Landscape analysis of traditional tribal healers and their healing practices in the tribal-dominated states of India

doi:10.21203/rs.3.rs-3409841/v1

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Landscape analysis of traditional tribal healers and their healing practices in the tribal-dominated states of India

https://doi.org/10.21203/rs.3.rs-3409841/v1

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Tribal communities have a rich history as some of the earliest inhabitants of the Indian subcontinent, living in harmony with nature for thousands of years. These indigenous or ethnic groups are spread throughout India, with significant concentrations in states like Chhattisgarh (30.5%), Jharkhand (26.0%), Odisha (22.8%), Madhya Pradesh (21.0%), Gujarat (14.7%), Rajasthan (13.4%), and Maharashtra (9.3%). In the peninsular region, notable tribal groups include Bhils, Santhals, Gonds, Ho, Kondh, Kols, Mundas, and Kharia, while in the northeast region, the prominent ones are Nagas, Mizos, Mikris, and Kukis. However, their access to healthcare is hindered by limited infrastructure, illiteracy, poverty, unemployment, socio-economic challenges, and marginalization. As a result, tribal communities often turn to traditional healers and indigenous medicinal practices, giving preference to traditional healing over modern healthcare options. Tribal traditional healers lack formal medical degrees, but their deep connection with indigenous communities makes them a preferred choice for healthcare. They are easily accessible to tribal populations and offer cost-effective services. These healers rely on their extensive traditional knowledge and skills, utilizing locally available medicinal plants, animal, and mineral substances, and incorporating specific ritual practices in their treatment methods for patients. Tribal healers are integral components of the available local healthcare system and play a critical role in delivering primary care services.

The primary objective of this landscape analysis was to conduct a comprehensive examination of the socio-economic status, healing practices, and knowledge transfer methods of tribal healers and folk practitioners. Additionally, it aimed to create an evidence-based roadmap for their integration into the mainstream through upskilling, certificating, and federating the tribal healers.

The study was ethnographic descriptive cross-sectional research conducted between May 15^th and September 30^th, 2023. The study comprised 1649 participants, encompassing Herbalists, Spiritual Healers, Diviners, Bone Setters, and Traditional Birth Attendants hailing from 43 districts in 7 tribal dominated states predominantly inhabited by tribal communities, namely Chhattisgarh, Jharkhand, Odisha, Madhya Pradesh, Maharashtra, Assam, and Arunachal Pradesh. Data collection occurred across 43 districts situated within the aforementioned states. The selection of tribal healers was done using an Exponential non-discriminative snowball non-probability sampling approach. The research methodology encompassed ethnographic research, interviews with healers, and documentary analysis.

The analysis showcased the diversity of traditional healers, representing about 240 tribes, and emphasized the rich cultural and regional variations in their healing practices. The study involved tribal healers with an average age of 52.6 years, of which 82.4% were above 40 years old. These healers had varied roles and expertise, such as general herbalists, bone setters, Ojhas, or Dondai, each employing distinct diagnostic methods and treatments for the indigenous population. About 53.9% of folk healers were skilled in indigenous medicine, using natural substances for healthcare. Additionally, 42.5% of religious practitioners integrated social, cultural, and religious beliefs into their treatments, including rituals and sacrifices. Knowledge transmission followed the traditional guru-shishya tradition, where tribal healers learned from experienced healers orally, without written texts. Certification was valued as a way to gain public trust, and NGOs and federations played pivotal roles in advocating for traditional healing practices. Successful integration into mainstream healthcare required collaboration, coordination, and mutual respect between traditional and modern healthcare providers. Despite deep-rooted connections with their own communities, traditional healers face several common challenges in their practice such as Stigmatization and lack of recognition, Limited resources and infrastructure, Lack of formal training and certification, Legal and regulatory challenges, Ethical and legal dilemmas, and economic challenges.

In conclusion, the landscape analysis shed light on the diverse healing traditions within tribal communities, emphasizing the importance of preserving and respecting these practices to safeguard cultural heritage and wisdom. Integrating traditional healing into comprehensive healthcare systems can enhance inclusivity and provide holistic care for tribal populations.

