Tropical Medicine and International Health
doi:10.1111/tmi.12499
volume 20 no 7 pp 952–960 july 2015
Medical pluralism among indigenous peoples in northeast India - implications for health policy Sandra Albert1,2, Melari Nongrum3, Emily L. Webb4, John D.H. Porter4 and Glenn C. Kharkongor3 1 2 3 4
Indian Institute of Public Health, Shillong, India Public Health Foundation of India, New Delhi, India Martin Luther Christian University, Shillong, India London School of Hygiene & Tropical Medicine, London, UK
Abstract
objectives The government of India is promoting and increasing investment in the traditional medicine systems of Ayurveda, Yoga, Unani, Siddha and Homeopathy (AYUSH) in the northeast region of India. But there are few empirical data that support this policy decision. This study estimates the awareness and use of the different medical systems in rural Meghalaya, a state in northeast India with a predominantly ethnic tribal population. method We conducted a cross-sectional multistage random sample household survey across all districts of Meghalaya. To enable appropriate estimates for the whole of rural Meghalaya, the data were weighted to allow for the probability of selection of households at each stage of the sampling process. results Both local tribal medicine and biomedicine were widely accepted and used, but the majority (68.7%, 95% CI: 51.9–81.7) had not heard of AYUSH and even fewer had used it. Tribal medicine was used (79.1%, 95% CI 66.3–88.0), thought to be effective (87.5%, 95% CI: 74.2–94.1) and given in a variety of disorders, including both minor and major diseases. In the 3 months prior to the survey, 46.2% (95% CI: 30.5–62.8) had used tribal medicine. Only 10.5% (95% CI: 6.1– 17.6) reported ever using any of the AYUSH systems. conclusion Our comparative estimates of the awareness and use of tribal medicine, different systems of AYUSH and of biomedicine among indigenous populations of India question the basis on which AYUSH is promoted in the northeast region of India and in the state of Meghalaya in particular. keywords indigenous peoples, medical pluralism, health policy, health system, northeast India, Khasi tribe
Introduction The WHO’s traditional medicine strategy recommends the integration of traditional and complementary medicine (T&CM) into national health systems [1, 2]. India’s first national health policy in 1983 formally recognised that the Indian Systems of Medicine (ISM) could contribute to public health care and recommended efforts to integrate ISM into healthcare delivery systems [3, p. 601]. Although little was done over the next decade, in 1995 the Department of Indian Systems of Medicine and Homeopathy (ISM&H) was established [3]. In 2003, it was renamed the department of AYUSH [4, p. 22–32], an acronym representing Ayurveda, Yoga, Unani, Siddha and Homeopathy medical systems. 952
The AYUSH systems are largely codified systems that have over time become selectively institutionalised and professionalised [4–6]. Numerous medical colleges in the country offer undergraduate and postgraduate training in the AYUSH systems [4, 6]. These institutionalised traditional systems can be considered as part of the ‘professional sector’ in India if one were to use Kleinman’s classification [7, p. 53–59]. But the professionalised forms of traditional medicine are not the only traditional systems that exist in the country [8–10]. The non-professionalised sector includes the non-codified systems referred to as the folk sector by Kleinman [7]. In India, these systems are increasingly being referred to as Local Health Traditions (LHT) in policy documents [11]. LHT is a broad appellation used to cover home remedies and folk healers including
© 2015 John Wiley & Sons Ltd
Tropical Medicine and International Health
volume 20 no 7 pp 952–960 july 2015
S. Albert et al. Medical pluralism in northeast India
medicine systems of different tribal (indigenous) ethnic groups [10, 11]. Previously the distinction between folk healers and practitioners of the codified traditional systems was not so marked. This distinction became ‘politically significant’ after the introduction of institutionalisation and registration of practitioners of traditional medicine [10]. Last [12] suggests a close link between a nation’s dominant political philosophy and the development of a ‘national medical culture’. Indian historian Panikkar [13, p. 174–75] notes that the movement to revitalise traditional medicine in India represented both a struggle for cultural hegemony against the coloniser and struggles between different classes within the colonised society. Thus, unequal power relations exist between biomedicine and traditional systems and between the different traditional medicine systems in India [8, 14]. In this study, the term ‘indigenous tribal traditional medicine’ is used to refer to the medicine practiced by the traditional healers of Khasi and Garo tribes of Meghalaya who use medicinal plants. It has been abbreviated to ‘tribal medicine’ and used synonymously to distinguish it from other traditional