VOLUME 18, NUMBER 4                                                           JULY / AUGUST 2005

Medicine and Society
The Tribal Health Initiative model for healthcare delivery: A clinical and epidemiological approach
HARI PRABHAKAR, RAVIKUMAR MANOHARAN

ABSTRACT
  Background. Tribal populations generally have poor health outcomes, often because of a healthcare delivery system that does not cater to their needs. This study evaluates a current healthcare model for tribals, and explores it in combination with the health status of the target population, placing emphasis on the long term sustainability and cross-implementation of the model.
  Methods. We examined the health system from the perspective of the base hospital, by concentrating on mortality patterns, inpatient incidence of selected infectious and non-infectious illnesses, and the preventive and curative health services administered by the hospital to the community.
  Results. Gender susceptibility patterns revealed disparities in anaemia and tuberculosis besides fluctuations in gastrointestinal disorders, tuberculosis and typhoid. A combination of gender- and age-susceptibility patterns revealed specific age intervals for mental health-related disorders. Mortality patterns indicated an increase in youth deaths and suicide, with an overall reduction in infant mortality. However, an increased tribal confidence in allopathic medicine was noted after implementation of the health system.
  Conclusion. The base tribal hospital is important in administering primary and secondary healthcare, health education, disease surveillance, community outreach and for continued confidence in allopathic medicine. Diet-based morbidities may be combated via organic farming and banning local alcohol production, while anaemia may be combated through continued iron, salt and folic acid supplementation to women. The formulation of mental health programmes and long term educational initiatives at the village level are critical to reducing suicide and infant mortality. Further epidemiological studies are required to gain a complete picture of health within the population, and successful implementation of the model elsewhere must factor in sociocultural disparities among tribes.
Natl Med J India 2005;18:197–204

INTRODUCTION
A combination of factors such as geographic isolation, low economic status, different societal attitudes and traditional beliefs, and provider inadequacy have led to tribal populations throughout India often being denied access to allopathic health services. Basu confirmed that compared to metropolitan areas, there were gaping disparities in the health status of tribal populations.1 Genetic abnormalities and sexually transmitted diseases are common in the tribal populace; the prevalence of the sickle cell gene calculated to be over 20%, with an estimated 5 million individuals predicted as carriers. Glucose-6-phosphate dehydrogenase (G6PD) deficiency is present in about 15 million tribals who reside primarily in high-incidence malaria zones in the states of Assam, Madhya Pradesh, Maharashtra, Orissa and Tamil Nadu. However, Chhotray and Ranjit2 found only a weak association between infectious diseases such as malaria and G6PD deficiency. A study on the genetic polymorphisms among 16 tribal populations of central India by Das et al.3 revealed that the genetic structure of the populations was highly influenced by sociocultural adaptation and the practice of inbreeding within the tribes. Malnutrition and gastrointestinal disorders are common among tribal populations, and major deficiencies have been detected in gross amounts of calcium, vitamin A, vitamin C, riboflavin and animal protein. Furthermore, certain tribal groups such as the Onges, Jarawas and Shompens of the Andaman and Nicobar Islands are facing extinction due to endemic diseases, venereal diseases and an unusually low sex ratio.
  In light of the inadequate health infrastructure for the tribal population, this retrospective hospital-based observational study from the year 2000 aimed to examine a current healthcare delivery model, the Tribal Health Initiative (THI), offered to a Malayali and Lambadi tribal population of approximately 10 000 in the Dharmapuri district of southern India. By combining statistical and epidemiological data with documentation of clinical and preventive measures used to combat predominant health problems in the area, we sought to delineate a general impact analysis of the THI while also seeking paths by which the healthcare model could be optimized. Given that the base hospital currently functions as the nodal point for the healthcare delivery model, the end-points of the impact analysis revolved primarily around examining the hospital’s provision of health services with respect to the changing trend in the health status of the target population. Hence, the paths that could be the objects of potential optimization would include the base hospital’s provision of adequate community and clinical interventions, coupled with active disease surveillance and primary healthcare provided at the village level. We hope that the results of our study would serve as a platform for the creation and augmentation of potential and existing tribal health systems that could gradually be extended throughout India to address the concerns surrounding tribal healthcare.

