Tribal Health: A Public Health Exigency and Road Map to Future

Abstract

Tribal health is a special concern for India as it has not been addressed holistically in last 75 years of post-independence era. The evidence of present status of health of tribal people which constitutes more than 8.6% of total population is not convincing. Although the information available in bits and pieces shows a dismal picture of their health. They suffer from triple burden of disease and the morbidity profile is poorer than the non-tribal population. Though the tribal people have poor health but it was assumed that uniform national pattern of healthcare would address their unmet health needs. The different terrain, different social environment, and different culture make their healthcare needs different and hence their health remains an unsolved problem. Although, there has been push from government toward their health but a holistic approach to understand their need is important. Collaborative partnerships between tribal communities, healthcare providers, and government agencies are essential to developing culturally appropriate and sustainable solutions that honor their traditional knowledge and provide modern healthcare to them which is accessible and acceptable to them.

The Merriam-Webster dictionary defines a tribe as a social group composed chiefly of numerous families, clans, or generations having a shared ancestry and language.[1] Although there is no universal consensus to define a tribal community, the International Labour Organization has set criteria to identify a tribal population. According to this criterion, a tribal community is that which self-identifies itself as belonging to a tribal people; has social, cultural, and economic conditions which distinguish them from other sections of the national community and their status is regulated wholly or partially by their own customs or traditions or by special laws or regulations.[2]

In a similar vein, the Constitution of India also does not have a fixed definition or even a criterion to define or identify a tribal community, which have been designated as Scheduled Tribes in the Indian context. Article 342 of the Constitution which deals with this issue needs to be understood with the context of historical backwardness of a community in order to identify it as being tribal in nature. Other qualities that distinguish a tribal community from other communities include simplicity, geographical isolation, shyness, and social, educational and economic underdevelopment. The ultimate power to recognize a population as being tribal is vested in the President, who can take the decision in consultation with the state government.[3]

To classify the Scheduled Tribes of India, the first effort was made through the census of 1931 by preparing a list of “primitive tribes”. Four years later, a listing of “backward tribes” was done under the Government of India Act of 1935. The list was revised in 1950 after the independence by making addendum to the list. The list has been amended several times, the latest amendment done as recently as July 2023.[4] The Scheduled Tribes list now includes 730 tribal groups which constitute approximately 8.6% of the total Indian population and numbering around 10.4 crores.[5]

As per the recommendations of the Dhebar Commission (1960-1961) in 1975, the Government of India (GOI) also recognized some tribal communities as Particularly Vulnerable Tribal Groups (PVTGs). “Particularly Vulnerable Tribal Groups” (PVTGs) were referred to as Primitive Tribal Group, this was modified later in 2006. Initially, the list of PVTGs had 52 groups; later 23 groups were added in 1993 making it a total of 75 groups. These groups were distinct from other tribal groups in one or more of the following characteristics: conservation of their age-old pre-agricultural practices; survival on hunting and gathering; declining or no population growth; and poor literacy levels.[6]

SOCIODEMOGRAPHIC MILIEU

The social and geographical isolation of tribal communities since ancient times has had an enduring impact on their current development status. The tribal population in our country forms a heterogeneous group with wide variation not just in terms of their diversified cultural norms and practices but also in their social background, physical status, and health conditions. The distinction holds true not only in geographical areas but it also persists between different groups or members living in same tribal territories. While other communities have reaped the benefits of rapid technological development, the tribal communities have lagged behind in this regard. As a result, the scheduled tribes display poorer rates in all development indicators such as literacy rate and per capita income when compared to that of other communities. The major concern for the tribal population at large is that they are not incorporated into the mainstream socioeconomic activities of the country, resulting in their lower educational (41% Illiteracy) and economic attainment (41% Below Poverty Line (BPL)). Tribal life is often marred by deficient resources, poor living conditions, and non-access to schemes and services that are provided by the government.[7,8,9] Their geographically isolated habitats and residing in hard-to-reach areas habitually make their problems insurmountable. Moreover, indelible social beliefs, attitudes, and cultural practices that are imbibed in their routine life have significant bearing on their health status and health-seeking behavior. A majority of this population in India lives a miserable life and encounters abject poverty. It is harder for this indigent populace to afford the healthcare services. It is one of the substantial barriers to healthcare utilization. Although the government provides free medicine and health checkup in many states, but the accessibility badly affects the healthcare seeking of tribes.

