The Myth of the Healthy Tribal*
Amar Kumar Singh**, S.K. Sinha**, S.N. Singh**,
Meera Jayaswal**, M.K. Jabbi***
Health Modernity has been defined as scientifically correct information,
attitudes and behaviour in relation to physical and mental health, family
planning and childcare, personal hygiene and environmental sanitation and such
other issues which are essential pre-requisites for healthy living and,
therefore, for human and social development. A Health Modernity Scale, in the
form of an interview-schedule, was administered on 991 tribals (male and female)
in two rural blocks of Ranchi district in South Bihar. Their health status was
also measured through health indicators, such as living conditions and food
habits, age at marriage of women, fertility and family size, immunization and
malnutrition in under-five children, and death and disabilities. The tribal
community studied had very low health status and Health Modernity.
PLEASE close your eyes and think of an average tribal person in the native
habitat. The mental image, most likely, will be of a healthy, strong, carefree
man with a flute on his lips, and of a woman, with flowers in her hair, dancing
happily on the wild beats of the drum. This stereotype of a tribal, held by most
Indians, alas, is a hollow romantic myth.
This myth has been exposed by the grim facts of a Health Modernity Survey
sponsored by the Indian Council of Medical Research in two rural blocks, Kanke
and Namkum, of Ranchi district in Chotanagpur region of Bihar.
The present paper describes the sad story of this tribal community, which,
after four decades of Independence, deceived by the mirage of political promises
and bypassed by modernization and development, continue to be over-whelmingly
illiterate (81%), poor (58% having monthly income of Rs. 200 and less and
another 31% between Rs. 201 and 400) and unhealthy (29% families reporting
illness). Less than 8% of the children were immunized. Two-thirds of the
children
under five were malnourished, 44% having severe malnutrition. A large majority
of the sample (71%) took tobacco, mainly in the form of raw leaves called khaini,
chewed with lime. Most of them (89%) drank alcohol, mainly haria, a home
brewed rice-beer. The daily consumption of meat, fish, egg and milk was by less
than 1%, of pulse by a small 8% and 65% did not eat green vegetable. Two-thirds
of them did not take baths daily; the percentage of women being as high as 90.
Nor did they wash their personal clothes (91%) or clean their nails (95%)
regularly. An average tribal woman married early at the age of fifteen and had
six children, two of them dying in her life-time. The average tribal family had
seven persons with only about two rooms. Deprived of basic physical facilities
they lived in squalor and garbage, with pigs and hens, without electricity,
sanitary latrines, ventilation, outlet for smoke, drainage and sewage. Less than
4% had scientifically correct knowledge of, and attitudes to, physical and
mental health, diet and nutrition, and family planning and childcare.
| Illiteracy |
81% |
| Poverty |
58%(< Rs. 200 p.m.) |
| 31%( Rs. 201 - 400 p.m.) |
| Unhealthy (Families reporting ill health) |
29% |
| Children immunized |
<8% |
| <5 children, malnourished |
75% |
| Tobacco (Khaini with lime) consumption |
71% |
| |
|
A tribal, like anyone else in the world, cannot be healthy living in poverty,
ignorance, starvation and garbage. Despite these, if he seems happy to others,
or to himself, there is something wrong in the definition of happiness.
I
Health and Human Resource Development in India
Health Status in India
Health has been acknowledged as an essential pre-requisite for human resource
development. The Seventh Five Year Plan underlines this in the chapter on Health
and Family Welfare (GOI, 1985). It has
been argued that low health status and high fertility in India are the main
obstructions against human resource development (Singh,
A.K. 1986). The health status in India is distressingly low as reflected in
numerous dismal statistics on health indicators such as high rates of infant and
child mortality, fertility and low birth-weight, low life-expectancy and
immunization-coverage, and wide-spread malnutrition (Table
1). The low health status in India is confirmed repeatedly by the high
prevalence of easily preventable diseases at low cost, such as blindness,
tuberculosis and diarrhoea.
The statistics given in Table 1 give a bird’s eye-view of the gloomy
situation of health status in India. A few more studies may be mentioned to
supplement these.
Physical Quality of Life Index
A Study on Physical Quality of Life Index (PQLI) is available for thirteen
major states of India. The PQLI is a broad indicator of overall health status as
it combines three variables namely, infant mor5tality, life expectancy and adult
literacy. A value of 100 points indicates a satisfactory health status. All the
states of India have a low PQLI, and in most states the females score lower than
males (GOI 1979).