THE TRIBAL HEALTH INITIATIVE MODEL
The THI healthcare delivery model is based on a 3-tiered framework of healthcare staff (doctors, health workers and health auxiliaries) with a base hospital as its nodal point. The base hospital functions as the centre and administrator of the health system, which was our primary reason for choosing the hospital as the setting of our study. The first phase of the base hospital, the outpatient facility, was a mud and thatched hut erected in 1993. By the end of 1996, the hospital had expanded to a 10-bedded facility with an operation theatre, labour room, neonatal care facility, emergency room and a laboratory. Currently, the hospital has 20 beds. Tubal ligations and intrauterine devices are provided on a voluntary basis to tribal women who desire to end or limit their reproductive capabilities. While on-site doctors oversee up to the secondary level of curative treatment in the hospital setting, the roles of the health worker and health auxiliary involve a limited combination of clinical and preventive services, both in the hospital and in the 21 tribal villages to which the THI provides health services. The hospital has a multimedia centre that organizes weekly screening of health education videos for inpatients. The THI, however, does not provide immunizations to its target population.
  The THI health workers are tribal women who have studied up to the eighth standard of school, and received one-and-a-half years of hospital-based residential training in primary and secondary care. After successful completion of their training, they are deployed at the base hospital to function as nurses. They also participate in the technical aspects of peripheral health activities that take place in the field.
  Health auxiliaries are illiterate tribal women, past childbearing age, who function as the THI’s first point of contact for patients in each of the 21 villages. They receive a total of 25 days of training at the base hospital. Health auxiliaries register births, deaths, marriages and pregnancies in their respective villages, register and periodically weigh children under 5 years of age, collect pregnant mothers for village antenatal clinics, and refer complicated diseases and deliveries to the base hospital. Health auxiliaries are also trained to provide services for the prevention, detection and treatment of malnutrition, as well as for the early detection and treatment of respiratory infections. Six medicines are provided by the THI’s base hospital to the health auxiliaries to aid in managing minor medical conditions of patients with common ailments (Table I). Graphical methods, including colour coding, are used to familiarize health auxiliaries with the medicines provided to them (e.g. ‘the red medicine [paracetamol] is for mild fever’), and descriptive methods are used to teach health auxiliaries to make a symptomatic diagnosis of common morbidities such as a cold, fever and respiratory infections. Children are weighed with the aid of Teaching Aids at Low Cost™ (TALC ) weighing scales that allow the documenter to make graphical notations on pre-formatted weight charts to track the growth status of children. These qualitative methods have obviated the need for literate village-based health staff.

To examine an allopathic healthcare model for tribal populations, however, it is important to realize that the alternative medicinal systems including Ayurveda and Siddha are often rooted in tribal assumptions of healthcare delivery. Not surprisingly, the health status and health-seeking behaviour in the area of study before the THI intervention, as documented by Karunakaran4 (Table II), is highly skewed towards alternative medicine. Implementation of an allopathic healthcare delivery system in tribal areas requires considerable time to surmount the cultural and social barriers associated with these medical interventions.

METHODS
We chose the year 2000 as the starting point for this study based on our observation of general tribal confidence in the allopathic inpatient services provided by the THI (Tables II and III). Specifically, door-to-door interviews of tribals in selected villages during 1999 revealed that a majority (77.9%) of the individuals had confidence in the efficacy of the allopathic health services provided by the base hospital. This was in contrast to the Karunakaran study of 1987, which showed that tribal confidence in allopathic medicines varied dramatically as a function of the disease.4 While a multidisease surveillance system to monitor the incidence of morbidities in the village setting was not available at the time, we used the base hospital of the THI to observe the incidence and treatment of severe and predominant gastrointestinal diseases, mental health-related disorders, typhoid and anaemia in the in-patient setting. We know that the use of a hospitalized population as a denominator for calculating the incidence of specific conditions may not be an accurate indicator of the health status of the population as a whole. The data may be reflective of the sector of the population that is willing to receive allopathic services from the THI system. To that end, we specifically denote these epidemiological observations as ‘inpatient incidence’ in contrast to incidence data that could be calculated from an active and comprehensive surveillance methodology. The gastrointestinal disorders under observation were acid peptic disease, acute gastritis, acute gastroenteritis (diarrhoea), cholecystitis, colitis and duodenal ulcers. Given that THI’s implementation of the Revised National Tuberculosis Control Programme (RNTCP) began in early 2000, we felt it appropriate to begin monitoring tuberculosis disease management and incidence both among inpatients and out- patients. Mortality patterns, however, were delineated through a combination of inpatient and field data collected by the base hospital via THI’s health auxiliaries deployed in the villages. The health auxiliaries also reported deaths occurring in the 21 villages, as well as the symptoms associated with the deaths.

