My first experience working with the tribal community in the Nilgiris, Tamil Nadu, was 10 years ago, when I chose to do my rural service obligation in a secondary care hospital that works for the health welfare of the Adivasis in this region.
In one of my first encounters, I saw a middle-aged man brought into the hospital after being mauled by a bear. He had at least three fractures and a completely disfigured buttock area. I started with a low dose of local anesthetic, doubting if it was enough to keep him comfortable. To my surprise, while cleaning the wound, I noticed that his heart rate did not cross 60 beats per minute, and his face was as calm as a stone with no expression of fear or pain whatsoever.
Pain beyond the physical realm
Pain, as we now know, is a complex interplay of cultural, social, and psychological experiences. I was amazed to see such living examples, where some people seem to have a higher threshold of pain. Some tribal communities in India may culturally express or report pain differently, possibly due to lived experiences, social norms, or limited access to care.
To cite another example, the labour room, which is the most chaotic and distressing area of any hospital, was an incredibly calm place with young mothers calmly delivering babies. The caregivers were staff from the Adivasi community, who added to the sense of a stress-free birthing experience by ensuring a holistic and familiar birthing environment for the mothers.
Pain has not just a physical component, but also psychological and emotional components. The threshold for pain tolerance varies between individuals depending on age, gender, previous experiences like surgeries, etc. Despite the limited supply of narcotic agents (especially for the rural hospitals), physical pain has probably been the easiest to manage in such settings in my experience. The bigger worry in the community currently is the other forms of pain, which have been extremely hard to manage.
Rising burden of mental health disorders
Over the last decade, the number of Adivasis suffering from mental health disorders, functional pain, abuse, and addictions has increased considerably. Infectious diseases such as pneumonia, tuberculosis, and gastroenteritis, which were the most common causes of hospital admissions in the past, have transitioned into cardiovascular diseases, strokes, cancers, and mental health conditions.
These disorders, unlike the former, require continued and often lifelong interventions, which can be challenging despite having a dedicated community health program. Suicides have been among the top five causes of death for the last five years. The number of patients with depressive and psychiatric disorders has grown exponentially and proportionately to the number of alcohol users.
At the heart of the matter lies a difficult question: How do we begin to manage the pain that emerges when one’s sense of purpose has been stripped away?
Losing the forest, losing purpose
The Adivasi community residing in this region includes the Moolakurumbas, who were traditionally hunters, Paniyas, the cultivators, Bettakurumbas, the elephant mahouts, Irulas, the snake charmers, and the Katunayakans, the honey gatherers. These five communities have lived off the forest since time immemorial. The forest provided everything they needed and was their deity, too.
With the introduction of the forest rights and the tiger reserve, these original dwellers were forced out of the forest and had to settle in lands given to them. These lands were often unfit to cultivate or had been converted into tea estates.
Their unique skill sets of cultivation, hunting, and honey gathering, rooted in principles of environmental conservation, were then reduced to daily wage employment in tea and coffee estates and areca nut farms. Many families were coerced or misled into selling their land by the migrant population, either by force or intimidation.
Tribal leaders from the five different communities got together for the first time to fight for their rights, leading to the formation of the Adivasi Munnetra Sangam (AMS). Their advocacy led to fulfilling lives for their communities, ensuring they had access to healthcare, education, and employment. However, decades of marginalization and exploitation have left the present generation grappling with a sense of disillusionment and loss of direction.
Cycles of addiction and despair
The widespread availability of tobacco and alcohol, often introduced or supplied by external employers, has contributed to rising rates of addiction, affecting both men and women, including adolescents and even pregnant women.
The tradition of alcohol supplied by employers has been culturally entrenched. Absence of gainful employment also leads to a higher risk of alcohol abuse among the youth. Additionally, alcohol is often seen as a customary part of several rites and rituals.
Despite the presence of health awareness initiatives, committed counselors, and de-addiction and rehabilitation services, the cycle of substance dependence and social disengagement continues to take a toll on the community’s well-being. Four of the top five causes of death are directly related to tobacco and alcohol use.
