Tribal health research in Orissa.
Orissa is situated on the eastern coast along the Bay of Bengal and constitutes 482 kilometer stretch of land with coastline, rivers, mighty waterfalls and dense forest of eastern ghats with rich wild life. The forest-cover (including tree cover) was estimated as 34.2% of the total geographical area of the state in 2001. The state has wide geographical variations and divided into four geophysical zones namely; Northern plateau and upland region, Central tableland, Eastern ghat region and the Coastal belt.
A considerably large segment i.e, 22% of the Orissa's population comprise of tribals who inhabit in all the above four zones in their traditional dwelling places of remote rural areas, in the deep forests and hilly interiors. Of all the states of India, Orissa has the largest number of tribes; as many as 62 of 645 tribal categories, of India. Majority of these tribes inhabit in the eastern ghats hill range, which runs in the north-south direction through Mayurbhanj, Sundargarh and Koraput districts of the state. Though all the districts of Orissa have tribal populations; some have a huge presence, while some have only a handful of tribals. Koraput, Mayurbhanj, Rayagada, Kalahandi, Nawrangpur and Malkangiri are few districts where more than half of the population is tribal. Of the 62 tribes, few tribes are in a better economic position and are well mixed up in the modern society, whereas there are many who lead a completely secluded life and are still primitive in their social development with differences in their culture, traditions, language and rituals, there are 13 such primitive tribes in the state who need special attention.
Out of the total region of the state, the undivided districts of Koraput, Bolangir and Kalahandi (known as KBK districts), which have been divided into eight districts since 1992-93, are considered as a multifaceted backward region due to hilly terrain, poor communication and natural calamities. Severe droughts and floods also hit this region in quick succession. As per 2001 census, about 38.41% people of these districts belonged to Scheduled Tribes (ST) including four primitive tribal groups (PTG), i.e., Bondas, Didai, Langia Sauras and Dangaria Kandhas. As per an estimate (1999-2000 NSS data), 87.14% population in southern Orissa are below poverty line (BPL) and literacy rate (43.33%) is much lower than the state average of 50.50%. The ST population suffers from high morbidity on account of under-nutrition, endemic malaria and other infectious diseases. The widespread poverty, illiteracy, malnutrition, absence of safe drinking water, poor sanitation and living conditions, poor maternal and child health services and ineffective coverage of national health and nutritional services have been traced out in several studies as possible contributing factors towards the health conditions prevailing among the tribal population.
ICMR's Regional Medical Research Centre (RMRC), Bhubaneswar conducted multidisciplinary research studies over two decades on prevailing communicable and non-communicable diseases; such as malaria, viral hepatitis, diarrhoeal disorders, haemoglobinopathy and allied disorders in tribals in the state and neighboring areas. It also provided support to the State Health Department and national programmes in disease surveillance activities, epidemic investigation, referral diagnosis, programme evaluation and manpower training. The Centre undertook HRD activities in the form of training and research to post graduate students for Ph.D/MD degree, MSc. dissertation and short term training to doctors and technicians from state health departments and National Vector Borne Disease Control Programme (NVBDCP), Delhi, who could be subsequently engaged in different health programmes in the state including in the tribal areas.
The highlights of research activities undertaken by Regional Medical Research Centre, Bhubaneswar as well as the future research prospects are highlighted in the present write-up.
Orissa records very high morbidity and mortality due to malaria, mostly reported from eastern ghat region affecting tribal population. Hence several surveys were conducted in the region to assess the malariogenic indicators, chloroquine sensitivity pattern, parasite population and vector species.
Survey amongst four primitive tribal groups (PTG) during 2003 revealed high slide positivity rate (9.5 to 14.2) with Plasmodium falciparum rate ranging from 91 to 93.5% and spleen rate in children from 25 to 35%. Susceptibility of P. falciparum to chloroquine in seven tribal dominated district was studied in vivo during 2005-09. The study revealed chloroquine treatment failure in 58-100% cases. Accordingly state control programme has adopted the second line of antimalarial drug i.e., artesunate based combination therapy (ACT) in all the reported areas, to be used as the first line drug in treating malaria.
P. falciparum was seen as the most important species causing high mortality in the tribal areas, P. vivax being the next common prevalent species causing morbidity. For the first time RMRC has also reported P. ovale infection in three tribal patients from two hilly tribal villages of Koraput district. Another study (2009) undertaken in tribal dominated districts revealed 8.3% of the blood samples to be positive for P. malariae by microscopy while P. malariae was shown in 44% cases by using polymerase chain reaction.
Diarrhoeal disorders are being observed both in costal and tribal regions of Orissa. Although the magnitude of the illness is more in the coastal belt, the morbidity and mortality becomes more when it affects the tribal population because of remoteness of the area and lack of health awareness in the population. In a cross sectional study (2002-03) conducted in 4 primitive tribes of Orissa, the diarrhoeal diseases were shown to occur throughout the year attaining its peak during the rainy season. Bacteriological investigations of rectal swabs revealed Vibrio cholerae (2.5%), Escherichia coli (39.2%), Salmonella (0.2%) and Shigella species (1.8%) in culture positive cases. This was attributed to poor hygiene, lack of safe drinking water, low literacy, blind cultural beliefs and difficulty in accessing to medical facilities.
