Suchismita Mishra, Yadlapalli S. Kusuma, Bontha V. Babu:
Concepts of health and illness: Continuity and change among migrant tribal community in an Eastern Indian city
Concepts of health and illness: Continuity and change among migrant tribal community in an Eastern Indian city
Suchismita Mishra
Sambalpur University, suchismita44@gmail.com
Yadlapalli S. Kusuma
All India Institute of Medical Sciences, kusumays@gmail.com
Bontha V. Babu
Indian Council of Medical Research, babubontha@gmail.com
Abstract
As a community acculturates, health and illness concepts undergo change; yet communities continue to hold to their native logic, beliefs, perceived causes, recognition and classifications of illness and subsequent management of them. We studied these concepts among a migrant tribal community living in the slums of Bhubaneswar, an eastern Indian city. In-depth interviews were conducted with specifically selected community members, key informants and traditional healers. The community's perspectives of illness and its causes; and how the continuing cultural concepts and acquired modern knowledge and culture contact due to migration influence treatment seeking for various illnesses are discussed. The need for strategies for optimum utilisation of healthcare services is emphasised.
KEYWORDS: indigenous medicine, ethnography, migration, acculturation, beliefs, perception, India
Introduction
The World Health Organization has defined health as a state of complete physical, mental and social well-being (World Health Organization 1980). However, the meanings and perceptions of health, illness and health-seeking behaviour are not the same across cultures. Some scholars have reported that among tribal ethnic groups, health is seen as a functional rather than a clinical concept (Mahapatra 1994). As a cultural concept and as a part of social structure and organisation, the meaning of 'health' continuously changes and adapts itself to changes in the wider society. Perception, the process by
ANTHROPOLOGICAL NOTEBOOKS 19 (3): 61-69. ISSN 1408-032X
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which information is gathered and interpreted (Marshall 1994), is central to the analysis of social phenomena, and cultural analysis is crucial to the planning and implementation of health care services (Richman 1987; Raharjo & Corner 1990; Caplan 1993; Last 1993). Hence, to deal with the concept of health and illness it is necessary to include the causes of illness, the treatment seeking behaviour and the utilisation level of health care services.
People living in slums are vulnerable to ill health due to low socioeconomic status and poor living conditions, which are unhygienic and conducive to infections. Low levels of awareness and lack of access to preventive and curative aspects of care aggravate the situation. This ethnographic study has been undertaken among a tribal community living in urban slums, which migrated from a hilly forest area over the last 12 years. It is hypothesised that the migrant community has been changing at a certain pace along with their concepts of health and illness. The change in the surroundings and eco-system of tribal people compounded with intrusion of non-tribal elements into tribal domain play a vital role in the changing tribal ethos, value system and worldview. Hence, the concept of health and illness in the context of migration and acculturation is investigated. The aim of the present study is to understand the concepts of health and illness among tribal migrants living in Bhubaneswar, an eastern Indian city.
Methodology
The present study was undertaken in Bhubaneswar, the capital city of Orissa, an eastern Indian state. Tribal-dominated slums were first identified after pilot study, and from them four slums were selected on the basis of predominance of a tribal community. These four slums are dominated by Santals, one of the major tribes of India. Most of the Santal families have migrated from hilly forest areas of Mayurbhanj district of Orissa state and a few are from its neighbouring districts and have been staying here for the past 12 years. All the households of the slums were enumerated, and information on the total number of family members, their age, education, years of living in the urban area and occupation from each household was collected.
In-depth interviews were conducted with the general community members (29 men and 21 women) and key informants (13 men and 13 women) in the slums. This tool is intended to access the perception of the community on the health and health care services. During the selection of key informants, the guidelines of Spradley (1979) and Hudelson (1994) were followed. Key informants are defined as the individuals who possess special knowledge and who are willing to share their knowledge with the researchers (Hudelson 1994). They have access to the culture under study in a way that the researcher does not have. The key informant is someone with whom the researcher develops a special relationship of information exchange. A set of criteria is used to identify the key informants, and those interviewed are willing to share the information with the researcher. Headmen of the slum, the members of elected bodies, community health workers, the shop keepers, and members of local administrative bodies were identified as key-informants. The check-list for key-informant interviews included questions on the general perception of health with regard to gender, the symptoms of an ill person in gender context, the diseases found in
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Suchismita Mishra, Yadlapalli S. Kusuma, Bontha V. Babu:
Concepts of health and illness: Continuity and change among migrant tribal community in an Eastern Indian city
their area and the beliefs related to those diseases, etc. The traditional healers were also interviewed (six men and one woman). All these personnel were selected after information gathered during the regular field visits of the researcher during the year 2007. Traditional healers were interviewed to understand the cultural perception of various diseases, for which illnesses people come usually to them, the treatment and care provided by them for various illnesses, gender differences, etc. All these in-depth interviews were conducted by following Pelto and Pelto (1978) and Lengeler et al. (1991). The mother tongue of Santals is Santali; however, all people knew Oriya, the local language of the state. All interviews were held in the latter language. Prior to interviewing, consent was obtained from each participant by explaining the purpose of the study. They were audio-recorded with the consent of the respondents, and were later transcribed, translated into English and entered into a database. Content analysis was carried by coding the data. The data were subjected to thorough and repeated reading. The data were coded while reading. The coded text was reorganised under various themes and inferences were drawn. The study protocol is approved by the doctoral committee of Sambalpur University, which reviews ethical issues while also approving the research programme.
