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By Rahul Goswami
With only 407 doctors, inadequate sanitation and poor development indicators, Nagaland's people have limited access to quality healthcare. A report from the north-east
Education, especially of girls, and the implementation of sanitation measures makes a discernible difference to family and community health in a Naga village. That, for the residents of Khonoma, a tribal hill village in the north-east Indian state of Nagaland, is an incontestable fact. The problem however lies elsewhere, and it is when the individual elements of the education-sanitation-gender mix fail to combine that the tribals of the region bear the consequences.
For the last three decades India's north-east has witnessed various forms of unrest, conflict and violence. In Assam, the region's largest and most populous state, these were manifested in an anti-foreigner movement, insurgency and ethnic violence. In the tribal-dominated hilly states of Manipur, Mizoram, Nagaland and Tripura, the secessionist movement took violent turns aggravated by army operations.
Nagaland, like the seven other states that are clubbed together as the 'North-East', does relatively well compared with the country average in terms of literacy rate (71% for male and 61 for female; all-India percentages are 75 and 54) but, like the others, suffers from an unusually high percentage of school drop-outs. In these villages, scattered across the rugged Naga hills that lie between the plains of lower Assam and the frontier with Myanmar, it is the girl who is most likely to drop out of school and least likely to return.
At the Christian Welfare School in Khonoma village, principal Kushilto Sebastian Rolno is a worried man. "We are struggling financially and it's getting more difficult to support needy students," he said. With support, he added, students will be able to sit through their exams and, he hopes, complete their secondary school. In the nearby district of Peren, conditions are much worse. There, in at least a dozen villages no primary schools are working at all. "There are neither permanent nor ad hoc teachers in most of the schools," said Zanglam Khongsai, the village council secretary of Phaijol, one of the affected villages.
Neilelhuno Chasie is a young woman in her late teens and has finished secondary school, which she said "perhaps helped (me) learn about (the importance) of safe water". In these hills, with the water sources being icy streams at 3,000 metres and above, clarity is seen to be equal to purity, and there is no filtration done whatsoever, despite the hill villages building and maintaining elaborate piped systems of water transfer, collection tanks and sharing systems. The water they bathe with and wash dishes with is the water they drink.
"Nagaland has a significant burden of infectious diseases, which is closely linked to sanitation and water facilities," observed the state's Human Development Report 2003. According to data from the National Family Health Survey of India (1998-99) less than a quarter of the state's households have flush toilets and about half use pit toilets. Whether in a village like Khonoma or in neighbouring Mezoma and Jotsoma, or whether in the state capital Kohima, the indifference to sanitation is visible.
It is however not a problem found in Nagaland alone. "Unfortunately, the region has been treated on a par with the rest of India and the education, research and development, policy and planning of the 'mainland' has been applied in this area," said Dr Abdhesh Gangwar, an expert on the traditional agricultural systems of North-East India and programme co-ordinator for the Centre for Environmental Education's Himalayan sector. Such an approach, he said, "has so far failed" and is in part responsible for the militancy and social unrest in the region. Dr Gangwar stressed the point that the region contains unique ecosystems, and is "very specific ecologically and from the socio-economic and socio-cultural angles". Hence it needs locale-specific research, education and planning systems.
Little of this is visible in Nagaland's capital, where one of the historic battles of the Second World War was fought. The famous Kohima War Cemetery is flanked by residential roads and the houses in view of the quiet cemetery's immaculately maintained hedges are densely crowded together, seeming to teeter atop each other. There is no dearth of flush toilets here, but the waste is simply channelled further downslope, just as it is in the villages -- the capital's civic authorities display little concern over the absence of public hygiene. According to the Census of India 2001 data, six out of 10 households in urban Nagaland expel their sewage via open drains. This compares with 35% that do the same in rural Nagaland, but only because six out of ten households in Naga villages have no drainage at all.
When it comes to modern diagnostics however Kohima reflects the widening rural-urban gap that is so worrying regional planners. The private sector Apollo Hospitals, in coordination with the central Ministry of Information Technology, the state government and Marubeni India Pvt. Ltd. -- a subsidiary of the giant Japanese global trading firm -- has set up a telemedicine unit in the capital's main medical centre, the Naga Hospital, which relies on three ISDN lines. Apollo has followed that centre with two more in the north-east -- in the states of Sikkim and Mizoram.
The new equipment and remote consultations have not however helped the state's doctor-population ratio. It remains at 1:4,900 as against the recommended 1:3,500 and the draft state Human Development Report points out that Nagaland -- a state with a population of 1.98 million -- has only 407 doctors including 98 specialists: "This wide gap has contributed to limited access and compromise in the quality of care... most existing facilities are ill-equipped and devoid of access to modern diagnostic and therapeutic aids."