  Diagnosis of patients in the inpatient, outpatient and field setting of the THI with the morbidities under examination took place using the diagnostic rubric outlined in Table IV, with the exception of tuberculosis, which was diagnosed and treated using the RNTCP protocol.5

Statistics
Selection of sample size and method of allocation. The statistical universe for monitoring of the incidence of severe gastrointestinal disorders, mental health-related ailments, typhoid and anaemia included only those patients who were admitted as inpatients to the THI in 2000 (558 patients), 2001 (644 patients), 2002 (733 patients), and 2003 (850 patients). All outpatients, therefore, were excluded from the study sample, as their illnesses were minor. From the inpatient sample, those diagnosed with the observed morbidities (Table IV) were analysed by gender. Mental health-related cases were further categorized according to both gender and age groups at 5-year intervals of age. Incidence monitoring of tuberculosis, however, included both inpatients and outpatients in 2000 (12 947 patients), 2001 (12 796 patients), 2002 (14 124 patients) and 2003 (17 033 patients). Individual cases were categorized according to gender, sputum positivity/negativity and extrapulmonary diagnosis, and RNTCP treatment regimens (categories I, II and III).
  The statistical universe for the analysis of mortality patterns included inpatients, outpatients and village populations within THI’s geographical scope of health services. The subjects were divided into 5 representative age groups beginning with the infant group (0–1 year), the child group (2–5 years), the youth age group (6–15 years), the ‘age of productivity’ group (16–50 years) and the geriatric age group (51+ years). To illustrate tribal social factors that may detract from THI’s allopathic interventions, infant mortality was separated into deaths occurring from medical morbidities, and those occurring from male or female infanticide. The presence of infanticide was determined through direct questioning of the parent(s), who often clearly stated their involvement in the death, and observations of induced asphyxiation or the presence of poisoning-related symptoms. Finally, mortality patterns as functions of predominant morbidities in the area were examined through diagnosis and allocation of deaths occurring from neonatal causes (neonatal death), suicide (mental health), pneumonia (lower respiratory tract infection), meningitis (neurological disease), acute gastroenteritis and dysentery (gastrointestinal disorders).

Statistical analysis. We calculated the incidence rate of gastrointestinal disorders, mental-health related ailments, anaemia and typhoid in the inpatient setting by considering the population at risk to be the total number of inpatients in a given year. The incidence rate of tuberculosis, however, was calculated by considering the population at risk to be a combination of inpatients and outpatients for that given year. While these incidence rates do not provide a comprehensive measure of population health with respect to the morbidities under observation that would be attainable through a multidisease surveillance system, our goal was to examine an allopathic healthcare model from a clinical and epidemiological perspective. Taking into consideration the ability of an allopathic healthcare delivery system to single-handedly provide health services to a relatively small tribal population with confidence in allopathic health services, we believe that calculating incidence rates using inpatient and outpatient admissions provides a relatively accurate description of the healthcare model’s influence on the target population. As previously mentioned, however, a bias does arise when using hospital-based data to reflect the health status of the population in general, given that persons who avail of hospital services are (i) those individuals who are sick, and (ii) those who are confident in allopathic interventions. Gender-dependent susceptibility of examined morbidities required the use of previously described gender categorizations to assign a percentage of a given disease’s incidence to the appropriate gender in the inpatient and/or outpatient setting.
  Determination of age- and selected disease-specific mortality involved standard percentage calculations based on the number of deaths associated with previously categorized age groups and selected morbidities, respectively. Infant mortality rates were calculated through standard formulas, where the number of births and deaths corresponded to those occurring both at the base hospital and in THI’s geographic area from information furnished by THI’s health auxiliaries. For infant mortality rates, 95% confidence intervals were calculated, while the relatively small number of events and sample size used in calculating disease incidence rates (limited to inpatients and outpatients) did not necessitate the calculation of invariably wide confidence intervals.