TRIBAL HEALTH AND BURDEN OF DISEASES

Tribal health refers to the physical, mental, and social well-being of indigenous communities who identify as members of a particular tribe or nation. These communities often have unique cultural traditions, languages, and histories that shape their health beliefs and practices. The tribal communities today face the triple burden of diseases. While malnutrition and communicable diseases such as malaria and tuberculosis have always been prevalent in the tribal communities, an epidemiological transition has also been observed with increasing prevalence of non-communicable diseases such as hypertension and diabetes due to rapid urbanization, environmental distress, and changing lifestyles. The third burden is one that is arising due to acculturation and urbanization among tribal communities and Indian population in general is that of mental illness, e.g.: depression and drug addictions. The main reason for this is social and economical remodeling of tribal communities and Indian society as well.[8,9]

Common diseases that disproportionately affect tribal communities which resulted in the poor health outcome which continue to prevail are infectious diseases, reproductive, and child health issues and malnutrition.[10] Non-communicable diseases including mental stress and substance abuse are rapidly increasing in the tribal society. Tuberculosis and hemoglobinopathies are major deterrent to their health and contribute to their major morbidities.[11,12] As compared to the national population, the indicators for tribal communities reflect the same above-mentioned disparities, approximately 50% of tribal girls fall below the BMI level of 18.5 and around 65% tribal women (15-49 years age) are suffering from anemia (compare this with presence of anemia among non-tribal women at 47%). A disproportionately high number is 72% tribal men in age group 15-54 years are addicted to tobacco; similarly more than 50% of them suffer from alcohol abuse, contrast this with tobacco and alcohol abuse among non-tribal is at 56% and 30%.[8] Even in a progressive and developed state like Kerala, tribal carry a greater burden of underweight (46.1 vs. 24.3%), anemia (9.9 vs. 3.5%), and goiter (8.5 vs. 3.6%) compared to non-tribals in early last decade.[13] Injuries due to accidents, snake and animal bites, and violence in conflict situations are also prevalent due to residing in difficult natural geographic terrain, lack of connectivity to mainstream and harsh environments.

Same inequity is visible for other important health indicators too, namely Infant mortality rate (IMR), Under 5 Mortality rate (U5MR), percentage of women and children with anemia and percentage of stunted, wasted, and malnourished children as compared to the non-tribal population.[7]

THE TRIBAL RELIANCE ON TRADITIONAL MEDICINE AND ITS CHALLENGES

Tribal communities are known to share a deep connection to nature, maintain their own customs, institutional, and traditional practices and religious beliefs. Such is traditional medicine that stands out, the knowledge of traditional medicine is transmitted orally from one generation to next.[14,15] They rely heavily on traditional medicine, which has roots in ancient Vedas and scriptures.[16] Traditional remedies continue to remain a major source of primary healthcare for physical, mental, and social ailments for 80% population of Asia and Africa, where these indigenous communities have preserved the knowledge and practiced the art of healing for generations.[17]

There are several reasons for high reliance on traditional medicines among tribes. Firstly, due to their habitation around hills and forests which give them easy access to medicinal herbs which are used in making over 25,000 plant-based ailments for various ailments.[18,19] The familiarity with medicinal properties of local flora is high in tribal regions.[20] Also, the practitioners are consistently available and part of the community, enhancing the popularity of traditional methods.[21] Secondly, traditional medicine is compatible with tribal culture, beliefs, and their harmonious connection with nature, rendering its wide acceptability.[22,23] Lastly, its affordability compared to modern healthcare contributes significantly, making tribals to rely more on traditional medicines and practitioners.[24]

Unfortunately, these healing methods face erosion within tribal groups due to several reasons. Additionally, the majority of tribes lack access to affordable modern healthcare, leading to a high incidence of communicable and non-communicable diseases, along with genetic disorders. Thus, it remains a major dilemma of tribal health in India.

Factors contributing to the decline in traditional healthcare among Indigenous populations include: Lack of comprehensive policies integrating traditional medicine into the healthcare system; Insufficient scientific evidence on its quality, safety, and effectiveness; Absence of formal training programs and consistent standards for practitioners; inconsistent standards in traditional medicine products and practices.[25] Dispersed literature without a dedicated accessible database; Incompatibility of traditional medicine research with Western medical research norms, hindering publication; Degradation of forests and land leading to the extinction of medicinal plants[26]; and Policies meant to protect forests and tribal interests impact negatively their access to resources.[27] These challenges at policy and research levels contribute to the erosion of traditional medicine practices among tribes.

MODERN HEALTHCARE SYSTEM IN TRIBAL AREAS

Despite remarkable technological advancements in modern healthcare worldwide, accessibility remains a critical challenge in developing and underdeveloped nations. This issue is prominent among tribal and indigenous populations, leading to significant health disparities.[28] Non-availability of modern healthcare services is one of the perturbing factors affecting tribal health in India. The shortage of healthcare infrastructure is alarming, with a shortfall of 9357 Health Sub-Centres (HSCs), 1559 Primary Health Centres (PHCs), and 372 Community Health Centres (CHCs) in tribal regions nationwide. Specifically, states like Madhya Pradesh, Jharkhand, and Rajasthan exhibit the most deficiencies, with 468, 295, and 235 PHCs, respectively, within the tribal areas.[29] Geographical challenges also hinder healthcare access as health centers are often remote and difficult to reach due to scattered habitats and rough terrain. Limited transport facilities, both public and private, alongside inadequate ambulance services, further compound the issue.[30]

In terms of human resource at healthcare settings of tribal regions, severe constraints in healthcare human resources persist across all levels, notably reflected in the reluctance of external professionals to serve in tribal areas. The population norms of public health facilities have also not been fulfilled with each health facility serving a greater population than recommended in the tribal areas.[7] As per recent rural health statistics, peripheral health centers have 82.3%, 32.6%, and 27.9% deficiency of specialists, technicians, and nurse posts.[29] There’s a notable scarcity of doctors and nursing staff in primary healthcare system of tribal regions and this aggravates the poor health indicators among tribal population.