Results
Concepts of Health
Every culture has its own distinct explanations of health and illness. In the Santali language, the sense of health was termed as beskinijabe. A person is considered as healthy if he/she is able to do the work expected as per gender and age. The physical appearance of body implies health as good or bad. Fever is the often cited example indicating bad health. According to the traditional healers, the running of nerves, pulse rate, colour of the urine, colour of the eye, etc. indicate whether one is healthy or ill. Weakness of the body also indicates ill health. Alcoholic intake is metaphorically cited as an illness in their community, owing to its consequences on family and community; it is also claimed that alcohol intake leads to several other diseases.
From the key informant interviews, it is revealed that health is not anything other than the present condition of the body. 'Health' means the physical condition, and it is no longer linked with the mental or social condition. When it was asked how their health was, almost all study participants said that their health was good as they had no fever. The absence of any disease or illness is termed as good health; if fever is present in the body, it is considered that health is not good. Thus, the concept of health refers only to physical health. Broadly, the concept of health and illness varied according to the gender owing to the physical structure of the body, in addition to gender-related roles in society. According to them, illness is attributed to more than one cause and, hence, they seek different types of treatment from different sources, depending on the type of illness.
Concepts of Illness
The informants described ill health as appearing dull, weak and turning dark, lack of appetite, sleepiness, the inability to walk, the inability to talk, startling movements,
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drowsiness, sunken eyes, pale and dry eyes, pain in the body, etc. Changes in the colour of urine and faster pulse rates also imply ill health. The symptoms of ill health for children are not taking food, lack of interest in play, sleepiness, hotness of the body and frequent crying. Physical characteristics such as pale colour of the body, rashes on the body, protruding belly and narrowing of buttocks also symbolise ill health.
Concept of health and illness, according to gender
We attempted to determine whether the health and illness concepts and prescriptions of the community change along gender lines. It was reported that as men and women possess sex differences, and as they differ in their physical characteristics, certain illnesses occur in women while certain others occur in men. The examples cited were men have hydrocele and women have menstruation-related illnesses such as white discharge (leucorrhoea) and stomach ache (phulbata). It is believed that women affected by phulbata cannot bear the child. Such women face severe humiliation in the community. Among men, some other diseases such as harris and garmi occur. In harris, men look weak and have dark circles below the eyes. In addition, whitish fluid oozes with urination. Garmi is the next stage of harris, and in garmi, wounds occur around the genitals and sometimes they bleed. Thus, they mainly acknowledged the differences in the illnesses experienced by men and women and attributed these differences to biological differences.
Types of illness
Illnesses are broadly categorised by the study population as mild and severe. However, the perception varied from the community members to the traditional healers. Severe illnesses are those that are thought to require medical treatment, and mild illnesses are those that do not need any medical treatment. Thus, illnesses that need urgent bio-medical intervention and those of long duration are considered to be severe illnesses. However, there are a few exceptions. For example, measles and jaundice are considered to be severe illnesses; however, modern medical treatment is not sought for these illnesses; instead it is believed and feared that if modern medical treatment is taken, the illness may recur and may even lead to death. Hence, only the traditional treatment by the traditional healer is sought for these illnesses; in the case of measles, seeking modern care is even a punishable offence in this community. The traditional healers reported that these illnesses recur if modern medical treatment is sought. It may also be noted here that for other illnesses the traditional healer himself advises people to go to the medical facility.
Illnesses with less pain and which occurs usually like cold, cough, and headache are considered to be mild illnesses. The evil-eye-related illness is also considered to be a non-medical type of illnesses, as it can only be cured by a traditional healer. People reported on the transmission of some illnesses. The concept of the transmission of diseases is gained from biomedical knowledge people gained through different sources. Thus, illnesses are also classified as transmissible illnesses (such as measles, diarrhoea, leucorrhoea, scabies, etc.) and non-transmitted illnesses. It may be noted here thatjaundice is considered to be a non-transmitted illness.
