Since the late nineteenth century, an increasing number of groups have sought to provide health care for the tribal peoples of India. The British colonial rulers were concerned above all to control and open these notoriously malarious tracts for exploitation of their forest wealth, and they established dispensaries in which their officials could receive treatment as well as provide vaccinations and dispense quinine and other basic drugs and treatments for local people. They were followed by Protestant missionaries, who provided medical care as a means to gain the sympathy of tribal peoples with a view to ultimately converting them to Christianity. This process began to be contested during the early twentieth century by Gandhian nationalists, with their own views on sanitation, cleanliness and health. After independence in 1947, the state extended its programme through Primary Health Centres and various preventive campaigns – such as vaccination, inoculations, and DDT spraying to eliminate mosquitoes. Others entered on the scene, such as committed NGO workers, Catholic fathers and nuns, evangelistic faith healers, religious organisations, and political and quasi-political groups. Despite all this attention, health care in such areas is at best patchy, and generally highly inadequate.
Conference papers will examine both this history and provide a contemporary survey of this process in the context of the tribal areas of Gujarat, Maharashtra, Madhya Pradesh and Rajasthan. In India as a whole, the tribal peoples today make up about 8 % of the total of population of over one billion, while in Gujarat they make up almost 15 % of the population of fifty-one million. They belong to a range of kinship-based communities associated with interior regions that are often hilly and with poor soil. During the colonial period, they were excluded from large tracts of their homelands, which were reserved for government-controlled forests. Subsequently, many have been displaced through large-scale irrigation and other development projects. As a result of these processes, many are unable now to make a living from the low-grade land they retain, and have to work as migrant labourers outside their own region, for example as seasonal agricultural labourers and on construction sites in the towns and more prosperous rural areas. The conditions of work are very bad, they live in temporary camps or slums, and wages are low and often paid only partially. Their general condition is characterised by poverty, social exclusion, susceptibility to exploitation, and poor health. The desire to provide improved health services for these tracts has a number of causes. For some, such as NGO workers and a few dedicated doctors, there is a commitment to social service. For others, such as many official health workers, it is just a career posting which they have to fulfil on the orders of their employer, the government. Politicians have a vested interest in appearing to provide health care in such areas, for the scheduled tribes are important within the modern Indian political system. Since Indian independence in 1947, their vote has been decisive in a significant number of parliamentary and state assembly seats. In Gujarat, for example, the tribal vote is crucial in 33 out of a total of 181 state assembly seats (18.23%), which in tight elections would be enough to determine the result. For this reason, different political fractions of the dominant classes have a strong interest in extending their power and influence over the tribal peoples, and health and healing is a major weapon in their armoury in this respect. In addition, improved health profiles in such tracts help to open them up for economic exploitation by outsiders, as well as provide a potential base for a growing market in internal tourism.
Indigenous Healing Systems. How was healing carried on in tribal areas in the past? The myths and legends of the tribal people reveal that they suffered from a wide range of ailments – endemic as well as epidemic – in the past. Before the 1880s, they were left largely to their own devices when ill. In a few cases, they may have sought herbal and faith based cures from wandering mendicants – such as sadhus and pirs – who resided in forest tracts. Most healing was by relatives and neighbour using herbal and other folk remedies. Tribal specialists who used herbal remedies, cauterisation, divination and exorcism, treated the more intractable cases. These people were highly respected and had considerable social power. These forms of indigenous healing continued and evolved after 1880, and, indeed, are practiced widely to this day. In general, colonial officials, missionaries and the Western-educated Indian elites have been unsympathetic towards such practices, though in recent years drug companies as well as forest officials have sought to exploit their knowledge of herbal remedies. Such healers do not generally like to impart their knowledge to others, and this can create tensions. This history may be examined, and contemporary healers of this sort may be examined to determine their current influence.
Contemporary Tribal Understanding of Health and Healings. Some recent research has revealed that many tribal peoples continue to regard sickness as having dual physical and supernatural aspects, with both aspects requiring treatment in their own ways. Thus, in the first instance, a family member may use herbs reinforced with a charm. If the illness persists, a village-based specialist is generally consulted. Herbalists who administer desi-dvai (country medicine derived from herbs, bark, roots etc.), pulse specialists and midwives-cum-‘wise women’ (dai) cater to the physical side, while the exorcists, grain diviners, priests – who use mantras fitted to specific complaints – seek to combat the supernatural causes. Beliefs persist that are alien to modern allopathy, such as the classification of sicknesses according to whether they move ‘down’ or ‘up’ the body. When allopathic facilities are available – and in many cases they are not – tribals are often prepared to use them. It is, for example, widely believed that certain problems, such as fever and headache, yield well to allopathic drugs and injections. These are often described as angrezi bimari or ‘English illnesses.’ Nonetheless, while taking this ‘English medicine’ from ‘doctors’ – who may be qualified or unqualified – tribals will still consult their own ritual specialists so that the efficacy of the allopathic cure is enhanced with charms, mantras and exorcism. Research on the Bhils of southern Rajasthan has found that there is a widespread belief today among Bhils in humoral principles, with distinctions, for example, being made between diseases of cold (sardi ki bimarai) and diseases of heat (garmi ki bimari). Such beliefs were not recorded in earlier ethnographic reports on the Bhils, opening up the possibility that they have become widespread only in recent years, being evidence for a growing popularisation of Ayurvedic principles during a period when this system of medicine has received a certain degree of state patronage. [Sushila Jain and Seema Agrawal, ‘Perceptions of Illness and Health Care among Bhils: A Study of Udaipur District in Southern Rajasthan,’ Studies of Tribes and Tribals, Vol. 3, No. 1, 2005, pp. 15-19; Veena Bhasin, ‘Sickness and Therapy among Tribals of Rajasthan,’ Studies of Tribes and Tribals, Vol. 1, No. 1, 2003, pp.77-83]. Further research is needed to discover whether this is true for other tribal groups. The great faith that exists among tribals in the power of the intravenous injection and the glucose drip may also be examined.