For Dr Ahu, the man in charge of the primary health centre (PHC) at Khonoma, whose responsibility is the medical needs of four villages whose inhabitants together number about 7,000, the existing facilities are all that he and his staff have to work with. He is able to divide his time between the village centres every week, guiding his four-wheel drive vehicle over the rough and pitted rural tracks that criss-cross the hills at between 1,500 and 2,000 metres.
"We see lots of typhoid -- which is endemic although there are no epidemics -- and lots of injuries from the logging activity in these hills. Snakebites too but these haven't been fatal, and lots of enteric fevers," he said. The village isn't lacking in traditional healers, or practitioners of indigenous medicine, and bonesetters. Dr Ahu, like many doctors in the north-east, views them as essential adjuncts to the formal systems. "They may go first to the traditional healer, or come to us, and if one doesn't work they'll go to the other," he said of the propensity of the villagers to look for a cure in either system.
In the approach discussions to Nagaland's Human Development Report, which is to be released this year by the state government and the United Nations Development Programme, the former chief secretary of Nagaland, R S Pandey, emphasised the fact that gaps in the health care infrastructure and institutional strengthening of the health sector need to be adequately addressed. He particularly called attention to the "poor statistical base" in Nagaland and suggested that a sample survey would help present the real picture.
Until that happens and brings with it greater clarity, the PHCs and sub-centres in the hill villages are being locally maintained following the ‘communitisation’ of the centres -- which simply means that their management is the responsibility of the village community they are assigned to. This is the result of the Nagaland Communitisation of Public Institutions and Services Act of 2002, intended to take advantage of the traditional social capital of the Naga tribal communities.
In the health sector it means making the management and maintenance of the health institutions the property of the community. In general, communitisation has worked to the extent that it has engendered a sense of ownership of the facilities, woefully under-equipped though they are. As part of communitisation, hill tribal villages have collected Rs 10 per household as contributions towards PHC maintenance, village cleanliness drives have been organised, community-built houses for sub-centres and staff quarters have been donated, and private medical practitioners have volunteered their services free on fixed days.
Such successes however speak more of the cohesiveness and strength of the traditional village institutions rather than indicate public faith in the state's healthcare systems. Of the latter in fact there is little. Using the findings of the latest Comptroller and Auditor General's report on Nagaland, the state public accounts committee has censured seven state government departments for misutilising funds, including those provided for an AIDS prevention programme. In one case, Rs 1.78 million (about EUR 35,600) meant for the state AIDS control programme was diverted towards the unauthorised purchase of five vehicles.
These revelations only embitter the parents of those children who have had to drop out of schools on account of their being unable to meet the fees. According to the national Human Development Report 2001, the drop-out rate for boys and girls in classes one to ten is 64 and 61% respectively for the state (national average 65 and 70%). The state numbers however hide a more worrying trend that teachers point to -- that girls drop out between the ages of 12 and 14 and are far less likely than male drop-outs to return to their classes.
"This is a trend that many schools are seeing," said Sr Jossy, headmistress of the St John Bosco School in Khonoma, which has about 300 on its rolls. "If a boy drops out because he has failed his exams or any other reason, he is likely to come back, but only rarely is that the case with the girls, who then do field work." The private schools -- the majority of which are managed and run by church trusts -- impart to their students practical lessons in elementary personal and community hygiene. "These lessons go back to the parents of the children," said the headmistress,
Even so, Women's Organisations in the tribal villages exert themselves to raise the general level of hygiene in their communities. These tend to be informal groups -- distinct from self-help groups and with no direct presence on the village councils -- whose members nominally include all the village women. The group in Khonoma observes, every month, a 'sanitation day' on which the women clean the village pathways, public drains and public toilets. That concerted effort, the office-bearers of the Women's Organisation said, is still not enough to keep the public toilets clean.
A popular perception of the north-east region is that the status of women in tribal societies is equal to that of men. Barring some exceptions, such as in Meghalaya, this is not so. That social imbalance, when combined with "intense pressure on agricultural land, low per capita income, a low profile of healthcare services and low consumer expenditure levels", as the National Council of Applied Economic Research observes, presents an overall picture of human development in the region that is dismal.
"Despite having vast potential resources, the north-east region stands much below the national average in terms of developmental indices," commented a recent report by North-East Network, a regional non-governmental organisation that focuses on women's issues. "Fifty years of planning in the country has made very little change, if any, in the socio-economic life of the region. All these have led to a widespread feeling of neglect."
(Journalist and researcher Rahul Goswami is lead author of a recent environment impact assessment study for a community habitat in Nagaland)
InfoChange News & Features, December 2004
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