Statistical Epidemiology

Health Policy

Tribal populations

Tribal healers

Traditional medicine

Marginalization

Cultural beliefs and rituals

The indigenous communities in India, known as “Vanvasi”, have been the original inhabitants of the Indian subcontinent for millennia. Their longstanding presence is steeped in a deep connection with nature, reflecting a rich culture and heritage characterized by traditional practices. India boasts a diverse array of more than 700 tribal communities, each distinguished by its exclusive language, culture, and heritage. Notable tribal groups encompass the Bhils, Gonds, Santhals, Mundas, Kols, and Nagas. Indigenous communities are present across India, with notable concentrations in Chhattisgarh, Jharkhand, Odisha, Madhya Pradesh, Gujarat, Rajasthan, and Maharashtra states. Healthcare in tribal areas of India faces unique challenges stemming from geographical, cultural, socio-economic, and infrastructural factors. The tribal population often experiences limited access to quality healthcare, leading to health disparities. Therefore, tribal healers play a critical role in providing primary care services to tribal communities in India. Traditional tribal healers often view health as a state of balance and harmony between the individual, their community, environment, and spiritual realm. This balance can be physical, mental, and spiritual. Illness is often seen as a disruption of this balance. This disruption can be caused by several factors, including physical factors (such as infection or injury), psychological factors (such as stress or trauma), and spiritual factors (such as offending a deity or violating a taboo). Spiritual practices, rituals, and ceremonies are seen as ways to achieve and maintain this balance. Ancestors and spiritual beings are seen as influential in health and illness. Traditional healers believe in seeking guidance, protection, and healing from ancestors and spirits. Rituals and ceremonies are performed to honour and connect with these spiritual entities. Chickenpox, smallpox, unsafe deliveries, fever, snake bites, typhoid, pneumonia, tetanus, malaria, and seizures are among the illnesses that people believe to be brought on by evil spirits and the gods' wrath.

In every tribal community, there are few individuals who can recognize evil spirits and they are also skilled at controlling those sinister powers. Communities are calling them “Ojha” (exorcists/tribal healers) and they treat persons who are afflicted with various forms of evil magics. Ojha’s not only treat fever, pain, and other serious illnesses in tribal people, but they also assist the entire village's land to retain its fertility, which leads to good agricultural output.

Apart from this, various myths and misconceptions are also predominant among tribal communities such as taboos related to menstruating girls/women. Due to several preconceived notions about the subject, women in some tribal societies still lock themselves away for five days during their menstrual cycle, eschewing food and all forms of comfort. Menstruating women are forced to sleep on the floor by the “Baiga” tribe. They are dealt with as patients, as though they had a contagious illness. Similarly, Contraception is forbidden in Kashmiri tribal communities known as Gujjar-Bakerwals in the Ganderbal district because they believe that God created children, whereas family planning interferes with nature.

Their primitive culture keeps them together and forges beautiful emotional bonds among them, but it is also disappointing that in this contemporary social structure, indigenous peoples also maintain significant cultural variations from the rest of the population. These differences are present not only in spiritual practices but rather social, economic, and health systems too.

Despite the fact that traditional tribal healers are not medically trained people but the tribal community regards them as competent to provide medical care and treatment utilizing substances extracted from plants, animals, and other natural resources and specific practices in accordance with social, cultural, and spiritual contexts as well as the experience, knowledge, and convictions which are prominent in the tribal community related to the physical, psychological, and social wellbeing coupled with the causes of illness and physical impairments. Traditional healing methods, rituals, and ceremonies vary across diverse tribal cultures and regions and are utilized by tribal healers in a broad spectrum. These practices often have deep-rooted cultural and spiritual significance, focusing on holistic well-being and harmony with the natural and spiritual realms. There are different kinds of traditional tribal healers. They can be informally classified based on methods of treatment into those who:

a) Carry out animal sacrifices and occult practices.

b) Use only belief systems and tantric rituals.

c) Use herbs and faith (that includes mantras and certain rituals).

d) Use herbs to treat their patients.

