The Health of Indigenous Populations in South Asia: A Critical Review in a Critical time

Abstract

Despite South Asia’s promising social inclusion processes, staggering social and health inequalities leave indigenous populations largely excluded. Marginalization in the South Asian polity, unequal power relations, and poor policy responses deter Adivasi populations’ rights and opportunities for health gains and dignity. The ongoing COVID-19 pandemic is likely to result in a disproportionate share of infections and deaths among the Adivasis, given poor social conditions and exclusions. Poor health of indigenous people, inequalities between indigenous and non-indigenous groups, and failures in enforcing constitutional and legal provisions to reclaim indigenous land and cultural identity herald deeper structural and political fractures. This article unravels health inequalities between the Adivasis and non-Adivasi populations in their social context based on a critical review of secondary sources. We call for intersectoral policies and integrated health care services to address systemic inequalities, discrimination, power asymmetries, and consequent poor health outcomes. The current COVID-19 pandemic should be viewed as a window to pursue real change.

Despite South Asia’s substantial progress in health and social development during the post-colonial period, indigenous populations have far worse health indicators, and they die younger compared to the general populations.^1,2 Adivasis (indigenous peoples are known in South Asia as Adivasis (original inhabitants)/scheduled tribes/tribals/Janajatis (in Nepal). We used it synonymously, but instead of Janajatis, we used only Adivasis, to maintain consistency. These population labels have diverse origins; see Government of India³) tend to live in inaccessible or difficult-to-access terrains, facing a range of inequalities and lingering privations: poverty, land alienation, lower life spans, increased mortality and morbidity, hunger, illiteracy, and insecurity, as well as limited access to health care services, resources, productive employment, and politics.^3,4 These challenges, which foster disempowerment, vary across and within South Asian countries. Over the past decades, several affirmative efforts have been initiated to address indigenous issues globally and regionally, ranging from country-specific constitutional and legal provisions to the 2 United Nations International Decade (1994–2004 and 2005–2015) of the World’s Indigenous Populations, the latter seeking to focus high-level attention. The United Nations’ efforts since the 1970s to protect indigenous rights, land, cultural identity, health care practices, and political participation were aligned with a similar policy focus from the World Health Organization (WHO) and International Labour Organization. Moreover, the endorsement of pro-poor pathways to universal health coverage promoting access to services and financial protection for all, as well as the Sustainable Development Goals integrating indigenous health and rights, have further expanded the prospects for mitigating health inequalities and social exclusion of Adivasis.

However, human right violations, deprivation, poor social conditions, and discrimination against Adivasis mar the social and public health fabric of contemporary South Asia.^5,6 The ongoing COVID-19 pandemic may worsen their perilousness, with growing threats of food insecurity and racial/ethnic discrimination. All these herald deeper structural, policy and political fractures. The neoliberal economic ascendency in South Asia, emphasizing limited state intervention in the welfare sectors and increasing privatization, accentuate and legitimize the inequalities.^7,8 Indeed, public-sector health spending as a percent of gross domestic product in India, Pakistan, Nepal, and Bangladesh is low (with Bangladesh being the lowest at 2.6%).⁹ Globally, South Asia reports the second-lowest human development index in 2017 (0.638), comparable only to sub-Saharan Africa, with the lowest belonging to tribal regions.⁹ What explains the disturbing contours of health inequalities of Adivasis in the South Asian context? There is a need for an analysis beyond biomedicine’s positivist epistemic claims of objectivity as a vital exemplar of “scientific” and “legitimate,” devoid of historical and social context that limits an adequate portrait of indigenous health. This constrains the multiplicity of creative responses to alleviate health and concomitant social and moral ills.¹⁰ The pertinent question here is how and why the integration of social and historical vulnerabilities and marginalization of tribal populations are often erased from theoretical inquiries, analytical trajectories, and political and policy directives, although this question is beyond the scope of the present article.

Given the complexities, this article aims to analyze the health of Adivasi populations with a focus on inequalities between Adivasis and non-Adivasis in South Asia, placing them within their social context. We review secondary sources, including national and international peer-reviewed and gray literature, through an ecosocial lens. The eco-social theoretical approach is rooted in an understanding of the historical, multiple, interactive, and continuous processes and structures configuring health inequalities.¹¹ This enables us to understand how multiple interactive social factors, including power asymmetries and poor policy responses, structure health and health inequalities of Adivasis within the specific historical and social context of Adivasi life in South Asia. The article focuses on the 4 major countries of South Asia with substantial Adivasi populations: India, Bangladesh, Pakistan, and Nepal. We begin with descriptions of health inequalities among Adivasi populations compared to non-Adivasi groups, followed by a critical synthesis of available literature linking discrimination and poor social conditions, including political participation and social policies. We conclude by making an argument for non-discriminatory intersectoral policies and integrated health care services to address the glaring inequalities, considering the impacts of the COVID-19 pandemic to improve the health of Adivasis.