medicines of the AYUSH systems. A major impetus for the promotion of AYUSH systems in India was the launching of the National Rural Health Mission (NRHM) in 2005 ‘to carry out necessary architectural correction in the basic healthcare delivery system’ [15]. Post-NRHM, most states have been facilitating increased pluralism in health system delivery by establishing AYUSH facilities (co-located facilities) alongside biomedicine in the same premises [16]. There are about 370 million indigenous people spread across the globe [17, 18]. From antiquity to contemporary times, they have suffered from invasions, colonisation, forced assimilation and destruction of their cultures [18–21]. And in many ways, their rights and cultures continue to be threatened [18, 22, 23]. Many indigenous peoples have ancient systems of traditional medicine which are well accepted in their communities [22]. This knowledge is part of their world view of physical, mental and social harmony and is embedded in the context of their natural environment [22, 24]. Indigenous peoples have been described as ‘the guardians of the natural world, protecting many of the plants that form the basis of our most important medicines’ [25]. In India too, different tribes have their own tribal medicine that is locally popular and their indigenous knowledge has been documented in several ethnobotanical and ethnopharmacological studies [26–32]. Although the term ‘indigenous peoples’ is widely used in the literature, other terms exist: tribes, first peoples/ nations, aboriginals or minority ethnic groups. The
© 2015 John Wiley & Sons Ltd
Indian government recognises ‘tribals’ as a separate demographic entity in the census and tribal ethnic groups are notified as scheduled tribes as per provisions contained in Clause 1 of Articles 342 of the Constitution of India [33]. ‘Tribal’ is a colonial designation that once had pejorative connotations of being uncivilised, but now the word is widely used and accepted. In India, the three terms adivasis, ‘tribals’ and, more recently, ‘indigenous peoples’ are used at different historical points of time and for different reasons [34]. The oldest term, adivasis, is of Sanskrit derivation and means original inhabitants, but this term has limited acceptance in the northeast region of India where it is used only to refer to specific communities from central India. Those who claim indigenous status in the northeast prefer the term ‘tribal’ and or the more recent term ‘indigenous peoples’ [34]. Within India’s federal structure, the northeast region has eight states that are together bordered by Nepal, Bhutan, China, Myanmar and Bangladesh. The region is largely populated by indigenous peoples, with over 160 scheduled tribes and over 400 other tribal and subtribal communities and groups [35]. It is proposed to have been a corridor for ancient human migrations, to Southeast Asia [36]. While there are important similarities in their tribal social organisations, it has been argued that the common label of the northeast implies a mistaken homogeneity [37, p. 28]. The Indian state of Meghalaya has a population of 2.96 million, 86% of whom are identified as scheduled tribes [38]. Meghalaya’s main tribes are the Khasi–Jaintia and the Garo; all are matrilineal [39]. Although in recent decades a distinction has been made between Khasis and Jaintias, the latter may be considered as a subtribe of the former. Recent genetic evidence shows that the Khasis came from an ancient Austro-Asiatic migratory group and the time to the most recent common ancestor (TMRCA) for the Khasi is estimated to be approximately 57 000 years [36, 40]. Its indigenous traditional medicines are oral traditions that are largely un-documented [41]. The figures of 0.7% from the National Family Health Survey (NFHS) of households in the state seeking care from traditional healers is likely to be an underestimation [42]. Meghalaya was not a part of a national study commissioned by the Ministry of Health and Family Welfare on ‘Status and Role of AYUSH and Local Health Traditions under the National Rural Health Mission’ [16]. The report noted the poor quality of and lack of disaggregated data on utilisation of the AYUSH services in the northeast. Generally, AYUSH services were less frequently used than allopathic services for instance in the northeastern state of Nagaland it was used only in 4% of instances. Since the launch of NRHM, the 953
Tropical Medicine and International Health
volume 20 no 7 pp 952–960 july 2015
S. Albert et al. Medical pluralism in northeast India
AYUSH systems of medicine have been increasingly promoted in Meghalaya’s public health system [43, 44]. The basis for adopting a pluralistic approach to health service delivery is the assumption of the acceptability of these services in the community. But there is little empirical evidence that demonstrates peoples’ preferences for different medical traditions, especially in northeast India. This study bridges this gap in evidence by estimating awareness and use of different medical systems in rural Meghalaya.