Nutritional Status
Several studies have demonstrated the low nutritional status of the majority
of the population. Data for malnutrition in children between 1-5 years are
available from 1969 to 1980 collected on large samples in different states by
National Institute of Nutrition (NIN,
1981; UNICEF 1984). Though there is evidence that
there has been improvement in the nutritional status of children, still only 15%
of the children studied in 1980 had normal nutritional status. Majority of the
Indian population, both in rural and urban difference in the country is quite
high. The percentages of consumers below the level 2800 KCAL are 56.39 for rural
and 71.0 for urban population. There are also significant regional variations in
under-nutrition (Das Gupta 1984). The states, of Kerala,
Tamilnadu and West Bengal have the highest under nutrition, and states of Jammu
and Kashmir, Punjab, Himachal Pradesh and Rajastan have the lowest.
Infant Mortality
Though the urban population is more malnourished, it has a lower infant
mortality rate than the rural population. This rural-urban difference in infant
mortality favouring the urban, has been continuing, without much change, from
1970 to 1982 (GOI 1985; UNICEF
1984). The lower infant mortality in urban areas is perhaps mainly because
of the fact that larger proportion of urban population has access to medical
facilities at the time of child-birth. During 1979-78, 66.2% births had received
institutional and trained medical attention in urban areas; the corresponding
percentage for the rural population was only 16.5% (Visaria
1985. P. 1400). There is evidence that the infant and child mortalities in
rural as well as urban areas, are lower when child-births are attended by
trained medical personnel compared with when attended by untrained ones (UNICEF
1984, p. 29). A greater percentage of rural population (64%) is unaware of
available MCH services compared with the urban (54%). As a consequence of this,
lesser number of rural population (17.7%) avail of the MCH services than the
urban population (20.8%) (Operational
Research Group, 1983, p. 55).
ICMR-UNICEF Study of Child Survival
Unhappily, the dark picture of the low health status in India gets a shade
darker by each new study. A recent ICMR-UNICEF sponsored study, covering a large
sample of 180,000 in three uban slums of Madras, Delhi, and Calcutta and three
rural areas near Chandigarh, Varanasi, and Hyderabad, has reported very high
perinatal (65.3), neo-natal (57.7) and infant (94.5) mortality rates; 29.3
stillbirths per 1000 deliveries, and low birth-weight of less than 2500 gms in
39.3% of births (ICMR, 1986).
Vaccine-preventable diseases
As is reported in Table 1, there is very high incidence of
vaccine-preventable diseases in India. India’s share of total incidence of
vaccine-preventable deaths and disabilities in the third world is the highest.
For polio, tetanus and measles India’s share is 40% , 31%, and 39%
respectively. On the other hand, India contributes only 15% in prevention of
paralytic polio and 10% in deaths by other diseases (John 1986). Grant in his
annual report on the State of the World’s Children 1987 has recorded that
"whether the issue is diarrhoeal deaths or vaccine-preventable diseases,
low birth weight or malnutrition, infant death or childhood disability, nearly
30% and sometimes more of those affected live in India" (Grant 1987, p.
62).
SES and Health Modernity
Singh (1984 a, b), on
the basis of his study on "Health Modernity and its Correlates in South
Bihar", has reported that SES is the most powerful correlate of health
status and health modernity. This study was sponsored by the Indian Council of
Medical Research to develop a Health Modernity Scale. This served as a pilot
project to the Health Modernity Education Project (HMEP) reported in this paper.
