PATTERNS OF HEALTH CARE UTILIZATION AMONG ADIVASIS

<p>By Tilak U. Shah<br /><br /> <br /><br />INTRODUCTION<br /><br />Adivasis (tribals) comprise over 8% of India's population, the majority of whom live in central India in an area often referred to as the &quot;tribal belt.&quot; The 85 million people who constitute the Indian adivasis have historically lagged behind the general population in terms of education as well as economic assets. In 2001, over half the adivasis lived below the poverty line, and more than 70% were illiterate. These figures are far worse than the national rates of illiteracy and poverty, both of which were under 30% (1). A large proportion of advasis eke out a living as farmers from inferior and degraded lands in the hills, and through seasonal migration to work as laborers on farms or in towns in the richer plains regions (2).<br /><br />The issue of health care is of critical importance amongst the poor, given the serious economic consequences severe illness can have on their fragile incomes. Since its independence in 1947, the government of India has pursued a program of establishing Primary Health Centers (PHCs) to meet the health-care needs of rural areas. Unfortunately, the Ministry of Tribal Affairs reports that these centers are both inadequate and under-utilized, due in part to insufficient funding coupled with the reluctance of doctors and nurses to live in villages. It is not surprising then that the scant data available indicate maternal and infant mortality rates among adivasis are over twice those of the general Indian population (3).<br /><br />The lack of adequate medical care in adivasi areas has provided an opening for religious organizations to promote their agendas through health-care. Historically, adivasis have considered posession by deities and witches to be the cause of many ailments. Traditional treatments therefore consist of rituals to propitiate the deity or identify and torture witches to drive evil spirits away (4). Herbal remedies obtained from the forest complement rituals in the traditional treatment model. In recent years, Evangelical Christian missions have succesfully gained mass converts by convincing locals that neither old deities nor doctors can cure their illness, only prayer to Jesus. This has caused great alarm to Hindu nationalists, who view conversion to a &quot;foreign&quot; religion as a betrayal of Indian nationalism. They in turn have launched counter-proselytization movements that have placed a large emphasis on providing medical care through &quot;camps&quot; where cataract surgeries, optometric care, and dental procedures are performed. Tensions between the Jagats (adivasis who continue to worship traditional deities), Bhagats (Hindu converts who shun traditional practices such as animal sacrifice and consumption of meat) and Christians have led to violent conflicts that have received substantial attention by the Indian press (5).<br /><br />When I first arrived in the village of Tejgadh, my intention was merely to gain experience in diagnosing and treating common diseases in rural India by evaluating patients at a free clinic run by BHASHA (a charitable organization with no religious or political affiliation). Once there, I found a dearth of information on current notions of health and disease amongst adivasis and providers (both mainstream and traditonal). Such information can provide an insight into patterns of health-care utilization in the tribal belt.<br /><br />In order to gain a better preliminary understanding of the emic perspective, I conducted field work in the Chota Udaipur region of Gujarat. This area is populated predominantly by the Rathwa caste of adivasis . Sources of information included: (1) Casual observation and participation in villagers' conversations. (2) History of illness provided by patients at the BHASHA clinic. (3) Participation in community health outreach programs. (4) Formal interviews of villagers, physicians, community health workers and traditional healers in Chota Udaipur.<br /><br /> <br /> <br />THE PRIMARY HEALTH CENTER (PHC)<br /><br />The Indian government has established a heirarchy for state-run health care that is fairly uniform in the tribal belt. Each PHC serves about 30,000 people and is staffed by a single general practitioner or GP (a physician who has completed a year of internship training following medical school). At the taluka level (comprising about 90-100 contiguous villages or a population of about 200,00-250,000) the government hospital is supposed to be staffed by an internist, a general surgeon, a pediatrician, an anasthesiologist, and a radiologist. All other specialized care is available at the district level (an amalgam of 8-10 talukas). Unfortunately, as I learned, not all pieces of this therotetical heirarchy were in place. There was no general surgeon posted at the hospital in the town of Chota Udepur that served the taluka . Also notable was the absence of CT or MRI scanners, which limited the diagnostic capability of the radiologist at Chota Udepur. Thus referrals from the PHC often had to be made to the private hospital in Bodeli, which had more facilities, but was also considerably more expensive.