Table 1 Numbers sampled at each stage of sampling Stage of sampling
Khasi–Jaintia Hills
Garo Hills
Total
Districts Blocks Villages Households (HH)
4/4 8/22 16/3262 388/1861
3/3 4/17 8/3577 200/504
7/7 12/39 24/6839 588/2365
For districts, blocks and villages, denominators show the total number of units in the study area, for that stage of sampling. For households, denominators show the total number of households in the selected villages.
Methods Setting Meghalaya state is hilly (500–2089 m) with difficult and inaccessible terrain; it contains the wettest region in the world, the Cherrapunji–Mawsynram belt, with an average 7500 mm of rainfall per year. Meghalaya is divided into seven administrative districts, which are further subdivided into 39 blocks and 6839 villages [45]. The Khasis and Garos largely inhabit separate areas of rural Meghalaya referred to as the Khasi Hills region and the Garo Hills region. Four districts (22 blocks and 3262 villages) are in the Khasi Hills region and three (17 blocks and 3577 villages) in the Garo Hills region. Study design In April and May 2010, we conducted a cross-sectional survey of households from 24 villages in all seven districts of Meghalaya. There was no prior listing of villages, households or individuals in the study area for use as a sampling frame; therefore, households were selected using a multistage cluster sample design with three stages [46]. In the first stage, two blocks from each of the seven districts were selected at random. The two blocks with large urban areas, Mylliem block in East Khasi Hills District, which contains the capital city Shillong, and the Rongram block in West Garo Hills District where Tura, the largest town in the Garo Hills, is located, were excluded from the sampling frame, as the aim of this study was to calculate estimates for rural Meghalaya. For two of the selected blocks, there were difficulties in recruiting suitably qualified field personnel within the timeframe of the study; thus, these two blocks were excluded leaving a total of eight blocks from the four districts in the Khasi Hills region and four blocks from the three Garo Hills districts for inclusion in the survey (Table 1). In the second stage, with the assistance of the Block Development Officers, the Primary Health Centres and Sub-Centres (SC) in the selected blocks were listed 954
and one SC selected from each block at random. The SC location was used as a guide to further select two villages from each block, one relatively close to the SC (but not the village in which the SC was located) which was accessible and the other much further away and defined as ‘remote’ by the Block Development Officer and the headmen. Permission was obtained through the University’s review process and from the relevant village headman and members of the local traditional administrative bodies. Using lists provided by the village headman or secretary as the sampling frame, approximately 25 households were randomly selected from each village. Where no lists of households existed, the selection was carried out with the assistance of the headman and his assistants using pathways and areas within the village as a guide. Informed verbal consent of participants was obtained before the interview. Survey data were collected through structured interviews with closed and open-ended questions. Taking into consideration the matrilineal family structure in Meghalaya, the questionnaires were administered to a senior female family member, usually the mother, and in her absence another female elder. Interviews were conducted in the local language by indigenous research assistants who spoke the local language as well as English. Each interview was conducted by a pair of research assistants. The research team attended a training workshop which incorporated filling in sample questionnaires and roleplay. Some of the questions on awareness and use of tribal medicine were informed by a pilot household health survey that was conducted in a village in Meghalaya in 2007 [47] with the addition of new exploratory openended questions on diseases for which tribal medicine was used. Data were entered into Excel and then imported to Stata version 11 [48] for analysis. All analyses were adjusted for the multistage sampling design using svy commands in Stata. To enable appropriate estimates of the use of
© 2015 John Wiley & Sons Ltd
Tropical Medicine and International Health
volume 20 no 7 pp 952–960 july 2015
S. Albert et al. Medical pluralism in northeast India