Therefore, a summary of this study is being reported here. A factorial sample
design (4X2X2X2X2) was taken to represent: (i) four religious and ethnic groups,
namely, Hindus, Muslim, Tribal Christian and Tribal Hindu/Sarna, (ii) two
categories of sex: male and female, (iii) two categories of residence: rural and
urban, (iv) two categories of age: 21-30 and 31-40 years, and, (v) two
categories of socio-economic status: low and high. The sample consisted of 1280
cases, taking 20 cases in each sample cell from Chotanagpur. A supplementary
sample of rural Santhal Pargana of 160 cases was added to the main sample, thus
yielding a grand total of 1440 cases. The SES scale was a combination of
caste/tribe, income, education, and occupation. Health Modernity was measured by
a 50-item scale measuring scientific information and attitudes to mental and
physical health. A behavioural measure of Health Modernity was also used,
covering such themes as personal hygiene, consumption of alcohol and tobacco,
and religious behaviour to avoid and/or cure illness. The analysis of variance
had shown that the F-value for SES was the largest compared to those of
religion, rural-urban residence and sex. All of these factors had significant
independent influence on health modernity. The significant influence of SES was
also found in separate ANOVA for all the four religious-ethnic groups. The
extent of Health Modernity was only 23% and majority of the persons with health
modernity (82%) belonged to the high SES category (Figure
1). The four religious-ethnic groups, on the basis of their Health Modernity
Scores, were ranked in this order: Hindu (highest), Tribal Christian, Tribal
Sarna/Hindu, and the Muslims (lowest). In each of the four religious-ethnic
groups, the high SES, without exception, had higher health modernity score than
its counterpart low SES group. The Health Modernity Scale had significant
positive correlation with all the four components of SES, namely, caste/tribe,
education, income and occupation; education having the highest correlation
value. The attitudinal Health Modernity had positive significant correlation
with behavioural measures of Health Modernity. A further analysis of the data,
taking only the female cases (640), confirmed the findings of the main analysis
supporting the strong relationship of SES and Health Modernity(Jayaswal,
1985).
Health and HRD in India
The Health status in India is perhaps even worse than what the governmental
statistics reveal, which, as is the common practice, are boosted in the positive
direction by the loyal officials. The low health status in India, caused by the
combined forces of poverty, illiteracy, ignorance and governmental failure, is
clearly a major obstacle in human resource development, health becomes the first
foundation stone of human personality. Gopalan (1983) has estimated that because
of pervasive malnutrition about 81% of the Indian children fail to develop their
genetic potential for their physical and mental development. The Government of
India have rightly acknowledged the importance of Human Resource Development by
establishing a separate ministry for it, with health as its component.
Admittedly, human resource development has many dimensions but health is of
primary importance, because it comes first in the development process, and,
therefore, performance in other dimensions is importantly influenced by
achievement in health.
II
Health Education: Importance and Difficulties
Despite Illiteracy and Poverty
The existing low health status is the rock against which all attempts of
human resource development crash and flounder. Poverty and illiteracy are the
two main correlates of low health status and these will undoubtedly prove great
obstacles in attempts to improve the quality of health. Indeed, it seems
difficult to achieve the goal of ‘Health For All’ with the existing poverty
and illiteracy levels. The cut-off point of poverty-line has been computed to be
Rs. 107 and Rs. 122 per capita per month for rural and urban population
respectively. But despite this very low level of cut-off point about 37.40 per
cent were below the poverty line in 1983-84. The rates for Scheduled Castes
(50.92) and Scheduled Tribes (57.15) are even higher (Singh,
P. 1986). The literacy rate is a meager 36 percent, the female literacy is
only 18 percent. In the six states of Uttar Pradesh, Bihar, Andhra Pradesh,
Madhya Pradesh, Rajastan and Orissa, constituting 52.77 percent of the total
Indian population, the female literacy rate varies between 11 (Rajastan) to 21
(Andhra Pradesh/Orissa) percent. It was even lower for women of SCs (11%) and
STs (8%). The disappointing poor performance is economic and educational
development in the four decades of post-Independence India as likely to continue
in the foreseeable future. Thus, it seems certain that we have to cope with the
health problems despite poverty and illiteracy.
Grant (1987) has correctly asked:
Can we really say that we must wait for the return of economic growth when
over 3 million children a year are dying of diarrhoeal dehydration which can be
prevented by basic family health education and by oral therapies costing less
than a dollar? And can we really say that it is too expensive, that we must wait
for economic development’ when 3.5 million children a year are dying of
diseases which can be prevented by immunisation at an additional yearly cost
which is less than the price of five advanced fighter planes.
(Grant 1987, p.9) In an earlier report on The State
of the World’s Children, 1982 Grant had very poignantly recorded that:
"The cost of immunising third world’s infants works out at approximately
five dollars per child. The cost of not doing so works out approximately five
million deaths a year" (Grant 1982, p.9)
New Health Messages
Recent developments in medical science has provided information and
technologies which are so simple that an illiteracy person can understand them,
so inexpensive that a poor person can afford them, so complete that every
individual scan self-administer them without the expert guidance of doctors and
hospitals, and, most important of all, are so effective that a significant
reduction in malnutrition and illness, and death and disability can be achieved.