<br /><br />At the village level, the government attempts to train one midwife in each village to handle uncomplicated deliveries and about five health care workers (HCWs) for every 12-13 villages. The midwives, nurses, and health care workers operate under the supervision of the GP. Literacy is the only major prerequisite to be a HCW, whose major responsibility is to go from hut to hut and take surveys of births, deaths, and illnesses. Patients with a fever are supposed to begin empiric antibiotic treatment following a blood draw. For those whose tests come back as positive for malaria or tuberculosis, the HCWs monitor the patients to ensure that they complete the entire course of treatment. The major difficulty with this exercise according to a HCW in Tejgadh is that many villagers are suspicious of blood draws and tend to deny they have a fever once they learn of the blood test. Other job expectations of a HCW include organizing polio vaccination camps, plotting the growth of children in the government schools annually, and chlorinating every well in the villages once a month (although a HCW interviewed informed me that this was not uniformly done).<br /><br />The GP at Tejgadh's PHC was Dr. Dilip Kumar, a native of the state of Bihar. The lack of laboratory tests and medications meant that he had to treat most patients symptomatically with paracetamol (acetaminophen), domstal (domperidone), vitamin B12 shots, or intravenous fluids. The government did have a strong program for the detection and treatment of malaria and tuberculosis (TB). But since microscopy for malaria parasites and an acid fast stain to diagnose TB from sputum specimens were the only two tests available at the PHC, the most common diagnosis was still fever of unknown origin. No tests or treatments were available to screen for diabetes. The HIV prevention program consisted of a small sign at the PHC advocating condom use (which did not seem to have had the desired effect, since many young males in the taluka mentioned routinely participating in unprotected intercourse). In fact, the prevalence of HIV in the taluka was unknown since an unpublished screening test of 100 students at Bordeli college constituted the extent of research on HIV in the area. <br /><br />Dr. Kumar's view of the situation at the PHC was fatalistic. &quot;People here don't distinguish between physicians, badvos (traditional healers), or ayurvedic practitioners. Except for the physician who retired from the PHC to run a private clinic which resulted in my posting here, all the khangis (private practice physicians) are quacks without real medical degrees. Great advances have been made in medicine. I wish the government would provide us some better facilities to take advantage of these advances. But whats the point of wishing for these things? Nothing I say or do is going to change the situation here.&quot;<br /><br /> <br /><br /> <br /><br />COMMUNITY HEALTH<br /><br />With a population of over 5000, Kanalva is a fairly large village, and so it is divided into a number of falis . During his survey of one such fali Govindbhai (a HCW for BHASHA) stopped by a hut to ask the residents if anyone was sick or disabled there. Indeed, a member of the family had been having difficulty walking for years, they answered matter of factly. <br /><br />The extreme atrophy seen on inspection of his left leg suggested he may have been suffering from a common complication of infection by the polio virus. Govindbhai mentioned if the patient could give him his name and age, BHASHA could arrange for him to have an operation in Baroda. Age was not something most villagers tracked and so this number was noted by consensus after a little debate between the family members. <br /><br />During the conversation, a lady entered the hut holding a baby girl in her arms. She had heard the HCW was there and wanted to ask him if anything could be done about her daughter's chronic vomiting. The child had been taken to the PHC, then the khangi , and finally even to the badvo , but none of their treatments had provided any relief. Yet another lady walked in from a nearby hut to complain about a high fever she had been having for the last few days. But it wasn't high enough in her opinion to warrant a blood draw. Shortly after the lady's entry, a badvo came in looking to speak to the medical student who he had heard was interested in gaining mahiti (knowledge) about health-care in the village. Much mahiti could not be gained however, because he was completely inebriated. Payment for services rendered by the badvo in Kanalva was in the form of goats or alcohol, and the badvo usually enjoyed his &quot;payment&quot; in the afternoons. Thus ended the survey of the fali . Word of mouth had allowed Govindbhai to complete his survey by visiting just one hut.<br /><br />Govindbhai's work in Kanalva was not finished though. He explained that he was involved in substance abuse treatment in the village as well. This was surprising, since none of the other HCWs had mentioned this task before. I then learned that he was a prominent member of a Bhagat sect that shunned the consumption of alcohol. &quot;Substance abuse treatment&quot; was accomplished by convincing Jagats to join their sect and take vows of abstinence.