Inequalities in Health Indices of Adivasis

The notions of Adivasi/indigeneity are complex and definitions vary worldwide, with differing histories of colonization, politics, culture, and geographical terrains of living. In South Asia, broadly, they include heterogenous ethnic groups with distinct cultural patterns and community histories. The population distribution of Adivasis varies in the 4 countries: India (8.6%), Nepal (40%), Bangladesh (1.8%), and Pakistan (15.4% Pashtuns alone). Indeed, there is a lack of ethnicity-disaggregated data, which masks inter- and intra- country/community inequalities. Nevertheless, the available evidence, based on studies, reports, and demographic health surveys, indicates significantly poorer health outcomes for Adivasis compared to non-Adivasi populations.^5,12,13 This was particularly evident in terms of infant mortality rate (IMR), maternal mortality ratio (MMR), life expectancy at birth, and stunting (Table 1). Notably, although IMR among the Adivasis in India dropped to 44.4 (per 1,000 live births) in 2015–2016 (62.1 in 2005–2006), it was higher than the other (32.1)¹² (“other” indicates populations other than Scheduled caste, Scheduled tribe, and Other backward class, official social categories of the census). Similarly, child mortality was double (13. 4 per 1,000 live births, other 6.6) and under-5 mortality considerably higher (57.2 per 1,000 live births, other 38.5). In the Adivasi-dominated areas of Pakistan (Balochistan and Federally Administered Tribal Areas [FATAs]), IMR ranged from 70–129,⁴ and MMR (per 100,000 live births) was unacceptably high (758), despite the overall declining trend for Pakistan as a whole (from 400 in 2004–2005 to 276 in 2006–2007).¹⁴ In Bangladesh’s tribal region, Chittagong Hill Tract (CHT), high health inequalities were seen compared to the general population.¹⁵ In addition to mortality differentials, in Nepal, the gap between Adivasi and non-Adivasi populations in life expectancy in 2009 was a staggering 20 years.⁴

Table 1. Health and Poverty Indicators of IP and BP^a in Selected South Asian Countries.

Country and time period	IMR		MMR		Life expectancy		Stunting (%)		Individuals/households below poverty line (%)
	IP	BP	IP	BP	IP	BP	IP	BP	IP	BP
Bangladesh	51	45	–		–	72.8	48	42	62	32
Year	2009	2009	–	–		2017	2014	2014	2009	2010
India	74.3	61.7			63.9	67.0	51.1	43.1	40.6	20.5
Year	2008	2008		–	2011	2011	2008–2009	2011–2012	2011–2012	2011–2012
Nepal	59	55	645.9	565.0	66.7	66.6	41.2	40.8	23.7	17.7
Year	2006	2006	2009–2010	2009–2010	2011	2011	2011	2011	2010	2010
Pakistan	86	78	380	276			57.6	49.3	–	–
Year	2007	2006–2007	2007	2006–2007	–	–	2011	2011	–	–

Abbreviations: BP, Benchmark Population; IMR, infant mortality rate; IP, Indigenous Population; MMR, maternal mortality ratio.

Source: Anderson et al.;² for Bangladesh: UNDP⁹ and MOHFW;³⁴ Nepal: for stunting, Pandey et al.²³ and for IMR, Demographic Health Survey 2006. Nepal: USAID, New Era and Ministry of Health and Population; 2007.

^aBenchmark data are provided for local and national non-indigenous populations or total populations. For details, see Anderson et al.,² UNDP,⁹ and MOHFW.³⁴

Apart from the avoidable mortality, social vulnerabilities accentuating biological consequences for Adivasi populations in South Asia were evident in the quadruple burden: undernutrition, infectious morbidities, genetic disorders (sickle cell anemia), and noncommunicable diseases (NCDs).^4,16 India’s latest comprehensive national nutrition survey (2016–2018) reveals that more than half (53.1%) of the Adivasi children (1–4 years) have anemia compared to 37.7 percent for the other, while even more were stunted (41.5%) and underweight (41.5%).¹⁷ Notably, between 1985–1989 and 2007–2008, there was a decline in intake of most of the nutrients among the Adivasis in several states of India.¹⁸ Compared to India, a lesser proportion of Adivasi children of under-5 in Nepal had anemia (44%) and were underweight (26.9%) (in 2011), while stunting (41.2%) was more or less equal.¹⁹ In Bangladesh, anemia prevalence among Adivasi children was 62% and stunting 48% compared to the national averages of 49% and 42%, respectively.¹⁵ According to the 2018 National Nutrition Survey of Pakistan, 2 Adivasi-dominated areas had the highest stunting: Khyber Pakhtunkhwa (districts of FATAs merged to Khyber Pakhtunkhwa in May 2018) (48.3%) and Balochistan (46.6%).²⁰