RESULTS AND DISCUSSION
It should be noted that rather than performing a mere impact analysis of a tribal health system on its target population, we sought to combine and augment the salient and effective features of the existing THI as a means of developing a holistic medical model that can be extended throughout India to address the poor health outcomes among tribal populations. However, interventions that do not seem to be making pronounced changes in tribal health status are not necessarily ineffective or irrelevant, as health is an entity that far exceeds its medical implications. This is especially true for tribal populations for whom allopathic medicine remains either inaccessible or unacceptable. Additionally, we acknowledge that the small sample size in this pilot study used to explore the health system allows for multiple interpretations of the data, which can be made more robust in future studies by employing a larger cohort not limited only to the base hospital and its periphery. The use of percentages in a small sample can also be misleading and, thus, the denominator for calculating percentage values has been shown.
  As the environment plays a critical role in the framework and evaluation of a health system, we provide some details of the geographical area of the study and socioeconomic status of the tribals. The rough and hilly terrain of Sittilingi can only be traversed via jeep, bus or motorcycle. Up to Dharmapuri, the district headquarters, the roads are motorable , but accessibility is difficult further towards the hospital and the tribal area. The primary healthcare centre nearest to the tribal area is in Kotapatty, about 3 km from the hospital, though a lack of medical supplies and staffing has precluded any effective interventional movement. Tribal patients seeking tertiary treatment must go either to Salem (about 60 km from the THI), or to the government hospital in Harur (about 40 km from the THI). Poor transport facilities play a major role in restricting patients to the THI. A few non-certified medical practitioners provide door-to-door glucose solutions and sugar tablets to ‘alleviate’ minor ailments of the tribals. Traditional healers are also present in certain villages and, as attested to by Harsha et al.,6 over 45 species of plants are still used in the area to treat a wide range of ailments such as fever, cough, skin diseases, rheumatism, snake-bite, jaundice and dysentery.
  A majority of the tribal men in the area are migrant workers, earning around Rs 1000 per month. The growth of inexpensive and iron-rich pulses such as raagi and white rice, allows for limited domestic agricultural activity on the arable land.7 About half of the 21 villages of the study area have government housing facilities, though the government schools, like the primary healthcare centre, are small and understaffed, offering only 1 or 2 days of schooling for the children. Not surprisingly, studies by Kuriyan8 and Das et al.9 on the viability of a tribal health programme in Maharashtra and Gujarat, respectively, cited understaffing of primary healthcare centres, exploitation of migrant labourers, and inadequate supplies of medicines as primary causes of under-development and poor health outcomes. In terms of common trends among the population, there appears to be a growing tendency towards mental health disorders and chronic diseases such as diabetes and hypertension. While in the past, tribal populations may have often largely suffered from infectious and congenital diseases, the gradual domestication of tribal areas and the increased influx of tribals into the mainstream population may be the causal factor behind the changing nature of the morbidities. However, this requires further study and does not affect the validity of our findings, given our focus on primary care in examin-ing the health situation of the area in tandem with clinical and community-based interventions administered by the base hospital. Undoubtedly, it is the responsibility of the health system to augment its preventive and curative health services to combat the diseases present in the tribal population.
  Figures 1 and 2 illustrate the inpatient incidence rates of gastrointestinal disorders and gender susceptibility of these disorders, respectively. While incidence rates of acid peptic disease, acute gastroenteritis and acute gastritis demonstrated clear sigmoidal curves, the incidence of cholecystitis, colitis, dysentery and duodenal ulcers was too small to draw any valid conclusions about their trends. However, the disparity in gender susceptibility of dysentery and colitis in the inpatient setting is of interest, though further studies with a larger sample size are necessary to delineate any statistical correlations. The male and female incidence rates for the morbidities are cumulative from the year 2000 to 2003, and do not illustrate potentially significant gender fluctuations by year. Nutritional studies by Yadav and Singh10 and Rao et al.11 noted the major role played by protein and caloric deficiencies coupled with the poor dietary practices in the detrimental health outcomes of the tribal population under scrutiny. Thus, if the fluctuations in gastrointestinal disorders are found to be a result of the dietary practices in the area, they may be combat-ed through a greater emphasis on nutrition and self-sustainable agriculture at the village level, via the health auxiliaries. Specifically, introduction of organic farming in the area would allow for less reliance on the ration rice provided to tribals, often containing high levels of pesticides that corrode the mucous lining of the stomach. The known impurities of locally brewed alcohol and the high levels of alcohol consumption in tribal areas also play a major role in degrading the mucous membrane and increasing the susceptibility to gastrointestinal disorders.12 While alcohol consumption may be considered more of a social problem than a medical one, its implications on tribal health require interventions at the community level. Some villages in the THI’s scope of services have formed committees to abolish the local production of alcohol, and direct support from health auxiliaries and health workers in the formation and deployment of these committees may be an initial step towards reducing gastrointestinal disorders.
  Figure 3 illustrates the inpatient incidence rates of major morbidities. The relatively consistent decrease in the incidence rate of typhoid from 32.3 in 2000 to 8.2 in 2003 is evident. No dramatic trends from 2000 in cumulative susceptibility to typhoid were discerned. The reduction in typhoid may be a result of the increased reliance of the tribals on protected wells for their drinking water.