Within traditional tribal healers there could be specializations with some healers only focusing on fractures, poisonings, or jaundice, and so on and so forth. Tribal healers deeply understand and respect the cultural values, beliefs, and practices of their community and offer personalized care, considering the individual's physical, mental, emotional, and spiritual well-being. These healers are often accessible and available to community members. They may hold regular sessions or visits to their practice spaces or travel to patients' homes, making healthcare easily accessible and convenient. They actively engage with the community by involving them in healing rituals, ceremonies, and gatherings. This inclusivity fosters a sense of belonging and collective healing. Tribal healers show genuine empathy and compassion towards patients, understanding their pain, suffering, and challenges. This compassionate approach creates a strong bond and trust within the tribal communities.

While they maintain a strong connection with their community, a linkage with modern healthcare remains incomplete for tribal healers. Recognition from modern healthcare systems, stigmatization, limited resources, and lack of formal training are often elusive for them, presenting challenges in collaborating with modern healthcare providers and advocating for their patients. Advancing the integration of traditional healing practices into modern healthcare systems can pave the way for acknowledgment, acceptance, and collaboration, thereby enhancing the preservation and transmission of these valuable practices.

The study design for qualitative research on traditional tribal healers and their healing practices was carefully crafted to capture the richness and complexity of their knowledge and practices. An Ethnographic descriptive cross-sectional study was conducted in 43 districts of 7 states with 1649 tribal healers which comprise of Herbalists (1071), Spiritual Healers (433), Diviners (105), Bone Setters (34), Traditional Birth Attendants (6) to collect qualitative information that aligns with the research objectives, such as phenomenology, ethnography, or grounded theory. The core objective of the study is to in-depth exploration of socio-demographic status of traditional healers, numerous ailments for which community seek their assistance, diverse techniques and processes employed in healing of diseases, and the scope of integration of these traditional healers with public healthcare. The research study was performed in the natural settings of different tribal communities in seven tribal dominated states namely, Chhattisgarh (30.5%), Jharkhand (26.0%), Odisha (22.8%), Madhya Pradesh (21.0%), Maharashtra (9.3%), Assam (12.5%) and Arunachal Pradesh (71.4%). Districts in such states was identified depending on the density of actively practicing tribal healers, cultural diversity, geographic accessibility, and population size of tribal communities. The most suitable approach for this project was the utilization of the "Exponential non-discriminative snowball non-probability sampling" method. In this approach, one respondent (either a tribal or faith-based healer) was initially identified from each tribal community. Subsequently, these respondents were requested to assist in recruiting one or more tribal/faith-based healers from the same or different tribal groups within the same district and state. The study took place with traditional healers who play a central role in community well-being and continue to practice their healing arts and known for their strong connection to nature, ancestral worship, and profound healing knowledge passed down through generations. Access to the tribal communities and healers was facilitated through extensive engagement with community leaders and youth clubs.

The study employed various assessment methods, such as unstructured interviews, observations, and record reviews, to delve into diverse aspects of traditional healing practices, community perspectives, and social norms associated with such practices. The utilization of multiple data collection methods facilitated the triangulation of findings, enhancing the robustness of the study. Interviews and interactive observations were conducted in the healers' residences or healing centers, patients' homes, and occasionally in public spaces like markets, temples, or gathering areas. Prior to data collection, the on-field team conducted a thorough review of the study objectives, tools, and specific data collection methodologies to ensure the acquisition of high-quality data in an effective and efficient manner. Additionally, field team extensively studied the tribes, cultures, customs, prevalent diseases, and health-seeking behaviors of the community to establish a solid foundation before engaging in interviews with the healers.

During the initial phase, the on-the-ground team faced difficulties in locating tribal healers. However, with the assistance of tribal councils, youth volunteers, and community leaders, the district coordinators were able to establish connections with the healers. Confidentiality concerns led some healers to initially hesitate in disclosing information about their traditional practices, patients, or opinions. However, through building rapport and engaging in professional and comfortable dialogue, the researchers were able to create a sense of trust, leading to increased participation and cooperation. The healers freely shared insights into their traditional tribal healing methods and provided valuable information about other healers they were connected to. This approach facilitated further engagement with subsequent research participants.