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Suchismita Mishra, Yadlapalli S. Kusuma, Bontha V. Babu:
Concepts of health and illness: Continuity and change among migrant tribal community in an Eastern Indian city
Traditional healers' primary classification of illnesses classified as 1) evil-eye-related illness and 2) non-evil-eye related illnesses. Again, the evil-eye-related illnesses can either be mild or severe. The mild evil-eye-related illnesses can be treated with herbal medicine along with chanting mantras; whereas severe evil-eye-related illness warrants animal sacrifice, and it is reported that the traditional healer has to put more efforts to remove the severe evil-eye effect for curing the illness.
Causes of illnesses
People perceived different agents and behaviours as causes of illness. There may be single or multiple causes for a single illness. The causes of illness are summarised in three groups:
1)	Supernatural powers as the causative agents: People have the belief that illness occurs if gods and ancestral spirits are unpleased with them, and also due to the evil eye, ghosts or jealousy; and if the person is frightened with fear, then also illness can occur. Everyone is considered to be in possession of a certain amount of supernatural power. It is believed that children are more vulnerable to the evil-eye. People believe that whenever someone remarks that the child is beautiful or healthy, the child immediately develops illness and becomes weaker. The evil eye is believed to affect not only children, but also adults. For instance, if anyone sarcastically or earnestly remarks that a certain person wears fine clothing, the evil eye begins to operate. Jealousy (hinsa), as a form of the evil eye is attributed to cause of illnesses, and such illness can only be cured by the traditional healer.
2)	Physical and non-supernatural sources as causative factors: In this category, illness is explained as being caused due to disobedience of natural laws. A number of physical or natural causes of diseases operate directly on the individual to produce illness. Some such causes as reported by the study population are as follows:
(i)	Due to food: foods that are considered to be hot in nature (such as non-vegetarian food, spicy, sour and oily food which are believed to develop heat in the stomach) are thought to cause illnesses. It is reported that not taking food in proper time results in disturbance of the stomach, and leads to illness. Alcohol intake is reported as one of the major causes of illness. The respondents felt that using fertilisers and pesticides in vegetable crops is another leading cause of various illnesses.
(ii)	Change of season: several illnesses (mainly the cold and cough) are attributed to seasonal changes.
(iii)	Working conditions: working under severe hot or cold or working in rain are reported to trigger illnesses.
(iv)	Change in usual daily routines: it is believed that if a person changes in usual daily routine such as changing the time of major meals, the time of bathing, improper sleeping time, etc. results in occurrence of illness.
(v)	Physical surroundings and pollution: people often reported and complained that their habitations/slums are surrounded by the city's garbage that is
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dumped by the municipality. They often said that they are free from illnesses in their native area, as the native place is free from such garbage dumps and dirt, as well as that the air is so fresh, and the water is pure. It is reported that many illnesses occur due to the urban living conditions and polluted water and air. It is reported that change of place leads to attack of illnesses.
3) Contagious agents of illnesses: Touching the clothes and food of the ill person is strongly believed to cause certain illnesses. It is also reported that vectors such as mosquitoes and flies often transmit various diseases such as malaria. In addition to these, unwanted behaviour of the people is thought to be contagious in transmitting the illnesses. People stated that human behaviour that is against the cultural norms as one of the major causes of illness, including measles and other illnesses. It is also reported that having sexual contact with an ill person results in illness. People also mentioned that some diseases are hereditary in nature.
Discussion
In every society, a substantial and integral set of beliefs, knowledge and practices is related to the significant life experiences of health and illness. This is clearly visible in the present study. Tribhuwan (1998) observed that disease aetiology is an indispensable indigenous medical phenomenon of any community and precisely stems out from the meaning system (culture). In this study, people viewed health as the ability to work as per prescribed roles. Weinert and Long (1990) defined illness in terms of work. They found that people performed their work well are described as healthy even in pain or suffering from chronic illness or a life-threatening disease. Work roles are determined according to gender; thus the place and nature of work differ according to gender. Weinert and Long (1990) suggested that in a role performance model health focuses on the individual's ability or lack of ability to perform key roles, especially those associated with work and family responsibilities.
In the study community, health is seen as a person's ability to work according to his/her role; sleeping well, having a healthy appetite and being active. Illness is identified as a condition that interferes with normal daily activities. The study community reported various symptoms of illnesses where physical inactiveness is the central factor. In this regard, Foucault (1973) described that the symptom is symbolic of the activities that occur inside the body of the sick. The signs of sickness are actual signs of truth, and the symptoms themselves resemble a symbol of the illness. Symptoms provide the sick person and the practitioner an opportunity to understand the cause of an ailment. The symptom is the form in which the disease is presented (Foucault 1973).