While the incidence rate of anaemia proved to be sigmoidal in nature, the dramatic disparity in gender susceptibility to anaemia confirmed that it was more frequent in females.13 Of the 32 cases of anaemia in the inpatient setting, 27 occurred in females. The sigmoidal curve of the incidence of anaemia, coupled with the increased susceptibility of tribal women to anaemia, calls for continued iron and folic acid supplementation, to be distributed by health workers through periodic field visits and antenatal check-ups. Moreover, the provision of iron-fortified salt in these areas would reduce the prevalence of anaemia,14 as well as negate the need for special delivery systems for this dietary unit.15 The direct beneficiaries would be pregnant women, lactating mothers and young children, though the reduction in anaemia prevalence would also reduce the risk of maternal and foetal mortality.16 A study by Chakma et al.17 on the prevalence of anaemia in a tribal area of Madhya Pradesh further correlated marginal nourishment of children with blood loss in the intestine resulting in anaemia.
  On the mental health front, incidence rates of self-poisoning exhibited a gradual decrease, though any trends perceived from attempting hanging and hysteria were overshadowed by their inherently low incidence. Analysis of the incidence of mental health-related ailments as a function of age and gender (Table V) indicated that females were most susceptible to mental health deficiencies from 16 to 25 years of age, while men were most susceptible from 26 to 45 years of age. These age intervals for males and females broadly correspond to marital age, economic self-sufficiency and adolescence for tribal populations. This correlates with the tribal marriage patterns reported on the Hill Korwas18 and the Baigas.19 A majority of the tribal women have a low age at marriage (8–25 years), low literacy and little experience in domestic agriculture and self-sustainability. Additionally, a discerned 25.4% difference between the female and male incidence of mental health-related disorders in the inpatient setting provides further insight into the nature of mental illness prevalent among THI’s target population. The high incidence of mental health-related disorders and age-specific mortalities in the target population, including attempted and successful suicides, necessitates currently non-existent community mental health interventions targeted towards tribal women from 16 to 25 years of age, and tribal men from 26 to 45 years of age.
  An important addition to the tribal health delivery system, therefore, would be the presence of marriage counselling and peer psychotherapy sessions at the village level that could be facilitated through older members of the tribal community. These individuals could be given training at the base hospital in basic diagnostic and counselling procedures, and would complement the hospital’s ability to provide psychoactive drugs for temporary and symptomatic relief. Further investigation would be beneficial as to the effects of socioeconomic status on mental morbidities within the Malayali and Lambadi tribes. A study by Pandey and Tiwari.18 found that higher socioeconomic classes had higher rates of mental disorders, and that tribal groups that had different cultural patterns differed significantly in the rates of morbidity.
  Minor fluctuations in the incidence rate of tuberculosis neither discount nor validate the RNTCP protocol among the population, and a larger sample size is required for further analysis. A study by Narang et al.20 in the Wardha district of Maharashtra noted that the prevalence of tuberculosis among tribals was comparable with that of the non-tribal population, and a comparative study of RNTCP efficacy in tribal and non-tribal populations may be of benefit. However, analysis of gender susceptibility illustrated a more than 2-fold difference in the male incidence of tuberculosis (166 cases), as compared to the female incidence (76 cases), and confirms Park’s21 observation of male gender as a host factor for tuberculosis. The high proportion of sputum-positive diagnoses (38%) throughout the period of study could signify the continuing presence of a virulent tubercle bacillus among the target population. However, the low proportion of cases to which a category II treatment regimen was administered (10%) indicates the efficacy of the RNTCP treatment and the lack of treatment-resistant strains in the target area. Nevertheless, the presence of a virulent tubercle bacillus in the target population requires active surveillance at the village level, which could be facilitated through deployment of a multidisease surveillance system mentioned previously.