<br /><br />On the way back to his headquarters, the gram vikas kendra (village progress center) at Panvad, Govindbhai described how he had been recruited to work as a HCW. His father had known a lot about medicinal herbs, and had taught him much of what he knew. Prior to joining BHASHA, practicing vanaspati (herbal medicine) constituted a major portion of his income. It was his knowledge of vanaspati that had led to his recruitment as a HCW. Since his incorporation within the framework of allopathic medicine, his vanaspati practice had been scaled down. He still used vanaspati as a temporizing measure at night when the clinic was closed and the patient presented with what appeared to be a surgical emergency like appendicitis (for which he gave a remarkably accurate description of the signs and symptoms).<br /><br /> <br /><br />VANASPATI<br /><br />Ayurveda ( vanaspati ) is recognized as a legitimate science by the Indian government. Like medical colleges, a number of institutions in the cities train students to be vaids (Ayurvedic practitioners) using a standardized four-year curriculum. Adivasis are reported to have been the first to utilize many of the herbs considered to be an integral part of Ayurvedic therapy. Yet there are few licensed vaids in Chota Udaipur. Despite the lack of vaids, herbs are an integral part of the villagers' everyday life. This is because substances considered to have therapeutic value such as limdo trees, goat's urine, and fudina leaves can easily be obtained from their own back yards. So unlike mainstream medicine, vanaspati is cheap and readily accesible to the adivasis.<br /><br />Bhavsingh is a resident of Rangpur village who had studied vanaspati in the tribal belt while in college. In his opinion, vanaspati is as much of a lifestyle choice as a source of remedies. &quot; Jagats like me eat mutton and drink toddy (a local alcoholic beverage), which keeps us healthy. Bhagats have forsaken a healthy lifestyle and hence need to visit the doctor more often. Even when using vanaspati as a cure for disease, vanaspati must be treated as a lifestyle since it requires discipline. Allopathic medicine on the other hand provides immediate relief but does not rid the system of disease. The only drawback to vanaspati is that treatments are only effective when fresh, and so allopathic medicine is required if the plant needed for treament of a given illness is not in season.&quot; <br /><br />The concept of &quot;heat&quot; mentioned by Govinbhai also figures prominently in Bhavsingh's ideas of illness. Like Govindbhai, he feels vanaspati is better tolerated than allopathic medicine because it creates less &quot;heat&quot; in the system. Also, vanaspati and allopathic medicine should not be used concurrently because the combination creates excessive heat. I found this last point interesting because my allopathic training taught me to be cautious about combining drugs, especially given the documented toxic interactions between some ayurvedic and allopathic medications.<br /><br />While evaluating patients at the prakriti clinic run by BHASHA, I found the idea of &quot;heat&quot; to be a part of many adivasis' notions of disease. A patient at the clinic described his symptoms in the following manner: &quot;I initially had this burning feeling in my stomach every time I ate. I could feel the bile created by the heat in my throat. This heat has now spread to my neck and now I have pain in my neck as well.&quot; From an allopathic perspective, his history and physical examination suggested that his complaints were the result of two separate issues. The gastrointestinal problems were caused by acid reflux from the stomach while the neck pain was most likely due to muscle spasm. This conflicts with the adivasi notion that heat from the blood is the cause of all kudrati (physical) ailments, and disciplined measures to balance the heat is required to restore equilibrium in the body.<br /><br />Each village usually has a few laymen adivasis with a reputation for mahiti about vanaspati remedies. Bhavsingh introduced us to one such person in Rangpur. Although an illiterate farmer, JR had memorized many remedies learned through word of mouth. Sometimes, things he learned didn't appear to work, and so he discarded these remedies. Over the years, he felt he had acquired a degree of expertise in using vanaspati to treat patients with a variety of problems ranging from the common cold and kidney stones to jaundice and a variety of gastrointestinal problems. The ingredients for all these remedies were easily obtainable from their farms or around the village (such as cactus milk for the common cold and toddy to prevent kidney stones).<br /><br />When asked about their preference for vanaspati versus allopathic medicine, most villagers responded that they considered both effective. On closer examination though, I find that adivasis initially tend to visit the PHC physician or a khangi in times of severe illness. Vanaspati treatment is initiated when mainstream medicine either does not provide immediate relief, is not accessible, or is unaffordable. Even when JR developed severe lower abdominal pain and dysuria a few years ago, he initially consulted the physician. It was only when he realized that he could not afford the kidney operation the doctor had recommended that he used vanaspati as a cheaper alternative. The alternative treatment was a concoction of jowar grains and ginger recommended by an adivasi with mahiti in the neighboring village. Since this treatment was associated with a complete resolution of symptoms, it is now part of his arsenal of herbal remedies to recommend to fellow villagers.