Tribal women give birth under tree, cut umbilical cord with a stone: Dr Abhay Bang

What is the current condition of tribal persons in India?
Currently, India is home to nearly ten crore tribal persons. There are over 705 indigenous tribes in the country. It is a humungous population and we cannot afford to ignore it. While 29% of India's households use LPG services for cooking, barely 8% tribal households have access to clean cooking gas. In Nashik and Thane, 25% and 14% of population respectively belongs to scheduled tribes. These districts rank among the top three in India for large tribal population. While 65% of the mothers in general population get hospital and medical services for delivering babies in an institutional set up, hardly 35% of tribals have access to these services. In spite of fast-paced development of India, to this date, some tribal women during labour pangs go deep in the forest and sit under the tree to deliver the baby alone. After the baby comes out, the umbilical cord is severed by the mother, who crushes it with a stone or cuts it with a bamboo strip. The placenta of the baby is then buried in the ground. If the baby survives, the woman comes home with it.

Is it that tribal welfare is ignored when financial budgets are charted out?
This is not the case. Between 1977 to 1985, the budget allocated for family planning in India tripled. The number of contraception surgeries doubled, but strangely the birth rate of the country remained the same. This suggests that in spite of so much investment, nothing changed on ground.

The Government of India has allotted an annual budget of nearly Rs 5000 crores for Tribal Development. So there is absolutely no dearth of money allocated for development.

So where does the problem arise then?
The loophole is in the design of the development policy. The state has a rubber-stamp model in the name of tribal health. A district hospital which is slated to tend to a population of ten lakhs and is replete with all facilities is up to 150 kilometers away from remote villages. One Auxiliary Nurse Midwife (ANM) from a Public Health Centre (PHC) is allocated the responsibility of tending to 15 villages with a population of 8000 persons spread over 20 kilometers. How much distance will one poor woman traverse in a day on foot? Also, how far can a mother on foot walk with a sick baby in her arms? In a such a dire scenario, 40% of women and children don't receive health care.

Is there a dearth of doctors in the tribal areas of Maharashtra?
Yes. In 1986, my wife Rani, who is a gynaecologist, conducted the first caesarean section surgery ever, on a pregnant lady in Gadchiroli. Over the past 25 years, three hospitals have started in the district. Services have penetrated only but partially up til the block level. Each district consists of up to twelve blocks made up of multiple villages. While each block should have one gynaecologist, one surgeon, one paediatrician and one physician, there are no surgeons, anaesthesists, paediatricians or physicians. Gadchiroli has only five gynaecologists for the entire district. Most of the times, the doctors' posts are vacant. Specialist doctors do not prefer to stay in remote jungles.

Is it a problem that ayurvedic physicians are providing allopathic care in tribal areas?
But then what is the way out? Maharashtra government allows that out of two doctors in a PHC, one doctor can be an ayurvedic practitioner. 70-80% of MBBS doctors start preparing for their post-graduate exams and have no interest whatsoever in serving in rural areas. A large number of PHCs are run by ayurvedic doctors. Most MBBS doctors shun the compulsory bond signed with the state to serve in rural areas. The state government has failed to recover the fine amount of over Rs 800 crores, from these doctors over the years. If the state were to recover the fine money, up to three hospitals dedicated solely for tribal health can be built with that kind of an amount.

What repercussions do poor healthcare facilities have on children?
Malnutrition is prevalent in the region not only because there is lack of food but also because there is lack of adequate knowledge in the tribals so as how and what to feed the baby. Close to Rs 30,000 crores are allocated to Integrated Child Development Scheme (ICDS) for tackling malnutrition. But we are not witnessing results of a proportional quantity. For the first six months a child is supposed to be breastfed and eventually between 7 – 24 months of the child's growth, s/he is supposed to be fed mashed bland food like legumes, rice, vegetables and grains along with breastfeed. The tribals do not follow this feeding pattern. Also lack of sanitation causes frequent infections in the children. A child may suffer from 10 – 12 bouts of infections including flu, diarrhoea, scabies and ulcers. Each bout reduces the child's food intake for close to two weeks. The child is bound to get malnourished in such a case. It has an extremely detrimental effect on the state of children.

How did your experiment with women in the community providing home-based care revolutionize the health care system in Gadchiroli and eventually across India?
In 1995-96, we conducted field trials in 39 villages of Gadchiroli by training women from the community to provide medication and care for basic illnesses like malaria, diarrhoea, childhood pneumonia and care for pregnant ladies and new born children. After home-based care for expectant mothers was introduced, number of children dying between the age of 0 and 1 year reduced by 62% in the next three years, reported the subsequently published study in Lancet Journal, based on the trials. The women were known as Stree Arogya Doots (or female health messengers). The pilot model was rolled out across all the districts in Maharashtra in 2004. Accredited social health activists (ASHAs) were appointed to go from home to home to provide maternal and child care. This

formed the first pioneering home-based care maternal and child model of the world. In 2008, the eleventh five year plan incorporated the ASHA model of care for entire India and several states eventually operationalized the policy.

What are the future health threats to the tribal population and what is the way ahead to tackle such problems?
Non-communicable diseases (NCDs) like high blood pressure and diabetes in the tribal population are booming. 15% of the population suffers from high BP. The tribals are under an immense amount of stress due to their exploitation and the naxal activity. They feel threatened by modernization. Now we will initiate trials to train men christened as 'Ashok,' workers to deal with counselling for mental health, tobacco and alcoholism as well as NCDs.

How did you convince the tribals to seek health care from professional doctors?
What tribals need and what we provide them are two completely different things. Probably like a square peg in a round hole. We went from village to village and sat around night fire asking them what they wanted. We democratized the provision of health services for them. We assembled tribals from fifty villages and asked them to vote for their top health priorities. They said their weak women needed to be revived and their children had to be saved from dying. Big buildings intimidated them so we built a 30-bedded hut-based hospital to make them feel at home. Over 500 major surgeries including that of gynaecology, paediatric surgery, urology and neuro-spine annually occur at our hospital in Gadchiroli now.

What measures are being taken to incorporate tribals into the main stream?
We are encouraging the next generation to become technologically sound and astute. We are training ASHA workers on audio-visual computer aids. Also alongside the youngsters are being provided facilities to study Information Technology. While in 2004, 4601 youngsters had enrolled for MS-CIT course offered by Maharashtra Knowledge Corporation Limited (MKCL). By 2014, up to 7370 youngsters in Gadhchiroli are receiving IT education.