  Studies on the knowledge of tuberculosis among the tribals of the area, as carried out by Rajamma et al.22 in Andhra Pradesh, may also be helpful in formulating further interventions. Srivastava and Yadav,23 for example, cited the major breakdown in active surveillance, coupled with the inaccessibility of health agencies near affected villages as the cause of the outbreak of malaria among a tribal population of Gujarat. The recent appearance of meningitis as a cause of mortality would also benefit from active surveillance, such that mass chemoprophylaxis utilizing rifampicin or the meningococcal vaccine may be administered to appropriate closed village communities.24 As tribal communities in the area are often close-knit and live in close proximity to one another, clinical and preventive measures are necessary to reduce the risk of meningococcal transmission that arises out of close contact.25
  Age-specific mortality, infant mortality inclusive and exclusive of infanticide and selected disease-specific mortality are shown in Figs 4–6, respectively. While the percentage of deaths attributable to the infant, child and geriatric age groups remains unremarkable in trend, a 4-fold increase in deaths attributable to the youth age group (6–15 years) was observed from 2000 to 2001. Further analysis of health conditions and environmental factors in the area during that time are required to explain this startling statistic. However, this is in contrast to studies by Gujral et al.,26 which found that deaths of children among a tribal population in western India were 4-fold higher in children under 3 years as compared with those over 3 years of age.
  Examination of infant mortality patterns revealed that a major and growing proportion of deaths were caused by infanticide, though infant mortality as a whole decreased from 78.8 in 2000 to 68.3 in 2003. Although inpatient admissions to the base hospital have increased progressively over the years, the fact that neonatal deaths and infant mortality have not decreased at an inversely proportional rate may reflect the need for continued augmentation of the village-based health auxiliaries in providing antenatal care and counselling, coupled with the provision of a nutrition plan to reduce complications during pregnancy and delivery. Basu and Kshatriya27 also noted that, among the tribal populations of Madhya Pradesh, the mortality remains distressing when compared with the national population. Morality patterns revolved around a fluctuation in neonatal deaths and suicide, with acute gastroenteritis, pneumonia and dysentery playing a role in reducing the number of deaths from 2000. Furthermore, meningitis was a cause of mortality in 2003. This correlates with the study on infant and child mortality in the Bhil tribe of the Jhabua district by Taneja and Vaidya,28 which noted that the major causes of death among neonates were preventable and included tetanus, diarrhoea, measles, acute respiratory infections and fever. In comparison to initial values, however, neonatal deaths, suicide, gastroenteritis and dysentery were observed to play a smaller role in mortalities within the target area.
  Mahanti29 notes that the inaccessibility of tribal areas has often precluded implementation of children’s health facilities, nutritional programmes and elementary education, and thus child welfare in tribal areas has not improved. Hence, the fluctuations in infant mortality in the area necessitate continued growth monitoring of babies, implementation of food supplementation programmes for pregnant women at the village level, and the provision of family planning services by the base hospital. Additionally, the multifactorial nature of infant mortality requires a multipronged approach. This is especially true in our area of study, where infanticide is socially acceptable and accounts for a major proportion of infant deaths. Thus, medical services must be augmented