European and American Protestant Missionaries. What was the impact of the Protestant medical missionaries who provided the bulk of biomedical care for these people from the 1880s to the 1950s? The first missions to focus specifically on the tribals of India began work in the late nineteenth century. The relevant missions were mostly Protestant at that time, though since the 1930s Catholic missionaries have been playing a more and more active role in this sphere. Missionaries found that they could win sympathy and converts through medical work, and they therefore invested much energy and finance in establishing dispensaries and hospitals. They were the first people to provide biomedical care for the tribals – a healing system known to the latter as ‘English’ (‘angreji’) or ‘foreign’ (‘vilayati’) medicine (‘dawa’). This medical work could give rise to a complex local politics, in which the tribal healing specialists sought to defend their power through opposition to the medical work of the missions. The missionaries often insisted that Christian converts renounce the indigenous healing systems, and particularly the traditional practitioners, who they often viewed as their rivals. These politics may be explored.
Nationalists. How did Indian nationalists and then – after 1947 – the Indian government seek to meet the health needs of the tribal people? By the early years of the twentieth century a more westernised middle class was emerging in India that was taking biomedical treatment and also training in medical schools to practice biomedicine. They were often resentful of the stranglehold that European colonial doctors exercised over the profession. Also, many were critical of the use that missionaries made of medicine to gain a foothold in the tribal areas. This fed into a growing nationalism, in which the Indian elites asserted their right to run clinics and hospitals. Nationalists went to work in the tribal areas from around 1920 onwards, carrying out social work of various sorts with the aim of winning popular support for their cause. Whether or not tribal people trusted the motives of the elite nationalists any more than the white missionaries is however a moot point, and needs to be investigated. Did the nationalists in any way help to inculcate a wider popular acceptance of biomedicine? Those who were most likely to have had some success in this were the Gandhian nationalists who went to some tribal areas to establish ashrams that were in direct competition with the mission stations. Few of them were however qualified doctors, and they generally encouraged varieties of preventive care, involving sanitation, abstinence from drugs and alcohol, sexual self-control, dietary reform, as well as naturopathic and indigenous herbal remedies. Through the latter, they sought to distance themselves from the hegemony of biomedicine, proposing an ‘Indian’ alternative. It has to be investigated whether or not this provided legitimacy to certain forms of folk medicine, such as herbal remedies.
Government-provided health care. Before Indian independence the colonial state provided almost no biomedical care for the tribals of this region. The government of independent India sought to rectify this situation after 1947 through a programme of state-provided biomedical treatment in a network of Primary Health Centres (PHCs). Roger Jeffrey [The Politics of Health in India (Berkeley 1988), pp.170-1 and 261-80], has argued that in India in general PHCs were chronically under funded and failed to provide adequate care for the mass of the Indian people. Was this the case also in this tribal region? A study of one PHC in a tribal area on the border between Maharashtra and Gujarat found that the system was operating to good effect, with a diligent local staff, but it was probable that this situation was the exception rather than the rule [V. Kamat, ‘Reconsidering the Popularity of Primary Health Centres in India: A Case Study from Rural Maharashtra,’ Social Science and Medicine 41, 1 (1995), pp. 91-2]. Other reports argue that PHC’s rarely function in tribal areas [e.g. Shyam Ashtekar and Druv Mankad, ‘Who Cares? Rural Health Practitioner in Maharashtra,’ Economic and Political Weekly (Mumbai) 36, 5 and 6 (3-10 February 2001), p. 449]. There is absenteeism by staff, or, when they are present, they treat tribals with an attitude of superiority and contempt. High fees may be extracted for treatment, even though this contravenes government rules. Another set of questions relate to the medical and semi-medical campaigns carried out by the state, such as vaccination and inoculation programmes, anti-malaria insecticide spraying (now been abandoned for environmental reasons, leaving nothing in its place), and family planning drives, involving mainly female sterilisation and male vasectomy. In recent years, there has been a lot of funding and effort invested in the campaign to eradicate polio. In general, these ‘campaigns’ have a reputation for poor planning and inappropriate and insensitive implementation, none of which builds confidence in government-provided biomedicine. Also, interested parties may appropriate the funds. Is this also the case here?