By the time of the mid-term assessment, over 400 interviews with tribal healers had been conducted. The team successfully addressed operational challenges and sought appropriate solutions. They were encouraged to continue reaching out to as many tribal healers as possible, ensuring comprehensive participation and data collection for the study. At the conclusion of assessment process concluded on July 15, 2023, the field team successfully gathered information from 1649 tribal healers across 43 districts in 7 states. Throughout the assessment, the district tribal health coordinators shared their valuable field experiences and highlighted the challenges they faced during the data collection phase. Notably, most interactions with tribal healers revealed their willingness to share their extensive knowledge and expertise acquired from their gurus, as well as their openness to learning new skills and practices, including those related to modern medicine. To ensure data integrity and security, all information collected on-site was carefully transferred to the digital tool, following necessary precautionary measures.

Socio-economic status

The survey primarily covered participants from tribal-concentrated regions: Odisha (30.6%), Chhattisgarh (26.7%), Jharkhand (24.3%), and Madhya Pradesh (10.1%). Interaction with healers from about 240 tribes revealed substantial diversity. Notable tribes included Gonds (n = 211), Kandha (n = 192), Murias (n = 117), Santhal (n = 89), Munda (n = 76), Oraon (n = 67), and Bhils (n = 66). While each tribe showcased distinct variations in lifestyle, culture, and language, they shared a common tendency to seek traditional healing for various health issues.

The average age of tribal healers was 52.6 years (SD ± 11.9), with a significant majority (82.4%) being above 40 years old (n = 1358). Literacy rates were suboptimal, with 43.2% being illiterate (n = 713) and only 2.3% having a university degree or higher education (n = 37). The study indicated a strong correlation (p < 0.05) between age and education level, with younger healers having higher educational attainment. Specifically, 44.5% of those above 35 years were found to be illiterate, compared to 30.6% among those aged 35 or below.

Characteristics	Frequency	Percent	Characteristics	Frequency	Percent
State			Education
Arunachal Pradesh	19	1.2	Illiterate	713	43.2
Assam	54	3.3	Lower primary education (1st to 4th std)	335	20.3
Chhattisgarh	440	26.7	Primary education (5th to 8th std)	302	18.3
Jharkhand	400	24.3	Secondary education (9th to 10th std)	203	12.3
Madhya Pradesh	167	10.1	Pre-university education or intermediate	58	3.5
Maharashtra	65	3.9	Diploma or Pre-university	1	0.1
Odisha	504	30.6	Graduate	29	1.8
Tribes			Post-graduation or doctorate	7	0.4
Gond	211	12.8	Prefer not to say	1	0.1
Kandha	192	11.6	Traditional healing practice
Muria	117	7.1	1–2 years	30	1.8
Santhal	89	5.4	3–5 years	142	8.6
Munda	76	4.6	6–10 years	289	17.5
Oraon	67	4.1	More than 10 years	1188	72
Bhil	66	4.0	Family members
Others	831	50.0	Less than 4	523	31.7%
Gender			5–9	1006	61.0%
Male	1543	93.6	10–14	99	6.0%
Female	106	6.4	More than 14	21	1.3%
Social Category			Socio-economic class
Schedule Tribe	1384	83.9	First quantile (< 1179)	253	15.3
Schedule Caste	101	6.1	Second quantile (1179–2358)	368	22.3
OBC	136	8.2	Third quantile (2359–3930)	264	16
General	28	1.7	Forth quantile (3931–7862)	299	18.1
Religion			Fifth quantile (> 7863)	465	28.2
Hindu	1370	83.1	Sources of Income
Muslim	15	0.9	Agriculture	1348	81.7%
Sarna	55	3.3	No other source of income	174	10.6%
Christian	209	12.7	Labour	31	1.9%
Age			Business	26	1.6%
Less than 20	2	0.1	Other sources (Government pension, Poultry, or skilled work)	70	4.2%
21–40	289	17.5		70	4.2%
41–60	942	57.1	Health insurance schemes
61–80	402	24.4	Yes	754	45.7%
More than 80	14	0.8	No	895	54.2%

In summary, the study revealed that a majority of tribal healers (93.5%) were male, with a significant portion (83.9%) belonging to scheduled tribes. Hinduism was the dominant religion (83%), followed by Christianity (209 healers). Over 72% of healers had a decade or more of experience, averaging 12.4 years in traditional healing. Most tribal healers (68.3%) had households with 5 or more members. Regarding income, 15.3% earned less than Rs. 1179 per person per month, while 28.2% earned over Rs. 7863. Higher education correlated with higher per capita income (52.8%).

