The poor health infrastructure in India’s scheduled areas failed its Adivasis during the pandemic

As the Covid-19 pandemic ravaged the world and employment opportunities dried up, in many countries including India, Adivasis returned to their intergenerational, ancestral homes, often situated near forests.

In the course of the reporting of this story, many of the Adivasi community workers from Jharkhand echoed one sentiment: “If at all we have to die, it is better to die among our loved ones.”

India announced a nationwide lockdown on March 24. Within a few days of the announcement, the distress among the communities on the margins of society was palpable. Even as Adivasis made long journeys home, some were beaten to death simply for attempting such arduous travel, while others could not finish the trip at all. In one of the most chilling incidents, a 12-year-old girl Jamalo Madkam from Chhattisgarh fell dead from exhaustion just 11-km short of her Bijapur home after having walked 100 kilometres.

Despite the immense hardships that Adivasi communities faced as a result of the stringent lockdown, the first response to their distress did not come from the Ministry of Tribal Affairs or the Ministry of Health. Instead, it came from the Ministry of Environment, Forests, and Climate Change which, on April 6, restricted people from entering protected forests on the grounds of human to animal transmission, despite there being little scientific evidence of any such transmission possible.

In fact, highlighting a major blunder which hurt Adivasis and forest communities, reports suggested that tribal affairs minister Renuka Singh may have quoted from a non-existent study. The ministry had earlier said that less than 3% of the Adivasi population was impacted by the Covid-19 pandemic.

Limited access to healthcare

Adivasi communities who are already victims of neglect when it comes to rights, recognition and state support suffered even more during the pandemic.

The National Family Health Survey 2015-’16 points to some grim statistics for the health of Adivasi communities in India.

According to the National Family Health Survey report:

• The under-five mortality rate among Adivasis (57 deaths per 1,000 live births) is considerably higher than other backward classes (39 deaths per 1,000 live births)
• Adivasi women are less likely to receive antenatal care from a skilled provider (73% as compared to 86% from upper castes)
• Adivasi women are less likely to deliver in a health facility (68% as compared to 83% from upper castes) and are less likely to receive a postnatal check within two days than women from any other caste/tribe group (64%-69%)

Some of the biggest problems that Adivasis faced in accessing healthcare were concerns related to unavailability of drugs and providers (56.5% and 54.9% respectively) followed by concerns of an absence of a female provider (45%). This was closely followed by issues of distance to health facilities (42%) and lack of transport (40.9%).

Overall, as many as 76.7% Adivasis faced at least one big problem in accessing health care facilities.

Despite policymakers agreeing that there is no comprehensive policy for Adivasi healthcare, a solution based on reliable data is still absent.

Poor data, grim prospects

An expert committee set up by the two ministries responsible for health and family welfare of tribal rights, in 2013 had studied the health issues, culture, and the extant healthcare infrastructure in scheduled areas and sought a way forward through consultation.

They published their findings in 2018, after four years of research. Though the report titled Tribal Healthcare in India: Bridging the Gap and a Roadmap for the future noted that “tribal people face the triple burden of diseases”, it also noted that there is no single source of data available about Adivasi populations to create a countrywide disease burden profile.

They did, however, find that Adivasi people bear a “disproportionate burden” of communicable diseases, including diseases like tuberculosis and malaria.

As many as 30% of all malaria cases are reported among Adivasis, who also account for 50% of the mortality associated with malaria even though they account for only 8% of the population.

An Indian Journal of Medical Research paper traces the reasons for this, saying: “The presence of various malaria parasites and vector species, climatic diversity favouring growth and proliferation of the parasite and vector as well as a highly susceptible human population have resulted in high malaria transmission in tribal areas”.

Alarmingly, the death rate among Adivasi communities is 703 per population of 100,000 against a national average of 256. Only 11% of these cases are treated.

Given the severe shortage of healthcare professionals in Adivasi-dominated areas, the report suggested the need to motivate and train local people, especially Adivasi youth, to join the healthcare workforce.

About the presence of frontline workers like the Accredited Social Health Activists, the report had noted that “no numbers are available as to the density of ASHA workers in tribal areas or the average number of people covered by them”. It added that, in these areas where there is little trust in the health systems, they could play a crucial role.

Deplorable quarantine quarters

As migrant workers returned to their home states, Covid-19 cases spiked, especially in Adivasi-dominated areas. This trend also coincided with the relaxation of the lockdown in various states.

Rajim Kewas, a resident of the Khair Khuta village in the Mahasamund district, Chhattisgarh, described the conditions at the centres where the returning workers were being quarantined.

“The quarantine centres are in deplorable condition,” Kewas said. “There is no arrangement for water, nor are there toilets or food. As a result, their family members had to supply food from their homes in a clandestine manner.”

Kewas said this led to people falling sick due to a lack of care and nourishment.

She painted a grim picture based on her visit to the Khair Khuta quarantine centre. “We could see that there were snakes and lizards,” she said. “The khapra [roof] was broken and water was dripping. They were not getting food nor sleep. Those in quarantine centres were kept like prisoners.”

Kewas added that “no one was checking on the pregnant women and children suffering from malnutrition” so “[they] suffered even more”.

“Because of fear, people didn’t want to go to the mitanis [a term used in Chhattisgarh for ASHAs],” she added.

The community fends for itself

Given the lack of an existing, robust health network and the absence of governmental support, many Adivasi communities over the years have resorted to various coping mechanisms.

One example is that of the Bhot community in the Spiti Valley town of Kaza, in northeast Himachal Pradesh.

The region experiences harsh winters with night temperatures dropping to 25 degrees Celsius below zero. Because of its remote location, access to healthcare is a major issue here. Close to 10% of the total Adivasi population of Himachal Pradesh stays in the Lahaul and Spiti district, including other communities like Lahaulas, the Lambas, the Swanglas and the Khampas.

