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OJHAS Vol. 10, Issue 1:
(Jan-Mar 2011) |
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| Genetic Disease
Burden, Nutrition and Determinants of Tribal Health Care in Chhattisgarh
State of Central-East India: A Status Paper |
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Balgir RS, Division of Human Genetics,
Regional Medical Research Centre (ICMR), Bhubaneswar-751 023, Orissa. |
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Address For Correspondence |
Scientist-F/Deputy Director (Senior Grade) & Head,
Department
of Biochemistry,
Regional Medical Research Centre for Tribals,
Indian Council
of Medical Research,
Near NSCB Medical College & Hospital,
P.O. Garha, Nagpur Road,
Jabalpur-482 003,
Madhya Pradesh, Central India.
E-mail:
balgirrs@yahoo.co.in |
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Balgir RS. Genetic Disease
Burden, Nutrition and Determinants of Tribal Health Care in Chhattisgarh
State of Central-East India: A Status Paper. Online J Health Allied Scs.
2011;10(1):4 |
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Submitted: Mar 16,
2011 Accepted: Mar 31, 2011; Published: April 15, 2011 |
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| Abstract: |
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Tribal health is an important aspect of development and progress of
the people. This study pertaining to genetic disease burden, nutritional
status and biomedical anthropological assessment with particular reference
to determinants of tribal health care has been carried out among the
four tribes, namely, Bhatra, Gond, Kondh and Paraja of Orissa residing
adjacent to the bordering districts of Chhattisgarh The population genetic
structure of a tribe is the outcome of socio-cultural practices, bio-psychological
behavior, genetic constitution, and eco-environmental conditions. Tribal
communities in India, in general and of Chhattisgarh state in particular,
are highly vulnerable to various genetic diseases, nutritional deficiencies
and unrealistic practices and lack of access to basic health facilities.
A total of 815 blood samples comprising of 166 Bhatra, 219 Gond, 254
Kondh and 176 Paraja tribes were collected randomly under aseptic conditions.
The frequency of sickle cell hemoglobinopathy (3.2-22.5%),
β-thalassemia
trait (0.5-8.5%), and G6PD enzyme deficiency (6-16%) is very high among
the tribes of Chhattisgarh. However, the prevalence of Rhesus negative
blood group is very low (0-0.6%). The frequency of hereditary hemolytic
anemia is also high among the tribals of Chhattisgarh. Both communicable
and non-communicable diseases harbor the tribal population. The nutritional
deficiencies are rampant. Tribal people are engrossed with superstitions
and have faith in traditional healers who practice magico-religious
rites along with indigenous herbal treatment for the common ailments.
Traditional folk medicine and health culture play a significant role
in shaping tribal life. These health practices differ from one tribe
to another. Unless locality specific, tribe specific and need-based
health care system is evolved which should be appropriate, acceptable,
accessible, and affordable, the true goal of health for all cannot be
achieved in India.
Key Words:
Tribal health;
Genetic disease burden; Nutrition; Communicable disease;
Non-communicable disease; Biomedical anthropology; Chhattisgarh
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It has been
enumerated that there are nearly 635 tribal communities in India of
which Bhils and Gonds represent the largest number. Tribal populations
constituted 8.08% (about 68 million) of the total population of India
according to 1991 census. The projected tribal population was more than
83 millions by the year 2001. Their largest concentration (about 87%)
is comprised of the states of Rajasthan, Gujarat, Maharashtra, Madhya
Pradesh including Chhattisgarh, Andhra Pradesh, Orissa, Bihar including
Jharkhand, and West Bengal. About one-fourth of the total tribal population
of India lives in Madhya Pradesh including Chhattisgarh (23.7%), followed
by Maharashtra (11.3%), Orissa (10.8%), Bihar including Jharkhand (10.2%),
Gujarat (9.5%), Rajasthan (8.4%) and so on in the decreasing order.(1) Out of these 635 tribes, there are about 75 tribes which are extremely
in under-developed stage, and have been listed under primitive tribes
in India.
The state of
Chhattisgarh is situated in between the states of Madhya Pradesh and
Orissa in the Central-East part of India which came into existence on
1st November 2001. It borders with the state of Jharkhand
in the North and, Andhra Pradesh and Maharashtra states in the South.
There are about 30 scheduled tribes in the state of Chhattisgarh (Table-1).
The tribal populations constitute about 32.46% of the total population
of the state, which means that every 3rd person of the state
is a tribal. The forest reserve covers 44% of the total area of the
state and comprises 12% of the forests of India. The state is famous
for the cultivation of rice and is known as rice bowl of India. It has
rich biodiversity and has been declared as the herbal state of India.
