An indigenous healer preparing herbs for a mixture. Credits: Mira Kudva Driskell, NFLC 2017
Many indigenous communities, such as those within the Nilgiris Biosphere Reserve (NBR), experience health and wellbeing levels below the national average. The various tribes of the NBR, collectively referred to as “Adivasi”, the South Indian term for “indigenous”, suffer as the health disparity continues to widen, fueled by a gap in healthcare services. Inequalities in health and health care must be addressed for the good of all; as stated by the United Nations, “ensuring healthy lives and promoting well-being for all at all ages is important to building prosperous societies” (United Nations, 2017). This has been one of the Keystone Foundation’s goals to improve Adivasi wellbeing.  At Keystone’s Nilgiris Field Learning Center, my partner, an Irula student named Abinaya Devi, and I conducted an ethnographic study in two areas settled primarily by the Irula tribe. Our initial goal was to evaluate the efficacy of Keystone’s community health worker programs, but ultimately we shifted focus and concentrated on delineating the underlying factors that have led to poor health and wellbeing in indigenous communities.
Our observations underscore the strong bonds between indigenous communities and their lands, both in the NBR and around the globe. Environmental changes within the NBR are the result of a series of historical policies established by British colonizers and, subsequently, the Indian government. Whether the value of land is determined by measures of commercial profit or biodiversity, policies have consistently marginalized indigenous communities and disregarded or explicitly barred traditional indigenous practices associated with their native lands, such as slash-and-burn agriculture. Policies dating back to the 1800’s have resulted in loss of indigenous lands, usufruct rights, and traditional livelihoods. These changes to the land have degraded indigenous Irula identity and, ultimately, undermined the health and well-being of the Irulas (Parthasarthy, 140).
Recent droughts and increased exposure to non-indigenous groups weaken Adivasi community identity and contribute to poor health status. Despite acute stresses, the public healthcare system remains inaccessible to the Adivasis of the NBR. This inaccessibility is caused by discrimination and policies which inadvertently marginalize indigenous communities and their culture, echoing historic land use policies. Efforts to improve communications between the Adivasi tribes and government institutions must be made to increase accessibility to the public healthcare and to ameliorate socioeconomic and socioecological conditions.
Traditional way of life and historic pressures in the NBR

Annai Nerunji: Used by indigenous healers to cleanse blood. Credits: Shaalini Ganesalingam, NFLC 2017
Historically, the NBR has been home to several Adivasi tribes with linguistic evidence suggesting the Todas, Kotas, Irulas and Kurumbas, have been settled in the reserve for at least 2000 years (Zvelebil, 7). Although these tribes lived in geographically separate areas with limited contact with each other, they developed a trade of goods and services such as ghee, sorcery/healing, metal tools, honey, and resins. This trade not only forged strong economic and cultural relations between tribes but also demonstrates the importance of native lands and ecosystems to the livelihoods and well-being of the indigenous tribes.
While the semi-nomadic Irula tribe did receive goods through trade, their primary means of subsistence was through hunting and gathering non-timber forest products (NTFPs) in the lower-altitude subtropical forested areas (Blue Mountains, 285). Likely influenced by the peoples settled in the plains below, the Irulas developed intensive slash-and-burn or “swidden” agriculture. They would use tools made by the Kotas to cut down and burn select patches of the forests until only nutrient-rich ash remained. After a ritual worship of the Būmi Tāyi, or Mother Earth, the fields were sown. Typically, the plots would be cultivated for one or two seasons before being laid to fallow for three to five years (Zvelebil, 80). According to Henry Harkness’ observations in 1832, Irula gardens grew bananas, edible roots, jackfruit, chili, lime, and orange plants (Blue Mountains, 285). Additionally, the Irulas grew Italian, little, and finger millets, dating back to Neolithic times (Blue Mountains, 292-293).
The traditional way of life in the NBR has since been uprooted by historical policies implemented by the British and later the Indian government which directly or indirectly affect Adivasi connections to native lands. Since the late 1800’s, the British, valuing the commercial potential of the NBR, introduced several non-indigenous plants, such as cinchona, eucalyptus, coffee, and tea, which destroyed and continue to destroy the complex native ecosystem. For example, eucalyptus, originally introduced from Australia for commercial oil extraction, outcompete native plants for water, draining their soils of moisture. But it is the tea that arguably has had the greatest impact on the NBR’s hills, which have been blanketed by tea plantations since the 1960’s.
