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Health: The relationship between hunger, illness and death in the district dates backto the eady records of the health department of the erstwhile SantalPargana district.Records show that deaths caused by diseases ike cholera, smallpox and malanaoccurred more in the yearsof famine and bad hatvest. In the years1897, 1906, 1908and 191,9 deaths caused by diseaseswere high. The same yeafs wefe marked byfamines and bad harvests.l0 Although the British rulers introduced allopathic med-ical facilities in the districts, their inadequate spread,on the one hand, and the acute-ness of hunger, poverty and ignorance, ofl the other, have made people victims ofseveraldiseases.The 1.92I censusnoted a huge fall of 83,744 in the population,mainly becauseof the endemic attack of cholera.ll

Before the introduction of allopathic medicines, people of the atea genenllypractised two kinds of medicines - Etwruedicby the kabirEs / uaids)and unani 0y th.hakims).Another kind of medicine was also introduced to the district with the growthof Santal settlements in the late 18th and ea$y 19th century. This medicine was calledrehet ran in Santali (iterally "root medicine", meaning herbal medicine), Rev P.O'Bodding, in his book, SantalMedicineand Connectedolklorw ([1925] 1986) had record-ed more than 300 prescriptions. At the sametime the Santals,who formed alarge pattof the population by the middle of thelgth century, carried on their beliefs on evilspirits (bonga), orcery and witchcraft as both preventive and curative treatments.l2

However, despite their traditional beliefs and cultural practices the Santals wetefound to be quite receptive to allopathic medicines. Although, O'Malley,Roychoudhury and others have accused the Santals and other adiuasisof being,"allergic to vaccination" and "abhorring allopathic medicines", fecofds (noted bynone other than Roychoudhury) show that a programme of mass vaccination againstsmallpox produced excellent esults.l3And as present-dayobservationsshow,almostall the adivasis have widely accepted allopathic medicine as their main souSceoftreatment of illnesses. n our study, we found few patieflts using traditional and othersources of treatment (that are not allopathic), even though allopathic treatment wasnot only mole expensive but suffered from gross corruption and abuse (mainlybecauseof its wide practice by people with litde or no competence). In rutal areasof Dumka district people mainly depended upon unqualified allopathic medicalpractitioners, If such is the case, he question afises - why do they not visit the mod-ern (allopathic) public health services?

Let us look at the present day health facilities provided by the goveffiment.Compared to other parts of Jharkhand, Dumka district is better placed n terms

of health faci1ities.14 ourteen PHCs (located at the block headquartefs), fifty-oneAdditional PHCs (henceforth APHC - located in different villages of the blocks)and 386 sub-centres form the framework of the government rural public health ser-vice. Each of the PHCs, as on 31 March 2002, serveda population of 26,993,whichwas much more than the prescribed norm. Each of the PHCs on that date cateredto an ^verage areaof 95 square km. In a district with hills, forests and difficult ter-

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prescribednorm. Each sub cefltre, on average,served a population of 4,545, whilethe prescribed norm for the hilly and tribal areas s one sub centre per 3,000 popu-lation. E,ach sub cenfte catered to an area of 16 square km.Table L4 Public health facilities in Dumka

Personsserved^Prre^ftF

Notmas PefGOI

Avetage areacovered undet

ezch centfeTotal Number of PrimaryHealth Cenres (PHC) 65 (including 14 PHCslocatedat blockheadquarters)

26,993 20,000 95 sq.km

Toral Number oF sub-centrcs 386 5,000 16 sq.km:zr,z: PrasadDr, H.tri Shararc,Dr Dbamterdra Kumar, andAbinaslt Kunar, National Atti-Makrial PragranneQa$),:':ria InpletnertationPlon- 200J, Dislit Danka, lharkhand

\!'hile accessibility to public health services was difficult, the actual services pro--:iied, as reported by many respondents and as observedby this team), were almostI ,n-existent. For example, in Dumka Sadar Hospital, diagnostic services like x-ray,:,-hological tests,malariaparasite ests,etc.were not available.Besides he cost of the:;>rs (rvhich were also, as a doctor remarked, not quite reliable), patients also had tor-r':irneady the entire costs of the prescribed medicines as they were "in short supply".-\s regards the staff strength, as on November 2002, there was a Iarge gap:,.r,r'een he posts sanctioned and the staff in actual position.Table 2.5 Strength of health staff in Dumka district

flrn (::il Surwon, Damka, in at interyiew on i I Ouaher 2002.W*- .i:rylara. Su ako. 'Distirl lnPlementatiln P/an. Natiana/ Anti Malaia Pmjranne, 2002'.