The high levels of poverty-related infectious diseases among Adivasis in South Asian countries include diarrheal disease, tuberculosis, leprosy, and malaria, while NCDs are on the rise.^4,14,21 The impact of the newly emerging COVID-19 pandemic has yet to be analyzed. However, the poor social conditions are likely to result in a disproportionate share of infections and death among the Adivasis. In terms of NCDs, in India, 1 in every 4 tribal adults (25% of men and 23% of women in 2007–2008) have hypertension, which is close to the national average,¹⁸ whereas diabetes, cancers, stroke, injuries, and mental illness pose a major threat to Adivasi health.^21,22 The epidemiological transition milieu is similar in other South Asian countries.⁴ In immunization coverage of children, Nepal has the highest achievement for all basic vaccines for both Adivasis (93.5%) and the general population (87.1%).²³ India (62% in 2015–2016) lags behind Nepal, Bangladesh (71% in), and Pakistan (65.6% in 2017–2018) in immunization coverage of children among the general population. Nevertheless, the basic vaccination rate in India was higher (55.8%) than coverage of children aged 12 months in the CHT (51%) and children aged 12–23 months in the FATAs (30.4%).^4,12 In 2015, full immunization coverage in the FATAs was alarmingly low (15.7%), and in Balochistan, every second child was not immunized.²⁴ Further, high prevalence of genetic disorders such as sickle-cell anemia was reported as early as 1952 and onward, among the Adivasis of South India.^25,26 The accumulated effects of poverty and undernutrition worsen Adivasi populations’ predisposition to genetic diseases.

Maternal Health

South Asia made significant strides in improving maternal health, and MMR declined to 19% of the global burden, although it was inadmissibly high.²⁷ The maternal health narratives of Adivasis have been masked by a lack of disaggregated data, and narrow interpretation of maternal health as reproductive health.²⁸ However, even in the limited information available, largely on indicators such as MMR and antenatal care (ANC), Adivasis lag behind. In India, in 2015–2016, the proportion of Adivasi women who received ANC from Skilled Birth Attendants (SBAs) was 72.9% compared to 85.6% for other and 79.3% for the country, while full ANC (15%) coverage among them was abysmally low.¹² The FATAs of Pakistan received less ANC (71%) from a trained person than the country overall (86.2%), while delivery in a health facility was less than half (49.1%) compared to 66.2% for the country.²⁹ Notably, rural (59.9%) and urban (79.2%) disparities in prenatal care in the FATAs and in Balochistan (rural 41% and urban 65%) were striking.³⁰ Bangladesh was not very different as only a quarter (26% in 2014) of rural women received 4 or more antenatal checkups.³¹ The proportion of deliveries assisted by SBAs was 3 times lower in CHT-Bandarban (7.6%) and less than half in Rangamati (11.5%) and Kagrachari (9.1%) districts, compared to the national average (25%). In Nepal, in 2011, a little over one third (35%) of the hill and terai Adivasi women accessed ANC from SBAs, while an even smaller proportion delivered in a health facility with the help of SBAs (28.8%).²³

In maternal anemia reduction, South Asia made little progress, as between 1995 (53%) and 2011 (52%) there was hardly any positive change.³² More than half of the Adivasi women in the reproductive age group (15–49 years) in India (60%) and Nepal (56%, terai Adivasi) were anemic.^12,19 Pakistan and Bangladesh were likely to have a higher proportion of Adivasi women who were anemic because of high levels of poverty and food insecurity among them compared to non- Adivasis.^15,30 While Pakistan has not progressed much in anemia reduction—if not worsened, as the national average remains 52.1%—Bangladesh has achieved considerable reduction (39.9%).^31,33 Further, there are higher levels of adolescent marriage (52% for CHT compared to 35%for Bangladesh; 14.4% for India compared to 10.8% for other; 35.4% for Adivasis in Nepal) and pregnancy, which often convolute maternal health of Adivasis.^34–36 The FATAs of Pakistan have a higher proportion of first pregnancy (3.4%) and live birth (9.8%) among women aged 15–19 years compared to the national averages of 2.4% and 5.7%, respectively.³³ All these maternal health issues were likely to increase the risk of complications and MMR. Notably, indigenous women were twice as likely to die from pregnancy-related causes compared to nonindigenous populations² while access to health care services was constrained.

