the Tribal Health
Plan in the Scheduled Areas, in addition to the regular health budget for these areas.

15. Data on the Scheduled Tribe population is a basic ingredient for planning, monitoring and evaluating health programs in Scheduled Areas. All national data systems – the Census, SRS, NFHS, NSSO, and DLHS – should be asked to plan for and generate Scheduled Tribe-specific estimates on health indicators at the district level and above. One percent of the total budget for the Scheduled Tribe population (TSP) should be allocated to the generation of reliable, timely, and relevant segregated data on Scheduled Tribes population, from the local to national level. This will provide the crucial instrument – the facts – necessary to guide program managers, policy makers and the Scheduled Tribe population itself.
Towards this, the specific measures recommended are –

a) Construction of a composite Tribal Development Index (TDI)
b) Construction of a composite Tribal Health Index (THI) including the indicators on health status, determinants and health care.
c) Ranking of 151 districts with more than 25 percent Scheduled Tribes population and of states on these indices.
d) Creation of a high power national body under the Ministry of Health and Family Welfare to facilitate the commissioning and collection of relevant data and monitoring of the indices and progress. This body should complete the work through the various existing agencies/surveys such SRS, NSSO, NFHS, DLHS, AHS, NNMB, the TRTIs in the states, the ICMR institutes network on tribal health, and finally, the health ministries in the states. Necessary administrative and financial authority should be provided to this body. Broadly, one percent of the total health budget for tribal areas (the regular health budget for Scheduled Areas, including the health component in the TSP) should be devoted for this purpose.

16. Research: From the public health point of view, certain aspects of tribal health need research. These are:

a) Epidemiology, disease patterns and mortality rates in Scheduled Areas
b) Traditional belief systems and practices, and effective communication methods
c) Tribal healing systems
d) Methods of health care delivery in Scheduled Areas.
e) The AYUSH (Ayurveda, Yoga, Unani, Siddha, and Homeopathy) department and the Indian Council of Medical Research should incorporate these into their scope of working.

17. The Proposed Goals of the Tribal Health Plan should be:

a) To attain the Millennium Development Goals (2015) on health and nutrition for the Scheduled Tribe population in India by the year 2020
b) To bring the health, sanitation and nutrition status of the Scheduled Tribe population to the same level as that of the non-Scheduled Tribe population in the respective states by the year 2025
c) To create the human resources necessary for provision of healthcare in Scheduled Areas, as per the norms set by the High Level Expert Group on Universal Health Coverage (2011), by the year 2025
d) To create and make functional the institutions for participatory governance (Tribal Health Assemblies and Councils) at all levels in the Scheduled Areas by the year 2016
e) To annually generate Tribal Health Plans at all levels by the year 2017
f) To annually allocate and spend 8.6 percent, in proportion to the Scheduled Tribes population, of the total Health Sector Plan and Non-plan budget, plus 10 percent of the TSP for the implementation of the Tribal Health Plan.

Alternative Answer

THE normal health of the tribal people cannot be said to be very bad but their condition often becomes chronic after repeated infections. Besides, the fundamental question that arises in this context is that how much of the modem amenities in public health are percolating dowm to the tribal strata of Indian society. Before taking up this question let us examine the problems of health facing the tribals.

THE tribals suffer from many chronic diseases but the most prevalent taking heavy toll of them are water-brone. This is mainly due to the very poor drinking water supply. Even when it is available in plenty, it is mostly dirty and contaminated and consequently the tribals are easily susceptible to intestinal and skin diseases. Diarrhoea, dysentery, cholera, guinea worm, tapeworms, etc., are often the results of this situation.

DEFICIENCY of certain minerals and other elements is also one of the reasons for the diseases. In the Himalayan ranges there is goitre, a disease of the thyroid gland due to iodine deficiency. The incidence of venereal diseases is also high among the tribals of certain parts of Himachal Pradesh, Himalayan Uttar Pradesh, Madhya Pradesh, Bihar, Orissa and Andhra. Tuberculosis which is intensified by nutritional deficiency is also common in many tribes. Besides, most of the tribal people have not yet developed an immunity and when they come in contact with new diseases they fall an easy prey to them.

According to Dhebar Commission,one of the diseases of which the tribalis mortally afraid is yaws which occurs in the northern region of the Agency Area in Andhra Pradesh, southern Orissa, Chanda district of Maharashtra and Bastar district of Madhya Pradesh. Hansen’s disease, as leprosy is now called, is common throughout India and has not spared the tribal people. It is extremely bad in the Agency Area in Andhra Pradesh, in Kikir Hills in Assam, Bankura and Purulia districts of West Bengal, Santhal Parganas of Bihar, from Mayurbhanj upto Puri in Orissa. Scabies,, ringworm, small pox and anaemia are also common.

DHEBAR Commission is of the view that there is no lack of will on the part of the State Governments to do as much as possible in the direction of the health and medical facilities. There are four principal reasons for the shortfall :
(a) the need for a correct approach;
(h) problem of personnel;
(c) inadequacy of communications; and
(d) rules about supply of medicine.