Self-Employed Doctors. What is their role, and how well qualified are they? Ashetakar and Mankad’s survey [cited above, p. 450] of a tribal area of Maharashtra of 1999-2000 found that 71% of the biomedical practitioners in this area were self-employed private doctors. Of them, 3% had full biomedical qualifications, 76% had inappropriate qualifications for the medicine they practiced, and 21% had no qualifications at all. Is the situation similar throughout the tribal region? Many of the self-employed doctors are also non-tribals and belong to various high caste groups. How do these caste affiliations affect the administration of medical care to their patients? What sort of tensions do their social affiliations incur between such doctors and their patients? In Gujarat, where tribals tend to be slightly better educated than others in India, a significant number of tribals have been able to take advantage of their Scheduled Tribe status to take up places in medical colleges reserved for this category. Many now practice in their home regions, being based often in small towns, where they may be known disparagingly by the local elites as ‘tribal doctors’. This category is not found in the above survey, and there are no studies of them. Do they provide a more effective care for tribal people? What is their experience of medical work? What is their relationship with medical professionals from more elite backgrounds? What is the social and political role within their community that they believe that they perform? A significant number appear to be involved in politics at various levels.
Non-Governmental Workers. Continuing in the tradition established by the missionaries and the Gandhian nationalists, many non-governmental organisations are now involved in health projects of one sort or another in tribal areas. Some are purely secular and are not aligned to particular political parties, and they have carried out some exemplary pioneering work. The problems encountered by such organisations and some of the internal strategic issues debated within them may be examined. A growing number of NGO organisations have religious and political affiliations. For example, in Gujarat the Swadhyaya Parivar (literally: Self-Help Family), which seeks to inculcate a new morality, in which villagers work together in harmony to develop their resources so as to alleviate poverty and want. The sect claims to have about two million members, of which about four-fifths are found in Gujarat. It focuses on a range of socio-economic issues, one of which is that of health. It advocates various measures to improve health, such as village sanitation and a healthy lifestyle, which includes abstinence from alcohol. Members provide their labour to bring about village improvements on a voluntary basis, a practice known as shramabhakti (devotion of labour). It also runs periodic health camps, with doctors who come from outside to treat people and provide minor surgery [V. Shah, N.R. Sheth and P. Visaria, ‘Social Transformation as God’s Work (A Study of Swadhyaya),’ unpublished paper of the Gujarat Institute of Development Research, Ahmedabad 1998]. There are other Hindu sects also active in carrying out medical work in the tribal belt, such as that of Swaminarayan. These activities may be investigated. Another prominent organisation that has recently been carrying out such work is the Art of Living group whose activities include ‘charitable’ dispensation of medicines through free medical camps and programmes geared towards encouraging healthy lifestyle practices such as yoga workshops. Health has thus become a popular avenue for ‘charitable’ work in tribal areas. What are the motivations for such work and how have the tribals received it? Has there been a noticeable increase in such activities in the recent years?
Christian Faith Healing. A significant development in tribal regions in the past two decades has been the growth of Christian faith healing by evangelical denominations, such as the Pentecostalists, Seventh Day Adventists and the Friends Missionary Prayer Band. Medical missionaries of the older established churches refused to countenance faith healing and miracle cures, believing that such ‘superstitious’ practices undermined their wider credibility. The new churches have no such reservations, believing that many maladies can be cured through prayer and faith in Jesus. Using such an approach, they appear to have gained far more tribal converts to Christianity than the older churches were ever able to achieve. The Friends Missionary Prayer Band, for example, claims to have over 26,000 followers in the South Gujarat tribal belt [E.D. Dasan, ‘Conversion and Persecution in South Gujarat’, in Krickwin C. Marak and Plamthodatil S. Jacob (eds.), Conversion in a Pluralistic Context: Perspectives and Context, ISPCK, Delhi 2000, p. 175]. Riled by their success, Hindu nationalists have accused them of ‘anti-national activities’ on the grounds that Christianity is a ‘foreign’ religion. They have even attacked them violently. They accuse the Christians of quackery and seek to counter them by organising biomedical camps to provide the masses with more ‘scientific’ remedies. Health clinics now operate in the tribal areas that are organised and run by groups that are a part of the Sangh Parivar. Healing and medical provision has thus formed an important element within a sharp political conflict in the tribal region [for some preliminary and question-raising remarks on this see D. Hardiman, ‘Christianity and the Adivasis of Gujarat’, in Labour, Marginalisation and Migration: Studies on Gujarat, India, in Ghanshyam Shah, Mario Rutten and Hein Streefkerk (eds.), Sage Publications, New Delhi. pp.189-91]. These various activities and conflicts may be examined.