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Table 1: Distribution of different
scheduled tribes in old districts of Chhattisgarh before the reorganization of the state on 1st November 2001.
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Name of district |
Names of scheduled tribes |
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Surguja
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Baiga, Bharia-Bhumia, Binjhyar,
Dhanwar, Gond, Kawara, Kasalwal, Kol |
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Bilaspur |
Baiga, Bhajua, Bharia-Bhumia,
Binjhyar, Dhanwar, Gond, Kawara, Kasalwal, Kharia, Kol, Korwa, Majhwar,
Nagesia, Oraon, Pardhan, Pardhi, Saonta |
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Raigarh |
Bhajua, Bharia-Bhumia, Binjhyar,
Birhor, Dhanwar, Gond, Kawara, Kasalwal, Kharia, Kol, Kondh, Korwa,
Majhwar, Munda, Nagesia, Oraon, Saonta, Sawar |
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Durg |
Gond, Halba, Kawara, Pardhi |
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Raipur |
Bhunjia, Binjhyar, Gond, Halba,
Kamar, Kawara, Kharia, Kondh, Oraon, Sawar |
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Bastar |
Bhatra, Gadaba, Gond, Halba,
Kannar, Korwa, Maria, Muria, Pardhan, Pardhi, Paraja |
The diseases
of genetic origin in man are manifested, in general, in interaction
with the environment. The delineation of causative factors behind a
disease requires in depth investigations into socio-cultural and bio-psychological
milieu of the people. It may include diverse factors such as the sanitation,
hygiene, parasitic load, breeding pattern, preferential marital alliances,
nutritional pattern, perception about a disease, health seeking behavior,
prevalence of inherited diseases, and the alikes.(1) All these socio-economic
and cultural, psycho-biological and eco-environmental correlates which
play a significant role in the health and disease process must be taken
into consideration in drawing up any conclusion about a particular population
or tribal group. Further, these concomitant factors vary from one population
group to another.
Tribal communities,
in general, and the primitive tribal groups in particular are highly
disease prone, and do not have required access to basic health facilities.
They are mostly exploited, neglected, and vulnerable to various diseases
with high degree of malnutrition, morbidity and mortality.(1) Their
misery is compounded by poverty, illiteracy, ignorance of the causes
of diseases, hostile environment, poor sanitation, lack of safe drinking
water and blind beliefs, etc.(2)
The article
in hand is designed with a view (i) to present a status paper in general
on the tribal health, genetic disease burden, and nutritional status;
and (ii) biomedical anthropological assessment and development among
the tribals of Chhattisgarh in general and Bhatra, Gond, Kondh and Paraja
tribal people of Orissa in particular belonging to the adjoining area
of the state of Chhattisgarh.
For the present
study, 815 Ashram-school-tribal students aged 6 through 15 years were
randomly selected from different schools from the districts of Koraput
(Paraja =176), Nawarangpur (Bhatra =166), Kalahandi (Gond =219), and
Kandhamal (Kondh =254) in the state of Orissa. Most commonly encountered
tribal groups in these areas are Bhatra, Paraja, Gond and Kondh in the
districts. These are bordering districts of adjoining state of Chhattisgarh
and have high concentration of tribal people inhabiting both in the
states of Chhattisgarh and Orissa. In other words, these tribals represent
the similarities in socio-cultural traditions and genetic homogeneity
because they share a common genetic pool with the tribals of adjoining
states of Chhattisgarh and Orissa.
About 2-3 ml.
of intravenous blood samples were collected from unrelated students
(children) after taking informed consent from each individual under
aseptic conditions in ethylene diamine tetra acetic acid (EDTA) coated
vials in the presence of a medical doctor. Blood samples so collected
were transported within 24 hours of collection under ice-cold conditions
to the laboratory at Bhubaneswar where the analyses were carried out
following the standard procedures and techniques. Background information
was collected from each individual as well as from each tribal community.
The sickling
test was performed by wet sealed method using 2% freshly prepared sodium
metabisulphite solution following the methodology of Daland and Castle.(3) Further, routine hemoglobin (Hb) electrophoresis was performed
using cellulose acetate membrane (CAM) in Tris-EDTA-Borate (TEB) buffer
at pH 8.9 (4,5) and fetal hemoglobin as per standard procedures.(4) The hemoglobin A2 was estimated by elution method and
the value of more than 3.5% was taken as the cut off point for
β-thalassemia
trait. The glucose-6-phosphate dehydrogenase (G6PD) enzyme deficiency
was detected by using dichlorophenol indophenol (DCIP) dye as described
by Bernstein (6) and, subsequently, confirmed by WHO procedures (7)
and Beutler et al.(8)
It has been
observed that the tribals, unlike the general populations in Chhattisgarh,
are vulnerable as well as have major threat of biomedical health problems.