Access to Health Care Services: An Enduring Concern

Adivasis in South Asia suffer from poor and often less health care access.⁴ Needless to say, most of them in remote areas largely rely on traditional birth attendants’ wisdom, acceptability, and accessibility, particularly for ANC and delivery services. A variety of structural, geographical, and political reasons and disjunctures—including catastrophic health spending, shortfall of health infrastructure, living in remote and hilly terrains, and institutional discrimination—hinder Adivasi communities’ access to health care.^16,23,34 Women’s access is further constrained by limited income stemming from unequal gender relations.²³ In India, in all of the 8 primary obstacles to accessing health care—including getting permission and money for treatment, distance, concern that there are no medicines, and lack of providers generally and female providers specifically—Adivasi populations rank highest.¹² Nepal, Bangladesh, and Pakistan have similar reasons for poor utilization and dissatisfaction in the use of public-sector health services.^24,34 Further, shortfalls of infrastructure and manpower figure as a major impediment to access: In India in 2017, health facility shortfall in the Adivasi areas was 1,240 primary health centers, 273 community health centers, and 6,503 sub-centers and vacant positions (of sanctioned posts) of 27.6% of doctors at primary health centers and 22.4% of nurses at primary health centers and community health centers.³⁷ In CHT, around 50% of health providers’ posts were vacant,³⁴ and the FATAs lack adequate health care provisions.¹⁴ In Nepal in 2013, only 23% and 39% of sanctioned posts of doctors and nurses, respectively, were filled at primary health care clinics.³⁸ Unethical medical practices and poor quality of services further endanger health care access. For instance, in 2014, in Bilaspur, India, 12 women (largely tribal and Scheduled caste) lost their lives following a mass sterilization drive without any aseptic precautions.³⁹ However, in India, despite all barriers, Adivasis have maximum public-sector health care utilization for both inpatient (48.2%) and outpatient care (59.6%), more than any other groups.⁴⁰ This illustrates the compelling call for publicly funded, quality health care services conducive to the specific sociocultural context of Adivasis and the need to have underlying discriminatory social conditions driving poor health and health care access explored and addressed.

Discrimination and Poor Social Conditions

Historically, community life and health in South Asian countries were entangled with systemic discrimination and confounding inequalities of caste, class, gender, ethnicity, poverty, and beyond.^8,13,41–43 Pakistan has the highest inequality in South Asia in education, food deficit, and life expectancy, followed by India (with the exception of food deficit) (Table 2).

Table 2. IHDI Index (IHDI), Health-Related Inequalities, Health Expenditure, and Food Deficit in Selected South Asian Countries (2017).

Countries	IHDI value	Overall loss (%)	Inequality in life expectancya(%)	Inequality in education (%)	Inequality in income (%)	Health expenditure % of GDP	Food deficitb
India	0.468	26.8	21.4	38.7	18.8	3.9	105
Bangladesh	0.462	24.1	17.3	37.3	15.7	2.6	107
Nepal	0.427	25.6	16.6	40.9	16.3	6.1	54
Pakistan	0.387	31.0	31.0	46.2	11.6	2.7	151
South Asia	0.471	26.1	21.4	37.7	17.6	4.2

Abbreviations: IHDI, Inequality-adjusted human development; GDP, gross domestic product.

Source: UNDP;⁹ for food deficit, von Grebmer K. et al.⁴⁶

^aPeriod 2015–2020.

^bPeriod 2014.

In terms of poverty among Adivasis, the incidence in rural areas of India dropped to 33.8% in 2009–2010 from 52% in 1993–1994, although it was much higher than the national average (23.7%). Notably, per capita daily consumption of energy and protein decreased in rural India between 1993–1994 and 2011–2012; in 2011–2012, protein intake among Adivasis (1,990 kcal) was much less than recommended.³⁷ Nepal’s reduction in poverty between 1995–1996 and 2003–2004 was not uniform, as it declined only by 10% among the Adivasis compared to 46% among Brahmin-Chhetris (upper castes).⁴⁴ In 2011, the poverty incidence among the hill (28.3%) and terai (25.9%) Adivasis was nearly 3 times higher than that of the hill Brahmins (10.3%).⁴⁵ The proportion of the population in multidimensional poverty among the FATAs of Pakistan in 2015 was nearly double (73.7%) compared to Pakistan as a whole (38.8%).³⁰ Having the highest global hunger index in South Asia in 2014, Pakistan (19.1) and Nepal (second highest at 16.4)⁴⁶ were likely to have higher nutrient deficiencies in the Adivasi areas. Despite Bangladesh’s significant poverty reduction, in CHT, 60% of the population live below the poverty line and, according to the direct required calorie intake (2,122 kcal), 62% of all households irrespective of ethnicity live below the absolute poverty line, compared to the national average of 31.5%.^15,34 Moreover, the spread of the COVID-19 pandemic will lead to unprecedented poverty and food insecurity among the Adivasis of South Asia.⁴⁷

