By Glenn C. Kharkongor
They cannot represent themselves, they must be represented.
This quotation, from Karl Marx, referred to peasant consciousness in France during the mid-19th century. Quite far removed from its original context, the quotation has become an exemplar of many causes. The most notable uses have been by Edward Said in his seminal book “Orientalism” and in Gayatri Spivak’s essay “Can the Subaltern Speak?” The former uses the quotation to characterize the mis-depiction of Eastern peoples by Western scholars, while the latter uses the same quotation to find resonance in subaltern movements, including feminism. Both these works allude to the influence of colonialism, so pervasive even today. In the current era, however, the purveyors of colonialism are mostly native.
Tribal health in India was the theme of a recent webinar, one of a series conducted by the South Asia Institute of Harvard University and the Lancet Citizens’ Commission on Reimagining India’s Health System. Lancet is a leading medical journal with an international outlook. The Commission, composed of medical academicians, corporate figures and health activists, plans to release a report by August 15, 2022, with a view to providing a boost to India’s goal of Universal Health Coverage by 2030.
The panelists at the webinar included two tribal representatives, who presented their data, experiences and perspectives on tribal health. The commendable initiative to include tribal speakers was taken by Dr Thelma Narayan of Sochara, a prominent public health training and activist organization based in Bangalore. Such invitations are a rarity. Tribals are hardly ever called upon to speak at public fora or in expert committees that deliberate on tribal matters. In fact, they are often brought in only as adornments to decorate such events, to beat a drum or sing in their colourful costumes. “The Adivasi Will Not Dance”, a popular book published in 2016, is a satirical riposte to the assigned place of tribals in Indian society. The book, nominated for The Hindu Literary Prize in 2016, has been translated into many Indian and European languages.
Tribals are not a pocket community
There are 105 million tribals in India, about 8.5% of the population. If it was a country, it would be the 14th largest country in the world, about the size of the Philippines or Egypt, larger than any country in Europe, apart from Russia. Indeed, if you put together the 350 million indigenous peoples of the world, with whom we share many health and other social characteristics, it would be the third largest country after China and India.
Even seventy-five years after Independence, this large segment of the population continues to suffer from dismal health indices. While improvements may be cited, the gap between tribal and non-tribal populations has widened. Tribal infant mortality has halved over the last 25 years, but the gap with other social groups has increased. Malnutrition during pregnancy and childhood remain very high, along with high prevalence of communicable diseases like malaria and TB, and non-communicable diseases such as cancer, mental illness and substance abuse. A major problem is teenage pregnancy and high fertility rate, yet sexual health and sex education are hardly mentioned.
The expert committee report on Tribal Health in India, published in 2018, has many insightful observations. The report asks what it calls a glaring question: “Nearly seven decades after Independence, why do the tribal people still suffer from inequity in health and health care compared to others?” The report makes three admissions: Tribal health is abysmally poor, separate data sets are not collected, and tribal culture is not on the health radar.
Data and aggregated data
That the lack of sufficient data on indigenous health has been a limitation to developing appropriate strategies and programs has been noted by Lancet in 2009. Other researchers have pointed out that national or state-wise data are not generally disaggregated for tribal populations and data from tribal majority states include non-tribals.
Generally any discussion on health begins with looking at data. If one is considering tribal or indigenous health, there is compiled data on the WHO website, or in special issues such as what Lancet brought out in 2009 and 2016. Then there is national data in the National Family Health Surveys and the National Sample Surveys.
Aggregated data of course serves its own function of informing national policy ,special health schemes and budgetary allocations. This is where the usefulness generally ends. Aggregated data is a big homogenizer. The more than hundred million tribals in India are very different in culture, social structure, and economic capacity. While it is sometimes considered that all tribals suffer from low health indices, this is not always true. For example, among the hill tribes of Northeast India, the Mizo tribe ranks near the top of the country, but our state languishes at the bottom. If we attempt to take aggregated data and apply it to a village, there may be a misfit.
Cultural unfamiliarity
The Tribal Health Report says “A lack of understanding of tribal culture and an imposition of schemes and mechanisms that are culturally alien to the tribal people, have exacerbated the problem.” However, under the ten challenges outlined in the report, cultural understanding is not mentioned.
For a researcher, counsellor or health worker, data on health challenges are best obtained by sitting around the fireplace, sharing a cup of tea, and for women researchers, talking about children. Health and well-being begin with cultural comfort. Data collection needs to go beyond the one-on-one interaction of a survey. We are a collective society.
Culture permeates mental health. The Diagnostic and Statistical Manual DSM, the bible of mental health included cultural distress only in its fifth edition (2013) and the WHO International Classification of Diseases listed cultural syndromes only in its 10th edition (2016). The Tribal Health Report calls mental health the third most important burden, but if we don’t take cognizance of cultural factors, we will hardly make a dent in mental health.
What do we need?
We need focused community-specific strategies that concentrate on flagship health problems. Each problem must be taken alongside its social and cultural factors. For example, antenatal care must address single mothers, abandonment of women and the customs that permit these. Malnutrition in children must be taken along with poverty, loss of traditional diets, and deforestation which have depleted wild edibles, still collected by one-third of the rural population.
The key to unlocking the dilemma of poor tribal health is culture. No doubt poverty and other factors need to come in, but you can trace many problems to the bypassing of culture. They are a few pockets of tribal health success such as Gadchiroli, Bissamcuttack and Gudalur, which demonstrate a cultural approach, but these are just a few islands in the ocean of tribal health misery.
Neglect of tribal agency
A member of the audience at the webinar asked the question of whether “The term ‘security’ in tribal health security would mean elements of force, as in being forced to test for Covid and get vaccinated, ‘surveillance’, as in being surveyed for malaria-blanket screening and TB-active case finding, and ‘prescriptive practicing’, as in being asked to follow remedies that are culturally acontextual or run counter to the adivasi way of life.” He went on to say that “This in itself is at odds with the ‘coverage’ part of Universal Health Coverage which assumes that all Adivasi people would get insurance cards and then access treatment in (pre-prepared) packages.” So the question on the table is, “How can we build in elements of agency and autonomy so that tribal peoples can co-participate in discourses that pertain to their own situation, rather than being represented by the state establishment, its policy actors and knowledge generators.
At the webinar we were shown an inscription by Prof Amartya Sen, praising the Tribal Health Report. The remarks of the eminent and empathetic Nobel Prize winner, himself a champion of health equity, are much appreciated, but it might have been more meaningful to have obtained the imprimatur of the tribal community for a report on their own health. The 12-member expert committee contained only two tribals. Nehru’s Panch Sheel for tribal development included the dictum that the “people should develop along the lines of their own genius and we should avoid imposing anything on them”. Perhaps we don’t need to be handheld, shepherded or spoken for any more. Maybe we can write our own script.