These communities, the Bhots in particular, were successful in keeping Covid-19 at bay for long by practicing rigorous self-isolation. Only recently have some Covid-19 cases been detected.

As Takpa Tenzin, a 37-year-old social activist and president of the Spiti Civil Society, put it “There is a health clinic in Kaza and there are primary healthcare centers at the village level.”

“But we do not have any specialists or surgeons,” Tenzin said. “Even to get an ultrasound, we have to either go to Shimla or Rampur, both at a distance of more than 450-km.”

“The problem is that even if we get a doctor appointed by political pressure, the doctors also do not want to come to these areas,” Tenzin said. “They resign and join a private facility or apply political pressure to go somewhere else.”

Postings in Adivasi majority areas are seen as “punishment” postings. Tenzin laments that while the government says that it will provide helicopter services, even basic services are not available.

The residents of Kaza were extremely worried as they had heard about the spread of the disease. They feared that, if Covid-19 infections spread in the community, there would be “great trouble as health services are not at all up to the mark”, said Tenzin.

People migrate to warmer areas like Dharamsala, Dehradun, etc. in the winter as the extreme weather conditions are difficult for the elderly and the children to endure.

The period of lockdown in March coincided with their return. Strict quarantining measures were adopted by the community to protect themselves.

“It was only after some weeks passed that the administration hired a vehicle and started taking people to Simla for testing,” Tenzin said. “We did not have ventilators and it was only provided after pressure from the local community here.”

The population of Lahaul and Spiti districts is around 31,000. In the scenario of a community spread one ventilator would not suffice at all.

“Even the government seems confused – sometimes they enforce the lockdown, sometimes they lift it. Sometimes they ask us to use N95 masks, sometimes they say that the masks are not effective,” Tenzin said.

Tenzin thinks that such mixed messaging is not helpful for remote communities as the flow of information is already restricted and difficult.

“Pregnant women have to leave for Simla two to three months before their due date,” he added. “So how would we have travelled during Covid-19? We are aware of the situation of health facilities in the rest of the country, compared to which the situation in areas where Adivasi people live is worse.”

Victims of bias

Mohammad Safi, a resident of the Tumriya Khatta village located in Uttarakhand’s Rajaji National Park said his daughter fell sick at the start of April with a fever.

“But we could not visit the hospital out of fear as there were rumours that we had also attended the Tablighi Jamaat,” he said. “How this rumour was spread is beyond my understanding.”

The Muslim missionary group was blamed in India after an event it held in Delhi spawned Covid-19 clusters across the country.

Safi is one of the Van Gujjars, a community of nomadic pastoralists who have lived and moved around the Himalayan region for thousands of years.

The Van Gujjars have often been in the crosshairs of forest department officials, who have tried to evict the community on a number of occasions.

Safi finally got his 14-year-old daughter tested in July, almost four months after she first got the fever.

There are often issues with government authorities trying to forcibly evict such communities from areas they have inhabited for generations.

On June 16, forest officials allegedly beat Van Gujjar women with sticks, tore their clothes and assaulted them in order to evict them despite a stay on any such eviction by both the Nainital High Court of Uttarakhand and the Supreme Court of India. This situation was repeated in September, this time in another village, Kalega.

Covid-19 ignorance

There are major issues relating to a lack of information among Adivasi communities and forest dwellers about the protective measures that should be taken during the Covid-19 pandemic.

Sister Divya Maria, a nurse at the Caramel Hospital situated in Mahuadanr in Jharkhand’s Latehar district with a majority Adivasi population, said that it is only by “a sheer stroke of luck” that the areas in which she goes for relief and aid work have not seen a mass Covid-19 outbreak as yet.

“Once it reaches there it will be like wildfire,” Maria said. “Precautionary measures are not being taken. Lockdown was followed out of fear, not because people were made aware of the necessity for isolation. Moreover, many impoverished families are not in a state to self-isolate.”

Activists and researchers put together recommendations and submitted a report to tribal affairs ministry early May, saying, “It is important to prepare information materials in…local Adivasi languages that clearly explain the nature of the disease, quarantine and containment measures, testing, myths etc, emphasising on the coordination between health department workers (ASHA, ANM and others) and traditional healers so that… traditional knowledge systems are part of these response mechanisms.”

Still, the response of the government has been either to dismiss the impact or trivialise it by saying that there has been no major outbreak.

A dark winter

As the winter approaches, many communities which are reliant on their harvest collections and other preparations that they make during summer seasons, find themselves at a loss.

Sonam Dolma, president of the Mahila Mandal in Spiti is anxious about the winter, which brings with itself the regular cough and cold.

“We are very worried about the winters,” Dolma said. “Anyone with a little cough and cold is testing positive for Covid-19 and we have to make special arrangements for isolation as one needs to keep places warm.”

“We are not able to use the rest houses to isolate people,” Dolma said. “Largely, we are relying on local medicines for the treatment of fever, cough, cold etc.”

Dolma added that women face more issues since they can not separate their children from themselves – especially newborns – leading to a situation where children are exposed to the disease.

Many others say that they either could not finish the repair work for their shelters or could not arrange warm clothes due to shortage and disruption in livelihood opportunities.

The threat posed by Covid-19 to these communities is far from over.

“The herbs and medicines we consume being closer to forests are helping us face the pandemic,” Sokalo Gond, a Gond Adivasi from Sonbhadra district in Uttar Pradesh wondered aloud whether governments, both at the Center and states, will start looking into this urgent need to connect public healthcare systems with those of the community and traditional ones.

This article is the second in a three-part series on India’s Adivasi community.

This article first appeared on The Third Pole.