‘‘Medicine is a social science, and politics is nothing else but medicine on a large scale ’’, commented Rudolf Virchow, which roughly translates to the fact that in order to treat illnesses, we have to address the causes of causes i.e. the underlying social determinants of health. The WHO Commission on Social Determinants of Health defines social determinants as the conditions in which people are born, grow, work, live and age and also the wider set of forces and systems shaping the conditions of daily life.
Tribal populations have different socio-cultural and economic contexts and hence, their health determinants are also specific and different. My attempt is to address a few of these in the following case study.
I am trained as a primary care physician and I have been working in tribal areas of central India since 2012. For the past one year I have been working with a not- for- profit organization called Swasthya Swaraj in Kalahandi district in the state of Odisha, India. Kalahandi is known for regular droughts and famines which are worsened by recent climatic changes. It has a large tribal population (27%) and is also one of the most impoverished and backward regions in India which regularly experiences conflict due to left wing extremism.
We were working in the most backward block of the district – Thuamul Rampur Block which is tribal predominant. The project area consisted of 75 villages selected from 6 gram panchayaths with a population of about 15000. These villages were the most inaccessible in terms of road, telecommunication and electricity. Some of the attributes of the tribal population of the region that I observed during my brief stint were the following: 1) they were in geographical isolation which excluded them from many state supported policies and programmes 2) they had a distinctive culture 3) they were shy and reluctant to interact with non tribal community 5) they experienced economic and social backwardness.
Challenges that I faced as a physician
As I started seeing the patients with severe under weight and multiple sufferings, I wondered how to treat those conditions. I felt ill equipped as a physician under those circumstances as I was trained only to treat diseases in the medical school. Questions like “who were the sick”, “what were their sicknesses” and “why were they sick” struck me and thus started my personal journey to find answers to these perplexing questions.
The primary health challenges of the tribal community were malaria, tuberculosis, gross malnutrition, high infant mortality, maternal mortality and under five mortality. Malaria had a long and sordid history in these tribal pockets. It was hyper endemic and major public health problem causing high number of mortality and morbidity. Tropical climate with high temperature and humidity with medium to high rainfall provided a conductive environment for breeding of vectors of malaria transmission. Under nutrition due to food insecurity with non availability of health facilities contribute to a high disease burden of tuberculosis among the tribes. Around 55 patients were on anti tubercular treatment in our clinic and five people had died that year. Due to severe poverty coupled with food insecurity, chronic malnutrition was common among tribal population especially the children. The malnutrition was worsened by repeated malaria attacks. Average weight of adult male and female attending clinic was 48kg and 43kg respectively. In an area where deliveries were mostly self deliveries by the mother herself unassisted by anyone, the concept of antenatal care did not exist. Maternal deaths and infant deaths were common occurrences and people did not think that this was avoidable. This was taken as ‘natural’ in the belt. Malaria during pregnancy was one of the important causes of the maternal deaths.
In my enquiry to find answers to my questions, I found that these diseases were not simply occurrences of ill health. They were the biological manifestations of underlying social and economic reality of that population.
Biological manifestations of underlying social and economic reality – how?
In this segment, I would like to corroborate my answer through my readings, interaction with the community and the social and economic realities of the population that I witnessed.
The tribal community has a unique socioeconomic and cultural environment with their own health culture and health needs. Land is the basis of their socio-cultural and religious identity, livelihood and their very existence. The “modern” developmental processes which started in India after the Second World War encroached upon tribal land and forests in order to exploit natural resources through mining, construction of dams and so on. The tribal population neither had participation nor were they consulted in any of these processes. They fact that they were not politically vocal and organized made them the most vulnerable and marginalised population. This led to displacement, land alienation and forced migration which had deep social, cultural, economic and psychological impact on the population.
Tribal population traditionally had subsistence-oriented agricultural economy with shifting cultivation. Due to deforestation and erratic rainfall with conventional agricultural practices, food security was in danger. They were also not equipped with modern skills that led to them being low wage labourers in the non tribal settings.
The education system based on modern methods and in languages other than their mother-tongue alienates them from it. They attach no meaning to it since it contributes in no way to their livelihood, culture and identity. Basic infrastructure of schools available in the region is also abysmal and no non tribal teacher is willing to teach in hilly and difficult terrains.
The rich culture of tribal has a profound impact on their health seeking behaviour. They have a characteristic belief system regarding causes of illness and health providers need to understand and be sensitive to their culture. Tribals relate illness to evil spirit and so local healers called ‘Guru’ only can replace that evil spirit by good spirit.
The lack of basic infrastructure like road, electricity, telecommunication and sanitation even after 70 years of independence with an almost non functional health system is most reflective of the reality of their totally marginalized existence. The nearest access to a health facility for a pregnant lady is about 100 Kilometres away.