These health information and technologies are related to diarrhoeal diseases and
respiratory infections, immunisations and monitoring the growth of the child,
diet and nutrition, cleanliness of food and water, personal hygiene and
environmental sanitation, birth control and birth-spacing, and breast-feeding
and supplementary food for children at the weaning age. These down-to-earth, and
what UNICEF has labelled "do-ables", are revolutionary breakthroughs
in medical history because of their potentialities to save millions from deaths
and disability. The Oral Rehydration Therapy (ORT) is an example of this. An
illiterate mother can be taught to prepare a drink at home with a certain
proportion of salt and sugar or its substitute, measured with a pinch of fingers
and a scoop of hand, and save her child from diarrhoea dehydration, the greatest
killer of infants. These new messages make the individual, rather than the
doctor, responsible for his health. The informed individual will be his own
doctor, always available, motivated and without any cost. In his critique of the
industrial western civilisation Illich argues like a Gandhian, that health care
may best be left to the individual.
A world of optimal and wide-spread health is obviously a world of minimal and
only occasional medical intervention. Healthy people are those who live in
healthy homes on a healthy diet in an environment equally fit for birth, growth,
work, healing and dying.
Illich I. (1976): The Limits of Medicine.
P. 274).
Importance of Health Education
Health education is importance because it is available right now, in the
prevailing conditions of illiteracy, poverty and governmental apathy and
failure. Health education is important because it is effective, tested and
proven in the experience of the third-world. A significant reduction in the
incidence of death, disability and malnutrition in India can be achieved through
health education. This reduction possible through immunisation, ORT, balanced,
nutritious but inexpensive diet, better child care through growth chart,
breast-feeding and supplementary food, improvement in cleanliness of the village
and home of the body of the person, of food and water, and above all, by changes
in health attitudes and health habits. The annual incidence of death in India by
vaccine-preventable diseases (measles, tetanus and pertusis) is 128,000 and
polio-related disability is 200,000. About 2500 children die each day because of
diarrhoea and 30,000 children become blind annually (Table
1). All this is avoidable tragedy, and avoidable at affordable cost.
The importance of health education has been emphasised by Mahler, the
Director General of WHO:
It is not accidental that health education was given the place of pride in
the AlmaAta Declaration; not is it accidental that the global strategy
constantly refers to educational interventions as the means par excellence for
enlisting the involvement of people in all walks of life and for making them
true artisans of health and development.
Mahler (1983): World Health April - May,
p.4
Difficulties in Health Education
Health education, however, is as difficult as it is important. The apparent
simplicity, rationality and feasibility of health educational messages are
forcefully and optimistically advocated by Grant, the Executive-Director of
UNICEF, in his annual report on the State of the World's Children. This is
understandable in view of his moral convictions and international role. Grant is
in fact, quite convincing when he is arguing his case, as a possibility. But, he
undermines or only hints indirectly and obliquely through inferences, the most
important obstacle in the improvement of health status in the third world,
including India: the lack of political will and moral commitment of the ruling
elite despite their public declarations.
Health education is difficult and its effectiveness is uncertain because of
five main reasons. Firstly, the factors of poverty and illiteracy will put a
limit to the improvement of health status through health education alone.
Secondly, health education, to be effective, needs to be supplemented by
creating concrete health and health-related facilities, such as facilities for
immunization, maternal services, safe d4rinking water, and sanitary latrines.
Given the level of prevailing poverty in India, these depend mainly on
governmental performance. Thirdly, health education demands the involvement and
participation not only of the community, which is loudly publicised in the
literature, but also of the health educator. In the absence of a sense of
commitment to the cause and emotional involvement of the health educator, health
education, with all its newly-acquired glittering audio-visual aids of films and
slides and flash cards and flip charts, will only be fashionable gimcracks of
urban research scholars, of social workers and governmental agencies. It is
necessary that a health educator not only explains how a soak-pit for drainage
of bath water or a garbage-pit is made, but he actually works with the villagers
in these activities. Fourthly, the health educator must have rapport and empathy
with his target-group. This is possible only when he has a commitment to the
cause, and the commitment is not only academic and research-oriented but is
emotional and moral. Fifthly, health education cannot produce miracles
overnight. The age-old unscientific and unhealthy attitudes and habits are
reinforced by folklore and customs, are inculcated in the minds from childhood
in the process of socialisation, and re-strengthened by poverty and illiteracy.