The association between social, cultural, and economic factors and health has been reported extensively. In the study population, health and illness are viewed from the cultural point of view. The cultural interpretation is seen even for the illnesses for which the community accepts the modern biomedical; thus, the concepts are not separable from their native logic. The illnesses are classified on the basis of cultural explanation (for example, perceived aetiology) and severity. The treatment-seeking behaviour is often
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Suchismita Mishra, Yadlapalli S. Kusuma, Bontha V. Babu:
Concepts of health and illness: Continuity and change among migrant tribal community in an Eastern Indian city
based on this classification of illnesses. Green and Britten (1998) showed that subjective meanings influence how patients integrate treatments with everyday life, and other studies have also shown that lay beliefs about medication differ from standard biomedical interpretations (Jones 1979; Donovan & Blake 1992; Verbeek-Heida 1993; Marinker 1997; Conrad 1985; Mishra et al. 2012). Cultural ideas play a central role in determining who needs medical care, when and for what conditions/illnesses and with what results (Hahn 1995). Some illnesses are believed to be cured by herbal medicine, where as some are believed to be cured by allopathic medicine. Besides these two types of treatment, spiritual-based treatment by the traditional healer is also common in this community. Similar findings are reported (Bastien 1982; Neumann & Lauro 1982; Green 1985); these studies emphasised that individual treatment choices are shaped by the type of illness, the seriousness of the illness and whether treatment is sought for physical symptoms or for the ultimate (social and supernatural) cause of the illness.
The study population expressed that the environment is a key factor for causing illness and emphasised that the environment is a key factor for leading a healthy life. Health is influenced by several factors, and change in climate is one of these determinants. However, the nature and influence of these health determinants are not fully understood (International Arctic Science Committee & Draggan 2012). The study population migrated to the urban area for economic reasons, but they feel nostalgic for their native place and even expressed that they preferred living in their earlier habitat.
In this study, we can see the co-existence of cultural and biomedical concepts regarding health and illness and similar observation is noted among Bhils of Rajasthan, India (Bhasin 2004; Jain & Agrawal 2005). This finding is somewhat in contrast to the earlier studies that were carried out during 1970s and '80s (Erinosa 1978; Oke 1995) in which causes of illness are classified into three categories: supernatural, preternatural or mystical, and natural forces. It appears that in the course of time, certain concepts undergo change while the other cultural concepts continue; the acceptance of biomedical logic may not replace the cultural concept of illness and often both concepts co-exist. Perhaps it is a part of the acculturation process. This continuity and change of cultural concepts regarding health and illness are clearly seen in this community, and has a considerable bearing on the treatment seeking behaviour. While certain illnesses such as measles and jaundice are purely seen with cultural lens and led to the deterring of biomedical treatment; some other illnesses are thought to be treated only by modern medicine. However, often people follow traditional treatment for several illnesses, sometimes biomedical treatment is sought, if the traditional treatment fails, or sometimes both the treatments continue. The perceived causes of diseases have a considerable bearing on determining the choice of treatment, which leads to delays in seeking modern health care.
Conclusions
This study has revealed that the present migrant tribal community has been changing at a certain pace along with their concepts of health and illness. Cultural values show a profound impact on perception of illness among the community. Cultural exchange
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with the non-tribal people brings some change in their concepts and views. Thus, this community, with their traditional perception along with modern facilities, is attempting to adapt to the modern world, i.e. urban culture. However, the avoidance or delay in seeking medical care in some cases needs an approach that considers their perception about health and illness. Present-day health education has also been heavily influenced by research of illness perceptions and health-seeking behaviour. We feel that a targeted approach to address the healthcare needs of such migrant communities is necessary in order to make the available public health interventions and medical care available, accessible and acceptable to these vulnerable communities.
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Povzetek
Ko se skupnost akulturira, se spremenijo tudi koncepti zdravja in bolezni, vseeno pa se skupnost še naprej oklepa svoje domačijske logike, prepričanj, zamišljenih vzrokov, zaznavanja in klasifikacij bolezni ter nadaljnjega upravljanja z njimi. Te koncepte smo proučevali med migrantsko plemensko skupnostjo, ki živi v slumih vzhodnoindijskega mesta Bhubaneswar. Poglobljeni intervjuji so bili opravljeni s posebej izbranimi člani skupnosti, ključnimi informatorji in tradicionalni zdravilci. Z njimi smo govorili o skupnostnem videnju bolezni in njihovih vzrokov ter kako zaradi vpliva migracij na obravnavo različnih bolezni vplivajo kulturni koncepti in pridobljeno sodobno znanje. Za optimalno izrabo zdravstvenih storitev bi bilo potrebno izdelati ustrezne startegije.
KLJUČNE BESEDE: avtohtona medicina, etnografija, migracija, akulturacija, prepričanja, zaznavanje, Indija
CORRSPONDENCE: BONTHA V. BABU, Health Systems Research Division, Indian Council of Medical Research, Ansari Nagar, New Delhi 110 029, India, Email: babubontha@gmail.com.
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