IT IS often seen that in many interior areas, tribals are reluctant to come forward for medical treatment because they have got their own system of diagnosis and cure. It is a popular belief among many tribes, especially those inhabiting far flung interior and isolated areas, that disease and misfortune are caused by hostile spirits, ghosts of the dead or the breach ofsome taboo.It leads to the‘logical’conclusion that what is caused spiritually should be cured spiritually and that is why the tribals of interior areas prefer their own watch doctors, sorcerers, shamans, etc. Medical personnel are contacted as a last resort. This state of affairs becomes further agonising when the physician starts considering the local witch doctor-priest as his rival. Dhebar Commission, interestinglycomments that “a pious invalid will send for both the priest and the physician.The priest wall pray for him,the physician will give him a pill. The theory is that God answers the priest’s prayer by making the pill more efficacious :the physician is the instrument through which the divine compassion works”. The local sentiments, sensitivities and susceptibilities should be well taken care of if the fruits of the modern medicine have to reach this section of the society. Dhebar Commission cites interesting examples from north-eastern tribal areas where the medical staff has been asked to regard the native medicine man not as his rival but his ally. The doctors have been directed not to be antagonistic to the system of tribal’s diagnosis and cure, cease to sneer at it as ‘superstitious’ and extend to it the sympathy they would feel for any other kind of faith healing and psychological treatment, of which there are ample examples throughout the world. A wise doctor, under such conditions, will make friendship with local priest, invite him to visit his hospital and let him offer prayers and make sacrifices for his patient, exampling that his own way of treatment is supplementary to his. The work of the local priest-doctor has really valuable psychological function is some cases. If the patient thinks that he is ill because a ghost or a demon has attacked him, only priest can remove the fear and restore confidence to his patient. The essential thing for the medical staff is to take the right attitude to tribal medicine and the tribal priest. The most successful doctors have been those who have interested themselves in what we may call medicalsociology, in such things as the tribal pharmacopoeia, the tribal theory of the influence of dreams on health, tribal methods of diagnosis’’(Reportof the Scheduled Areas and Scheduled Tribes Commission).

ANOTHER problem in public health among the Indian tribes concerns the shortage of medical personnel and qualified nurses in the face of continued belief in the old system and a steadily rising faith in the new. A majority of men and Women of the medical profession are very reluctant to offer their services inthe rural and tribal areas. This is due to a number of problems. There are difficulties of housing, education for their children and contact with the glamorous world outside. According to Dhebar Commission, the solution lies in having a special cadre for a period of twenty years to secure the medical personnel required for the tribal areas. Simultaneously, efforts must be made to train the local people, so that after twenty years or so, they will be able to staff their own hospitals. Besides, the use of Ayurvedic and herbal medicine should be encouraged because of the fact that the tribal people are already used to herbal remedies and hence there will be little; problem of acceptability.

DUE TO local geographical and ecological condition and relatively not easily accessible areas of tribal habitations, the mobile dispensaries and health centres shall be more purposeful than the static one. However, it is also not realistic to provide these mobile centres with ambulance or ( large vans which often cannot getalong the rough roads or track, even if in fine weather. An ordinary jeep is quite sufficient to take a doctor with is staff and medicines to a number of outlying villages. It might even be considered that an improved type of bullock cart could be sometimes used for the mobile units. In the north-eastern region these units have to move about in the most difficult country side on foot, and doctors there perform successful operations under the most adverse circumstances in the village camps. It requires sincerity and dedication to/ work under such conditions.

THE rules and procedures of indenting for medical supplies in the remote areas is very frustrating. The scrutiny of stock is piade on the basis of the normal requirements of the plains areas. It is forgotten that the medical personnel in tribal areas have not only to treat the patient but also brave the rigours of climate and on many occasions to meet the urgent requirements they require the maintenance of stocks of special remedies at hand.

ANOTHER very important problem concerning health in the tribal areas is the addiction of the tribals to spirituous and highly intoxicating liquors and drinks. The indigenous liquor is prepared by fermentation of the rice, millets and other grains. This is the traditional liquor of the tribals which- is prepared within the four walls of the home and consumed by all the family members. The second variety is the distilled liquor which the licence holders from the government sell. It is really an intoxicant and carries little food value. The poor tribals, in most cases, are coerced to discontinue the preparation of home-made liquor and made to purchase the distilled liquor from the contractors. After making them addicts of this variety of liquor they are made to part with the property or enter into exploitative bargains. The only-practical solution is the banishment of liquor contractors and the harmful liquor from the tribal areas so that they may be left free to brew their own liquor and fulfil one of their important nutritional and cultural needs by themiselves.

DRUG addiction is another serious health problem with several tribes. Singpho tribe of Arunachal Pradesh is a case in point. From 40,000 about 150 years ago, the Singphos have been reduced to around 1,000. Though recurring wars, disease and malnutrition have playeda role but deadly addiction to opium is the chief culprit for their fast dwindling population. It is said that opium has diminished the tribe’s fertility, increased the death rate and contributed to the vicious circle of poverty.

Almost every house of the Singpho has a small hearth in one of the corners above which hang a blowpipe, a large spatule, a packet of raw tea leaves, opium and tobacco. At any time of the day haggard, skinny tribesmen can be seen making the tobacco-opium concoction that they smoke along with generous swigs of the bitter tea liquor. Opium has become an inseparable part of Singpho life. You can tell a Singpho by smell. They have become too indolent to look after their cattle and lands yet they must buy the opium, mostly by selling the elephants they trap. They have smoked it for decades and their forefathers were induced to it by the British. Official agencies and more importantly some devoted and sincere reformist Singphos and voluntary social organizations have begun a serious campaign to wean the addicts away from opium. Let us hope that they succeed in their efforts.

THE speedy spread of health education among the tribals is very crucial As most of the tribals are illiterate, various audio-visual methods may be adopted to put across to them the basic principles of health and sanitation. Needless to say that for raising the standard of health of the tribals, cooperative endeavour is necessary among the States the Centre, the non-official organizations and the medical personnel.