Not surprisingly, the health messages, with all their apparent rational
advantages, meet the resistance of entrenched age-old traditional attitudes and
beliefs and of simple ignorance. For example, a very large number of others
discard the first breast milk after child-birth in the wrong belief that this is
harmful to the baby, not knowing the nutritional and immunisational value of
colostrum contained in it. Many unhygienic personal habits, related to taking
bath daily, washing personal clothes, washing hands before meals and after
toilet, washing of the utensils before serving food in them, cleaning of nails,
gargling before sleeping, defecation in the open, and consumption of tobacco and
alcohol, have been inculcated in the individual through the process of
socialisation. These have become ingrained in the life style and one has
developed blind-spots to their adverse aspects. Some of these are reinforced by
traditional culture, such as drinking of haria (alcohol) in the tribals.
Some others become inescapable because of poverty, lack of resources, and life
conditions. Many women do not take bath because of the burden of work, paucity
of water, and lack of privacy. Clearly, the life conditions force the poor women
to abstain from bath.
Health education is not a fashionable charity-show organised by upper-strata
ladies, seeking limelight. It is a serious job demanding a great deal of
understanding, patience and hardwork in uncomfortable conditions. Health
education is possible, despite odds and difficulties. The greatest ally of
health education is the natural desire of every individual to be healthy and of
every mother to see her child grow without any disease and disability.
The Importance of the Child in Health Education
The child assumes special importance in the process of health education for
two reasons. Firstly, the health of the child is the crux of the health of
community (Singh 1983, p. 30). Child-care, therefore,
becomes the most important component of health education. The child can be
reached through its parents, particularly the mother, who is the logical
inescapable target for health education. Secondly, the child is no less
important a target for health education. In fact, with long-term perspective he
is the target, because the health attitudes and habits begin during childhood. Investing
in children is investing in the health of the community argues a Worldwatch
Paper :
Child health reflects and determines the human conditions. It results from,
contributes to social development. The growth of societies depends on the
capabilities of their people and these, in turn, depend on health and education.
Child health affects growth, learning and work.
Chandler W. U. (1985): Investing in
Children, Worldwatch Paper 64, Washington, p. 5.
III
Health Modernity: Concept and Scale
The Concept of Health Modernity
Health modernity is scientifically correct information, attitudes and
behaviour in relation to physical and mental health, family planning and
child-care, personal hygiene and environmental sanitation and such other issues
which are essential pre-requisites for healthy living and, therefore, for human
and social development. The concept of Health Modernity is an extension of the
concept of modernity which has been widely used in social science literature to
describe a socio-psychological pre-disposition considered to be a prerequisite
for economic, social and political development. Thus, it has been argued
economic development in India and many third world countries has been
handicapped by non-modern attitudes to work and social organisations. The
foreign-imported machines have produced far less in third world countries than
their output in their native countries. Democracy has failed or has not become a
way of life because of the persistence of feudal, non-modern attitudes on such
issues as equality of man, respect for dissent, and work-commitment. The
non-scientific and non-rational attitudes have proved to be the major obstacles
to socio-economic and political development.
The component of health has been missing in the concept of modernity. Since
modernity is considered as a means of development, which, in turn, means the
well being of the common man, the component of health logically becomes the most
eligible component of modernity. Singh has argued that:
If modernity is a pre-requisite for social, economic and political
development, Health Modernity is the pre-requisite for human development, which
undoubtedly is the summum bonnum of all development. The individual must
be alive and cognitively competent to be economically productive, socially
liberal, and politically democratic. Admittedly, Health Modernity does not
ensure and guarantee social, economic and political modernity, but nonetheless,
it is a fundamental precondition of all development
Singh, A. K. 1984b, pp.7-8
Health Modernity Scale
Health Modernity has three components: information, attitudes and behaviour.
A fourth component may be added, that of Health Indicators. The data on
informational-attitudinal and behavioural components of health modernity can be
obtained from the individual. The health indicators are environmental, social
and demographic factors, data for which can be obtained from the individual
(e.g. physical living conditions) as well as from the societal sources (e.g.
health facilities). The health indicators are the correlates of health modernity
which influence it and are also influenced by it. Therefore the component of
Health Indicators has been kept separate from the Health Modernity Scale.
The Health Modernity Scale (HMS) covers seven main dimensions, namely: (i)
Physical Health (PH), (ii) Mental Health (MH), (iii) Diet and Nutrition (DN),
(iv) Family Planning (FP), (v) Child Care (CC), (vi) Breast-Feeding (BF), (vii)
Health Habits Behaviour (HMB). The first Six are combined to make a total Health
Modernity Attitudinal Scale.