}l:rhasweta Devi, one of the finest writers and activists of our time, once sug-grmtd rhat the hospitals of NflestBengal be renamed after the different hefs (kanb-M*ti iimimwkh, roarab,etc.) hat are mentioned in Hindu mythology.ls One wonders

P:.s:s Sanctioned Actuallyposted Vacant PercentshortaEelfecical Ofhcers r ) t 1 1 0 BlJ 42\ ;ses 29 28 3C,;"rliDounderS 56 3 53 95ll"rr,rarorv Technicians 65 L I 44 68I-::ir rechnician I 0 0lDrrers 33 2 oft,lErq'risors BO 60 20 25$Iotdourpose Health workers (X4a1e) 261 139 t L zIdra-cpurposcHealth workers fcmalcl 410 435 35 7

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as to iust how the PHCs and other hospitalsof Dumk^ are o be describedlSome ofthe PHCs visited were sharedwith various animals - goats, cows and dogs. Parts ofsome PHC buildings had nearly collapsed. Manv doctors we came across during thestudy in Dumka did not seem to find it necessary o use the stethoscope at the hos-pital, let alone using "the scelFel as the sword". tilfe heard a doctor murrnu/lr'g,"aalata hai salaub mathachatne! Ihe damned lot turns up tochew our headsl)"Many of the government doctors in Dumka, as in Suri, were engaged in privatepractice. However, compared to Suri the number of- private cl,inics and nursinghomes was found to be much less in Dumka. There #r. uborrt 20 such clinics andfive nursing homes in all - the reason being attributed to the economic and socialbackwardness of the district.

Some government doctors, aswe were informed by people in Dumka tovm andin the villages, insisted that the patients see them at their private chambers. We per-sonally knew of a woman who was advised by a doctor in the Sadar Hospital to getadmitted to his own nursing home for better treatment. A doctor once told one ofour researchers,"priuatemeinaane ke lfuenahin kahengeo @a marneke lfie haspatalmerakh denge?flWhat should I do, ask fpatients] to visit private doctors, or let them stayin the povernmentl hospital and die?)r'

Both in Birbhum and Dumka, it seems, private practice is rampant and is fastreplacing the public health delivery system. The difference is merely one of degree.While in Birbhum public services are available o a certain extent and the poorer peo-pie can get some relief and benefits by using these services, n Dumka the publicmedical system is virtually non-existent. There is another difference as well. InBirbhum the quacks - despite growing in number - are yet to monopolise the mar-ket and private medical practice is carried on primarily by qualified allopathic doc-tors. In Dumka, Poverty, ignorance and inaccessibiJity o government health services(in terms of connectivity, etc.) work together to create a happy hunting ground forquacks. (For more onqwacks, ee ection .)

5 r L . . r ci 0 h i o F B r - o c K SThree blocks from each of the districts were selected for the purpose of the

study. In Birbhum the selected blocks were Nanoor, Sainthia and Rajnagar. Theselected blocks are spread across the district and are representative of the geo-graphical, topographical and demographic features of the district.

Nanoor is located on the alluvial plain, bordering Barddhaman and its lands areconsidered to be vety fertile. The population comprises Muslims and different casteHindus. As regards the heaith delivery system, Nanoor has one Block PHC, threePHCs and 30 sub-centres.The health staff of the Block health centres,as reportedby the doctor in charge of the BPHC, were insufficient in number to cater to needs.For example, of a required (and sanctioned) 60 field workers, there were only 43 atthe time of our interview (5 Mav 2003).