traditional medicine in the whole of rural Meghalaya, the data were weighted to allow for the probability of selection at each stage of the sampling process as follows: the probability of selection of each block was calculated as the number of blocks selected divided by the total number of blocks; the probability of selection of each village within a selected block was calculated based on the total number of villages in that block; the probability of selection of each household within a selected village was calculated as the number of selected households divided by the number of households in the village. The probabilities from each stage were then multiplied together to arrive at a final sampling probability for each household being selected. Estimates of preference for type or system of medicine such as biomedicine, tribal medicine, home remedies, pharmacy or others were calculated from responses to choice expressed for healthcare-seeking behaviour for minor or major ailments. The differentiation of minor and major was left to the interpretation of the respondent. Estimates of the prevalence of use of each system of medicine were calculated from responses to a four-point Likert scale [49] on frequency of use (with ‘very often’ and ‘sometimes’ being classified as using the system of medicine, and ‘rarely’ and ‘never’ being classified as not using the system of medicine). Distributions of reported effectiveness of tribal medicine, actual use in the previous 3 months, efficacy and cost were tabulated. The prevalence of awareness and use of AYUSH systems were also calculated. To evaluate differences in the use of tribal medicine between accessible and remote villages, proportions between these sets of villages were compared using design-based F-tests, an adaption of the standard Pearson’s chi-square test for analysing associations between two categorical variables which allows for the survey design [50, 51]. Results A total of 588 households were surveyed and the total number of persons resident in the households was 3633. Among the 588 respondents, 63% were from the Khasi tribe and 37% from the Garo tribe. 82% were Christian, and 18% followed indigenous tribal religions. The mean age of the respondents was 33.8 years (95% CI: 31.9– 35.6) and all were female. The main source of income of the majority of households was farming. The demographic details of the sample are presented in Table 2. The ethnicity of the population followed regional lines, that is all the people sampled from the Garo Hills belonged to the Garo tribe and all those from the Khasi Hills region belonged to the Khasi tribe, the only excep-
© 2015 John Wiley & Sons Ltd
tion was one village that fell in a border area in West Khasi Hills which had a Garo population. Twenty-two of the 24 villages sampled had one or more tribal medicine healers. The prevalence of reported preference and use of tribal medicine and biomedicine for major and minor ailments, and the prevalence of health-seeking behaviour and beliefs are summarised in Table 3. Disaggregated estimates by region, the number of individuals reporting each outcome and prevalence estimates before and after allowing for the survey design are also presented. The estimated reported use of tribal medicine across rural households in Meghalaya was 79.1% (95% CI: 66.3–88.0), with 13.5% reporting frequent use and 65.6% reporting that they sometimes used it. Tribal medicine was believed to be efficacious by 87.5% (95% CI: 74.2–94.1); 30% said it was very effective and 57% believed it to be somewhat effective, while 7% did not believe in its efficacy and 6% were unsure. 46% (95% CI: 30.5–62.8) had used tribal medicine in the previous 3 months, and of these, 91% (95% CI: 68.5–97.9) reported it as beneficial, with 58% reporting cure and 33% some improvement. Tribal medicine was reported to be used for both minor ailments and major diseases. The prevalence of reported preference for tribal medicine was higher for minor ailments (34%) than for major (23%) diseases (Table 3). In contrast, there was a high preference for biomedicine for major diseases (84%), while 52% said they would use it for minor ailments as well. It was apparent that most respondents would choose either biomedicine or tribal medicine as their first choice, and if unsatisfied with the response to therapy of their first choice, would try the other of these as their second. A majority had sought biomedicine from a public healthcare facility, 91% (95% CI: 73.8–97.4) reported visiting either a subcentre (SC), primary health centre (PHC) or a community health centre (CHC). Of those who had used tribal medicine in the previous 3 months, an average expenditure of Rs 189/- was reported to have been incurred (95% CI: 89.4–287.9). The reported average expenditure on biomedicine that included all or some of the doctor’s fee, medicines, transportation and laboratory tests in the previous 3 months was Rs 1417 (95% CI: 1060–1773 Rs). Although there were some differences between the Garo and Khasi regions in reported preference for and usage of each system of medicine, these differences were not statistically significant (all P > 0.05). Common ailments for which tribal medicine was reportedly used included diarrhoeal disorders, indigestion or gastrointestinal problems also referred to locally as gastric, a culturally understood childhood diarrhoeal 955
Tropical Medicine and International Health
volume 20 no 7 pp 952–960 july 2015
S. Albert et al. Medical pluralism in northeast India
disorder called nia~ ngsohpet [52], injuries, joint problems, jaundice and fractures. More than 40 disorders were reported by respondents for which tribal medicine was
believed to be efficacious. Table 4 documents the most frequently mentioned conditions for which tribal medicine or biomedicine was reported to be the preferred