The main themes covered in each of the seven dimensions have been listed in Table
2, which also lists the themes on Health Indicators. The coding of all the
seven dimensions have been done in a way that each of them has a range of 0-50
scores. There are 10 Likert-type items in PH, MH, DN, FP, and BF, each on a five
point scale. The CC has seven Likert-type and remaining non-Likert type items,
whereas the HMB has all non-Likert type items. The mixture of Likert and non-Likert
type questions was necessary because of the nature of the topic covered in the
themes.
The seven dimensions of the Health Modernity have statistically significant
positive inter-correlations, indicating that the seven sub-scales can be
combined to make an overall Health Modernity Scale. The split-half reliability
of the seven dimensions have been calculated and the correlations are
statistically significant. The correlation of Health Modernity Attitudinal and
Behaviour Scales is also statistically significant (269). This can be considered
as a criterion of validity for the attitudinal scale.
V
Health Modernity Education Project (HMEP)
In view of the importance of health education as a means of improving the
health status, particularly in the illiterate and poor population, the ICMR has
sponsored a Health Modernity Education Project (HMEP) in rural tribals in Ranchi
district of Chotanagpur region in south Bihar. An earlier survey had shown that
the tribal population in South Bibar had poor health status and very low health
modernity (Singh 1984, a, b).
The present paper is a summary of the bench-mark study of the HMEP, which not
only provides base-line data for the evaluation of educational intervention
programme, but is also a complete survey in itself.
Tribals in South Bihar
The 1981 census had counted 51,628,638 tribals in India constituting 7.53 per
cent of the total Indian population. Bihar accounted for 5,810,867 of them,
constituting 11.26% of the total tribal
population of India and 8.31% of the, total population of Bihar. The tribals
are mainly concentrated in Chotanagpur and Santhal Parganas. The districts of
Ranchi (56.41%), Singhbhum (44%) and Santhal Parganas (36.8%) have large tribal
populations.
The tribals are overwhelmingly rural. About 94% of them live in villages in
Bihar as well as in India. They are also illiterate. The illiteracy rate in
India is 76% for the males and 92% for the females; the corresponding
percentages for Bihar are 74 and 92. The rural illiteracy for both males and
females, is even higher. The tribals are poor. About 57.15% of the tribals were
below the poverty-line in 1983-84, the percentage in rural area being slightly
higher (58.40) (Singh P., 1986). Because of the
economic, social and educational backwardness of the tribals, the Constitution
of India has given them special protection. Seven percent of State Legislature
and Parliament seats and an equal percentage for admission in educational
institutions and appointment in governmental jobs are reserved for them. The
Constitution also provides them protection against social and economic
exploitation. Despite these safeguards, the atrocities against the scheduled
tribes have been increasing. There were 3340 cases in 1981 against 843 in 1967
and 2134 in 1979. (GOI, 1983; Singh,
A.K. in press).
The tribals are non-Aryans. They are called Adivasi, meaning original
inhabitants. They are described as aboriginals and primitives, often
derogatorily, as they existed early in the development of mankind. They are
called Vanvasi and Girijan because they live in
forests and mountains. The tribals are racially, linguistically and culturally
different from the non-tribals. However, the tribals are not a single homogenous
group; there are about 427 groups in India. Together they share their closeness
to nature, poverty, illiteracy and exploitation by the ruling elite of the non-tribals,
who are called Dikus in Bihar, literally meaning one
harasses.
The tribal groups are different in many ways: in physical appearance and skin
colour, dress and decoration, huts and household things, geographical terrain
agricultural crops, food and drink, flora and fauna, festivals and customs, and
language and folk-lores. These differences are not only among the tribals in
different parts in India, but they also exist between tribals of the same
region. These differences have important implications for the preparation of
health education materials. Clearly, the audio-visual materials appropriate to
one will not be suitable for the other.
In Bihar, the 1971 census had recorded 29 tribal groups, the four most
numerous being santhal (18,00,764), Oraon (8,76,218), Munda (7,28,106), and Ho
(5,05,172). The Oraon and the Munda live in Ranchi district. They have two
different languages, Kuruk (Oraon) and Mundari. But, they also speak a common
language called Nagpuria or Sadri, a simple bazar Hindi. They have common
customs and festivals. They inter-marry. They live in the same villages. The
sample of the present study has included mainly Mundas and Oraons.
Sample Location
The sample has been taken from Kanke and Namkum blocks of Ranchi district.
