There is no road to Bargur. To get to the village, in the Kotagiri taluk of Tamil Nadu’s Nilgiris district, you have to step down from a tar road onto a mud path that leads to a stream below. Then, you cross the stream and follow the path up to the village.
When I visited the village in early October, Mari Manday was still grappling with a tragedy. Manday, who said he was between the ages of 50 and 55, is a member of the Irula community, a Scheduled Tribe in the Nilgiris. The previous week, Manday’s eight-year-old granddaughter had died.
Manday is not sure what had caused his granddaughter’s death. “The first day she had fever, vomiting and diarrhea, and the second day it continued,” Manday said. “The third day, we took her to the hospital. But she died almost immediately after she reached the hospital.”
The child’s parents had also fallen ill and were admitted to the hospital along with her – their condition had improved and they were out of danger.
Manday was distraught that they could not save the child, particularly because they could not afford to take her to the hospital in time. If they had, he said, “Maybe she would have survived.”
Conversations with others who live in the area revealed that such struggles to access healthcare were commonplace.
The cost of an auto, jeep or car to the nearest hospital in Kothagiri, about 20 km away, is at least Rs 700. This cost is prohibitive to residents, many of whom are daily wagers and earn between Rs 200 and Rs 300 per day. Locals explained that in some emergency cases, hospitals send ambulances free of cost, but that in other instances, they have to pay.
Public transport in the area is unreliable. Jyothi N, a resident from a hamlet near Manday’s settlement said that a bus that usually passed through the area had not arrived for the last few weeks because the roads were in a poor condition. “We have to fully rely on private vehicles to go to the doctor now,” Jyothi said.
Jyothi herself was struggling with this problem when I met her. “My daughter, like so many others here, has also been ill,” she said. “I should take her to the doctor soon.”
Because travel is unaffordable, many in the area undertake arduous walks across the terrain, particularly challenging when they are ailing.
Dr Ajith JS, a community health specialist who works in the Gudalur Adivasi Hospital, explained that the risks of such journeys are far greater than they may seem. “In a two-dimensional view, it may seem like the distance to a primary health centre or a government hospital is only 4-5 km but if you look at it three-dimensionally, there could be a hill or a forest patch or a private estate in between the nearest primary health facility and the residence of the patient,” said Ajith.
He added, “It is either uphill or a dangerous slope. The roads are made of concrete and cement, which is often slippery, especially during rains. And so by the time they get to a road where they can access public transport, they are completely enervated.”
Doctors, too, cannot easily access some of these villages. “There are some areas which we can visit only two or three times a year,” Ajith said.
Manday recounted that one of his daughters experienced the immense risks of these journeys a few years ago. “We were carrying her in a makeshift stretcher and could not make it to the road on time and right when we were crossing the stream, she gave birth,” he said.
Efforts to bring better healthcare to locals are few and unreliable. In a neighbouring hamlet, a nurse visits once a week but since she does not have any fixed timings, Manday and his neighbours often miss her. Sometimes, a van operated by a local NGO makes rounds in the area, but they miss it also because they cannot see the road from their homes. “Unless one of us happens to be on the road, we have no idea that it is close by,” Manday said.
These challenges are particularly striking in light of Tamil Nadu’s overall strong performance in the field of health. The state has switched between the second and third positions over the last few years in NITI Aayog’s Health Index, indicating that it provides affordable healthcare, and also offers a high degree of specialised services. It is well known for drawing patients from other states and even countries to its hospitals.
But in the Nilgiris, the district in the state with the highest density of Adivasi population, a combination of factors has meant residents have little access to even basic health services. These include the villages’ remoteness and discrimination that locals face when they seek out health services. As activists and experts noted, these challenges are further exacerbated by the social and cultural alienation they experience as a result of their displacement from their traditional homes and ways of life.
While many in the region first seek help at hospitals closest to them, typically run by NGOs, since these are usually small, patients are often referred on to government hospitals. Locals said when they visited these, they often felt discouraged by the poor treatment they were met with.
Mallika Suresh, who lives in Sri Madurai panchayat in Gudalur taluk, is the mother of three children. Suresh, who is in her late thirties, and belongs to the Kattunayakan community, recounted that after her third and fourth child died shortly after birth, doctors and nurses at the government hospital in Gudalur had warned her that having another child was not advisable.
After losing two children, Suresh was heartbroken, but she had two sons, and now yearned for a daughter.
When she got pregnant again, for the first four months, Suresh did not visit the hospital, worried that she would be scolded.
But when Suresh’s due date approached, an NGO-run hospital in Gudalur referred her to the government hospital in Udhagamandalam, more popularly known as Ooty, 50 km away.
There, she recounted, she had one of the worst experiences of her life. Suresh, who was carrying her daughter in her arms as she spoke, wiped away tears streaming down her face as she recalled her ordeal. “They spoke to me very rudely, humiliated me for getting pregnant again,” she said. “I could not tolerate the way they were behaving. It left me very distressed.”