As the NBR hills suffered biodiversity loss and non-indigenous flora invasion, its native people also suffered from loss of rights and erasure of identity. To protect their commercial interests, the British created policies which denied Adivasis their land and usufruct rights to practice slash-and-burn agriculture, practice colonists felt wasted fine timber resources.  With the destruction of native ecosystems and the loss of land rights, Irulas could no longer sustain themselves through hunting, gathering, or subsistence agriculture. They became coolie laborers at tea plantations. The Adivasis (mostly Kurumbas and Irulas) began to fill the holes of their lost, land-based cultural traditions with those of the lower-caste, “untouchable” Tamils, recruited from the plains to work in the plantations alongside the indigenous workers (Zvelebil, 34, 83).
The Adivasi community felt limited change under Indian government rule, which continued to bar many traditional practices, particularly NTFP collection, not for commercial purposes but rather for the sake of conservation. Yet, analogous to the cultural diffusion of Adivasis during colonial era, indigenous culture was further adulterated by the second wave of wage labor workers who arrived from Sri Lanka under the Indo-Ceylon Agreements of 1964 and 1974. Within twenty years of the arrival of the first wave of migrants coming to the Nilgiris for plantation work, non-indigenous individuals outnumbered indigenous inhabitants (Blue Mountains Revisited, 153; Parthasarathy, 140).
The wellbeing of communities today
The destruction of the NBR is not only an environmental issue but also a social and health issue. The historical loss of livelihoods through regulation and the destruction of native ecosystems has translated into a loss of indigenous identity that can be observed today.  The Symposium on the Social Determinants of Indigenous Health held in Adelaide, Australia in April 2007 recognized “the disruption or severance of ties of Indigenous People to their land, weakening or destroying closely associated cultural practices and participation in the traditional economy essential for health and well-being” as a fundamental health determinant for indigenous communities (King et al., 76).   Our ethnographic study illustrated this claim’s validity in the NBR. Compounded by recent droughts and increased connection to the non-indigenous communities due to technological advances, the Irula and other Adivasi tribes are culturally and socially in flux.
Since the first wave of changes initiated by the establishment of plantations and the resulting immigration of non-Adivasi laborers, indigenous identity within these communities have gradually faced erasure. With the recent droughts and increasingly frequent elephant raids, another wave of cultural change is occurring within the NBR, fueled by financial necessity. As traditional millet farming has further become a gamble and rice, provided first under the Target Public Distribution System (TPDS) and later under the Antyodaya Anna Yojana (AAY) scheme, has become a culturally and economically effective grain substitute, Irulas no longer cultivate millets and other crops as their primary livelihood (dfpd.nic.in). Additionally, while subsistence agriculture and the gathering of forest products were sufficient for previous generations, today Irulas increasingly depend upon the goods and services offered through the cash economy. They turn to the only monetary jobs available to them – employment on regional tea and coffee estates, construction work as part of government 100-Day schemes, and other forms of manual wage labor. As the droughts catalyzed socio-economic changes that have been gradually occurring over the past several years, the Adivasi tribes have seemingly experienced a resurgence in awareness of and concern for the lost way of life. The conversations Devi and I had with villagers during our research has made it clear this cultural erasure because of the loss of land, land-based livelihoods, and cultural practices has affected unity within the villages and ultimately tribal health and wellbeing.
With the historic loss of lands and traditional livelihoods, the Irulas face socio-cultural stress. Many villagers we spoke to describe the loss of unity amongst villagers within the past generation, the primary cause of which is the shift in livelihoods. While villagers historically worked together to farm plots of land near their villages and made equal yield shares, the shift to the cash economy has resulted in monetary inequalities leading to the questioning of traditional Irula social hierarchies through kullangal or clans. This lack of social cohesion amongst the villagers has had two main negative health implications. First, it has led to the neglect of community needs. One young mother in a village described how the village waterways were not being cleaned because community members refused to work together. She noted that the traditional village leader lacked sufficient respect and authority to gather villagers for the task. The algae and debris polluting the waterways are significant health hazards, particularly for younger children–including the woman’s infant. Second, the neglect has affected the spiritual wellbeing of villagers. Several villagers in both areas felt that their deities have abandoned them because social and economic tensions have resulted in a failure to conduct religious festivities. The droughts only confirm their fears.
Changes in health-seeking behavior

Chart showing Keystone Foundation’s Community Health Worker (KCHW) Intervention. Credits: Drawn by Shaalini Ganesalingam with data from Ganesalingam and Abinaya, NFLC 2017
The social issues described by the villagers not only serve as a testament to how poignant the loss of native lands can be to the wellbeing of indigenous communities but also highlight how this loss affects traditional understandings of health and healthcare. The Irula understanding of health accounts for two origins for ailments: physical and spiritual. While physical ailments are not different from those described in allopathic understandings of health, spiritual ailments, manifesting as physical symptoms, are deemed to be caused anthropogenically or by naturally occurring spiritual entities.