The two blocks are adjoining Ranchi town. The villages selected are at a
distance of about 20 to 25 kilometers from Ranchi.
Sample Stratification
The basis of sample stratification has been sex (male/female) and four
age-categories, that is, 15-24, 25-34, 35-44 and 45+ years. In the sample
selection an interval of five years was taken, which was later increased to ten
to organise and facilitate data analysis. Each age-category in the sample has
approximately the same percentage, sex-wise, of the total sample size as is its
representation in the total adult population of the village. The sample consists
of 991 cases, with 498 males and 493 females (Table
3).
Sample Demographic Characteristics
The demographic characteristics of the sample in relation to education,
income men age at marriage a woman, family size and number of children born to a
woman, family size of women, average number of children born to and number of
depicted by the Project data of rooms are given in Table
4 A & Table
4B.
The demographic profile this tribal community highlights the following facts:
- The tribals are illiterate. About 81% of the total population is
illiterate, the percentage for women is as high as 95.
- The tribals are poor. Fifty-eight percent have no income or have income
upto only rupees two hundred per month. Another 31% have monthly income
between rupees 201 and 400.
- The tribal women marry at an early age. The mean age at marriage is 15
years which is lower than the national average of rural women (17 years).
- The tribal women have higher fertility than national average. The average
number of children born to a tribal woman is about six, higher by two than
the national average.
HMEP: Main Findings
The main findings of the HMEP are reported in relation to Health Indicators
and Health Modernity.
Health Indicators
In Health indicators we are reporting the data on living conditions,
prevalence of illness and disabilities, and malnutrition in children under five
years.
Living Conditions
It has been already noted that the mean age at marriage of women is 15 years,
and a woman has, on an average, about six children. The family size is 6.78 with
just about two rooms. As the data on living conditions (Table
5) show not even 1% had bath room, septic latrine and electricity. Only 23%
had separate kitchen but just about 2% had provision for the outlet for smote.
About 83% did not have ventilation in the sleeping room, 73% did not have cot,
81% had no blankets or quilts, and 89% did not have even mosquito nets. Only 22%
had wells and only 6% had drainage for waste-water disposal.
The tribal population of the sample did not have the bare basic physical
facilities necessary for healthy living.
Prevalence of Illness and Disabilities
About 29% of the families reported some kind of illness or disability at the
time of the survey (Table
6). About 10% of the families had some kind of eye-ailment; about 7% had
physical disability and 3% had chronic illness.
Contrary to popular notion, a large number of the rural tribals are
afflicted by illness and physical disability.
Malnutrition in Children Under Five
The malnutrition of children was measured in relation to the
arm-circumference by the coloured strip (Table
7, Figure
2). Only a quarter of the children had normal nutrition, and shockingly 44%
had severe malnutrition. A greater percentage of girls (47%) had severe
malnutrition than the boys (42%). The high prevalence of malnutrition can be
seen in relation to the food habits (Table
8). The daily consumption of meat/fish/egg and milk was less than 1%, even
though many families keep a few chickens and 76% actually had milch animals. But
they cannot afford to consume these; they sell these to earn a few rupees to
support their bare existence.
A majority of tribal children, like all poor children, are malnourished.
Extent of Health Modernity
The extent of health modernity has been reported in relation to: (i)
percentages of the ‘modern’ scorers, and (ii) mean scores of each of its
seven dimensions. A ‘modern’ response is a scientifically correct answer
representing information, attitudes and behaviour. In the scales of Physical
Health (PH) Mental Health (MH), Diet and Nutrition (DN), Family Planning (FP),
and Breast Feeding (BF) a modern scorer is one who obtains a score of 40 or
more, because there are ten items and a moderns response will get a score of 4
or 5 in each score in 4 or 5 in each item. The range of modern score in CC has
been computed item same way for the seven Likert-type items; for other items the
scoring is in terms of the degree of correctness of the answer. The items of
Health Modernity Behaviour (HMB) have also been coded similarly. As already
stated all scales have a range of 0-50 scores.
Overall Health Modernity
A very small, almost negligible, number of persons have qualified on this
test of overall health modernity (Table
9, Figure
3). The percentage of persons with health modernity varies from 0 to 5 in
the seven dimensions. Not even a single male, out of 498, had health modernity
in relation to Child Care; the percentage for the female was also less than 1.
Less than 1% males and females had health modernity in Physical Health, Diet and
Nutrition, and Child Care. The women, understandably, scored higher (5.3%) than
men (1.8%) on Breast Feeding, but, the important fact remained that 95% women
did not have scientifically correct information and attitudes in relation to
breast-feeding.
