Grinding poverty, poor health care facilities, and a variety of diseases, mainly malaria, claim a disturbingly large number of lives in the tribal areas of Andhra Pradesh.
Takumaharani Purbai, Odamchan gattal, Neendoramma Tumboramma Juggusal puttusal Mannesal Sathasal Yethubuddani deearu buddani
("O Takumaharani! We are performing your puja today/You reside in the boat and in the stream and everywhere/You never do fall asleep/You are always awake/We pray you protect us.")
ONE finds this prayer framed and displayed at the impressive museum of tribal culture located in Araku Valley of Visakhapatnam district in Andhra Pradesh. This is a prayer offered by the tribal people of the region to the all-pervading `evil power', seeking good health and longevity.
The prayers notwithstanding, hundreds of tribal lives were lost in recent weeks in the absence of a reliable health care system. Many more people are on the verge of dying.
The Telugu Desam Party (TDP) tried to embarrass the ruling Congress by alleging that more than 2,000 tribal people had died of malaria and other fevers in two months and petitioning the National Human Rights Commission. The charge was promptly denied by the government - just as the TDP government did in 2002-03 in the face of similar allegations. The government even collected `evidence' to establish that the TDP had inflated the numbers. It cited the example of Champuguda village, where the TDP claimed 44 people had died whereas there had been only one death.
The death toll is always open to dispute, but it is not as if there is no crisis at all. Buried in the maze of charges and counter-charges is the fact that the tribal people are victims, as always, of government apathy. The political debate does not encompass the cumulative effect of poverty, deprivation, illiteracy and exploitation on tribal mortality rates.
On an average, 312 tribal people die in the Integrated Tribal Development Agency area of the State every month. There could be several factors responsible for this, but there is no denying that malaria is a major cause of the deaths. Even if one survives an illness, it only leaves him or her more vulnerable to another, with the body's defences dwindling because of poverty and malnourishment. It looks as though the Gadabas, Valmikis, Paranga Porajas, Kondus, Nookadoras, Kammaras, Konda Doras and Bagathas, the tribes that inhabit the lovely hills around Araku Valley, have forgotten that the dead are supposed to be mourned. They have also stopped blaming the authorities for the deaths.
Poverty stops them from visiting the doctor when they fall ill. They say that the health workers who visit them every week pop a few chloroquin pills into their mouths at the first sign of any illness, leading to further complications. The maternal mortality rate is nearly 25 per cent and the infant mortality rate is around 165 for every 1,000, compared to 95 for every 1,000 at the State level. In 2002, the figure was 62 among the tribal people. The under-five mortality rate is also very high, nearly 50 per cent. Eighty per cent of the children are anaemic and 55 per cent under-weight.
Almost all the tribal girls get married by the time they attain puberty and 43.1 per cent of the pregnant women do not receive anti-natal medical care; no tetanus toxoid injections are given to an equal number and hardly 48 per cent are supplemented with iron and folic acid tablets during pregnancy. Circumstances compel more than 80 per cent of the women to deliver their babies at home, unattended and unaided by anyone.
The difficult terrain, locational disadvantages of primary health centres, non-availability of specialised services and lack of transportation add to the woes of the tribal people.
The tribal population in the Agency area lives in hamlets scattered among the hills. The three community health centres located in Araku Valley, Lothugedda and Paderu are not enough to handle the exigencies. The primitive tribal groups that live further up on the hilltops are almost shut out from health care facilities. Health is not a priority for them; what matters is livelihood, for they must continue to earn even if their health fails.
Sixteen-year-old Tangula Suvarna of Koranjiguda, for instance, was delivered of a baby boy without medical aid, though she had been down with malaria for three months. She could not afford hospitalisation. She was admitted to the Araku hospital three days after the delivery in a precarious condition.
Ameobiasis, scabies, jaundice, malaria, gastroenteritis and fractures (sustained owing to falls from trees) are just some of the common ailments here. The P Falciparum variety of malaria is widely prevalent. A local doctor said that the health care system in the region functioned without proper infrastructure and sufficient staff.
The health centres cater to 3,000-5,000 people between them. The health assistants, both male and female, make rounds of the hamlets that are scattered along the valley and in the hills, but their tight itinerary ensures only one visit to a village in a week. Each sub-centre covers 30 villages.