Tribal healers offered consultations for free (30.7%), voluntary payment (48.2%), or barter systems (1.5%) to maintain their sense of community service. They relied on agriculture (81.75%) and other sources for income. A significant portion (54%) lacked health insurance due to relying on self-prepared medicines, lack of awareness, or not perceiving a need for insurance. For personal healthcare, 85.6% reported spending Rs. 1000 or less monthly, while 7.4% spent between Rs. 1000 and Rs. 5000.

Tribal healing practices:

This section outlines primary traditional healing methods used by tribal healers for diverse health issues within tribal communities. Despite lacking formal medical training, these healers play a crucial role, specializing in various areas such as herbalism, bone setting, and spiritual practices. Common health concerns among indigenous people include malaria, diarrheal diseases, pneumonia, skin issues, menstrual problems, jaundice, tuberculosis, joint pains, and mental health disorders. Tribal healers employ unique diagnostic approaches rooted in cultural beliefs, including observations, conversations, and spiritual elements. Treatments involve herbal remedies, dietary advice, rituals, and a holistic approach to restore balance and overall wellness. Interviews revealed over 50% of tribal healers had expertise in treating musculoskeletal disorders, communicable and non-communicable diseases, and reproductive health issues, demonstrating their diverse capabilities.

The survey revealed that 53.9% of folk healers specialized in plant-based medicine and bone setting, using forest and mountain herbs to create various remedies. Religious practitioners (42.5%) employed a blend of cultural, religious, and social treatment approaches, often including rituals and sacrifices. Tribal healers, reflecting diverse tribes, have unique roles and local names derived from their languages and practices. Common settings for their healing practices include their residences (96.9%) and occasionally public places (0.6%). They prepare medicines using a mix of traditional knowledge, rituals, and natural ingredients, often dispensed in forms like powders, pastes, or decoctions.

Traditional healers are easily accessible, primarily in rural areas, and often provide consultations without set fees, emphasizing community service. Patients determine the consultation fee based on preference or engage in barter systems (1.5%). Healers attract patients based on reputation and effectiveness, with about 79.8% seeing five or fewer patients per day. Overall, traditional healers play a vital and accessible role in tribal healthcare, integrating cultural practices and natural remedies to provide care to their communities.

Transfer and preservation of healing knowledge:

Preserving traditional healing knowledge is crucial for its sustainability. In tribal communities, this knowledge is transmitted through oral traditions, apprenticeships, and mentorship, ensuring its perpetuation. Apprenticeships, where aspiring healers learn from experienced practitioners, are key in this knowledge transfer, providing hands-on experience and deep understanding of healing practices.

The transfer of traditional healing practices and herbal plant knowledge occurs through various means, including oral traditions, folklore, written records, and cultural taboos. This transmission is essential for the continuity of these practices, deeply ingrained in the community from ancient times. Approximately 46.6% of tribal healers actively pass on this valuable knowledge to the next generation, emphasizing its importance and longevity.

Training and certification

Training and certification can legitimize traditional healing practices, fostering community recognition and enabling collaboration with modern healthcare systems. Although formal certification programs for traditional healing might be limited, healers derive legitimacy from practical experience, community reputation, and adherence to traditional principles. Recognition often occurs through informal channels, like endorsement from respected community figures. Some healers enhance their skills through workshops and training programs organized by governmental or non-governmental organizations. Only 5.7% of tribal healers (n = 94) reported attending formal training sessions by institutions or NGOs, focusing on enhancing their knowledge about herbs and treatment techniques. Despite limited formal training, tribal healers continuously learn and refer to existing records and data. When queried about future training and certification interest, 78.0% of healers (n = 1287) expressed enthusiasm, recognizing the potential benefits and recognition it could bring to their clinical practice.