<br /><br /> Bhavsingh, a self-described proponent of vanaspati, spoke of a patient who had been shot in the leg with an arrow after an argument in the family. Physicians in Baroda informed him that he needed an amputation. Rather than lose his leg, he chose to return home and wrap bandages containing the extracts of leaves of all plants near his hut considered to have medicinal properties. After months of continuing this practice, he recovered complete function in his legs. The anecdote was intended to highlight the effectiveness of vanaspat i, but it also serves to demonstrate a typical pattern of health-care utilization.<br /><br /> <br /><br />BADVOS<br /><br />In his survey of 45 villages in Chota Udaipur, Chimanbhai Rathwa counted 177 practicing badvos in 2004. Chimanbhai classified the badvos based on whether they exercised chokhi vidya (clean knowledge) or meli vidya (evil knowledge). Both types are jagats who practice on the premise that diseases are either kudrati (diet and environment related) or manav sarjit (brought on by the evil eye or posession by other people or witches). Since badvos that practice meli vidya believe that saving a life requires taking a life, treatment often involves taking a badha (vow) to sacrifice a set number of goats in honor of adivasi deities if the illness resolves. In addition, cured patients paint the walls of their hut with illustrations of their deities (a practice that has evolved into an elaborate art form called pithora ). Badvos that practice chokhi vidya ask their patients to take vows that do not involve animal sacrifice. A third type of traditional healer is the Maharaj , whose practices seemed very similar to that of a chokhi vidya badvo , except that the rituals and offerings honored Hindu gods and godesses (6).<br /><br />The traditional healers surveyed claimed to have acquired their skill in a variety of different ways. Most commonly cited was that &quot;it just came naturally&quot; or &quot;god taught me the knowledge in my dreams.&quot; Other methods included inheriting the knowledge from their parents and gaining knowledge through penance or vows. A few said that they learned the skills from other badvos. Curiously enough, the majority of these healers were illiterate.<br /><br />Bhuria Naika of Jaloda village provides a representative illustration of these healers and their methods. Bhuria kaka (respectful term for elders in the village) reports he gained the &quot;gift&quot; in his dreams around the time he was married. Now an old man, he is a badvo of considerable repute despite his inability to read or write. His modus operandi involves chanting a mantra (spell) which causes the diagnosis to appear on a leaf plucked from the khakhra tree in his yard. As an example of how diagnoses become apparent to him he cites tuberculosis, which appears as blood oozing from the leaf. If the illness is Manav sarjit , then a combination of penance, vows, mantras, and herbs are &quot;prescribed.&quot; Herbal remedies are sufficient for certain kudrati conditions such as kamlo (jaundice) while others prompt a recommendation to go to an allopathic physician. Just as he refers patients to doctors, he claims to get referrals from doctors for diseases that range from bewitchment to arthritis (presumed from his description of the swan-neck deformity of rheumatoid arthritis). <br /><br />There is considerable heterogeneity in the way different traditional healers were compensated. Bhuria kaka does not demand any payment for his services. Patients are expected to donate what they feel is reasonable to the nearby temple (which he later collects). A maharaj near Panval lamented the only payment he received was coconuts, while the badvo from Kanalva was paid with alcohol. On the other hand, villagers in Tejgadh spoke of a badvo who charged two hundred thousand rupees to prophylactically ward off physical illness and evil spiritis for a year.<br /><br />None of the healers displayed any signs of antagonism towards allopathic medicine. The maharaj in Panval mentioned giving his patients allopathic medicine after blessing it with a prayer (since he was illiterate, he told the chemist what was wrong with the patient and bought whatever the chemist gave him). He was even receptive to the idea of receiving some basic training to recognize illnesses from an allopathic standpoint. Bhuria kaka maintained that he could make any diagnosis by staring at the leaf and therefore had no need for any further training. But he still referred patients to allopathic physicians.<br /><br />Most people did not express a preference for either system of healing and reported utilizing both allopathic and badvo medicine. Certain conditions were repeatedly mentioned by villagers as &quot;badvo diseases.