A severe diarrhoea outbreak due to V. cholerae occurred during July to September, 2007 in six tribal blocks of four districts of Orissa in the KBK region affecting more than one lakh tribal population with 162 deaths. The causative organism was V. cholerae 01 Ogawa biotype El Tor with ctxB gene of classical strain which is otherwise designated as hybrid V. cholerae 01. The Centre investigated the outbreak and timely reporting and water sample testing helped to take quick preventive measures. Following the epidemic, the risk prone areas were put under surveillance to check further spread.
Anaemia and Haemoglobinopathies
The tribal population of the region is affected by both nutritional anaemias and haemoglobinopathies. Studies were undertaken to look for the prevalence of anaemia, worm infestation and haemoglobinopathy disorders like sickle cell disease, thalassaemia and G6PD deficiency. In a study (2002-03) the overall prevalence of anaemia was observed to be 53.1, 60.5, 52.1 and 44.6% among Bondo, Didayi, Kandha and Juanga populations respectively. G6PD deficiency was observed in 0.6, 1.6, 7.5 and 4.3% of Bondo, Didayi, Kandha and Juanga population respectively. All of them were G6PD Orissa mutant variety.
One of the important causes attributed towards the prevalence of high degree of microcytic hypochromic anaemia was the high incidence of helminthic infestations largely due to hookworm. After intervention of iron (fersolate; 60mg elemental iron) with albendazole along with IEC activities, there was improvement in anaemia in the above PTGs.
The distribution of sickle cell disorders varied from 0-22.4% among 20 major tribes in Orissa. It was high among the Gond (22.4%), followed by Bhatra (18.1%), Paraja (14.8%), Kharia (7.4%) and Saora (7.3%), while Bhuyan, Kissan, Kolha, Lodha and Oraon did not have this disorder. The distribution of 13-thalassaemia showed 0-8.5% variation among them and high incidence of thalassaemia trait was noted among Paraja (8.5%), Santal (8.0%), Lodha (6.7%), Bhatra (6.6%), Kondh (6.3%) and Saora (6.2%). Low frequency of sickle cell gene was found in Bondo (0.6%), Didayi (3.2%), Juang (1.3%) and Kutia Kondh (1.5%) tribes of Orissa.
Hypertension, commonly ascribed as a modern disease and related to life style change, is quite common (above 50%) in some tribal population of Orissa. This indicated change in life style and risk for non communicable diseases in these population who are away from the developments.
Morbidity survey of 3 PTGs, from 3 districts has shown that pre-hypertension was present in around 48% population with stage 1 hypertension in 4.5 to 9.1 % individuals. Lanjia Saura population had high prevalence of hypertension (63% among men and 68% among women).
An attempt was made to look for microalbuminuria (a marker of kidney disease) and hypertension in tribal population of the state in a pilot mode, in adults above the age of 18 years from 17 tribes of 13 districts of Orissa. Systolic hypertension was detected in 5.4% people where as diastolic hypertension was detected in 68% people studied. Microalbuminuria was present in 27% of the tribal population and 37% hypertensives were shown to have microalbuminuria.
Since some of the primitive tribes are endangered with low population growth or declining population, it was felt important to address issues like hepatitis infection which has the potential to cause high mortality. A study was conducted to know the prevalence of hepatitis (A, B, C, D and E viruses) infection in five primitive tribes; namely Lodha, Saora, Mankidia, Khadia and Juanga. The prevalence of HBsAg was 0.8 to 3.7% of the population studied. It also indicated that magnitude of tribal population in the window period with detectable antibody to core antigen (Anti HBc) was 1.5 to 10timesthatof HBsAg prevalence. HCV infection was significantly high (13.4% and 8.47%) in two tribes. Tattoing, sharing of razor and multiple injection were the possible risk factors for transmission of hepatitis B and C virus in the primitive tribes.
Malnutrition is a major contributor towards low health indicators in tribal population. The Centre has addressed different dimensions of this condition from dietary assessment to macro and micronutrient deficiencies for more that fifteen years. Eleven tribes and castes have been studied from ten tribal dominated districts from all ages including children, elderly and adolescent girls.
The studies indicated undernutrition in more than 50% population in most of the tribes. The health and nutritional status of Dongria Kondh Primitive Tribal Group population was assessed in Niyamgiri hill tracts of Rayagada district (2006). Diet surveys by 24h recall method indicated that in about half (51.3%) of the households the consumption of cereals and millets was less than the recommended dietary intake (RDI). Mandua was the main source. The mean intake of pulses and green leafy vegetables was also inadequate The proportion of Dongria Kondh children with underweight was 66.7% of which 38.1% were with severe underweight. It was higher in comparison to Domb caste population in the area.