The genetical diseases pose a major burden on them. Hereditary disorders
of blood like hemoglobinopathies,
β-thalassemia,
G6PD enzyme deficiency, hemophilia, and color blindness, chromosomal
aberrations, congenital malformations, inborn errors of metabolism,
etc. among others take a high toll of life.(9) The preventive and
control strategies along with remedies for some of these hereditary
disorders have also been highlighted elsewhere.(10-16)
Analysis of
ABO blood groups among the four tribes showed that the blood group B
predominates over A among Bhatra, Kondh and Paraja except the Gond tribe
(Table-2). The frequency of blood group O is the highest among the Bhatra,
Gond and Paraja except in the Kondh tribe. The frequency of Rhesus negative
blood group is very low (0-0.6%) among these four tribes (Table 2) than
the average frequency in other Indian population groups. Low frequency
of this gene among the tribals of Chhattisgarh is a pointer to the high
selection pressure at this locus with a resulting loss of fetuses and newborns
at various stages of life.(17)
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Table 2: Distribution of ABO
and Rhesus (D) blood groups, sickle cell disorders, β-thalassemia trait, and G6PD deficiency in four tribes of Orissa adjoining Chhattisgarh
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Parameters
of Study |
Name of Tribe |
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Bhatra
(N=166) |
Gond (N=219) |
Kondh (N=254) |
Paraja (N=176) |
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ABO
Blood groups: |
| A
(%) |
25.3 |
33.3 |
29.5 |
27.8 |
| B
(%) |
25.3 |
21.5 |
37.0 |
33.5 |
| AB
(%) |
9.6 |
6.8 |
10.6 |
9.7 |
| O
(%) |
39.8 |
38.4 |
22.8 |
29.0 |
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Allele
frequency: |
| p |
0.301 |
0.227 |
0.243 |
0.214 |
| q |
0.301 |
0.154 |
0.293 |
0.251 |
| r |
0.398 |
0.619 |
0.464 |
0.535 |
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Rhesus
(D) Blood groups: |
| Rh +ve (%) |
99.4 |
99.5 |
99.6 |
100.0 |
| Rh-ve (%) |
0.6 |
0.5 |
0.4 |
0.0 |
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Allele
frequency: |
| D |
0.923 |
0.929 |
0.937 |
1.000 |
| d |
0.077 |
0.071 |
0.063 |
0.000 |
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Genetic Disorders: |
| Sickle cell
disorders (%) |
18.1 |
22.4 |
3.2 |
14.8 |
| β-thalassemia
trait (%) |
6.6 |
0.5 |
6.3 |
8.5 |
| G6PD deficiency
(%) |
6.6 |
5.9 |
6.7 |
15.9 |
The prevalence
of genetic disorders like sickle cell hemoglobinopathy,
β-thalassemia,
and G6PD deficiency among the tribals of Chhattisgarh state is very
high (Table 2). The frequency of sickle cell hemoglobinopathy ranges
between 3.2% to 22.5% and that of
β-thalassemia trait between 0.5% to
8.5% among the Bhatra, Gond, Kondh and Paraja tribes belonging to bordering
districts of Chhattisgarh and Orissa. The deficiency of G6PD is also
very high (6-16%) among these four tribal populations (Table 2). The
enzyme in all tribes appears to be similar, with more or less 10-20%
of the normal enzyme activity and normal electrophoretic mobility, which
has been found to be a new variant named “G6PD Orissa”.(18) The
Michael’s constant (KmNADP) for the substrates which actually translates
roughly into five-fold lower activity at limiting substrate concentrations
is high and shows the increased thermostability than the normal enzyme.