&quot; In the case of Ori (chickenpox), also referred to as mata no rog (holy mother's illness), it is considered inauspicious to send the affected child to a physician. The badvos have a fairly standardized treatment regimen that forbids the patient from bathing for nine days. During this time bidi leaves are burned and the smoke is directed towards the patient's back. On the ninth day, the badvo sprinles haldar water and goat's milk on the child. Even snake bites were mentioned as a disease that required a badvo's mantras. Three people mentioned a badvo who expected a friend of the bitten person to go to the badvo. The badvo cured the patient by slapping the friend. <br /><br />Many believe minor cases of diarrhea to result from downward displacement of the &quot;lever&quot; that connects the umbilicus to the intestine. Appropriate management of the diarrhea involves having the badvo manipulate the lever upward. A BHASHA volunteer from the University of Chicago who was in Tejgadh at the time did in fact report rapid resolution of his symptoms after he had this maneuver performed on him. I found it interesting that the first person to mention his faith in this remedy was Amrutbhai, a man who had modern surgery and rehabilitation to thank for saving his life following a motorcycle crash two years ago. <br /><br />There were some in the villages who disagreed with the badvos claims, although the patterns of disagreement differed based on the remoteness of the location. In Tejgadh, which is closer to urban Gujarat, many dismissed badvos as a comical feature of everyday life. Near Madhya Pradesh the disagreement was with the notion that only badvos could see the diagnosis on leaves. In their opinion, everyone had this capability. In fact, they claimed to have seen the diagnosis on occasion as well.<br /><br /> A surprising pattern I noticed was that the few people who strongly believed badvo medicine was superior to allopathic medicine were among the most educated people in the villages. Chimanbhai, a college graduate in Jaloda, expressed disdain for those adivasis who blindly followed the city people's medicine. A paralegal who had brought his son to Bhuria kaka's clinic son said &quot;allopathic medicine can make you feel better for a short while but after treatment you get sick again because the root cause has not been eliminated. Although badvo treatment takes time and discipline, it can permanantly rid you of the disease.&quot; It should be noted though that he had initially taken his son to the PHC. It was only after the bottles (intravenous fluids) at the PHC did not produce any symptomatic improvement did the paralegal utilize what he believed to be a superior type of treatment.<br /><br /> <br /><br />PRAKRITI<br /><br />BHASHA's free clinic is termed Prakriti (mother nature). Patients are referred to the clinic by BHASHA's community health workers. Some of the patients travel from villages hours away in order to be seen at the clinic. A nominal fee of five rupees (less than a dime) is charged for all services and medications provided. The physician at the Prakriti clinic is Dr. Shinglot, a professor at Baroda Medical College who offers his services twice a week on Saturday and Sunday. Minor surgeries are performed here, and a dispensary attached to the clinic stocks some basic medications for common ailments. Patients requiring a more extensive work-up are referred to Baroda, where free care is provided. In order to obtain this care though, patients have to make at least a three hour journey, and the round trip can cost over sixty rupees.<br /><br />The majority of the patients I evaluated complained of either joint pains, shortness of breath, fever, or skin lesions. Unless the joint pain was chronic and severe, a presumptive diagnosis of arthritis was made, and a two week course of ibuprofen was dispensed. No further investigations were carried out for such patients. Corticosteroids were also available at the clinic to treat eczema (topical preparations) and COPD (oral preparations). Lindane cream, topical and oral anti-fungals, and an ointment combination of salicylic acid and benzoic acid were available to manage the common problems of scabies, tinea infections, and hyperkeratosis respectively. Anti-hypertensives were also provided to patients, who were asked to follow-up at the clinic regularly. Thus, most complaints could be adequately dealt with in this outpatient clinic.<br /><br />Detecting and managing other conditions was a little more problematic. Only when patients complained of difficulty with balance or tingling in their feet was diabetes mellitus suspected (these symptoms can be caused by a late complication of diabetes). Such patients required a blood draw, and the blood had to be sent to a laboratory in Baroda to measure the random blood sugar. One patient described symptoms consistent with classic migraine, but unfortunately medication to treat her symptoms would have been unaffordable. Another young girl presented with severe mitral stenosis (a thickening of a valve in the heart). The preferred treatment at her stage of the disease was surgery, which was performed in only one city in the state. BHASHA could have made arrangements for her to go to Ahmedabad for surgery, but she was unwilling to travel that far, and so her condition had to be managed with medications alone.