Nutritional assessment of elderly (2000-02) population covering 4 major PTGs from 8 districts indicated chronic energy deficiency (CED)in about two-third of individuals and three episodes of illnesses were recorded per individual in average, where illness pattern was also enumerated.
The prevalence of anaemia (WHO criteria) among various target vulnerable groups ranged from 76% in preschool children and adolescents, to 85% in school age children.
For control of anaemia in adolescent girls, a 5-arm regimen approach is being tried in Saura girls of Gajapati district to assess the efficacy of iron and folic acid administration combined with deworming, vitamin B12 and nutrition education through existing Integrated Child Development Services (ICDS) network for sustainability, which is under evaluation.
Disease Outbreaks in Tribal Areas
State Health Department records many episodes of sudden deaths and undiagnosed deseases from remote tribal areas. Majority of them remain undiagnosed. Some of the outbreaks were investigated by the Centre and causative agent identified and recommendation made to State for effective control measures. Meningococcal meningitis from Koraput (1986), Chandipura encephalitis from Kandhamal (2009) and Vibrio cholarae hybrid strain form 4 districts of KBK region (2007) were the major outbreaks that caused high mortality.
Future Research Prospective
Different health and nutritional programmes are well designed and being implemented in the state. In spite of these, the Millennium Development Goals are not expected to be attained in the targeted period, more so in the outreach areas like KBK region. It is therefore, being planned to look for opportunities to improve interaction and collaboration among the programmes for more effective delivery of health services at the household level so as to expedite the health improvement.
It is planned to develop strategies for interruption of transmission of HCV and Vibrio cholerae infection in the tribal population and translate it into the health programme. Considering the possibility that hypertension in tribal population may become an emerging threat, a study is planned to find out the genetic and social factors, etc. and formulate strategy for prevention of hypertension in the indigenous population.
A field unit of the RMRC, Bhubaneswar has been established recently in KBK region; i.e. in Rayagada district for formulation and evaluation of strategies to control the most common epidemics / outbreaks of the region and to undertake comprehensive studies for improving the health conditions of vulnerable sections of population.
Some of the major future research strategies planned by the RMRC for improving health and well being of the tribal population in Orissa are highlighted as under:
Finding etiology of recurrent diarrhoea episodes in three tribal districts of Orissa and developing an intervention strategy
A study has been planned to investigate the etiology of diarrhoea in three southern tribal dominated districts of Orissa (Koraput, Raygada and Kalahandi) with past history of outbreak of acute severe diarrhoea. It is planned to identify the socio-behavioural and geographical risk factors and bacteriological profile of the causative agent so that strategy can be formed to prevent repeated episodes of outbreaks, diarrhoeal morbidity and mortality, the strategy will be translated into the local health programme.
Hypertension and its intervention in tribal community
In recent past National Nutrition Monitoring Bureau carried out surveys on hypertension in the tribal population. The prevalence of hypertension was maximum in the state of Orissa (Men:53.8%;women 48.8%). It reflects that tribals are now at risk of both communicable and non communicable diseases which need special attention before it yields progressive bad outcomes. Hence, a pilot project is being planned to identify the risk factors and suggest a preventive strategy to control hypertension.
The study will be based on collecting information on demography, nutritional and clinical assessment as a prospective cohort study/focusing on modifiable and non modifiable risk factors to formulate a social strategy which can be translated into practice.
Improving the interaction between maternal and child health and nutrition programmes in tribal population of Orissa
A community based intervention study is planned to see the impact of holistic and sustainable interventions on health and nutrition by convergence of the vertical programmes through participatory approach.
The study would aim at improvising the methods to address Millennium Development Goals i.e., reduce maternal and childhood mortality, especially in tribal dominated far to reach areas. Situation analysis will be carried out to design a formative strategy for implementation of interventions and subsequent analysis of outcome. The study will have in-depth assessment of programmes on child health and nutrition. Interventions will be based on interagency collaboration on day-to-day activities of workers at grass root level.
Strategy for prevention of hepatitis C virus infection in endangered tribes
A recent study addressing hepatitis virus infection among five primitive tribes indicated very high prevalence of HCV infection in two primitive tribles (Mankidia and Juanga). These tribes are primitive in their socio economic and cultural front and their population growth is either low or declining. Possible risk factors for spread of this infection has been studied in a cross sectional mode, which can be analysed in-depth pertaining to the socio-cultural behavior and amenability to change. This can form the baseline for developing an intervention strategy to curtail transmission of infection in the tribes. This study can be applied and translated into use by the national health programme that focuses on tribal health.
These strategies are some of the future research proposals identified by the Centre. However, these are not the ultimate and research as well as surveillance activities will continue to find solutions to the present and upcoming challenges in the tribal health like identification of health priorities and major causes of maternal and child mortality, approaches for primary and secondary level prevention of endemic diseases, etc. The knowledge generated from such programmes will be translated into action by enhancing linkages with the state health system.
This write-up has been adapted from the publication entitled "Tribal Health Research in Orissa" brought out by the Regional Medical Research Centre, Bhubaneswar, as part of ICMR Centenary Celebrations.