These abnormalities
co-exist in the population living in hyper endemic zones of malaria.(19) The other side of this health problem is even more alarming. Instead
of saving tribals from the grip of malaria, a medical doctor can do
a great harm by giving antimalarial drugs to persons who are G6PD deficient,
leading to some serious complications, resulting in severe jaundice
or anemia, and sometimes, resulting even in death.(20,21) Indiscriminate
use of such drugs for treatment as well as for prevention should be
done with utmost precaution, considering this factor. While eradicating
malaria, antimalarial drugs like primaquine and many other compounds
such as phenacetin, furadantin, certain sulphonamides and acetyl salicylic
acid (aspirin), etc., should be administered with caution to subjects
deficient in G6PD enzyme among the tribes of Chhattisgarh. This may
produce hemolysis of the red blood cells, causing severe anemia and health
hazards, and sometimes, fatal also. This is a problem not only for geneticists,
public health authorities, but also for the Tribal Health, Tribal Welfare and
Tribal Development personnel as well.(20-22)
The tribals
of Chhattisgarh have been exposed to infection of malaria for the last
several hundreds of years with the introduction of agriculture and,
as a result, the mutation of red cell enzyme and hemoglobinopathies
might have occurred in them to cope with the environmental threats.(19,23,24) The heterozygous advantage in affording protection against
malaria, particularly of the Plasmodium falciparum type, must have been
possibly the cause of a high incidence of such genetic disorders. The
study of different variants of hemoglobinopathy and G6PD deficiency
is an important area of research among the tribals of Chhattisgarh.
The tribals
of Chhattisgarh state follow territorial exogamy in marriage alliances.
The population of each tribal clan is not large enough and in course
of time, even though, the marriage takes place outside the clan, it
results in inbreeding at certain stage due to cross and parallel cousin
marriages.(14,16) Moreover, the marriage distance between the two
partners is very small which also leads to lack of genetic variety or
variations, in addition to genetic inbreeding in the population. This
brings the recessive or hidden characters on the surface and leads to
increased homozygosity (by bringing the defect in double dose) and affects
the health because of the combination of lethal traits in homozygous
condition. It is, therefore, necessary to carry out detailed surveys
to find out the disease profile and disease burden (cause and effects,
and economic and manpower loss) and dietetics of the tribals of Chhattisgarh
so that a comprehensive health promotive, health care and prevention
of genetic diseases as well as nutritional programme may be planned and
intervention strategies formulated for the vulnerable population in a befitting
manner.
The steps suggested
to be taken for the prevention and palliative treatment of sickle cell
disease (11), β-thalassemia
(13) and G6PD deficiency (10) are as following:
- The patient is advised to be warm, avoid cold bath or cold
drinking water or drinks.
- The patient should consume adequate amount of fluids especially
during summer in order to
prevent from dehydration and excessive hot temperature.
- Always prevent from getting any infection, i.e. viral, bacterial
or parasitic infection including malaria.
- Prophylactic antibiotics, immunization and anti-malarial drugs
are useful in crises.
- Care and caution should be taken to avoid those drugs causing
hemolytic anemia for G6PD deficient
cases.
- Vascular stasis should be avoided in routine activities.
- For normal life, prevention of infarcts and formation of
clotting or thrombi in circulatory
system is necessary.
- Administration of
magnesium sulphate or simple saline during crisis prevents from critical
condition. They prevent clotting process and delay thrombi formation
and act as vasodialatory
agents in dislodging nests of sickled cell in small vanules.
- To avoid intra-vascular sickling, the pH of the body should be kept alkaline with oral administration
of sodium bicarbonate (2-3 gms per day) in divided doses as a precaution to
prevent crisis especially during infections. It should be ensured that
the intake of sodium bicarbonate should be such that the urine reaction with
litmus paper remains
alkaline. Consumption of adequate quantity of local made squash (sharbat) from bill
fruit will prevent sickling and enhance soothing effect.
- Folic acid supplements without iron are useful. Iron supplements
should follow the serum iron estimation to avoid iron overload.
- Hemoglobin level should be maintained between 6-9gm/dl. This
degree of anemia with low oxygen affinity helps in efficient release
of oxygen to the tissues and sufficient to maintain active life.
- Blood transfusion is required only if the hemoglobin level falls
below 5 gm/dl.
- At the time of delivery
protracted labour or cesarean operation should be avoided.
- Ulceration especially of
leg ulceration, in some cases, may be resistant to treatment.
In cold weather, warm stockings should be worn. Circulation should be
improved by elastic bandages or stockings and advising the patients to put up
their legs raised for some time at night. Poor vascularisation
facilitates infection.
- Regular check up and follow up of these cases is highly
essential for monitoring the progress.