<br /><br />The presentation of many patients provides a glimpse into the lack of awareness and of well-trained medical professionals in the area. An elderly lady came in complaining of abdominal discomfort and constipation. On examination, her uterus was as large as that of a pregnant lady in her third trimester. She had noticed her abdomen getting larger for almost a year, but had not thought of it as important until her symptoms became very severe. Another young man when examined had ascites (fluid in the abdomen) that had caused significant distress for the last six months. He had been visiting a khangi (private physician) who had drained the fluid repeatedly without any further investigation. From the allopathic standpoint that the khangi was presumably working under, the most important step would have been to look for an underlying cause like chronic liver disease or disseminated tuberculosis. While I could not verify the khangi's credentials, the patient reminded me of Dr. Kumar's perception of khangis in the area. <br /><br />Very few of the patients at the clinic reported that they had tried vanaspati or consulted a badvo. The few patients who admitted to using vanaspati suferred from chronic arthritis not adequately controlled with ibuprofen. This seemed to fit in with my observation that allopathic treatment was the first type of health-care sought by villagers in the region. Also, the physician was referred to as &quot; sir &quot; or &quot; doctor sahib &quot; while badvos like Bhuria were called &quot; kaka .&quot; The term sahib is typically intended for an employer or a person of higher rank or social status. On the other hand kaka (literally translated as uncle) is an endearing and respectful term for village elders. This terminology suggests the physician is an outsider who is to be respected and to some extent feared while the badvo is a community member whose opinion as an elder must be respected.<br /><br /> <br /><br />CONCLUSIONS<br /><br />Traditional concepts of disease continue to remain firmly entrenched amongst adivasis in the Chota Udaipur region. Pride in their identity as bhagats or jagats is also an important influence on notions of health and purity. Yet the davakhano (allopathic clinic) is typically the first type of health-care sought in times of severe illness. Improving medical facilities remains an important goal in the tribal belt. But attempts to improve medical infrastructure in adivasi regions are likely to be more succesful if they are carried out in the context their socio-political environment. <br /><br />For instance, my initial reflex on learning about the lack of information on HIV/AIDS was that studies to assess its prevalence were necessary in the area. This reflex is not surprising given the culture of evidence based medical training emphasized in the United States as well as in urban India. But HCWs in Chota Udaipur have not been raised in a culture that values patient confidentiality, and anti-retroviral therapy is not available in the region. In such an environment, expending resources on detecting a disease associated with a considable stigma has worrisome ethical implications.<br /><br />The 100 person study on prevalence of HIV at Bodeli also tested for the presence of sickle cell trait and disease, a condition that may have been selected for in the past due to its protective effect against malarial infection. Arjun bhai , a former professor at the college, reports that 8% of the subjects had sickle cell disease and an additional 30% had sickle cell trait. HCWs and patients understood the condition as hereditary and associated with episodes of intense pain in the summer. Its management, according to Govinbhai was proper khorak (diet), although he could not elaborate as to what khorak was needed.<br /><br />Basic allopathic management principles rely on penicillin prophylaxis until age five and adequate analgesia and hydration during vaso-occlusive crises (the periods of intense pain). These treatments are inexpensive and readily available. The system of community health in place in Chota Udaipur seems well set up to monitor these patients. Also, the lack of stigma and presence of classic symptoms make the job of identifying this condition a lot simpler than HIV. Research and allocation of resources to debilitating and endemic conditions such as sickle cell anemia are thus likely to be of major benefit.<br /><br />Also, incorporating traditional herbs and healers into the mainstream paradigm of rural medicine is likely to improve the delivery of health-care in the tribal belt. Many healers are familiar with common manifestations of endemic diseases like tuberculosis, and even refer patients to an allopathic physician. As integral members of their communities, they provide psychological relief to patients with self-limiting conditions that manifest with distressing symptoms like chicken-pox and hepatitis A. Educating badvos to identify the subset of manav prakriti patients with a treatable psychiatric illness and providing allopathic training to more locals like Govindbhai who have mahiti about traditional treatments can serve as a bridge between the two models of illness. <br /><br /> <br /><br /> <br /><br />References:<br /><br />&bull; Socio-economic Profile of Adivasis in India: An Appraisal. Reddy KC, Indigenous Rights in the Commonwealth Project, South and South East Asia Regional Expert Meeting, 2002.<br /><br />&bull; Education Profile of States/Union Territories (2 nd Edition). Department of Education, Ministry of Human Resource Development, Governement of India, New Delhi, 1999.<br /><br />&bull; Annual Report 2000-01 . Government of India Ministry of Tribal Affairs, New Delhi, 2001.<br /><br />&bull; Ajay Skaria, 'Women, Witchcraft and Gratuitous Violence in Colonial Western India', Past and Present , no.155, May 1997.<br /><br />&bull; Satyakam Joshi, 'Tribals, Missionaries and Sadhus: Understanding the Violence in the Dangs', Economic and Political Weekly , 11 September 1999, p.2670.<br /><br />&bull; Chiman Kagadabhai Rathwa, ' Chota Udaipur taluka ma vasta adivasi samajma badva nu sthan ' .</p>