Historically, illiteracy and the consequent preponderance of menial jobs with limited income, often without cash payments, have characterized the South Asian Adivasi social milieu. In the CHT, only 2.4% completed secondary education;⁴⁸ salaried employment among the Adivasis was half (2.4%) that of Bangladeshees (4.7%), and the average income of rural Adivasis was 25% less than the national average.⁴⁹ The recent (October 4, 2018) abolition of reservation for the Adivasis in the first- and second-class government services in Bangladesh further discriminates against them.⁵⁰ More than 40% of the Adivasis of Nepal had no education in 2011, while lack of education was nearly double among the terai Adivasis (51%) compared to the Brahmins/Chhetris (27.3%).²³ Not surprisingly, 96.2% of those employed in Nepal were in the informal sector.⁵¹ In India, more than one third (37.2%) of the Adivasis had no education compared to 19.4% for the other.³⁵ Between 2001 and 2011, in India, an estimated 3.5 million Adivasis entered the informal job market, and only 5.34% were in professional and managerial jobs in 2011.⁴⁹ In rural India in 2011–2012, the percentage of households with casual labor was much higher among Adivasis (38.3%) than among the other (21%).⁵² Nearly half (44.2%) of the children (6–15 years) of FATAs never enrolled for school, and the literacy rate in 2013–2014 was only 33.3%, with female literacy less than half of that (12.7%).⁵³ The national labor force survey 2012–2013 of Pakistan indicates that nearly half (48.38%) of the population in KP and 31.49% in Balochistan work in the informal sector. In addition, there has been an alarming proportion of child labor in India (16.6%), Bangladesh (17.6%), and Pakistan.⁴⁹ In Nepal in 2008, the highest proportions of child labor (38.5%) and hazardous child labor (37.7%) were among the Adivasis.⁵⁴ These discriminations are intrinsic to the development discourses of South Asia, devoid of policy attention to prevent jeopardizing the health of Adivasis.

Hunger, Prejudice, and Covid-19 Pandemic

The emergence of COVID-19 potentially affects the indigenous communities in South Asia, as the global pandemic has uncovered social, ethnic, and political fractures and prejudices deepening poverty and marginalization.^55,56 Indeed, we currently lack ethnicity-disaggregated data and do not yet know the full impacts of COVID-19 on tribal communities. Notably, the lockdown in South Asia, initiated in late March 2020 largely for physical distancing, helped the privileged more than the marginalized, who live in cramped spaces and vulnerable conditions. South Asia, with a share of 23.4% of the world’s population and accounting for 1.25% of infections and 0.5% of COVID-19 deaths (as of April 20) in the world, is currently far better compared to North America or Western Europe.⁵⁷ However, with a large majority of Adivasi workers in the informal/casual sectors, hunger looms large for them following the lockdowns; food insecurity deepened, traditional livelihood (based on non-timber forest products) was disrupted, ethnic/racial discrimination was heightened, basic health care access was further deprived, thousands became jobless and stranded, and reverse migration (often tramping hundreds and thousands of kilometers) to their faraway villages increased while government and private assistance largely evaded them.^47,56–58 Notably, following a sudden, nationwide lockdown unaccompanied by any precautionary measures, India witnessed the greatest exodus ever since the partition, with crammed masses of migrant laborers, including the Adivasis, at interstate bus stations in Delhi/metro cities, unable to choose between hunger death and COVID-19. COVID-19 has been illuminating racism and right violations, particularly for Adivasis. For example, South Asia witnessed ostracization of people who have racial similarity to Chinese people such as North East Indians (because of the pandemic origin in Wuhan) and atrocities against Hazaras Shias of Balochistan, populations of CHT, and Adivasis of Nepal.^47,56–58 Further, unleashing of labor laws (extension of working time to 12 hours per day, denial of workers’ rights, etc.) in favor of corporate employers and entrepreneurs under the coverage of the pandemic, particularly in India, sent shock waves to the laboring class.⁵⁹ In short, the multifaceted social and ethnic discrimination heightens Adivasis’ health risks and deprivation in times of crisis.

Eviction and Land Alienation

In post-colonial South Asia’s social settings of unequal power relations, enforced eviction of Adivasi populations from their sociocultural habitat by the state and private-interest groups without fair dialogue, collective consent, or compensation, often through forgery and fraudulence, has been a continuous saga. When the colonial administration introduced new land revenue settlement, it transformed the customary collective land rights of Adivasis, favored infringement of land by the state and settlers, accelerated deforestation and destruction of the natural environment, and relegated Adivasis to migrant laborers.^60,61 The post-independent states in South Asia occupied tribal land for military and security reasons, natural resource extraction, and development projects; leased land to corporations; and created zoning regulations to protect industry and private interests. In addition to the destitution caused by ecological devastation, the development projects—industry, hydraulics (dams and irrigation), infrastructure (roads, railways), mining, and plantations—led to massive, enforced displacement and migration in South Asia.^3,4,62 Even in Kerala, with a history of land reforms and decentralized governance, Adivasis had to organize unprecedented struggles to reinforce Adivasi identity to regain their land rights, often in vain.^62,63

