V: A critical stock-taking of health services for the adivasis in western Odisha at the time of COVID-19 pandemic

I Introduction

The state of Odisha is home to the largest number of adivasi (original dwellers) communities in India, that is, 62 groups, of which 13 are identified as particularly vulnerable tribal groups in the country. Adivasi communities constitute about 23 per cent of the total population of the state (IIPS 2017). By the end of March 2021, it was widely reported in the print media that 10 districts of western Odisha, bordering Chhattisgarh and Jharkhand, were badly hit by the second wave of COVID-19. Secondly, in six districts of western Odisha—Sundargarh, Sambalpur, Kalahandi, Nuapada, Bargarh and Boudh—the COVID-19 test positivity rate was above 30 per cent—and these were included in the 15 districts in the country with a record of high positivity rate.

Stock-taking of the public health infrastructure in adivasi pockets of Odisha during the second wave—which is commonly iconified as much deadlier to be ravaging many lives—is pivotal as the state is duty-bound to develop this domain. Improvement in public health lies in prioritising preventive healthcare, supplying safe drinking water, generating gainful employment, ensuring nutrition security and sanitary reforms in alignment with the Directive Principles of State Policy. This approach would be preferable to policing methods which restrict the movement of people, high-cost curative measures centred on avant-garde medical infrastructure and pharmaceutically-driven public health. Sadly, conversations with the people from this region revealed that several teachers lost their lives while performing COVID-duty without safety gear on par with frontline workers. Stringent lockdown without much institutional preparation transferred the economic burden of preventing the risk of infection on to the rural and urban working population (Sujatha 2021). The reverse exodus of adivasi labourers met with unnecessary physical, emotional and economic hardships. Upon arriving at the railway stations in Odisha, they had to pay heavy amounts to private transports or even to trucks carrying essential goods to reach their villages owing to the state halting its inter-city bus services. Other returnees had to walk barefoot with luggage for this. Furthermore, they were coerced to quarantine at home. It is ironical that the Adivasi zone can be capitalised for industrial interest including supplying oxygen to central locations, but these economic gains have not been utilised for improving the standard of lives of adivasis of this region. The NGOs fighting for the rights of the adivasis find it contradictory that Odisha state boasts of exporting oxygen from western Odisha to 10 other states while maintaining the position that it has surplus oxygen, whereas on the ground, commoners in the hospitals have died due to a lack of oxygen.

II Inequality in health

Inequalities in health services or structural violence are not unfamiliar themes in the domain of sociology of health in India which focuses on social axes such as class, caste and gender that lead to production of ill-health conditions (Djurfelt and Lindberg 1980; Hollen 2013). It has been established that the virus itself does not discriminate among people. However, when the pathogen interacts with the social field, its pathways are mediated by the dynamics of social processes. So, the most afflicted people are the deprived and oppressed sections who are victims of multiple forms of discrimination. Furthermore, the enclavist nature of India’s healthcare structure in which a large chunk of health infrastructure is developed in the urban locations at the detriment of rural and tribal locales are spelt out in equity debates (Banerjee 1996). This neglect gets compounded by other systemic injustices like lack of basic amenities and the disinterestedness of the doctors to serve in rural areas (Bang and Bang 2010; Jeffery 1996). Adivasis are not always averse to modern medicine due to their cultural beliefs; rather, traditional herbalists and rural private practitioners occupy these spaces legitimately due to the absence of public health infrastructure (Das 2015; Nichter and Nichter 1996). The present argument extends this debate further by capturing the manner in which the indigenous system of medicine thrived when the state retreated from providing modern healthcare services.

A teacher from Lalnjigarh (an area under the Fifth Schedule of the Indian Constitution) Kalahandi, pointed out insufficient institutional measures were in place. The teacher said:

Rations for pregnant women and children, books, uniforms, etc. reach the people regularly through Anganwadi workers. Otherwise, villagers would complain. But there are limitations to the availability and the quality of health services. The Anganwadi workers and the Auxiliary Nurse Midwives are non-residents of the village who are not well-versed in the local dialect. This makes the already-inadequate health facilities weaker. Again, as they have to travel for work here, and unfortunately, the bus services to (and from) this village operate only once in a day and the roads are rough, transportation is difficult for them (and us). At times, we do not find a healthcare worker when we need one. In their absence, thus, ‘quacks’ proliferate and they are of many types. In my knowledge, indigenous healers and shamans are few but multi-purpose health workers running private dispensaries are common. Since adivasis are into cultivation, they barter their grains for these private practitioners’ medical service.

These narrations amplify the point that adivasis adopt remedies from divergent systems of medicine as practical rationality (Sujatha 2021) rather than as a consequence of a civilisation gap. However, when the tribals relied on their own system of medicine in the absence of any option, health functionaries and media resorted to victim-blaming tactics in terms of attributing ill-health to their irrational belief system. His account also shed light on how preventive measures against COVID-19 are deterred due to absence of civic amenities like water, roads, bathrooms and testing centres. Moreover, breathlessness and asthama is aggravated due to mining added risk for adivasis in the ongoing pandemic.