Women from an Irula village described two spiritual winds or kaatrugal. Muni kaatrugal are naturally occurring and cause dysentery and vomiting. They are easily cured through certain manthirangal (mantras) and herbs. Kurumbar kaatrugal are more formidable. Created by members of another local indigenous tribe known for its black magic, the Kurumbas, their effects cannot be cured. Two women from different areas explained that their family members became fatally ill due to curses believed to be commissioned by jealous neighbors. While these curses and winds have been prevalent amongst Irula communities for as long as current generations can remember, they are particularly concerning today because of the loss of traditional livelihoods and subsequent rise in social disunity. It is likely that villagers are increasingly blaming their illnesses on curses by fellow villagers because of the rise in inequalities within the village.
This, in turn, impacts healthcare-seeking behavior. Villagers who believe their illnesses are the result of curses seek treatment from indigenous Irula healers that offer pachai marundhu or green (herbal) medicine. After diagnosing patients by reading ink rubbed into betel leaves, healers provide mooligaigal (mixtures of medicinal herbs) and kasaayangal (herbal broths). One healer we spoke to claimed he had 5,400 mooligaigal in memory and could cure various physical ailments including diabetes, kidney stones, and inconsistent menstrual flow, in addition to spiritual ailments.
An indigenous healer explained that while outsiders continue to interact with him primarily for curing physical illnesses and improving an individual’s fortune, village members are no longer seeking traditional healers in the same numbers. Currently, 20-25 asaloor (non-local) people come to him each month, however, few village members request his service. He contended it was because villagers had recently developed “too high of an ego” to seek help from each other.
While “large egos” are a rather simplistic explanation for the change in usage of indigenous healthcare, it is not entirely dismissible. It intimates the influence of the increasing exposure to non-Irula society, its understanding of health and its healthcare system. Younger generations with greater exposure to non-indigenous society embrace allopathy, viewing their indigenous spiritual understandings of health as mooda nambikai or false belief. For the most part, however, rather than replace indigenous systems of health and healthcare entirely, the allopathic health care system has only been able to create a semi-porous dichotomy of health understanding within the Irula community.  Most Irulas, including most migratory wage labor workers who were not institutionally trained in the effectiveness of allopathy over pachai marundhu, are less likely to completely disregard indigenous healthcare. They are inclined to choose one system over the other or both depending on the accessibility of treatments for both systems in terms of cost, opportunity cost, distance, and time. It may even be argued that the perception of the origins of illnesses (“physical” or “spiritual”) is based on the availability and accessibility of these treatments.
Villagers informed us that the public healthcare system has been made more accessible in recent times. This is largely a result of two main public health interventions: first, the rise in mobile units, bringing free allopathic healthcare to historically isolated villages; and, second, the rise in Accredited Social Health Activists, commonly referred to as ASHA workers. Villagers turn to allopathy not only as the less expensive, but also the perceivably more effective, health care option. Many villagers disclosed that they would go to the hospital for certain illnesses, such as headaches, to get quick relief. A few patients told us that they would feel better instantly upon taking medicines. Ailments that are prevalent in tribal populations, particularly anemia, have become “brand ambassadors” of allopathy. We met several self-diagnosing villagers who explained to us that they just needed to get a little bit of blood. Despite advances in acceptance, public healthcare remained vitiated by barriers towards accessibility.
As health and community wellbeing continues to decline under cultural and socio-economic instability, the public healthcare system remains largely inaccessible. While the government is developing policies to alleviate identified underlying determinants of poor indigenous health, such as the provision of patta (or land rights), healthcare requires reform to bolster relations and treatment effectiveness among the Adivasi communities. During our visit to a primary health care center in one of the study sites, the leading doctor explained that her biggest challenge with tribal patients is that they often do not follow through on their allopathic treatments. Patients often take the medicine irregularly, do not attend checkup appointments, and refuse to visit tertiary hospitals to which they are referred. Frequently, patients abandon their allopathic interventions for traditional healers or temples. Others choose to carry out both forms of intervention simultaneously. While the herbal remedies of pachai marundhu rarely have any negative affect, some individuals carry out certain rituals at temple that can be physically straining.