India has the highest number of people displaced annually as a result of development projects: 60–65 million since independence.⁶⁴ Of these, 55% were Adivasis. The 12th five–year plan (2012–2017) of India categorically pointed out that “the compulsory acquisition of land for public purposes and for public sector or private sector companies displaces tribals forcing them to give up their home, assets, and means of livelihood.”⁶⁵ In India between 2001–2010, 25,747.53 acres, including 21,151.76 acres of forest land, were used for coal, uranium, and limestone mining.⁶⁶ According to the 68th National Sample Survey in 2009–2010, more than three-fourths of Adivasi households were either landless or had less than 1 hectare of land. The road expansion project in Kathmandu, Nepal, uprooted more than 150,000 people (90% Adivasis), ruining sacred heritages and subsistence; the 753 local demarcations that divided indigenous territories turned Adivasis to minority groups with limited decision-making power; and more than one quarter of the Adivasis other than Newar and Tharus did not have any title deeds, while a majority (80%) of Nepal’s marginalized hill indigenous populations have only meager (0.4166 hectares) land in their names.⁶⁷ This was despite Nepal being a signatory to the U.N. Declaration on the Rights of Indigenous Peoples (UNDRIP), which reiterates Adivasi rights over traditionally occupied and used land, water, and territories.⁶⁸

The process of displacement strengthened in CHT with construction of the Kaptai dam in 1962, which left 22,000 hectares of cultivable land flooded and 10 million people displaced—more than 70% of whom were in the Adivasi Chakma community.⁶⁹ Since the 1970s, the counter-insurgency in CHT vehemently evicted Adivasis, and the massive transmigration brought in a large number of Bengali settlers (40,000 between 1979–1985). As a result, 85% of the Adivasis in the plains became landless.⁷⁰ The report of the CHT Commission, “Life Is Not Ours,” reiterated that looting, arson, gang rape, and torture to death were adopted for the unlawful takeover of land from the Adivasis.⁷¹ The total targeted land acquisition by the forest department of Bangladesh since 1989 amounts to 218,000 acres, mostly tribal land.⁷² The development discourses and counterinsurgency in Pakistan displaced several million people, and military operations in June 2014 alone displaced as many as 1.5 million people from the tribal agency.⁷³ However, the redressal mechanisms initiated by international agencies and the forestry rules often promoted industrial forestry and policing of forests rather than protecting Adivasi land rights.^72,74

Gender Disparities and Violence Against Women

South Asia’s deeply entrenched gender discriminatory relations, often legitimized by state and legal discourses, discriminate against women in several social determinants of health, including education, employment, income, landownership, political participation, access to health care, nutrition, and decision-making.^8,75 Only one fifth of the women in the CHT can inherit property and, in some communities, almost no women can do so.⁴⁸ A similar situation prevails in some parts of India, Nepal, and Pakistan.^76–78 High levels of violence against women, including an increasing number of rapes (96 in CHT in 2010; 974 in India in 2016) and domestic violence (29% among Janajtis in Nepal), often persist with impunity in South Asia.^79–81

Around the world, conflicts and military interventions often exacerbate gender violence, and the Adivasi regions are particularly vulnerable as a result of increased military and militant operations. Evidence indicates that in conflict-affected areas of Pakistan, India, Bangladesh, and Nepal, women bear considerable physical, emotional, and financial cost. These include scarce livelihood and welfare inputs; sexual abuse from militants, security officials, and often family members; and enforced marriages, largely with impunity.^{76,78,80,82,83} The South Asian context of sexual abuse and impunity was well-narrated by the then-chairperson of the National Commission for Scheduled Tribes, India, cited in Sharma:⁸⁴

in 2015 in Bijapur district of Chhattisgarh around dozens of tribal women were assaulted and raped with force by police while central reserve police force stood outside the village as guards. The district police went in, ate bakra (mutton), drank alcohol, took away goods and went on a rampage, but mostly these cases don’t reach us.

Despite the accelerated focus on women’s “empowerment” in past decades, including the emphasis of Article 22.2 of UNDRIP⁶⁸ that “states shall take measures, in conjunction with indigenous peoples, to ensure that indigenous women and children enjoy full protection and guarantees against all forms of violence and discrimination,” the normalization of violence against indigenous women raises questions about the equality and empowerment concerns of existing policies and politics.

Politics and Social Policies: The Root of Inequalities

Politics and policies have a critical role in addressing health inequalities and poor social determinants of health. South Asia has several constitutional and legal measures to safeguard the interests of Adivasis—for example, India’s constitutional provisions (Articles 15, 16, and 46), Provisions of Panchayats (Extension to Scheduled Areas) Act (PESA) of 1996, and the Scheduled Tribes and Other Traditional Forest Dwellers (Recognition of Forest Rights) Act (FRA) of 2006. Bangladesh enacted the CHT Accord in 1997 to redistribute power between the government and the district and regional councils (devolution of power was restricted) and introduced 5 major acts for the CHT area to address Adivasi rights.⁴⁹ Ending the historical legacy of colonial laws denying rights and political representation to tribal regions, Pakistan’s constitutional amendment in May 2018 provided equal rights to millions of tribals by merging the FATAs to mainstream political, administrative, and legal frameworks.²⁹ Nepal has initiated special policies for the upliftment of Adivasis since the 1990s, and the first constitution (Article 18, 2015) has provisions for affirmative action and equality before the law.