The alcohol use, disease, and loss of purpose seem to be cyclical, with each feeding the other. When access to higher education is scarce, economic pressures weigh heavily, and alternative sources of income remain absent, alcohol misuse can emerge as a coping mechanism—or even a fragile source of comfort—for many within tribal communities, including children.
Stories behind the statistics
Health indicators like maternal mortality, immunisations, and neonatal and infant mortality rates are better than the national average at our centre, thanks to the extensive community health program and a 50-bedded secondary care hospital owned and managed by the Adivasi community. However, besides these indicators, there is the undeniable fact that alcohol and tobacco use in this population has remained higher than average.
Unfortunately, there are no indicators to measure the socio-cultural determinants that are proving to be detrimental to a good quality of life. Here are a few examples:
A 5-year-old boy gets admitted repeatedly with respiratory infections. He has persistently been seen to have severe malnutrition. His weight hasn’t improved despite treating his infections, ruling out congenital anomalies, and providing nutritional supplementation. We then find out that his father is a chronic alcoholic who doesn’t provide for the family. The mother is depressed because of this and is unable to care for her children.
A 30-year-old man was admitted for the fourth time in the last 3 months with a diagnosis of severe pancreatitis secondary to alcoholism. He goes back to drinking just a few days after every discharge. Upon telling him that the next episode of pancreatitis can be fatal, he shows no reaction since he believes he cannot work without alcohol. He finds it is normal to indulge in alcoholism at the end of a day’s labour since all his friends and uncles do it.
A senior hospital staffer, present since the hospital’s inception, recalls how patients were once accompanied by groups who stayed with them throughout their hospitalization—an expression of the profound community support that characterizes tribal life. Today, patients often arrive by ambulance with only one elderly companion—typically a spouse—and even when others accompany them, they tend to leave shortly after admission. How can a patient heal in the absence of visible community support? Part of the issue lies in the shift from traditional, community-based living to a daily wage economy that leaves little room for extended caregiving.
A pregnant woman in her final trimester is found to be chewing tobacco in the labour ward. She says she has been doing it throughout her pregnancy since there isn’t enough food at home to eat, and tobacco chewing keeps her less hungry.
Modernization has also introduced new forms of pain and fears in tribal communities that previously did not exist. In Adivasi culture, death has long been embraced as a natural and integral part of life, not an end, but a continuation of the life cycle through those yet to be born. This outlook fostered a sense of acceptance, free from fear or stigma surrounding death or the dying. Interestingly, it echoes the more recent concept of the 'Advance Medical Directive' found in educated, urban contexts.
However, prolonged exposure to non-tribal ways of life has gradually shifted this perspective, with death now often viewed through a lens of fear and sorrow, marked by loud grieving and emotional upheaval that were once absent from traditional practices.
Beyond the clinical: the need for holistic interventions
While these cases might appear to be purely medical, they are shaped by deeply rooted, multidimensional socio-cultural factors that belie simple or lasting solutions.
Some may argue that Adivasi communities could have fared better if left undisturbed, but throughout history, no community has remained untouched by the forces of acculturation. The particular challenge here is one of visibility: with tribal populations constituting only about 1% of Tamil Nadu’s demographics, their health and psychosocial struggles have minimal impact on the state’s overall development indicators, unlike states such as Madhya Pradesh or Jharkhand, where over 25% of the population is tribal.
The suffering experienced by this community today is not merely physical; it is psychosocial, rooted in a complex web of factors including loss of social support, grief, unstable home and work conditions, marginalization, and weakened social cohesion.
Tackling the underlying determinants of early financial independence and promoting alternative pathways for education, skill acquisition, and sustainable livelihood development may contribute to reducing the incidence of alcohol misuse among tribal populations. Furthermore, the implementation of comprehensive, context-sensitive interventions that address the broader socio-economic and cultural factors, including poverty and restricted access to opportunities, is essential for effectively addressing the complex interplay between tribal living conditions and patterns of alcohol misuse.
Edited by Radhikaa Sharma.
Image by Christianez Ratna Kiruba.