Nutritional Status
Nutrition is
prime concern of all living organisms. The quality and quantity of food
available play an important role in determining the health and well being of
individuals and the populations in general. Its applications involve social,
physical, biological and medical sciences.(25) These encompass from food
production, procurement and consumption, socio-economic institutions, cultural
practices and beliefs associated with food to biological needs of food,
nutritional deficiencies affecting growth and development, fertility, mortality,
morbidity, health and disease, nutritional variations as a mean as well as
consequences of adaptation, natural selection and, in short, the whole process
of biological evolution.(26) One of the major areas of nutrition is intimately
connected with health and well being of the people. It is said that healthy
people are a nation’s most valuable asset on whom rests the nation’s future.
Children of today are the builders of tomorrow who will man different walks of
the national life. The caliber of each of them will depend on their state of
mental and physical growth. It is well established that the course, both body
and mind takes to grow, is determined by heredity but to a large extent
influenced by environmental (epigenetic) factors particularly the nutrition.
Individuals
differ in their morphology because of their differences in genetic make up and,
therefore, carry various metabolic activities at different rates. Similarly,
some individuals may need more nutrition while the others need less to achieve a
similar morphology. The nutritional needs for energy expenditure vary with age,
sex, weight, body proportions, hormonal and physical activity of an individual.
Understanding
of the nutritional needs of adult humans is important not only because the
healthy people are more efficient and more productive in all spheres of life but
also in the national economic growth as well. Healthy people are also capable of
producing healthy progeny too who, in turn, will grow up to become future
healthy adults. The nutritional status of adults is an index of nutritional
status of a community and by comparison with normal or standards can bring out
nutritional deficiencies in population due to either inadequate or inappropriate
diet or due to ecological, ideological, socio-economical or epidemiological
factors.(27)
The clinical
assessment of tribal communities shows one or more signs or symptoms
of common deficiencies as listed in the Table-3. Numbness and tingling
of hands and feet due to vitamin B1 deficiency is very common. High
incidence of nutritional deficiency in some cases especially among vulnerable
segments like infants, children, pregnant women, and nursing mothers
is a matter of concern among the tribals of Chhattisgarh. These signs
and symptoms are largely non-specific and clinical examination alone
is not sufficient to establish a clear and definite diagnosis of nutritional
diseases and deficiencies, but dietary surveys and biochemical data
incorporated with clinical assessment may confirm the findings of inadequate
nutritional standard.(26) Future studies will throw more light on the
health problems of tribals of Chhattisgarh.
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Table 3: Clinical signs and
their interpretation among the tribals of Chhattisgarh |
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Body part
examined |
Clinical signs |
Interpretation |
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Hair |
Thin, dry with change of colour
to brown, red or even white |
Protein energy malnutrition |
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Neck |
Enlargement in front of neck
(thyroid) |
Endemic goiter |
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Eyes |
Whitish triangular patch on
the conjuctiva lateral to the cornea (Bitot’s spot: dry cornea) |
Xeropthalmia |
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Lips |
Ulceration at the angle of
the mouth (Angular stomatitis and chelosis) |
Riboflavin deficiency |
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Tongue |
Enlargement of the papillae,
pal colour with fissures, pale like blotting paper |
Riboflavin deficiency and
nutritional anemia |
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Gums |
Swollen, spongy, bleeding
on pressure, petechiae |
Ascorbic acid (vitamin C)
deficiency |
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Skin |
Reddish or brownish pigmentation
patches with peeling of skin |
Protein energy malnutrition |
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Nailbed |
Pale or white in colour (Koilonchia) |
Nutritional anemia |
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Chest |
Narrow, protruded forward
or bead like swelling on ribs. Octomalacia in adults with local skeletal
deformities, pot belly |
Rickets (vitamin D deficiency)
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Limbs |
Muscle and fat wasted; loss
of ankle jerks, calf muscle tenderness |
Marasmus (Protein energy malnutrition);
Thiamin (vitamin B deficiency) |
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Ankles and
Feet |
Swollen and pitting on pressure |
Kwashiorkor (Protein energy
malnutrition) |
The four tribes,
namely, Bhatra, Gond, Kondh, and Paraja in the present study manifested variable
nutritional status with regard to levels of hemoglobin and different grades of
anemia among both boys and girls separately as well as in combination (Table 4).
Maternal malnutrition is common among the tribal women.