with long term social interventions at the village level that involve education for prospective or current parents on the ill-effects of infanticide and the other options available to replace it. It is critical, however, that these interventions involve tribal health auxiliaries as a means to bridging the cultural gap. Finally, the healthcare delivery system would also benefit from placing special emphasis on antenatal counselling for tribal women, given that studies in Tamil Nadu have correlated female education with better health outcomes, infant and maternal mortality rates, and immunization rates for women and their children.30 Singh and Yadav31 also noted that high immunization rates among tribal children may be achieved through targeting illiterate mothers in inaccessible areas. These first-contact primary interventions, in turn, may also lessen the increasing rates of youth mortality seen in our age-specific mortality patterns. There is little doubt, however, that long term interventions of the healthcare delivery system in tribal populations may only follow from the devolution of endemic social and cultural assumptions of health, many of which are yet to be studied in the process of determining the best course of action. Nevertheless, the overall confidence of the study population in allopathic health services provided by THI is in contrast with Friedman and Somani’s32 epidemiological survey of tribal villages in southern Bihar, which noted that a lack of health awareness in the area remained the primary obstacle towards improved community health.
  In summary, a base hospital in a tribal area that offers up to the secondary level of health services serves multiple roles: providing clinical services, promoting health and wellness, and acting as an operations base through which hospital-based health workers and village-based health auxiliaries are trained to provide health services. The hospital also serves as a central database for field statistics provided by health auxiliaries, and a resource centre capable of upgrading the skills of health workers and health auxiliaries. It has often been argued that the presence of a hospital in a community intervention detracts from an emphasis on preventive and social medicine. We find the functionality of the THI base hospital to refute these assertions. Moreover, the training of tribal women in the hospital setting serves to empower women to examine and combat the causes of ill health, while also facilitating the target population’s confidence in allopathic medicine through deployment of hospital staff in the field. A critical augmentation of the THI healthcare delivery model, and other existing models, would be the presence of a hospital-based multidisease surveillance system that would monitor the nature and incidence of morbidities at the village level, thus allowing for timely and relevant interventions. This could be accomplished through designation of a literate individual in each tribal village to record morbidity patterns after basic diagnostic and data collection training at the base hospital. The focus on primary healthcare necessitates further intervention at the community level to increase awareness, and preventive and early medical care from the allopath, thus reducing the need for secondary management of morbidities at the base hospital. Additionally, traditional healers can be trained by the hospital in the basics of allopathy and integrated into the health system, such that other tribal groups will not hesitate to avail of modern medicine in addition to traditional healing practices. On a larger scale, the diversity among scheduled tribes of India in terms of social, cultural and economic development requires that the healthcare model be holistic in nature, taking into consideration the sociocultural pattern of the tribe in the specific ecological setting, when designing and deploying preventive and curative measures.