Table 2 Characteristics of sample Region Characteristic Tribe Khasi Garo Religion (2 mv) Christian Indigenous Other Age in years, mean (4 mv) Education (34 mv) Illiterate
doi:10.1111/tmi.12499
volume 20 no 7 pp 952–960 july 2015
Medical pluralism among indigenous peoples in northeast India - implications for health policy Sandra Albert1,2, Melari Nongrum3, Emily L. Webb4, John D.H. Porter4 and Glenn C. Kharkongor3 1 2 3 4
Indian Institute of Public Health, Shillong, India Public Health Foundation of India, New Delhi, India Martin Luther Christian University, Shillong, India London School of Hygiene & Tropical Medicine, London, UK
Abstract
objectives The government of India is promoting and increasing investment in the traditional medicine systems of Ayurveda, Yoga, Unani, Siddha and Homeopathy (AYUSH) in the northeast region of India. But there are few empirical data that support this policy decision. This study estimates the awareness and use of the different medical systems in rural Meghalaya, a state in northeast India with a predominantly ethnic tribal population. method We conducted a cross-sectional multistage random sample household survey across all districts of Meghalaya. To enable appropriate estimates for the whole of rural Meghalaya, the data were weighted to allow for the probability of selection of households at each stage of the sampling process. results Both local tribal medicine and biomedicine were widely accepted and used, but the majority (68.7%, 95% CI: 51.9–81.7) had not heard of AYUSH and even fewer had used it. Tribal medicine was used (79.1%, 95% CI 66.3–88.0), thought to be effective (87.5%, 95% CI: 74.2–94.1) and given in a variety of disorders, including both minor and major diseases. In the 3 months prior to the survey, 46.2% (95% CI: 30.5–62.8) had used tribal medicine. Only 10.5% (95% CI: 6.1– 17.6) reported ever using any of the AYUSH systems. conclusion Our comparative estimates of the awareness and use of tribal medicine, different systems of AYUSH and of biomedicine among indigenous populations of India question the basis on which AYUSH is promoted in the northeast region of India and in the state of Meghalaya in particular. keywords indigenous peoples, medical pluralism, health policy, health system, northeast India, Khasi tribe
Introduction The WHO’s traditional medicine strategy recommends the integration of traditional and complementary medicine (T&CM) into national health systems [1, 2]. India’s first national health policy in 1983 formally recognised that the Indian Systems of Medicine (ISM) could contribute to public health care and recommended efforts to integrate ISM into healthcare delivery systems [3, p. 601]. Although little was done over the next decade, in 1995 the Department of Indian Systems of Medicine and Homeopathy (ISM&H) was established [3]. In 2003, it was renamed the department of AYUSH [4, p. 22–32], an acronym representing Ayurveda, Yoga, Unani, Siddha and Homeopathy medical systems. 952
The AYUSH systems are largely codified systems that have over time become selectively institutionalised and professionalised [4–6]. Numerous medical colleges in the country offer undergraduate and postgraduate training in the AYUSH systems [4, 6]. These institutionalised traditional systems can be considered as part of the ‘professional sector’ in India if one were to use Kleinman’s classification [7, p. 53–59]. But the professionalised forms of traditional medicine are not the only traditional systems that exist in the country [8–10]. The non-professionalised sector includes the non-codified systems referred to as the folk sector by Kleinman [7]. In India, these systems are increasingly being referred to as Local Health Traditions (LHT) in policy documents [11]. LHT is a broad appellation used to cover home remedies and folk healers including
© 2015 John Wiley & Sons Ltd
Tropical Medicine and International Health
volume 20 no 7 pp 952–960 july 2015
S. Albert et al. Medical pluralism in northeast India
medicine systems of different tribal (indigenous) ethnic groups [10, 11]. Previously the distinction between folk healers and practitioners of the codified traditional systems was not so marked. This distinction became ‘politically significant’ after the introduction of institutionalisation and registration of practitioners of traditional medicine [10]. Last [12] suggests a close link between a nation’s dominant political philosophy and the development of a ‘national medical culture’. Indian historian Panikkar [13, p. 174–75] notes that the movement to revitalise traditional medicine in India represented both a struggle for cultural hegemony against the coloniser and struggles between different classes within the colonised society. Thus, unequal power relations exist between biomedicine and traditional systems and between the different traditional medicine systems in India [8, 14]. In this study, the term ‘indigenous tribal traditional medicine’ is used to refer to the medicine practiced by the traditional healers of Khasi and Garo tribes of Meghalaya who use medicinal plants. It has been abbreviated to ‘tribal medicine’ and used synonymously to distinguish it from other traditional medicines of the AYUSH systems. A major impetus for the promotion of AYUSH systems in India was the launching of the National Rural Health Mission (NRHM) in 2005 ‘to carry out necessary architectural correction in the basic healthcare delivery system’ [15]. Post-NRHM, most states have been facilitating increased pluralism in health system delivery by establishing AYUSH facilities (co-located facilities) alongside biomedicine in the same premises [16]. There are about 370 million indigenous people spread across the globe [17, 18]. From antiquity to contemporary times, they have suffered from invasions, colonisation, forced assimilation and destruction of their cultures [18–21]. And in many ways, their rights and cultures continue to be threatened [18, 22, 23]. Many indigenous peoples have ancient systems of traditional medicine which are well accepted in their communities [22]. This knowledge is part of their world view of physical, mental and social harmony and is embedded in the context of their natural environment [22, 24]. Indigenous peoples have been described as ‘the guardians of the natural world, protecting many of the plants that form the basis of our most important medicines’ [25]. In India too, different tribes have their own tribal medicine that is locally popular and their indigenous knowledge has been documented in several ethnobotanical and ethnopharmacological studies [26–32]. Although the term ‘indigenous peoples’ is widely used in the literature, other terms exist: tribes, first peoples/ nations, aboriginals or minority ethnic groups. The
© 2015 John Wiley & Sons Ltd
Indian government recognises ‘tribals’ as a separate demographic entity in the census and tribal ethnic groups are notified as scheduled tribes as per provisions contained in Clause 1 of Articles 342 of the Constitution of India [33]. ‘Tribal’ is a colonial designation that once had pejorative connotations of being uncivilised, but now the word is widely used and accepted. In India, the three terms adivasis, ‘tribals’ and, more recently, ‘indigenous peoples’ are used at different historical points of time and for different reasons [34]. The oldest term, adivasis, is of Sanskrit derivation and means original inhabitants, but this term has limited acceptance in the northeast region of India where it is used only to refer to specific communities from central India. Those who claim indigenous status in the northeast prefer the term ‘tribal’ and or the more recent term ‘indigenous peoples’ [34]. Within India’s federal structure, the northeast region has eight states that are together bordered by Nepal, Bhutan, China, Myanmar and Bangladesh. The region is largely populated by indigenous peoples, with over 160 scheduled tribes and over 400 other tribal and subtribal communities and groups [35]. It is proposed to have been a corridor for ancient human migrations, to Southeast Asia [36]. While there are important similarities in their tribal social organisations, it has been argued that the common label of the northeast implies a mistaken homogeneity [37, p. 28]. The Indian state of Meghalaya has a population of 2.96 million, 86% of whom are identified as scheduled tribes [38]. Meghalaya’s main tribes are the Khasi–Jaintia and the Garo; all are matrilineal [39]. Although in recent decades a distinction has been made between Khasis and Jaintias, the latter may be considered as a subtribe of the former. Recent genetic evidence shows that the Khasis came from an ancient Austro-Asiatic migratory group and the time to the most recent common ancestor (TMRCA) for the Khasi is estimated to be approximately 57 000 years [36, 40]. Its indigenous traditional medicines are oral traditions that are largely un-documented [41]. The figures of 0.7% from the National Family Health Survey (NFHS) of households in the state seeking care from traditional healers is likely to be an underestimation [42]. Meghalaya was not a part of a national study commissioned by the Ministry of Health and Family Welfare on ‘Status and Role of AYUSH and Local Health Traditions under the National Rural Health Mission’ [16]. The report noted the poor quality of and lack of disaggregated data on utilisation of the AYUSH services in the northeast. Generally, AYUSH services were less frequently used than allopathic services for instance in the northeastern state of Nagaland it was used only in 4% of instances. Since the launch of NRHM, the 953
Tropical Medicine and International Health
volume 20 no 7 pp 952–960 july 2015
S. Albert et al. Medical pluralism in northeast India
AYUSH systems of medicine have been increasingly promoted in Meghalaya’s public health system [43, 44]. The basis for adopting a pluralistic approach to health service delivery is the assumption of the acceptability of these services in the community. But there is little empirical evidence that demonstrates peoples’ preferences for different medical traditions, especially in northeast India. This study bridges this gap in evidence by estimating awareness and use of different medical systems in rural Meghalaya.