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Table 4. Different grades
of anemia among four tribal populations of Orissa adjoining Chhattisgarh
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Grades
of anemia |
Name of Tribe |
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Bhatra (%) (N=166) |
Gond
(%) (N=219) |
Kondh (%) (N=254) |
Paraja (%) (N=176) |
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Boys: |
|
Severe |
5.5 |
2.6 |
2.4 |
2.5 |
|
Moderate |
23.6 |
31.4 |
26.5 |
10.0 |
|
Mild |
41.7 |
54.9 |
41.0 |
49.2 |
|
Normal |
29.2 |
11.1 |
30.1 |
38.3 |
|
Girls: |
|
Severe |
0.0 |
0.0 |
0.0 |
3.7 |
|
Moderate |
12.6 |
30.0 |
11.8 |
5.6 |
|
Mild |
46.3 |
57.1 |
35.3 |
51.8 |
|
Normal |
41.1 |
12.8 |
52.9 |
38.9 |
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Boys
and Girls Combined: |
|
Severe |
2.4 |
1.8 |
1.7 |
2.9 |
|
Moderate |
17.4 |
30.9 |
22.2 |
8.6 |
|
Mild |
44.3 |
55.6 |
39.3 |
50.0 |
|
Normal |
35.9 |
11.6 |
36.8 |
38.5 |
|
Severe= Hb <7.0 g/dl; Moderate
= Hb 7.1-10.0
g/dl; Mild= Hb 10.1-12.0 g/dl; Normal= Hb>12.1 g/dl
|
Tribes in Chhattisgarh
cultivate land; grow cereals and millets such as ragi. The staple food
among the tribals is rice, maize, millet, wild fruits, etc. though they
are fond of ragi gruel. They prepare a concocted material which is known
as “Madia Paje”. It is made from grounded rice and millets that
is kept overnight for fermentation after boiling.(17) Vegetables, cereals
(dal), fish, etc. are added to develop taste. Liquor (Mahua) forms one
of the most important constituent of their daily diet which is taken
by women as well as children. They are addicted to mohua and salap liquor.
Consumption of such alcoholic drinks aggravates liver diseases prevalent
amongst them due to endemicity of malaria. This causes hepato-splenomegaly
(enlargement of liver and spleen). Cirrhosis of liver has been found
to be common among the tribals of Chhattisgarh.
The non-vegetarian
foods such as pigs, mutton, chickens, fish, crabs, field rats are taken
as and when available. They take buffalo, goat and pork meat, though
irregularly. These animals are not slaughtered in hygienic or healthy
conditions. In their daily diet, fats and proteins are inadequate; this
leads to various types of deficiencies. Inferior diet, semi-starvation
and unhygienic living conditions give rise to several diseases. Their
farm produce suffices for hardly 5-6 months requirements; for remaining
6-7 months every year, they have to depend upon wild roots, fruits,
flowers and leaves of wild plants. Fruits such as mango and jack provide
food to tribals for about 1-2 months. Food values, and harmful effects, if any,
of these wild items of forests are unknown; they may cause several types of
allergies and physiological impairment.(27,28)
Tribals have
their dwelling on the hill-top, sub-mountainous region or barren land which is
deprived of iodine, resulting in iodine deficiency. This leads to various iodine
deficiency disorders. The oil of wild seeds “Tora” is used for cooking and other
purposes including applying on injuries.
Slash and burn
type of shifting cultivation resulted in considerable degradation and shrinking
of forests. The disappearance of wild life in turn has deprived them of their
traditional sources of proteins. Such deficiencies, both qualitative and
quantitative, have resulted in under – and malnutrition.
Communicable Diseases
Tribes in general
do not maintain good health and sanitation. Some of the preventable
diseases such as tuberculosis, malaria, gastroenteritis, filariasis,
measles, tetanus, whooping cough, skin diseases like yaws, scabies,
etc., are also high among the tribals.(28,29) Most of the diseases
are due to insanitary conditions, lack of personal hygiene and ignorance.
Consciousness regarding bodily cleanliness is lacking, particularly
among the women and children. They do no even brush their teeth.
Lack of personal hygiene causes skin and infectious diseases. Scabies
and yaws top the list among all skin diseases.(29) Leprosy is rampant.
Patients are not segregated from their society and the disease spreads
because of close contact with infected patients. The incidence of some
viral diseases is quite high, particularly of the upper respiratory
tract with symptoms of rhinitis (running nose), pharyngitis, bronchitis, cold,
cough and fever. The incidence of tuberculosis is also high, the most common
type being pulmonary tuberculosis.(2,28) Poor ventilation and close contact with
infected members, because of the single room accommodation, are largely
responsible for the wide spread contagion.