Public healthcare workers find patients’ inconsistent behavior challenging, yet most villagers expressed that inconsistencies in healthcare and healthcare delivery caused their limited commitment and confidence in allopathy. We repeatedly heard two main concerns: first, that the public triage system in which patients visit primary health care centers (PHC) and are then referred to tertiary centers makes health inaccessible given opportunity costs of losing several days of work and transportation costs; and, second, while discrimination is now less explicit, it is not yet absent from the public healthcare system. In addition to several accounts of discrimination from villagers, I observed it firsthand during a field visit to one PHC, during which the leading doctor bluntly stated that Adivasis have low IQs. This mistreatment is one of the biggest deterrents for seeking allopathic care, according to many Irula individuals we spoke with.
Today, efforts are being made to bridge gaps in healthcare by both government and private organizations such as the Keystone Foundation. Working with The Banyan, an NGO providing mental health care, Keystone launched a program last year training village members to become Keystone’s community health workers (KCHW). The program helps support communities by improving accessibility to healthcare and targeting underlying factors that influence health and wellbeing.
KCHWs enable villagers to seek allopathic care by providing basic allopathic knowledge, ensuring patients take their medication regularly and consistently attend checkups. KCHWs versed in a patient’s history relay essential information to the various doctors that see patients during checkups. Trusted as village members and as employees of Keystone, an organization well known in the communities, they offer the invaluable service of translating illness for villagers across traditional and biomedical lines.
Beyond providing biomedical support, KCHWs are trained to identify social and economic underlying factors influencing community wellbeing. They help secure financial stability for vulnerable families by helping individuals apply for government financial support. Additionally, KCHWs often provide social support for ailing community members through encouraging conversations and, in certain occasions, rallying community support. In one village, a KCHW arranged an informal meeting with women in the village to discuss ways in which they could help prevent a woman recovering from a cesarean operation from suffering further physical abuse by her husband. This more holistic approach to healthcare, identifying and resolving several indirect factors, such as sources of psycho-social stress and cultural loss, can make allopathic treatments more effective and prevent illnesses.

Going from one village to the next with a Keystone Community Health Worker (KCHW). Credits: Shaalini Ganesalingam, NFLC 2017
While KCHWs are providing a significant service to their community, there are still gaps in service that they have the potential to provide. Given that they have been working in communities for less than a year, it is not unexpected. Keystone also intends for KCHWs to reduce stigmas related to certain illnesses, particularly those related to mental health. Although further training is required, KCHWs’ work towards destigmatizing mental health will be invaluable to patients in Irula village communities built on strong traditional social networks.
Perhaps the biggest potential lies not in an intervention targeting the tribal communities but in the simultaneous provision of a channel of communication to allopathic as well as other public services. Community health has a historical basis and is affected by several factors such as land and identity loss. Yet few, if any, institutions are working to educate the government on the underlying determinants of well-being found in Adivasi communities. Deficits in cultural understanding can make well-intentioned policies, such as the triage system, ineffective. Even non-healthcare-related policies can have detrimental health effects. For example, although rice rations enabled Irulas to withdraw from failing millet farming, the poor nutritional value of this ingredient compared to traditional staple foods leads to malnourishment and the “ambassador illness”: anemia. Moreover, existing policy barely addresses the limited occupational mobility of adult Irula day laborers and associated socio-economic stress.  As the program continues, it would be invaluable to create a means of sharing KCHWs’ growing experiential knowledge with local healthcare providers and government agencies to promote informed policies that address indigenous concerns.
The tribes of the NBR, not including the Badagas, are recognized by the government as having “scheduled tribe” status, denoting the most socioeconomically disadvantaged tribal communities within all of India. The decline in community wellbeing that plagues the indigenous communities is historically based in the loss traditional livelihoods of hunting, gathering, and swidden agriculture to environmental degradation and government policies that have marginalized the Adivasi tribes. As current droughts exacerbate existing trends of lost customs, diets, livelihoods, and indigenous beliefs, villagers are perceiving social cohesion at an all-time low.
Not only are the rising socioeconomic pressures threatening Irula way of life, they are also altering the utilization of indigenous health care, with certain services offered by indigenous healers being replaced by public allopathic services that are competitive in terms of accessibility, availability, and perceived quality. However, our research shows public health care falls short of effectively serving the Irula communities because of discrimination and lack of understanding of Irulas and their concerns. Future efforts must focus on creating platforms to increase awareness of underlying indigenous determinants of health and of indigenous understandings of health and health care to reduce stigma, improve accessibility, and create better informed public policies.
 
Shaalini Ganesalingam received a bachelor’s degree in International Agriculture and Rural Development from Cornell University. She is currently living in New York City.
Abhinaya Devi lives in the Aracode Valley, Nilgiri Biosphere Reserve. After her 12th grade she has successfully completed the NFLC course (class of 2017). She is currently pursuing a government recognised nursing degree from the Gudalur Adivasi Hospital.
Email: kf@keystone-foundation.org
 
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