Noncommunicable diseases among tribal populations in India

A case of double jeopardy

Introduction

India is presently in the middle of an epidemiological transition. While infectious diseases still remain an unfinished agenda, chronic noncommunicable diseases (NCDs) are rising at an alarming rate. Contributing to 62.1% of mortality, NCDs are now the leading cause of death in the country. A similar trend is now being seen even among the weakest and the most marginalized sections of the society – the tribal populations, living in geographically remote, isolated hilly, and forested areas far away from the mainstream. The tribal communities, in fact, suffer not only from the risk of chronic conditions but are also least able to cope with the consequences as the health infrastructure and the service available in areas where they live is abysmal, both in terms of availability as well as quality.

According to the 2011 census, the tribes of India were 104 million strong, constituting over 8.4% of India's population spread across the country in 30 states and union territories. Each of the 705 tribes in the country are diverse and unique in terms of environment in which they live, social system, culture and health care needs. Rich in traditional knowledge, they are among the most resilient and sustainable on the planet. Nearly 46%, however, live below the poverty line. The human development reports of various states indicate that the tribal districts and talukas are at the lowest levels on the human development index, compared to the nontribal revenue units.[¹] Among all the social groups in India, tribes have the worst health and social indicators. In addition, they suffer from a greater burden of NCD morbidity and mortality as well as from limited access to health-care services.[²]

The Burgeoning Burden

Although in the past, infectious diseases such as tuberculosis and malaria have been common ailments among tribal populations, there is now the compelling evidence to suggest that NCDs are increasing rapidly in these populations. Several studies in India indicate a high proportion of deaths due to NCDs, such as cardiovascular disease, diabetes, cancer, and chronic respiratory diseases, contributed by various NCD risk factors such as tobacco and alcohol use, sedentary life, and poor dietary intake.

In a recent study conducted by the Indian Council of Medical Research in 12 tribal districts of India, it was revealed that of surveyed 5292 deaths among those above 15 years of age.[³] Overall, NCDs accounted for 66% of the deaths, followed by infectious diseases (15%) and injuries (11%). Cardiovascular diseases were the leading cause of death in 10 of the 12 sites. In East Garo Hills (18%) and Lunglei (26%), neoplasms were the leading cause of death. An increasing trend in the prevalence of hypertension in adult tribal populations has been noticed over the last three decades in tribal populations.[⁴]

A study using the WHO STEPs approach was conducted among a total of 332 individuals of the Mishing tribe from Tinsukia district, Assam. Overall, tobacco use was 84% (men 94%; women 73%) and alcohol use was 67% (men 82%; women 50.) Eleven percent had abdominal obesity, 16% were overweight, and 26% had hypertension. Among the hypertensives, 24% were aware, 17% treated, and 2.4% controlled their hypertension. Older individuals had higher hypertension prevalence compared to younger individuals. Tobacco use, alcohol use, and unhealthy diet habits were high among men and women in this population, which were major NCD risk factors.[⁵]

Similarly, a high prevalence of NCD risk factors has also been observed in other tribal areas, including tribes in Thiruvananthapuram district in Kerala, Kinnaur district in Himachal Pradesh and in North East India.[^6,7,8]

Consequent to this development, there is, of course, the pressing issue of health-care service availability, quality, and access.[⁹] Health services are abysmally poor in tribal areas, partly due to the fact that no one – be it doctors, specialists or laboratory technician or male health workers want to serve in a remote tribal area. The per capita expenditure on health is low; consequently, health centers do not have enough supply of health technologies and lifesaving medicines.

According to rural health statistics released by the Ministry of Health and Family Welfare on January 12, 2023, a critical and significant gap exists in the health infrastructure resources providing specialized care, especially in tribal areas.[¹⁰] Health-care delivery and access becomes difficult due to poor road conditions, acute shortage of human resources for health, lack of equipment, language and social barriers, waiting time at health centers, and poverty, all of which add to the problem of health accessibility and sustainability.[²]

What Needs to be Done?

To reduce premature mortality from these chronic diseases, reaching out to the tribal populations, understanding their risk behaviors, and conveying NCD prevention messages focusing on the reduction of the modifiable risk factors associated with it is one of the important public health priorities in India. NCDs are slow-progressing diseases, and of long duration, most populations are often not aware they are at risk of having or already have these conditions. Therefore, attempts must be made to make detection, screening, and treatment services as accessible as possible, closer to where people live.

A comprehensive approach covering prevention, early diagnosis, and treatment is needed requiring relevant sectors, including health and others, to collaborate to reduce the risks associated with NCDs and monitor progress. Health promotion approaches, including through the use of folk media, can help people to live healthy lives and improve health-seeking behavior. Accredited social health activists have an important role to play in promoting health-related behaviors in the community and to bridge the gap between health services and the community.

India has adopted the United Nations sustainable development goals (SDGs) and enshrined in it is the commitment to Universal Health Coverage (UHC), thereby ensuring that “everyone everywhere has equal access to quality health care” they need. Therefore, making health services accessible to and equitable and acceptable for the tribal population is essential for achieving the SDG, especially goal 3.4 pertaining to NCDs.[¹¹]

Strengthening of health care institutions and systemswith sufficient trained health workers, outreach services and mobile care and creating health promoting environments and people centered primary health care can improve health outcomes and play an effective role in the prevention and control of NCDs. Since tribal populations often prefer traditional healers as they are in the community and easily accessible and trusted by the local population, there is a need to bring the two systems together so as to benefit the patients and the community.

The tribals are a diverse group spread across the country and have their own unique cultural patterns and social practices. Mapping and documenting health-promoting traditional practices in each state which have stood the test of time can help policy and program development. Social and behavioral research need to be carried out in close collaboration with the community to facilitate their participation and engagement togenerate health seeking behaviour.

Finally, it is clear that while NCDs are an important public health problem in tribal areas, the health infrastructure in these areas remains inadequate to properly address the problem. Preventing NCDs by reducing associated risk factors and provision of early diagnosis and treatment is, therefore, the need of the hour, which can help save lives and improve their quality of life.