The hill streams,
ponds or ditches serve many purposes. They provide water for drinking,
cooking food, cleaning utensils. These are places where people take
bath, wash their body after defecation, and clean cattle. The hill streams,
ponds or ditches which are highly polluted, are the only source of drinking
water, and are potent source of water borne diseases. The incidence
of diarrohea and dysentery (amoebic and bacillary), typhoid and other
gastric diseases is very high.(27) Occurrence of helminthic (worm)
infections, viz. Tenia solium, T. bovis, Ascaris lumbricoides (tape
worm and round worm), etc., is high due to their food habits. They consume
domesticated piggery. Dental diseases are also very common among the tribals of Chhattisgarh.
The areas where
the tribals reside are hyper-endemic for malaria, particularly of the
Plasmodium falciparum, P. vivax, P. ovale types.(27) The slide positivity
rate is as high as 15.6% for P.falciparum. Mostly the children suffer
from typical signs and symptoms of high fever of intermittent type with
shivers and profuse sweating. Adults generally manifest asymptomatic
malaria. Mortality rate from malaria is not high among the tribes of
Chhattisgarh.
Non-communicable Diseases
High fertility
is related to high infant mortality among the tribes of Chhattisgarh.
Infant mortality rate has been found to be very high among many tribal
groups (22) such as among Bhatras (148), Murias (123), Kutia Kondh (175
per 1000 livebirths). Bearing more children is a pride as they will
add to their income in future. The practice of consanguinity has an
impact on their fertility, mortality and morbidity profile.(16,30)
Among the tribes of Chhattisgarh, a higher incidence of reproductive wastage,
i.e. abortions and stillbirths has been recorded with neonatal deaths occurring
more frequently.
In some places
especially near the mining areas, the water of hill streams and ponds is not
only polluted, but also contains graphite, causing irritation in the
gastro-intestinal tract, resulting in gastric discomforts, abdominal pains,
hyper-acidity and constipation. The water contents have not yet been analyzed
and the effect of graphite on the human body needs thorough investigations.
Night blindness,
sexually transmitted diseases, etc. are also well known public health
problems of the tribals. Venereal diseases (syphilis and gonorrhoea),
cardiovascular (heart) diseases, diabetes mellitus, and renal (kidney)
diseases are not common among the tribals of rural areas except the
urbanite tribals. Similarly, high blood pressure is a rare but low blood
pressure is common among the tribals of Chhattisgarh.
Biomedical Anthropology,
Tribal Health and Development
Health is a
universally cherished goal. Health cannot be forced upon the people. It is
a positive attribute of life and the organization of health services to all
people is considered to be the key step towards development.(31) The study of
health culture of tribal communities belonging to the poorest strata of society
is highly desirable and essential to determine their access to different health
services available in a social set up. It is an important input for the
development of man and, thereby, to social and economic development of the
country. Health is widely linked with development. A rapid and equitable
economic development is a good health input and an adequate and equitable health
care system stimulates development with improving human productivity. That is
the reason; the investment in health is, sometimes, called an investment in
human capital.
Health care
is one of the most important of all human endeavours to improve the
quality of life especially of the tribal people.(1,2,9,20) It implies
the provision of conditions for normal, physical and mental development
and functioning of human being individually as well as in a group. A
great realization has come from the medical scientists that human being
can no longer be treated as an anatomical and physiological entity,
and that man’s individuality should be understood in terms of perceptions,
culture and belief system. Tribal health system and medical knowledge
over the ages, which is known as traditional health care system, depend
both on the herbal and psycho-somatic lines of treatment. While flowers,
plants, seeds, animals and other naturally available substances formed
the major basis of treatment, this practice always had a touch of mysticism,
supernatural and magic, often resulting in specific magico-religious
rites. Faith healing has always been a part of the traditional treatment
in the tribal health care system. Studies by anthropologists indicate
that traditional medicines do exist and persist even though the health
consumer has now access to western medicine. There is a need to scientifically
study the traditional tribal medicine and healing systems and combine
them with modern allopathy system so as to make it available and affordable for
the poor tribal population.
Health problems
and health practices of tribal communities have been profoundly influenced
by the inter-play of complex social, cultural, educational, economic
and political practices.(9) The common beliefs, customs, traditions,
values and practices connected with health and disease have been closely
associated with the treatment of diseases. In most tribal communities,
there is a wealth of folklore associated with health belief. Knowledge
of folklore of different socio-cultural systems of tribals may have positive
impact which could provide the model for appropriate health and health and
sanitary practices in a given eco-system. The health culture of the community
does not change so easily with the changes in the access to various health
services. Hence, it is required to change the health services to conform to
health culture of tribal communities for optimal utilization of health services.
