Overcoming the ‘outsider’ barrier in serving tribal communities

A year in, doctors at the Total Health clinic in Telangana's Amrabad Tiger Reserve have learnt that the key to gaining the trust of people in pentas deep inside the forest, is showing up consistently

We enter the 12×24 square feet space of the Total Health satellite clinic, set in the Mannanur CBET complex, run by the Government of Telangana. Dr Yedlapalli Aravind greets us with a wide grin. In his line of work, this smile is his biggest advantage. That, and his MBBS degree.

Tribes and the forest

The Total Health clinic, where Dr Aravind works, is situated on the border of the forests of Amrabad, India’s second largest tiger reserve. The modest two-room clinic, with stretchers on the porch, is surrounded by trees and shrubbery, given its close proximity to the government-run eco-tourism cottages. Every day people from a radius of 40 km visit the clinic with their health grievances. However, this was not the case even 8 months ago in 2021, when the clinic was first established. 

Dr Bharath Kumar, the first doctor at the Total Health clinic recalls the teething troubles: “We launched the clinic in September 2021. But even by the end of October, not a single patient would come here.”

The Nallamalla hills and forests are home to a significant Chenchu population – the overall population of the tribe in Andhra Pradesh and Telangana is over 64,000, according to the 2011 census. One of India’s oldest aboriginal tribes, the Chenchus live in settlements called pentas. These pentas, each with 20 to 50 residents, are situated deep within the forest, as far as 60 km inside. Without pakka roads and cellular networks inside the forest, accessing medical services has not been easy for the Chenchu tribespeople. Although Mannanur has a primary health centre (PHC), people still needed to walk at least 15 km through the forest before they could reach it. 

For the doctors at Total Health in Amrabad, earning people’s trust came with being consistent. Picture by M Javeed

“We realised soon that we would need to go inside the pentas to where the people lived, and hold medical camps,” says Dr Kumar. “We did that thrice a week to raise awareness about the clinic.” 

When they did, they were met with questioning stares.

A bridge to connect 

This barrier stems from the mistrust of the ‘outside’ world. There’s the government system, coaxing them to live outside the forest in brick-and-mortar houses, in a bid to protect the forest ecosystem and mainstream the tribe so they are not exploited by tradespeople and poachers. The Chenchus would have to leave their traditional huts made of bamboo and dried grass and also the lifestyle that comes with it, including their diet (they once were primarily hunter-gatherers). 

Years of prejudice against tribal communities by city-folk and the ‘developed’ villages around, only adds on to the suspicion of non-tribals. Many ‘good Samaritans’, coming in from cities, with the intent to help, force their own ideas of what’s best for the Chenchus. 

Caught between a forest, where fragmented and uncoordinated conservation efforts are worsening the effects of climate change, and a capitalistic world where money talks, the Chenchus face an identity crisis that makes them all the more apprehensive about mingling with the ‘other’. 

“Initially nobody would even talk to us,” says Dr Kumar. “Still, we would turn up at the pentas every week until they went from nodding at us in recognition to accepting us.”

“To build trust, consistency is key. Only then will a person come back for a follow up. That is important for long-term good health.” 

Dr Bharath Kumar

Dr Kumar’s team of 3, including a nurse and a pharmacist, would lay down their spread of medicines on a tarp, like merchants selling their wares at a country fair, and sit in wait. “People started approaching us, asking what the clinic was about, what we could treat and so on. We slowly started making friends.” 

The nurse Kale Renuka lays down the medicines she has brought with her for Bairapur penta. Picture by Raju Patil

Pandemic pressure

Then there was the apprehension of the city folk in a pandemic ridden world. Packed urban cities were the hotspots for the spread of Covid-19 and for most part of 2020 and 2021, the forest-dwellers took to blocking the roads, often with dry branches, to prevent outsiders’ entry into their settlements, in fear of contracting the virus.

During a medical camp at the Bairapur penta in February 2021, the doctors at Total Health recall how one of their patients poked fun at them. “This Covid is your folks’ disease, it’s a city disease. We don’t get it here,” he had said. 

Indeed, both doctors confirm that inside the pentas, people did not report fever or a cough as much as skin infections and joint pains. Learning traditional herbal treatments commonly applied by the Chenchus is important for the doctors to understand the context in which they operate. For example, the leaves of the nemalli chettu, which grows in abundance, are applied on rashes, something the doctors found out about only after having frequent conversations. The challenge was to talk about what was causing the rashes in the first place – often a lack of access to adequate and clean water and sanitation systems. 

Dr Aravind distributes water purification tablets to residents of Rampur penta. Picture by M Javeed

Both doctors in their 20s, have realized early that their job is not just to hand over a prescription, but also to familiarize themselves with the community and context, to provide holistic solutions. Today, Dr Aravind regularly distributes water purification tablets to the pentas and explains how to use them, as he knows that their most common complaint of skin infections is triggered by, and worsen, due to unclean water.  

“There is a slight difference in the doctor patient interaction in big cities. Here, you need to talk to first form a connection, so it’s more like counselling a friend,” says Dr Aravind, who has previously worked for an NGO in Rajahmundry, Andhra Pradesh. He moved to Amrabad on the recommendation of Dr Kumar. The two doctors met each other by chance, at a reading room in Kurnool where they became friends while preparing for their NEET exams. When Dr Kumar wished to leave to continue his studies with an MD in General Medicine, Dr Aravind took over. The idea is that no matter what, the camps must go on. Even when the doctors are unavailable, the satellite clinic at Mannanur is equipped with a teleconsultation facility to assist the patients.

Do they think their efforts have paid off? In November 2021, the clinic would get 2 patients a day. Today, they get 20. But their biggest achievement, they say, is when people in the pentas greet them with smiles not stares.

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