Association with NGOs and tribal unions

Tribal healers' association with NGOs and CBOs supports their professional growth, recognition, and sustenance of traditional healing practices. It enables collaboration, advocacy, and access to vital resources, benefiting tribal communities. While 1.8% of tribal healers (n = 29) reported affiliation with NGOs, 4.5% (n = 74) were part of tribal unions or associations. These affiliations significantly contribute to skill development, accreditation, and the revitalization of traditional healing practices.

Referral linkages

Tribal healers, potential tribal health ambassadors, could facilitate timely referrals when needed. However, the survey revealed that most lack awareness about the importance of referrals. Only a small percentage (17.4%) of tribal healers make referrals, primarily focusing on their expertise. They refer cases beyond their practice scope to specific healers or mentors within their community. Complex cases or pregnancies are often referred to Community Health Centres (CHCs) or Primary Health Centres (PHCs). Referrals are facilitated through frontline health workers, youth clubs, direct calls to doctors, or patient self-arrangements. Those with training recognize the need for referrals, but many have never encountered emergencies or lack awareness of referral processes.

Scheduled tribes, comprising 8.6% of India's population, are a diverse and vulnerable community. With 705 unique tribes, they possess distinct languages, cultures, and practices. Despite this diversity, tribal communities share a common reliance on traditional healers for healthcare. Traditional healers, leveraging indigenous wisdom and practices, use medicinal plants, rituals, and beliefs deeply rooted in their culture for health and healing. Belief systems, entwined with spirituality, shape these practices, influencing how communities perceive and treat diseases. These practices encompass tangible (herbal medicine, ritual objects) and intangible (skills, chants) elements in the context of illness. Additionally, traditional healing methods have defined roles, statuses, and behavioral norms within the community.

Socioeconomic status plays a significant role in shaping the scenario. Tribal healers, mostly older and male, lack socio-economic empowerment. The younger generation is hesitant to learn due to a lack of recognition and dwindling herbal resources from deforestation and displacement. Despite challenges, traditional healers are revered for their altruistic service, often accepting minimal offerings from patients. In remote regions with limited healthcare access, tribal healers are a preferred choice due to their availability, community ties, and cost-effectiveness. They extensively use herbs from forests and mountains, applying their knowledge of plants for various ailments. The challenge lies in preserving this traditional knowledge, especially due to dwindling interest among the youth and inadequate documentation.

Tribal communities possess a unique spirituality, distinct from mainstream religious texts, passed down orally across generations. This spiritual essence provides strength and solace during challenging times. Traditional healing systems, deeply ingrained in social interactions and cultural patterns, pass on knowledge of illness management from generation to generation. The challenge lies in documenting and preserving this knowledge for the future. Trust in the public healthcare system among tribal communities is low, driving them towards local healers. However, traditional healers lack formal recognition. Various NGOs and social institutions are assisting these healers, supporting their associations, sharing knowledge, and striving to integrate traditional healing practices with the existing health system. The decline in traditional healers is attributed to the younger generation's disinterest and migration, exacerbated by limited financial incentives and recognition.

Tribal communities' reliance on traditional healers for healthcare underscores the need to preserve and document this indigenous wisdom. Efforts are underway to support these healers and integrate their practices into the broader healthcare system, ensuring the continuation of this vital tradition.

Statement of ethics approval: The study was carried out with a strong commitment to ethical conduct, ensuring the welfare, rights, and dignity of all individuals and communities involved. Prior approval was obtained from the internal review board of the Piramal Swasthya Management and Research Institute.

Statement regarding potential competing interests - The authors declare no competing interests.

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Landscape analysis of traditional tribal healers and their healing practices in the tribal-dominated states of India

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Abstract

Introduction

Method and Materials

Results

Socio-economic status

Tribal healing practices:

Transfer and preservation of healing knowledge:

Training and certification

Association with NGOs and tribal unions

Referral linkages

Discussion

Conclusion

Declarations

References

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