She added, “At one point, I felt it would have been better to die than to remain in the hospital. But just for the sake of my child, I held on to whatever little strength I had and stuck on.”
She delivered her daughter at the hospital, but said that she would hesitate to return to it. “We look at doctors like they are gods, but they treat us so badly,” she said.
Kamalachi, a social worker who also belongs to the Kattunayakan community, said that the rights of Adivasi women and men over their own healthcare choices were often violated.
As a particularly egregious example, she noted that Adivasi women are often compelled to get sterilised after the birth of two children. “They somehow make us say yes even if we don’t want to,” she said. She added, “Sometimes they insert Copper-T and don’t tell women about it” – referring to the reversible contraceptive device.
People that Scroll spoke to also said that they were often given medication without being told what diseases they suffered from, and what the medication was meant to treat.
Manday, for instance, recounted that on one visit, he was given pills to take, but could only guess that they were for “BP or sugar”.
Patients are denied clear information even in more serious situations. “Once a neighbour called me and said the doctors had asked her to transfer her son to a hospital in Kozhikode and I was helping coordinate,” Kamalachi said. “The next thing I heard was that he had been brought dead to Kozhikode. We were not given any information of what had happened to him or how he died.”
Even this treatment is an improvement from what was meted out to locals just four or five years ago, Kamalachi explained. Then, she noted, healthcare workers actively segregated Adivasi patients from others.
“They would make Adivasis sit in a separate line and wait for a long time, but we would see that they would allow other people to go in first,” she said. “And when we went in to see the doctor, they would barely touch us and just write a prescription.”
Among the key structural factors that affects the health of Adivasis in the region is malnutrition.
One study, by the Association for Health Welfare in the Nilgiris, which surveyed more than 1,000 children under five years of age in the Gudalur and Pandalur regions, found that almost half were malnourished.
Manday also said that his granddaughter had been malnourished and had frequently fallen sick.
On the day I visited Manday’s house, residents in the neighbouring Adivasi settlements said that almost every house had someone who was running a fever or had a cold. They explained that they had become more susceptible to illnesses in the last few years.
A crucial reason for their low immunity and malnutrition, they argued, was the changes their diets had seen as a result of their displacement from their original settlements.
In 2008, the government, acting on the orders of the Supreme Court, resettled more than 800 families inside the district’s Mudumalai Tiger Reserve outside the forest. Over the years, many Adivasi families have also been forced to move out of forests to make way for expanding tea estates, as well as an increasing number of settler communities in the region.
Even in Suresh’s case, she and her neighbours from the settlement had been displaced from the heart of the Mudumalai Tiger Reserve to different parts of Gudalur. While some were settled in government-constructed houses near existing villages, some were given money to purchase land outside the reserve.
These locations are far away from their traditional hunting and foraging grounds, which also served as cultural centres for their communities.
Every Adivasi person I spoke to said they missed the food that they previously foraged from the forests. This included various kinds of leafy vegetables, native tubers, different types of millets, ragi, honey, pumpkin and mushrooms.
“We would eat so many different kinds of greens and that would keep us very strong,” an elderly woman who was Suresh’s neighbour, and who used to live in the Mudumalai Tiger Reserve, recalled with a smile. “None of that is available to us now.”
In a neighbouring hamlet, Velkan Verai, another elderly man who could not recall his age, and was displaced from his original home, said that when he was younger, he never needed to go far to get food or water.
“We would get fresh water all through the year and we would pluck so many greens, potatoes and vegetables from the forest,” said Verai, who is from the Paniya tribe, which is classified as a Particularly Vulnerable Tribal Group. “And we had enough land to grow anything else that we wanted. There was never a dearth of nutritious food for us.”
“Today, we don’t even have proper water,” added Verai, who, along with a few other Paniya families, lives in a government-constructed house.
Kamalachi said she too felt there was a significant difference in her own body from the time she lived inside the forest to the present, when she lives closer to the town. “Those days we could walk long distances, carrying heavy loads and not feel tired. The previous generation too had more strength and stamina,” she said. “Now we never have any strength to do anything.”
“Look at us now,” she added, showing me her thin arms. “We barely weigh anything.”
Communities’ displacement and their current low incomes particularly affect their intake of protein, a major part of their diet when they lived in forests. “We used to eat all kinds of meat when I was younger,” said an elderly man in Kil Kothagiri, who was herding his cows. “That’s what made us strong. Now we barely eat meat.”
Even those families who live closer to forests cannot easily access produce they once could because their entry into them is restricted.
“The forest department prevents us from going into certain parts,” said Manday, who still lives close to the forest.
Adivasi communities are now solely dependent on the food provided to them by the government – mainly rice, lentils, oil and sugar. Their displacement “has caused Adivasis to become heavily dependent on the public distribution system”, Ajith said.
Rice, which they receive in the greatest quantity, forms the bulk of their diet. Ajith noted that while it satisfied hunger, it did not provide adequate nutrition.
Further, the quantity of rice they are provided is not always sufficient. “We cook only once a day and eat only one meal a day, which is mainly just rice,” Suresh said.