The way blood smears are collected in the area prone to malaria defeats the whole purpose: they are collected after the patient has consumed medicines. The health workers in the villages are not properly trained, there is no one to ensure that these things are done properly.
A health assistant who did not want to be named said that a primary health centre sometimes collected more than 150 blood samples in a day, whereas a laboratory technician could handle at best 60 samples. The backlog is sent to the centres that are less burdened, because the smear can be preserved for a year under proper conditions. By the time the report reaches the centre that had sent the smear, anything between 30 days and six months may have elapsed.
In the absence of proper health care, the tribal people keep swallowing chloroquin tablets - in 1999, the government stipulated that anti-malarial treatment should be given to them "whatever be the cause of the fever". The result is that chloroquin has become almost a dietary supplement in the area. This leads to other health complications, and helps officials who readily deny that malaria is responsible for the large number of deaths.
There is a social angle to the problem. "Bagathas and Konda Doras" form the upper crust of tribal society. If a community health worker happens to be a `Valmiki, a Kondh or a Kotia', they prefer not to be treated by him or her. The visits of health workers from these groups are usually confined to their own social circles. The authorities refuse to accept these ground realities.
Health cards were introduced recently in the area to register health records of the tribal population. Nowadays, the health assistants visiting the hamlets once a week spend half their time making entries in the 600,000 cards issued. To the tribal people, the card is as good as a lifeline - something like a ration card; so they, too, insist on the completion of the formalities. A health worker is expected to collect blood smears, distribute tablets, chlorinate drinking water sources and teach the basics of hygiene. But, as Vanthala Hari of Champaguda village asked, "when death is knocking on our doors, do you expect us to listen to these lectures on cleanliness"?
When someone dies, the officials have any number of reasons to list in the records. Malaria over a prolonged period can impair every organ in the body and even induce liver or spleen disorders and neurological problems.
In desperation, the tribal people go to their guruvu, the local faith healer, who is accessible. He encourages superstitious beliefs, talks of chillangi (black magic) and cajoles them into taking his treatment. His `medicine' is a concoction of leaves and roots. The patient is asked to take it on an empty stomach and then told to forgo food for the next two days. It is a sure way of weakening the body's defences further.
The medical staff at the ITDA at Paderu said that they could "show any number of admissions but there were very few discharge reports because the patients simply vanished mid-way through the treatment". The doctors, wary of blame in case of death, often discharge patients without insisting that they complete the treatment. The patients stop taking treatment because they cannot afford hospitalisation. Sometimes, an ailing tribal patient finds the hospital closed to new admissions for the day by the time he reaches it, covering a long distance, and is forced to arrange for lodging for the night.
On paper, the medical infrastructure in the tribal areas of Andhra Pradesh looks impressive - more than 115 primary health centres and about 830 sub-centres, 30 mobile medical units and 21 hospitals and 18 dispensaries. But the dispersed location of the hamlets means long treks even for the health officials conducting door-to-door surveys and distributing medicines.
More than 40 per cent of the sub-centres have no male health workers, who are key to the anti-malaria programmes. Records show that against a requirement for 824 male health workers in the State, only 690 posts were sanctioned in the last decade. The ITDA Headquarters Hospital at Paderu did not have any in-patients in the first five years of its existence, because of poor infrastructure, truancy on the part of the staff and unfilled vacancies, according to senior Indian Administrative Service officer K. Sujata Rao, who did a study on tribal health care.
Private treatment entails extra cost, which can go up to Rs.2,000 in case of surgery and pregnancy. So, tribal people approach moneylenders, who charge 5 per cent interest and compound it by the same percentage once every three months. They are also sometimes forced to sell their produce at prices lower than the market rate to the moneylender. Alternatively, a tribal person can sign a contract for bonded labour for a year. A study by the Tribal Cultural, Research and Training Institute showed that the average annual income of a tribal family was Rs.4,327, and 20 per cent of this was spent on health care.
Haunted by poverty and illnesses that follow each other in quick succession, the tribal people seem resigned to a slow, agonising death. Like the forest cover around their traditional dwellings, the tribal population is also vanishing, slowly but steadily. As Appala Naidu, a tribal person working for a government department says: "It is a wretched life. There is no quality to it. Illness has become our second nature. Death at least is freedom from ailment."