ACKNOWLEDGEMENTS
We would like to acknowledge the following monetary and material resources used in pursuing our research: The Woodrow Wilson Research Fellowship, The Johns Hopkins University Provost Research Award and The Ethicon Corporation of Johnson & Johnson. A special thanks to Dr Regi George, Director, Tribal Health Initiative, for allowing us to observe his work.

REFERENCES

1. Basu SK. A health profile of tribal India. Health Millions 1994;2:12–14.
2. Chhotray GP, Ranjit MR. Prevalence of G-6-PD deficiency in a malaria endemic tribal area of Orissa (India). Indian J Med Res 1990;92:443–6.
3. Das K, Malhotra KC, Mukherjee BN, Walter H, Majumder PP, Papiha SS. Population structure and genetic differentiation among 16 tribal populations of central India. Hum Biol 1996;68:679–705.
4. Karunakaran T. Blossom India Report. Chennai:Indian Institute of Technology, Madras; 1987.
5. Government of India. RNTCP at a glance, 1999–2000. New Delhi:Central TB Division, Ministry of Health and Family Welfare; 1999.
6. Harsha VH, Hebbar SS, Hegde GR, Shripathi V. Ethnomedical knowledge of plants used by Kunabi Tribe of Karnataka in India. Fitoterapia 2002;73:281–7.
7. Irshad Ali AN, Das I. Tribal situation in north east India. Stud Tribes Tribals 2003;1:141–8.
8. Kuriyan J. Tribal health programme. Health Popul Perspect Issues 1982;5:44–54.
9. Das NP, Bhavsar S, Patel R. The growth and development of scheduled caste and scheduled tribe population in Gujarat and future prospects. In: Gujarat—2010. Challenges and opportunities. Meeting organized by State Planning Commission, Government of Gujarat, Gandhinagar, 3–5 November 2000.
10. Yadav RJ, Singh P. Nutritional status and dietary intake in tribal children of Bihar. Indian Pediatr 1999;36:37–42.
11. Rao DH, Rao KM, Radhaiah G, Rao NP. Nutritional status of tribal preschool children in three ecological zones of Madhya Pradesh. Indian Pediatr 1994;31:635–40.
12. Kate SL. Health problems of tribal population groups from the state of Maharashtra. Indian J Med Sci 2001;55:99–108.
13. Narasinga Rao BS. Studies on iron deficiency anemia. Indian J Med Res 1978;68 (Suppl):58–69.
14. Narasinga Rao BS. Anaemia and micronutrient deficiency. Natl Med J India 2003;16 (Suppl 2):46–50.
15. Sood SK, Nishi M, Russia U. Iron deficiency anemia—Indian scene with special reference to children. In: Lokeshwar MR, Manglani MV (eds). Proceedings on anemia in children. 1991:12.1–12.11.
16. Government of India. Manual for health workers. Vol. 1. New Delhi:Ministry of Health and Family Welfare; 1978.
17. Chakma T, Rao PV, Tiwary RS. Prevalence of anaemia and worm infestation in tribal areas of Madhya Pradesh. J Indian Med Assoc 2000;98:567, 570–1.
18. Pandey GD, Tiwary RS. Fertility in Hill Korwas—a primitive tribe of Madhya Pradesh. Man India 1996;76:325–9.
19. Reddy PH, Modell B. The Baigas of Madhya Pradesh: A demographic study. J Biosoc Sci 1997;29:19–31.
20. Narang P, Tyagi NK, Mendiratta DK, Jajoo UN, Bharambhe MS, Nayar S. Prevalence of sputum-positive pulmonary tuberculosis in tribal and non-tribal populations of the Ashti and Karanja tahsils in Wardha district, Maharashtra State, India. Int J Tuberc Lung Dis 1999;3:478–82.
21. Park K. Park’s textbook of preventive and social medicine. Jabalpur:Banarsidass Bhanot; 2000.
22. Rajamma KJ, Rao DVB, Narayana ASL, Ramachandran R, Prabhakar R, Rajamma KJ, et al. Health seeking behaviour, acceptability of available health facilities and knowledge about tuberculosis in a tribal area. Indian J Tuber 1996;43:195–9.
23. Srivastava HC, Yadav RS. Malaria outbreak in a tribal area of Gujarat state, India. Southeast Asian J Trop Med Public Health 2000;31:219–24.
24. Cvjetanovic B, Grab B, Uemura K. Dynamics of acute bacterial diseases: Epidemiological models and their application in public health. Part II. Epidemiological models of acute bacterial diseases. Bull World Health Organ 1978;56 (Suppl 1):25–143.
25. Kumar P, Verma. Antibiotic therapy for bacterial meningitis in children in developing countries. Bull World Health Organ 1993;71:183–8.
26. Gujral S, Chohan A, Gopaldas T. Age and sexwise child mortality and the influencing socio-economic factors in a rural and tribal population in western India. Indian J Matern Child Health 1992;3:113–17.
27. Basu S, Kshatriya G. Fertility and mortality in tribal populations of Bastar district, Madhya Pradesh, India. Biol Soc 1989;6:100–12.
28. Taneja PV, Vaidya NG. Infant and child mortality in Bhil tribe of Jhabua district. Indian J Pediatr 1997;64:409–13.
29. Mahanti N. Care and development of children in tribal areas. ICCW News Bull 1991;39:39–44.
30. Report of the Director General. Bridging the gaps. Indian Pediatr 2000;37: 1194–9.
31. Singh P, Yadav RJ. Immunisation status of children in BIMARU states. Indian J Pediatr 2001;68:495–500
32. Friedman MS, Somani J. Health conditions in the tribal villages of south Bihar: An epidemiologic survey. J Assoc Physicians India 2002;50:1376–80.