Table 1 Numbers sampled at each stage of sampling Stage of sampling
Khasi–Jaintia Hills
Garo Hills
Total
Districts Blocks Villages Households (HH)
4/4 8/22 16/3262 388/1861
3/3 4/17 8/3577 200/504
7/7 12/39 24/6839 588/2365
For districts, blocks and villages, denominators show the total number of units in the study area, for that stage of sampling. For households, denominators show the total number of households in the selected villages.
Methods Setting Meghalaya state is hilly (500–2089 m) with difficult and inaccessible terrain; it contains the wettest region in the world, the Cherrapunji–Mawsynram belt, with an average 7500 mm of rainfall per year. Meghalaya is divided into seven administrative districts, which are further subdivided into 39 blocks and 6839 villages [45]. The Khasis and Garos largely inhabit separate areas of rural Meghalaya referred to as the Khasi Hills region and the Garo Hills region. Four districts (22 blocks and 3262 villages) are in the Khasi Hills region and three (17 blocks and 3577 villages) in the Garo Hills region. Study design In April and May 2010, we conducted a cross-sectional survey of households from 24 villages in all seven districts of Meghalaya. There was no prior listing of villages, households or individuals in the study area for use as a sampling frame; therefore, households were selected using a multistage cluster sample design with three stages [46]. In the first stage, two blocks from each of the seven districts were selected at random. The two blocks with large urban areas, Mylliem block in East Khasi Hills District, which contains the capital city Shillong, and the Rongram block in West Garo Hills District where Tura, the largest town in the Garo Hills, is located, were excluded from the sampling frame, as the aim of this study was to calculate estimates for rural Meghalaya. For two of the selected blocks, there were difficulties in recruiting suitably qualified field personnel within the timeframe of the study; thus, these two blocks were excluded leaving a total of eight blocks from the four districts in the Khasi Hills region and four blocks from the three Garo Hills districts for inclusion in the survey (Table 1). In the second stage, with the assistance of the Block Development Officers, the Primary Health Centres and Sub-Centres (SC) in the selected blocks were listed 954
and one SC selected from each block at random. The SC location was used as a guide to further select two villages from each block, one relatively close to the SC (but not the village in which the SC was located) which was accessible and the other much further away and defined as ‘remote’ by the Block Development Officer and the headmen. Permission was obtained through the University’s review process and from the relevant village headman and members of the local traditional administrative bodies. Using lists provided by the village headman or secretary as the sampling frame, approximately 25 households were randomly selected from each village. Where no lists of households existed, the selection was carried out with the assistance of the headman and his assistants using pathways and areas within the village as a guide. Informed verbal consent of participants was obtained before the interview. Survey data were collected through structured interviews with closed and open-ended questions. Taking into consideration the matrilineal family structure in Meghalaya, the questionnaires were administered to a senior female family member, usually the mother, and in her absence another female elder. Interviews were conducted in the local language by indigenous research assistants who spoke the local language as well as English. Each interview was conducted by a pair of research assistants. The research team attended a training workshop which incorporated filling in sample questionnaires and roleplay. Some of the questions on awareness and use of tribal medicine were informed by a pilot household health survey that was conducted in a village in Meghalaya in 2007 [47] with the addition of new exploratory openended questions on diseases for which tribal medicine was used. Data were entered into Excel and then imported to Stata version 11 [48] for analysis. All analyses were adjusted for the multistage sampling design using svy commands in Stata. To enable appropriate estimates of the use of
© 2015 John Wiley & Sons Ltd
Tropical Medicine and International Health
volume 20 no 7 pp 952–960 july 2015
S. Albert et al. Medical pluralism in northeast India