Additionally, the local workforce lacks the necessary training, skills, and capacities to meet the required standards, posing a significant barrier to their effective utilization within the healthcare system. The needful and essential monetary allocation for tribal health is either not designated or underutilized in many states across our country. There is a lack of transparency in accounting of the actual expenditure on tribal health. The aforementioned issues are compounded with dearth of data and non-existence of monitoring and evaluation frameworks. Political disempowerment and exclusion of tribal population at national level legislation has exacerbated these problems. Tribal people are least included in the planning, prioritization, and execution of the national policies.

Indian health system, SDG, and tribal health

India is embarking on one health approach to adopt an integrated and holistic roadmap toward addressing the entire public health exigency. Sustainable Development Goals (SDG) 3 reflects the commitment to achieving universal health coverage, addressing various health challenges, and promoting overall well-being for people of all ages.[8] It recognizes the interconnectedness of health with other aspects of sustainable development, making it imperative to address the underlying and cross-cutting issues of health for all. A major impediment in attaining these objectives is rooted in the obstacles faced by tribal healthcare, characterized by insufficient availability, accessibility, and affordability of contemporary health services. This may be due to the fact that tribal habitations are scattered across the nation in large areas with poor connectivity, transport, and communication facilities and public health infrastructure is inadequate, understaffed, and underutilized in tribal areas. The tribal people have low awareness and utilization of health schemes and entitlements because of their close link with the environment and nature. They also face financial barriers, such as high out-of-pocket expenditure, lack of health insurance, and social security.

CONCLUSION

Tribal health encompasses a holistic approach that recognizes the interconnectedness between an individual’s physical, emotional, and spiritual health, as well as their relationship with their community and environment. Addressing the social determinants of health, such as poverty, education, and access to resources, is critical to improving tribal health outcomes. Even after 10 years of formation of Expert Committee on Tribal Health in 2013 which was constituted jointly by Ministry of Health and Family Welfare (MOHFW) and Ministry of Tribal Affairs (MoTA), the tribal people’s health is a grave and exceptional concern. Although the desegregated national data have tribal health data imbibed in it but for a more focused approach is needed to complete its comprehensiveness. There is a need of special health surveys pertaining to tribes covering all the tribes including PVTGs of all states. Collaborative partnerships between tribal communities, healthcare providers, and government agencies are essential to developing culturally appropriate and sustainable solutions that honor traditional knowledge while incorporating modern healthcare practices.

Considering these challenges, the following recommendations could improve the health status of tribal populations. (i) allocation of a proportional share of per capita expenditure toward tribal healthcare, with a primary focus on primary healthcare services, (ii) Addressing the shortage of healthcare personnel by either training a specialized group of doctors or task shifting or task sharing mechanisms in tribal health facility, (iii) introducing mobile healthcare units and periodic camp-based healthcare approaches, (iv) specialized training for paramedical staff, (v) rectifying the insufficient data concerning tribal health, illnesses, and healthcare accessibility, (vi) integrating traditional medicine into primary healthcare, (vii) conducting diverse research and clinical trials on traditional healthcare practices, (viii) implementing guidelines outlined by the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP) to safeguard the rights and well-being of tribal communities, and finally (ix) providing cultural competency training for medical and paramedical professionals can bolster their skills and rapport with indigenous populations, ultimately narrowing the healthcare disparities prevalent among tribal communities.

WAY FORWARD

India has now entered the 77^th year of its independence and is slowly emerging as a global leader in the truest sense. The years of bondage under foreign rule had handicapped the speed of progress, but since the attainment of independence a steady pace of development has been achieved. This is also true for the tribal communities, despite their current state of backwardness. The Government of India has launched many programs for their upliftment which have resulted in many improvements over the past few decades. A light of hope for a better future in this regard is reflected in the fact that all these indicators have shown an improving trend in the past decades, although a long path lies ahead to bring them up to parity with the other communities. The election of Shrimati Droupadi Murmu as the President was a historical achievement within the annals of India, with her becoming the first tribal person to occupy the highest constitutional office of India. Whether this heralds the dawn of a new and prosperous era for the scheduled tribes depends on the strides the nation can take together to achieve a state of parity for their progress.

Disclaimer

The opinions expressed in this article are solely attributable to the authors and should not be attributed to any institution /organization he/she has been affiliated in the past or at present.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.