Income loss and irregular rehabilitation of returned migrant families which manifested in the form of severe malnutrition are major issues that plagued Nuapada, Balangir, Boudh, Sonepur, Kalahandi and some pockets of Sambalpur. An NGO activist of Sambalpur who works on the livelihood predicaments of adivasis articulated how the requirement of instant cash drove tribals to remigrate:

In our estimate, at least 300 to 350 youths have returned from other states but they are not engaged in any work now. Since they have been returning, it is prudent to give them some work through the Integrated Tribal Development Agency (ITDA) so that they can sustain themselves in this interim period. Last year, when they were engaged in work through the Mahatma Gandhi National Rural Employment Guarantee Act, 2005 (MGNREGA), they faced the issue of delayed payments. It takes one to two months in the normal course. Aadhaar (a unique identification number) verification process further delayed it. But they were desperate when a local contractor who worked as a middleman lured them with the advance payment of ₹15,000 to ₹50,000, and migrated again even though they had decided not to migrate after the first lockdown.

The above illustration captures the face of mass hunger and worklessness during the pandemic that became mortifying and acquired metaphysical dimensions among adivasis (Mathson 2021).

III Invisible genocide

The NGO activist from Sambalpur threw light on the absence of institutional care for COVID-19 and reasons for the deliberate burying of specific data on adivasis suffering from COVID-19.

We have found that there has been no effort to test, and contact-trace in rural areas of Sambalpur, or you can say, in all of the western Odisha districts. They do it only in certain urban pockets, the area nearest to the District-Health Centre, and that is it. Western Odisha would not have suffered badly, had Temporary Medical Centres (TMCs) and door-to-door testing in rural pockets been set up. You know, if you asked the District Programme Manager about Block-level data, they would say, “it is against our protocol”. In our field-area, Jujomura block, we see lots of death-cases. If you see the district’s data, it shows that only 9 people have died, but in our count, 15 people have this far died in Jojumura Block itself and if we take this block as average it becomes 135 deaths. This is again only a rough calculation and in reality, it might be higher. If they would do testing in the entire district, then the block-level data would reflect based on which we can directly say how many STs and SCs are affected, since some Blocks predominantly belonged to STs, some others belonged to SCs, like that. Panchayat members, Junior Engineer and other officers have embezzled funds for beds, ventilators, air-coolers, etc. The state government is not interested in reallocating funds, nor are they setting up an inquiry as public officers can always escape citing that those cots got damaged, this and that. That is why they are not doing door-to-door testing as they know that they would be flooded with more cases and here people cannot afford to avail treatment from private hospitals. On the other hand, in home isolation, if a ventilator and oxygen are needed, they cannot arrange it, and by the time they reach district hospital, they are dying.

His lucid narration suggests that we term the present catastrophe as an ‘invisible genocide’ in the absence of testing and activating TMCs in areas inhabited by impoverished tribals and the lack of basic amenities critical as preventive measures.

Conversation with nurses from Sonepur corroborated the point that they are just given the target of collecting swabs from 18 to 25 households per day. Several respondents also lamented the difficulties of adivasis travelling to the Primary Health Centres (PHC) for testing and vaccination due to lack of transportation facilities. Added to these constraints is inadequate electricity and the lack of telephone and internet facilities, which further obstruct home-treatment through regular consultation with the physicians. Additionally, the issue of the health department handing faulty fever-screening devices to teachers and instructing them to concoct temperatures was raised by a teacher from a public school in Thuamul Rampur (a Fifth-Schedule area), Kalahandi. Concerned about the issue of ostracisation faced by adivasis suffering from COVID-19 owing to the dependence on common property resources for bathing and sanitation, he said:

Here, the stigma related to COVID-19 is causing further strain. People resort to ostracisation the moment they come to know that someone has tested positive. Villagers do not let the patient take a bath in the pond, carry water from tube well, etc. as they think that they too would catch the infection. The situation has become so bad that COVID patients take a bath and relieve themselves in the mid-night foreseeing violence.

The above account leads me to reiterate Scheper-Hughes’s (2015) point about the ‘silent death’ of poor tribals that remains hidden from the media. These deaths are not due to the deadliness of the ‘double mutant’ variant of the virus but due to systemic neglect and violence, as if their lives did not matter.

IV Discussion

From the entry point of treatment itself, we have seen ineptness and lack of compassion and care. This was visible as cases concerning the migrants in home-care were not being followed up, lack of testing, and then even basic facilities like thermometers were not being provided. These insights also point to the enclavist nature of health services as tests were confined to urban areas, COVID-19 hospitals and TMCs remained in urban locations, vaccine services also remained at PHC level rather than at sub-Centre or Panchayat levels.

But since the effects of public health service remain invisible, we can only visualise its potential. Untimely deaths of innocent tribals have occurred due to the unpreparedness in manpower training, corruption by public servants, crumbling of public health services and non-functioning of quarantine centres and TMCs. However, reporting in local media further added fuel to the fire by rendering tribals as recalcitrant traditionalists who did do not want to take the benefits of modern science and medical facilities. This process actually blinds us in our appraisal of the care-ethics of the state. Home treatment for the adivasis was an ill-conceived policy without ensuring electricity, high-speed internet connectivity and decongested dwellings. During home care, when COVID-19 positive adivasis used common property resources for taking their baths, they were subjected to ostracisation. There is systemic discrimination in terms of organising healthcare services, and simultaneously, the state persists in turning a blind eye to adivasis living in dehumanised conditions where they struggle to have access to basic resources like water, food, sanitation facilities and transportation.