As we know that
the health comes by evolution, not by revolution. Health must meet the people’s
needs as they perceive them. Health cannot be imposed from outside against
people’s will. It cannot be dispensed to the tribal people. They must want and
be prepared to do their share and to cooperate fully in whatever a community
develops the health program. It is rightly stated that
Go to the people
Live among the people
Learn from the people
Plan with the people
Work with the people
Start with what the people know
Build on what the people have
Teach by showing; learn by doing
Not a showcase but a pattern
Not odds and ends but a system
Not piecemeal but integrated approach
Not to conform but to transform
Not relief but to release
From the scourges of life! (1)
The tribes
of Chhattisgarh generally believe in benevolent and malevolent spirits
which affect and control their daily activities of life. These beliefs
pervade not merely their health practices but also their whole lives.
They have faith in their taboos, totems and beliefs, which shape their
thoughts, ideas and practices.(1,28) They call on their village priests
or religio-magical practitioners. These wisemen diagnose the disease
as due to the anger of a deity or evil spirits. In their belief system,
the etiology and pathogenesis of all diseases is nothing more than the
anger of evil spirits. Hence, the priest performs rituals, with animal
sacrifice to please them. It starts with small animals, hens, pigeons,
etc. and ends with bigger animals. Buffalo sacrifice is very common
in some tribals. They depend upon the priests and witchcraft doctors rather on
modern medicines.
Moreover, to
go to a medical doctor or hospital means to cover a long distance on
foot through dense forests and hills. There are no pucca (metalled)
roads or modern communication or transport facilities. Thus, the natural
geographical barriers prevent them from utilizing the meager available
medical services. Then it all depends upon the availability of the doctor
who exploits them by charging exorbitant fee and providing inadequate
medicines. Most of the times, the tribals remain unattended to by the
doctor for hours together and kept waiting isolated because of stinking
smell coming out of their unhygienic bodies and clothes, if they arrive
at the hospital at all. However, the attitude has now been gradually
changing among the tribals during the last few years due to the efforts of some
devoted social workers of non-governmental organizations (NGOs) who live with
them.
The biomedical
anthropological approach is a new dimension, arising out of the tradition
of holism in anthropology. It implies sufficient knowledge about the
culture, environment, natural and human resources, skill endowments
and the belief systems of a set of people.(9,25) This approach
is best suited to study the behavior of the people in health and disease,
encompassing the biological, biocultural and eco-environmental aspects of the
tribal population concerned.
The Government
of Chhattisgarh state is providing health care services to tribal people
through a three tier rural health infrastructure comprising sub-centres,
Primary Health Centres, Upgraded Primary Health Centres, and Community
Health Centres, etc., under the Minimum Need Program. Besides these,
the Ayurvedic and Homoepathic systems are also well accepted by the rural and
tribal folks, mainly because of cheapness, eco-friendly and familiar to their
indigenous way of treatment. The emphasis is being given by the state government
for wider application of the Indian systems of medicine and treatment rather
than the western allopathic medicine.
The preamble of
the Charter of the World Health Organization defines Health as “a state of
complete physical, mental and social well being, and not merely the absence of a
disease or infirmity”.
Therefore,
the health of the tribals cannot be viewed in isolation from the over
all goals and the health policies of the state. The tribes of Chhattisgarh
are not one uniform and compact mass, but present a wide linguistic,
ethnic and cultural variety. Any formula approach for health care among
the tribals is not only unsuitable but unrealistic also. Each tribe has its own
distinct concept, ideas, religions, dialects, superstitions, beliefs, values and
practices which govern their daily lives.
It is now increasingly
realized that the development process must be initiated from below,
and that the people must identify their own felt needs, that they must
have a role in executing the schemes meant for their development and
benefit and in fashioning their life in the way they like it. There
is a great deal in the people’s own traditions, their indigenous ways
that can be harnessed to ensure prosperity and happiness for a local
tribe. Any tribe must be encouraged to organize itself in order to take
advantage of the program designed for its development and health in
the light of human genetics, socio-cultural traditions and eco-friendly
environment. Unless locality specific, tribe specific and need-based
health care delivery system is evolved which is appropriate, acceptable,
accessible, and affordable, the goal of health for all would remain
a Utopian dream!
Author is grateful
to Dr. V.M. Katoch, Secretary, Department of Health Research, Government
of India and Director General, Indian Council of Medical Research, New
Delhi for providing the necessary facilities and to Headmasters and
Teachers of Ashram Schools, and students of Orissa for their cooperation
during the study. Thanks are also due to Mr. R.K. Mishra, Laboratory
Technician for laboratory work.
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