Twenty-five years ago, when the Gandhian doctor-activist couple Abhay and Rani Bang started working in the forest areas of Maharashtra’s Gadchiroli district, they found malaria to pose the biggest health concern for its predominantly tribal population. So, regular medical treatment apart, they also sought to impress upon the local adivasis the importance of using insecticide-treated mosquito nets. But malaria being deeply ingrained in the tribal psyche as retribution from “invisible super-natural forces,” not only were the medicines viewed as futile, even the nets soaked in insecticides were seen more useful to catch fish.
25 years later, malaria remains only somewhat less rampant and mosquito nets, too, are used but inadequately. Acceptance of medicines, however, has become widespread indicating a positive change of mindset. But, with many new socio-cultural and economic influences — basically market forces — making inroads, some fresh health problems have crept up. According to the National Nutrition Monitoring Bureau, 24 per cent of adivasi adults across India today suffer from hypertension.
As per the 2011 Census, India’s total tribal population stood at 10.43 crore. “That’s bigger than the entire populations of most countries. But while a lot has been written about tribal culture and history, little is known about their health status. We even don’t have data on tribal health separate from that on rural health,” says Abhay Bang.
Bang is chairing a 13-member expert committee set up by Union Health Ministry and the Ministry of Tribal Affairs, tasked with coming out with a nationwide status report on tribal health issues along with suggesting possible policy formulations. The panel is due to submit its report in March this year.
The Bangs — both doctors and masters in public health — have pioneered the home-based neonatal care or HBNC model that involves training rural women in becoming village-level newborn care providers, who visit mothers and babies in their homes.
The HBNC model of reaching the unreached and imparting care — including treatment for life-threatening illnesses — has not only helped reduce infant mortality rates in 39 intervention villages in Gadchiroli from 121 to 30 per 1,000 live births, but also been incorporated into the government’s healthcare programme since 2011. Today, there are over eight lakh accredited social health activists or ASHA community health workers, who have undergone multiple training sessions under National Rural Health Mission.
“Till such time public healthcare can reach everybody, HBNC should remain our best bet to keep rural and tribal neonatal health problems under reasonable check,” says Bang, who along with his wife have founded SEARCH (Society for Education, Action and Research in Community Health), an NGO 18 km east of Gadchiroli town.
While the “old” problems of malaria, malnutrition and mortality persist, Bang emphasises “new” health issues among tribals partly due to outside socio-cultural influences and steady inroads by market forces.
“Take diarrhea. A possible reason why it has become rampant among adivasis is because they have quit their traditional, yet more hygienic, cleaning practice after defecation by tree leaves. While they have started using water, shamed by non-tribal taunts of panpusya Gond (leaf-wiping Gond), it is not followed by cleaning hands with soap, thereby spreading diarrhea,” he notes.
But what explains the generally poor tribal health, despite their living in seemingly unpolluted natural ambience and with high-protein meats in their diets?
Bang attributes this to two things.
The first is the Indian Forests Act of 1865 that resulted in adivasis losing their unhindered access to natural resources, which now came under the government’s control. Even the water bodies from where they caught fish suddenly became out of bounds. The second has to do with large infrastructure and industrial projects, which, in the post-Independence period alone, have displaced an estimated two crore adivasis: Over 50 per cent of them in Maharashtra, for example, live outside the so-called Scheduled Areas.
Bang suggests that even malnourishment may be a relatively recent addition to tribal health problems: “There are no definitive studies, but it is generally believed that tribal populations were strong and hefty when they had unhindered access to forest resources. An old study of Brazilian aboriginals by the CIBA Foundation does point to this”.
The newer health problems are also a reflection of lifestyle changes taking their toll. Tribal women now list alcohol addiction among men as their biggest concern. The same goes with tobacco, with over 60 per cent of adults in Gadchiroli consuming it daily. These, alongside addition of salt in their foods (clearly courtesy outside influence) and stress, are contributing to increased incidence of hypertension, feels Bang.
But addressing tribal health problems is also about having more primary health centres (PHCs) and sub-centres. “Tribal areas have one PHC for every 20,000 people, as against 30,000 in non-tribal areas. There is also only one sub-centre for every 3,000 people, whereas it is 1:5,000 in non-adivasi areas. Even an auxiliary nurse midwife is expected to visit 12-15 small and scattered villages, which is impossible. All this has rendered the formal public healthcare system virtually dysfunctional,” he points out.
On top of these are problems of language barrier and lack of motivation among healthcare staff, besides vacancies and absenteeism when it comes to working in tribal areas. While the last two are often attributed to left-wing extremist activities, the fact is that “Naxals generally don’t come in the way of health and education work,” says Bang.