Ajith noted that the government had been making some efforts to remedy the situation. “In the last few years, the Public Distribution System has been providing millets alongside rice, but dietary diversity in most households remains a persistent challenge,” he said.
The Association for Health Welfare in the Nilgiris has also been supporting the government’s work by providing families with nutritional foods such as dates, peanuts, and a millet-based mix. Ajith said that these various efforts have led to a slow and sustained improvement in the levels of malnutrition over the last two years.
But he explained that this was not “a magic bullet solution” since the problem is often “intergenational” – that is, “malnourished mothers carry and give birth to low-birth-weight babies, who grow up to become malnourished children”. Thus, he noted, “We can’t bring them up to normal weight by merely supplementing their diets with high calories, as this might give rise to future metabolic disorders like high blood sugar and blood pressure during adulthood.”
Another pressing problem that the Adivasi communities are facing that is linked to their displacement is alcohol addiction. “Alcohol dependence is a massive issue among Adivasi communities,” social worker K Mahendran said.
In early October, as Mahendran spoke with the residents of a Paniya settlement about some compensation that was due to them as part of their relocation, he advised them not to spend it on drinking.
All the women instantly began to complain to him about how they were tired of putting up with their husbands’ addiction.
“They are not going to listen to us,” one visibly angry woman said.
Kamalachi’s husband died as a result of an alcohol addiction. “When we lived inside the forest, he didn’t have that much access to alcohol,” she said. She recounted that he would typically remain busy with work through the day. “But once we were moved closer to the town, it became easier for him to buy,” she said. “He began drinking all the time and eventually died due to it.”
She added, “Now there is a liquor shop in every nook and corner, and many Adivasi men end up spending most of their money on liquor.”
Ajith, who runs community health initiatives to address malnutrition and mental health in the region, has also found that alcohol dependency is a matter of great concern. “It is safe to assume that in the backdrop of undernutrition in these communities, consumption of alcohol will have much more addictive and toxic effects,” Ajith said.
Mahendren explained that suicides also occur often as a result of addiction. “Sometimes fights break out and we have had cases where often Adivasi individuals impulsively commit suicide,” he said.
In fact, the suicide rates among Adivasis in the Gudalur and Pandalur regions is also significantly higher than the general population, Ajith pointed out. While data from 2022 shows that the national average of suicides in the country is 12 per 100,000 persons, these regions saw 19 suicides among 34,000 persons in 2023-’24.
Ajith explained that in his research on mental health in the region, he had found that another factor behind the high suicide numbers was the inequality that communities had been exposed to in recent years.
“Just across the road from an Adivasi hamlet, they are able to see signs of development and prosperity, and people who are not struggling like them, which leads to a sense of hopelessness,” he said.
In contrast, most resettled Adivasis live in small, cramped houses. In one Paniya settlement close to Gudalur town, families lived in two-room houses around 300 square feet in area. Though they once had access to land to forage in and cook in, they now largely survived by cooking inside their homes, which had resulted in soot settling on the walls, turning them black. Many residents suffer from difficulty in breathing as a result of inhaling smoke indoors.
Displacement has also weakened community bonds. “They have become isolated, and now every individual has to look out for themselves, which is very different from the way community kinship bonds usually operate in Adivasi communities,” Ajith said.
He added, “Land alienation, rapid and unsustainable urbanisation, economic hardship made worse by restricted access to forests, and the flattening of cultural identities, all lead to a sense of alienation, further exacerbating feelings of social isolation.”
Dr Mrudula Rao, the medical superintendent and family physician at the Gudalur Adivasi Hospital, noted that a major obstacle to improving healthcare in the region was the reluctance of communities to seek help when they needed it. “There used to be a lot of fear about what we would do to them,” she said.
She explained that the Gudalur hospital was making an effort to address this problem and had seen improvement. For instance, the administration sought to ensure that Adivasis were consulted and made part of the process of delivering care. “The patients trust us as they see people from their own community and who speak their language treating them,” she said.
But persuading them to follow through on referrals to other, bigger hospitals, remains a challenge.
“In government hospitals, which often have big campuses, it’s easy to get lost if you don’t have help.”
The doctors said it would benefit the Adivasi population if doctors were sensitised to their needs. “Doctors sometimes see hill districts as punishment postings,” said Ajith. “Many doctors who get transferred here are on bonds, so they may not have an understanding of what the needs of the patients are.”
He added, “It’s important to make doctors go through sensitivity training so they treat Adivasi patients with extra care in order to encourage them to seek healthcare.”
Rao said that one way to address this problem would be for the government to sanction more tribal counsellor posts in healthcare centres and hospitals. As the website of the National Health Mission Tamil Nadu states, these counsellors help communities overcome “cultural shyness, lack of education/awareness, poverty, illiteracy, ignorance of cause of diseases, hostile environment”. In effect, they act as a link between health systems and tribal communities.
“It would be beneficial if there are tribal counsellors in every healthcare centre,” Rao said. “It would help patients get the care they deserve.”
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