I observed that the tribal community has the habit of living in hamlets in small and scattered groups in the hilly terrains around the forests. This scattered existence is one of the many excuses of the system for not being able to provide them with basic infrastructure. Tribal are mostly working in the forests and fields the whole day which make them vulnerable to repeated malarial episodes. The houses are built with mud and thatched roof with dark, damp and no ventilation. Thus, the living conditions of the community significantly contribute to their health concerns.
I also noticed that the number of cases of diarrhoeal diseases is surprisingly less than what we would expect, thanks to the organisation called GRAM VIKAS who has done great work by providing tap water to every household using the gravity flow technique. But in many villages where this is not done, people have to depend on river water and small puddles of water for drinking in summer leading to diarrheal outbreaks.
Reduced physical accessibility to health and other services is one of the most important barriers since the sparse pockets of tribal communities reside in difficult terrains inside dense forests. The situation necessitates an integrated approach to health care addressing social and ecological determinants by collaborating with individuals, government and other organizations.
My experiences with an initiative of change
So, then in 2013, there began a change initiative by a bunch of committed health professionals under the leadership of Dr.Aquinas Edassery. We attempted to address the plight of the tribal by introducing Comprehensive Community Health Model based on principles of Alma Ata declaration. It was the first initiative of its kind in this region and I was fortunate enough to be a part of the team. It is called ‘Swasthya Swaraj’ which means people’s health in people‘s hand. Our approach was based on Lao Tzu‘s saying-
“Go to the people
Live with them, learn from them
Love them, start with what they know
Build with what they have.”
We started with meetings with the tribal community, listened to their problems and suggested the selection of one married woman from each village to function as their health worker. We trained them with basic medical knowledge (monitoring pregnant women, nutrition) and skills to identify and treat common ailments including malaria and diarrhoea. The women who were illiterate were eager to learn; they picked up fast with the help of pictures and role plays and were very enthusiastic throughout the process.
Saiboni Nayak is the Swasthya Sathi (health worker) from Amthaguda village in Kaniguma cluster. She had leprosy diagnosed one year ago and is currently on treatment. She was asked by somebody once ‘what reward you get for the work you do in the village”? She spontaneously replied without a moment of hesitation, “Reward? My reward is the happiness of my people when I teach them and serve them”!
In addition to training health workers, we started two 24x7 clinics at two different locations with all the essential facilities including basic laboratory investigations and medicines almost free of cost. Local girls and boys who volunteered were trained by us to function as community nurses and paramedical workers.
As pregnant women cannot walk long distances to access antenatal care, we reached out to their hamlets by conducting monthly ante-natal and under five clinics. We ensured that they received nutritious food conducted regular malarial tests.
Instead of approaching tuberculosis control as a biomedical intervention, we responded to it by conducting special TB clinic every month with proper counselling, health education through role play, group meetings of patients and provision of take- home high protein nutritious food. Our health workers monitor TB patients in the village for proper compliance. The Postal Service is a functioning government department in these remote villages with one postman per panchayat. With the help of the postal department, patients were promptly contacted (through reminder post cards) when they did not turn up on the stipulated dates to the clinics. Usually the whole village would come to know when someone receives a reminder post card and this is an additional reinforcement to avoid missing the clinic. The postcard also serves as a tool for health education.
In order to address the issue of malaria we started community awareness programme by innovative ways like folk play, youth cycle rally through villages, community meetings, malaria songs and even tribal dances based on malaria songs. The idea was to inculcate awareness about the many steps to prevention including proper drainage system, providing insecticide treated bed nets, early diagnosis and prompt complete treatment with special focus on mothers and children.
Since children are the best medium to propagate knowledge and to promote healthy life styles in any community, we collaborated with government schools to impart health knowledge to children. We also worked towards transforming the schools as nodal points for health promotion of the children and through the children that of the villages.
Ame podibha dorkar (“we want to learn”) is an approach to education which Swasthya Swaraj (our NGO) is initiating and facilitating. In village after village we see the sad plight of children who assist the parents as full time agricultural labourers. The government primary schools remain closed. The teachers from different culture and sensibilities do not belong to the village. Moreover, the distance and lack of basic facilities are stumbling blocks for them. So we started to train local educated youth as teachers from the tribal community who will be able to look deeply on their own tribal culture, their language, critically analyse their traditions, their value systems and their great heritage. This innovative education programme is being just initiated in Kerpai panchayat
This model of change which we attempted was based on initiating community empowerment through the multi pronged approach of participation, involvement and mobilisation of community. This is just the beginning of a really long journey and we do not claim any tangible health outcomes as of now. But, the biggest success according to us, is the hope that we see in the eyes of our partners (the tribal community) brought about by our efforts.
To conclude I quote the heartfelt words of our director, Dr.Aquinas, “these precious human lives that fall off like the tender leaves of a tree proclaim that there is something seriously wrong with our system and our society. This stark inequity in healthcare in society which the poor have accepted passively as their fate cannot be tolerated any more. Our developmental paradigm and our medical education are called to question by this event which continues to happen not in small number in tribal belts.”