The low overall health modernity reflected in the small percentage of modern
scorers in the seven sub-scales of health modernity is confirmed by their mean
scores computed separately for 8 sample sub-groups based on four age-groups and
two sexes. (Table
10). The low health modernity remains approximately the same in all the 8
sample sub-groups with very little variation. Naturally, therefore, this trend
is also reflected in the aggregate scales of Health Modernity Attitudinal and
Health Modernity Attitudinal Behavioural.
Overall Conclusions
The health modernity survey in two tribal rural blocks in Ranchi district has
shown unhygienic living conditions, overcrowding, inadequate and imbalanced food
habits, pervasive malnutrition, early marriage, high fertility, non-adoption of
contraception, high prevalence of illness, and wide-spread misconceptions and
ignorance of physical and mental health, diet and nutrition and family planning
and childcare.
References
- Census of India (1981). Series I, Part II B
(1), Primary census abstract general population, 4.
- Chandler, W.U. (1985). Investing in Children.
World Watch paper 64. Washington.
- Das Gupta, R. (1984). Nutritional situation in
India: A statistical analysis. Economic and Political Weekly. 19, 34,
1491-1494.
- Future (1986). Life and living in South Asia. 18-19,
68-70.
- Gopalan, C. (1983). Nutrition at the base. Seminar,
282, February, 19-24.
- Government of India (1979). Survey
on infant and child mortality. New Delhi: Office of the Registrar
General.
- Government of India (1983). Report
of the commission for scheduled castes and scheduled tribes. New Delhi:
Ministry of Home Affaires.
- Government of India (1985). Sample
Registration Scheme 1981. Vital statistics division. Office of the
Registrar General.
- Grant, J.P. (1982). The state of the world's
children 1982. New York: UNICEF.
- Grant, J.P. (1987). The state of the world's
childm 1987. New York: UNICEF.
- ICMR (1986) Birth weight: A major determinant of child
survival. Future, 17, 53-56.
- Illich. I. (1976). Limits to medicine. London:
Marion Boyars.
- Jayaswal. M. (1985). Health modernity and its
correlates in women of South Bihar. Social Change, 15 (2), 7-14.
- John, T. (1986). Issues in immunization. Future, 17,
39-42.
- Mahler, H. (1983). Health for all: Everyone's
concern. World Health, April-May, 2-4.
- National
Nutrition Monitoring Bureau, National Institute of Nutrition (1981).
Quoted in UNICEF (1984). An analysis of the situation of children in
India, New Delhi.
- Operational Research Group (1983).
Family planning practices in India. Second All India Survey, Baroda.
- Registrar General of India (1983).
Survey on Infant and child mortality 1979. New Delhi. Office of the
Registrar General, India. Ministry of Home Affairs.
- Singh, A.K. (1983). Health modernity education in
India. Social Change, 13 (2), 27-34.
- Singh, A.K. (1984a). Health modernity and its
correlates in South Bihar (ICMR Report). Renchi University. Postgraduate
department of Psychology.
- Singh, A.K. (1984b). Health modernity: Concept
as correlates. Social Change, 14 (3). 3-16.
- Singh, A.K. (1986). Human resource development in
India. Barriers and prospects. Social Change, 16 (2&3),125-135.
- Singh, A.K. (in press). Intergroup relations and
social tensions in India. In Pandey, J. (Ed.), Third survey of research in
psychology. New Delhi: ICSSR.
- Singh, P. (1986). Trends In Poverty. Paper
presented at the seminar on Exploring India's Development: Perspectives for
the year 2000. Indian Association of Social Science Institution, New Delhi.
May 20-22
- UNICEF (1984). An analysis of the situation of
children in India. 1984. New Delhi: UNICEF.
- Visaria, L. (1985). Infant mortality in India:
Levels, trends and determination. Economic and Political Weekly, 20 (33),
1399-1405.
* This paper is an abridge version of Singh, A.K. (1997):
The Myth of the Healthy Tribal : Health Modernity in Two Rural Blocks of
Chotanagpur, Bihar. Report on ICMR Task Force Health Modernity Education
Project, Post, Graduate Department of Psychology, Ranchi University.
** Post-Graduate Department of Psychology, Ranchi
University, RANCHI- 8344001
*** COUNCIL FOR Social Development, 53 Lodi Estate, NEW
DELHI-110003
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