Yet, in South Asia, spaces for political representation and participation of Adivasis are limited, and development projects, together with forest and biodiversity conservation policies, continue to fail them. In India, Adivasis had to go on an indefinite hunger strike to implement some of the recommendations of the Bhuria Committee Report (2004),⁸⁵ which stressed participatory democracy emphasizing tribal community’s autonomy— control over their territories and natural resources.⁸⁶ India’s Wildlife Protection Act of 1972 and Forest Conservation Act of 1980 enhanced deprivation of forest-dwelling Adivasis by alienating land and curtailing livelihood and survival.⁷⁴ More than a decade after passing the Forest Rights Act to correct colonial and post-colonial injustice over their lands, the very constitutionality of this Act hangs in balance in India’s highest court.⁸⁷ Dam policies have displaced several million Adivasis, while efforts to improve their lives, such as the Integrated Tribal Development Programmes (1974),⁸⁸ were riddled with conceptual inadequacies, cultural insensitivity, and implementation failures. In the provision of health gains, the 16th Lok Sabha tribal sub-plan specifically emphasized manpower shortage, poor interdepartmental coordination, and lack of convergence of resources with line ministries.⁸⁹ The allocation of plan funds for the Scheduled Tribes, even in 2013–2014, did not reach the stipulated 8% (only 5.75% was spent). Indeed, there is a lack of legal binding on ministries in India to fulfill the targeted allocation.⁸³

Pakistan continued the draconian colonial rules— Frontier Crime Regulations—until May 2018, for governing FATAs and denying autonomy and political rights.²⁹ Notably, despite introducing in 2009 a special package of constitutional, economic, and administrative measures to protect the rights of Baloch populations, even today, Balochistan is among the most underdeveloped region in Pakistan.⁹⁰ Despite the awareness of tardy progress in social indicators and poor development of tribal areas in Pakistan’s 10th five-year plan (2010–2015), it lacks specific provisions to improve Adivasi life.⁴⁹ In CHT, political marginalization left questions of settlement, demilitarization, and rehabilitation of internally displaced populations, resource ownership, and autonomy unresolved.⁷² This was Further, forestry initiatives in CHT, such as the National Forestry Policy (1979) and the Master Plan of Forestry (1994), supported by the Asian Development Bank, and other projects of the World Bank limited Adivasi community rights and participation in development processes while promoting industrial forestry and policing of forest departments.⁷² While the deliberate restrictions and silencing imposed upon Adivasis by political parties in the constitution drafting process reflected Nepal’s shrinking space of political participation/representation of Adivasi communities,⁹¹ some of the constitutional laws and policies of Nepal foster racial discrimination; the caste system, often legitimized by the state, endorses marginalization and forced assimilation of Adivasis to the bottom of the Hindu hierarchy.^67,82 Thus, the discriminative policies and politics that institutionalized social and health inequalities further push Adivasis to the margins.

Discussion

Despite a scarcity of disaggregated data, the evidence on poor health indicators, fragile social conditions, and poor fit of programs to address vulnerabilities across South Asia indicate that intricacies of Adivasi health and life are mired in multiple axes of inequalities. The explanations for the disturbing contours of health inequalities of Adivasis are intrinsically rooted in their socioeconomic marginalization, cultural and resource alienation, environmental degradation, exclusion from political participation, and poor policy response. What was distinct for Adivasis compared to non-Adivasis was enforced displacement, often due to ostensible “development” projects, and discriminatory policies that socially and culturally alienated them. The health system failures aggravate the distresses.⁹² In the process of nation-building in the region, Adivasis were consistently disadvantaged, with limited or no policies for addressing their uprooted life, despair, and ill health. Given the exploitative trajectories and often flawed legaland policy discourses, the Adivasis lost their rights, land, livelihood, capabilities, freedom, health culture, and democratic space for reclaiming cultural identity and health. Adivasi women were intimidated through arrest, abduction, gang rape, and enforced marriages (to change the demography and ethnic identity), mostly with impunity.^71,76,80,82 Even in the relatively progressive state of Kerala, sexual exploitation of young Adivasi girls/women, largely by outsiders, and the resultant question of unwed Adivasi mothers living in deplorable conditions raises serious concerns.⁹³ Adivasis in South Asia are a population with deep “poverty as a consequence of the wealth of the land,”⁹⁴ which once they owned. All these atrocities and discrimination against Adivasi populations deny them a dignified life and health gains, as a host of offensives against human dignity, ranging from poverty and illiteracy to gender inequality and spectacular forms of human right abuses that are interconnected to health.⁹⁵ In this socially vulnerable context, emergence of the COVID-19 pandemic is likely to have far-reaching implications for health and life of Adivasis.