traditional medicine in the whole of rural Meghalaya, the data were weighted to allow for the probability of selection at each stage of the sampling process as follows: the probability of selection of each block was calculated as the number of blocks selected divided by the total number of blocks; the probability of selection of each village within a selected block was calculated based on the total number of villages in that block; the probability of selection of each household within a selected village was calculated as the number of selected households divided by the number of households in the village. The probabilities from each stage were then multiplied together to arrive at a final sampling probability for each household being selected. Estimates of preference for type or system of medicine such as biomedicine, tribal medicine, home remedies, pharmacy or others were calculated from responses to choice expressed for healthcare-seeking behaviour for minor or major ailments. The differentiation of minor and major was left to the interpretation of the respondent. Estimates of the prevalence of use of each system of medicine were calculated from responses to a four-point Likert scale [49] on frequency of use (with ‘very often’ and ‘sometimes’ being classified as using the system of medicine, and ‘rarely’ and ‘never’ being classified as not using the system of medicine). Distributions of reported effectiveness of tribal medicine, actual use in the previous 3 months, efficacy and cost were tabulated. The prevalence of awareness and use of AYUSH systems were also calculated. To evaluate differences in the use of tribal medicine between accessible and remote villages, proportions between these sets of villages were compared using design-based F-tests, an adaption of the standard Pearson’s chi-square test for analysing associations between two categorical variables which allows for the survey design [50, 51]. Results A total of 588 households were surveyed and the total number of persons resident in the households was 3633. Among the 588 respondents, 63% were from the Khasi tribe and 37% from the Garo tribe. 82% were Christian, and 18% followed indigenous tribal religions. The mean age of the respondents was 33.8 years (95% CI: 31.9– 35.6) and all were female. The main source of income of the majority of households was farming. The demographic details of the sample are presented in Table 2. The ethnicity of the population followed regional lines, that is all the people sampled from the Garo Hills belonged to the Garo tribe and all those from the Khasi Hills region belonged to the Khasi tribe, the only excep-
© 2015 John Wiley & Sons Ltd
tion was one village that fell in a border area in West Khasi Hills which had a Garo population. Twenty-two of the 24 villages sampled had one or more tribal medicine healers. The prevalence of reported preference and use of tribal medicine and biomedicine for major and minor ailments, and the prevalence of health-seeking behaviour and beliefs are summarised in Table 3. Disaggregated estimates by region, the number of individuals reporting each outcome and prevalence estimates before and after allowing for the survey design are also presented. The estimated reported use of tribal medicine across rural households in Meghalaya was 79.1% (95% CI: 66.3–88.0), with 13.5% reporting frequent use and 65.6% reporting that they sometimes used it. Tribal medicine was believed to be efficacious by 87.5% (95% CI: 74.2–94.1); 30% said it was very effective and 57% believed it to be somewhat effective, while 7% did not believe in its efficacy and 6% were unsure. 46% (95% CI: 30.5–62.8) had used tribal medicine in the previous 3 months, and of these, 91% (95% CI: 68.5–97.9) reported it as beneficial, with 58% reporting cure and 33% some improvement. Tribal medicine was reported to be used for both minor ailments and major diseases. The prevalence of reported preference for tribal medicine was higher for minor ailments (34%) than for major (23%) diseases (Table 3). In contrast, there was a high preference for biomedicine for major diseases (84%), while 52% said they would use it for minor ailments as well. It was apparent that most respondents would choose either biomedicine or tribal medicine as their first choice, and if unsatisfied with the response to therapy of their first choice, would try the other of these as their second. A majority had sought biomedicine from a public healthcare facility, 91% (95% CI: 73.8–97.4) reported visiting either a subcentre (SC), primary health centre (PHC) or a community health centre (CHC). Of those who had used tribal medicine in the previous 3 months, an average expenditure of Rs 189/- was reported to have been incurred (95% CI: 89.4–287.9). The reported average expenditure on biomedicine that included all or some of the doctor’s fee, medicines, transportation and laboratory tests in the previous 3 months was Rs 1417 (95% CI: 1060–1773 Rs). Although there were some differences between the Garo and Khasi regions in reported preference for and usage of each system of medicine, these differences were not statistically significant (all P > 0.05). Common ailments for which tribal medicine was reportedly used included diarrhoeal disorders, indigestion or gastrointestinal problems also referred to locally as gastric, a culturally understood childhood diarrhoeal 955
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S. Albert et al. Medical pluralism in northeast India
disorder called nia~ ngsohpet [52], injuries, joint problems, jaundice and fractures. More than 40 disorders were reported by respondents for which tribal medicine was
believed to be efficacious. Table 4 documents the most frequently mentioned conditions for which tribal medicine or biomedicine was reported to be the preferred
Table 2 Characteristics of sample Region Characteristic Tribe Khasi Garo Religion (2 mv) Christian Indigenous Other Age in years, mean (4 mv) Education (34 mv) Illiterate