Indeed, despoliation and subalternity of Adivasis were often accentuated by domination of the state and international efforts, apart from private capital.^3,4,72–74 This is often tended to be legitimized by organized politics and policy discourses. Notably, unequal distribution of power, income, resources, goods, and services internationally and nationally are causes of health inequalities.⁹⁶ People’s own experiences of substantive freedom, autonomy, control over sociopolitical opportunities, and the capability to exercise choices in the prevailing power structure play a crucial role in shaping population health.^97,98 Hence, to understand the fragile health conditions of Adivasis and their underlying social drivers, and to address their felt needs, we need a multifaceted approach—an approach that unravels the historical discrimination, cultural specificities, and social ruptures and continuities configuring health and health deficits, beyond looking into the embedded inequalities of poverty, social class, gender, patriarchal domination, and health system failures. Yet, the mainstream analytical approaches on health have not been able to substantively integrate the social injustices, cultural differentials, and ethical and moral issues, while integration of the discriminatory processes into theorizing on tribal ill health and designing interventions is even scarcer.

Notably, various international efforts—such as WHO’s⁹⁹ notion that indigenous people’s health and survival “is both a collective and an individual inter-generational continuum encompassing a holistic perspective incorporating four distinct shared dimensions. …the spiritual, intellectual, physical and emotional”; the UNDRIP’s⁶⁸ emphasis on the urgent need to promote Adivasi rights deriving from their socioeconomic, cultural, and political structures, histories, and philosophies, focusing on their lands, territories, and resources; and inclusion of the International Labour Organization’s Decent Work Agenda and its 4 pillars (employment creation, social protection, rights at work, and social dialogue) in the Sustainable Development Goals—recognize the substantive role of social context and cultural histories in improving the health and quality of life of indigenous communities. Unfortunately, public policies in South Asia fail to adopt such a perspective, while policies to specifically improve the health of Adivasi populations within or outside the health sector are uncommon.¹⁰⁰ Indeed, there is limited or no role for people and their experiences in the public and social policy discourses of neoliberalism.^7,101 Not surprisingly, the right to health as elaborated by the U.N. Committee on Economic, Social and Cultural Rights (1996)—“the right to the enjoyment of a variety of facilities, goods, services and conditions necessary for the realization of the highest attainable standard of health”—remains a far cry for the Adivasis.¹⁰² To improve the health of Adivasis, South Asian politics and policies need to problematize and redress the historically normalized context of alienation, health system failures, and processes of exclusion.

Conclusion

Despite South Asia’s promising policy progressions, many of these policy processes served to deepen health inequalities for the Adivasis. Their marginalization and the denial of state and constitutional safeguards raise important questions for the direction of public and social policies and, indeed, for representative democracy itself. As health inequalities of Adivasis are socially rooted, the specific multifactorial policy and intervention framework to address them should recognize the fragilities of ethnic context; specific historical, social, economic, and cultural discrimination; and adverse effects of development projects, including displacement and land alienation. The COVID-19 pandemic, which is likely to reinforce economic and health inequalities in South Asia, in turn may heighten indigenous communities’ subalternity. This calls for an immediate and long-term pandemic response. Further, future directives should pursue non-discriminatory intersectoral policies and integrated health care interventions to protect Adivasi rights and to address existing poor social conditions and structural inequalities. This is needed to achieve good health, which includes self-determination: recognizing and supporting what the Adivasi populations determine important for their health and well-being.

Biographies

Author Biographies

Chundankuzhiyil Ulahannan Thresia is an adjunct faculty with the Institute of Public Health, Bangalore, India, following research positions in public health schools, including Jawaharlal Nehru University, Delhi. Her recent publications include “Health Inequalities in South Asia at the Launch of Sustainable Development Goals” in the International Journal of Health Services.

Prashanth Nuggehalli Srinivas is a medical doctor and public health researcher with the Institute of Public Health, Bangalore, India. He leads the health equity cluster and is a fellow of the DBT/Wellcome Trust/ India Alliance. He has several publications on tribal health and other areas of health inequities.

Katia Sarala Mohindra is Director of Subaltern Health and an adjunct professor with the School of Epidemiology and Public Health, University of Ottawa. Her research examines the global and local forces that affect the health of subaltern populations.

Chettiparambil Kumaran Jagadeesan is a medical doctor and public health researcher working as deputy director with the Directorate of Health Services, Kerala, India. He was the state nodal officer for tribal health and is currently the state nodal officer of Aardram Mission (Government of Kerala), a novel program that strengthens primary health care and universal access to health care.