Tribal Healthcare System in Kerala during the Pandemic

: In Kerala, 36 Scheduled Tribe communities live in various districts. Wayanad has 35 per cent of the state’s tribal population. Out of these 36 tribal groups, Wayanad has eight major and three minor tribal groups. With the outbreak of COVID, the Government of India ordered a lockdown in March 2020 to protect people from the spread of COVID. In Kerala and Wayanad district, State Government initiated COVID prevention activities and awareness all over the state. To prevent COVID, the district administration started the corona tribal cell and coordinated COVID-19 activities. The main objective of the cell is to coordinate tribal health care issues related to COVID and non-COVID diseases during the lockdown period and also coordinate food support for the tribal people. District administration had fully engaged in protecting tribal health during the COVID outbreak by preparing an action plan and evaluation method. The objective of the study is to understand the tribal situation during COVID. It covers the changes in their livelihood, the ups and downs in their personal and social life, and the problems and challenges they faced during this process. For this study, the highest tribal concentrated Block of Wayanad district Kalpetta was selected. The state government and the district authority supported the tribal peoples during the COVID-19 pandemic to reduce their grievances.


I. Introduction
The World Health Organization declared the Novel Corona Virus outbreak a global pandemic and an international health emergency. COVID-19 poses a grave health threat to indigenous peoples worldwide.
Indigenous communities already experience poor access to healthcare systems, significantly higher rates of communicable and non-communicable diseases, and a lack of access to essential services, sanitation, and other vital preventive measures, such as clean water, soap, disinfectant and others. Likewise, most nearby local K.P. Suresh et al. Tribal Healthcare System in Kerala during the Pandemic ___________________________________________________________________________________________________________ 84 medical facilities, if and when there are any, are often under-equipped and understaffed. In addition, indigenous people face stigma and discrimination even when they can access healthcare services.
The World Health Organization (WHO), on 11th March 2020, declared the novel Coronavirus (COVID-19) outbreak a global pandemic with 118000 cases and 4291 deaths globally. Since health and safety are the utmost priorities, the Government of India imposed a lockdown on 24th March 2020, along with restrictions on freedom of movement and social and physical distancing. Self-isolation and quarantine measures were followed by closing all private and public sector establishments (Rawat D, 2021). All over the world, including India, COVID cases were reported rapidly. In India, COVID affected the day-to-day life of the people. Kerala is the first State from where a COVID-infected case was reported. On January27, 2020, the first case was reported in Thrissur District. Within a short duration, the number of cases increased, and State Government started preventive measures to control the COVID cases. The main preventive measures were isolation, wearing mask, using sanitizer, and keeping social distance.
On 22nd March, the Central Government announced the month long country-wide lockdown to prevent the spread of Corona virus. During the lockdown, the life of the people became highly affected. There is no contact between the people, which cut off their social life. People started spending their day-to-day activities in their homes. Though the lockdown had affected nearly all sections of the people, It is the marginalized and poor people whose lives were highly affected. Most of them had lost their livelihood options, particularly those in the village and tribal areas who earned their income through daily wages.
Balvir Singh (2020, accept in his study to assess the knowledge, attitude and practice of the general public of India on COVID-19. Jose Chathukulam (2021) describes how Kerala handled the pandemic and analyses the structural and systematic factors behind the State's success. The paper also points out the limitations of the Kerala model in the context of the pandemic. Dilip Kumar (2021), in a study, discusses the adoption of safety measures against COVID-19 by tribal families in Southern Rajasthan. Tripathy (2020) discusses the impact of Covid with reference to four tribes of India from four different states, namely, Jharkhand, Assam, Madhya Pradesh and Odisha. Kanniyan and Binub (2020) describe the COVID-19 experiences and problems in the context of Kerala.
This present paper attempts to explore the social life of the tribal people at the time of the COVID outbreak. It also examines the preventive measures of the Government as implemented at the local level to minimize COVID infections among the tribal peoples of Wayanad.

II. Materials and Methods
The main objective of the study was to understand the scenario among the tribes of the Wayanad District of Kerala owing to the COVID situation. Hence, it looks into the changes in their livelihood, the ups and downs in their personal and social life, and the problems and challenges they faced during this process. Kalpetta Block K.P. Suresh et al.
Tribal Healthcare System in Kerala during the Pandemic ___________________________________________________________________________________________________________ 85 was selected for this study as it has the highest concentration of the tribal population in. The study was conducted in two Panchayats, namely, are Muttil and Kaniyampetta. Semi-structured schedules, personal interviews, and case studies were used for data collection. Informal group discussions and 25 personal interviews were conducted with respondents above 15 years. Among these, 15 respondents were aged between 16-35 years, seven were between 31-50 years, and three were above 50 years. Five case studies were also collected as part of the field study. Descriptive and narrative methods have been used to interpret the data.
Secondary data was collected from the reports of the district administration and District Disaster Management Authority (DDMA), Scheduled Tribe department, Health Department, Panchayat and other Institutions. In addition, secondary data were gathered from regional newspapers, magazines, journals and books. . In the past, their livelihood activities were fishing, hunting, foraging and shifting cultivation. However, they are mainly engaged in settled agriculture, collecting non-wood forest produce and wage labour. The paper has four parts; the introductory section mentions the problem, objectives and methodology.

No of Families
Part II describes the socio-economic life of the tribal communities during the time of COVID. Part III analyses the measures adopted to prevent COVID cases in the tribal concentrated areas. Here it examines the structural and functional mechanisms adopted to prevent the pandemic. In conclusion, the paper analyses the system's efficiency in Covid prevention and how it worked during the pandemic. In the case of livelihood, most of the tribal people are dependent on wage labour or casual labour, which was the highest risk during the COVID time. PVTG communities, like the Kattunayakans, became detached from the mainstream because most of them had moved to the interior forest area. Their main livelihood activities are NWFP, honey and tuber collection. The lockdown restricted the people's movement and badly affected their livelihood. Hence, they were left with no other options but to depend on the government agencies for their survival.
The malnutrition and mortality rates among the STs are much higher than among the rest of the rural and urban people. Healthcare facility was limited in the tribal areas. The service availability of health care workers including doctors, nurses, and junior health inspectors was limited in the tribal area as compared to other areas.
Basic infrastructure and clean drinking water were unavailable in many tribal settlements, and had suffered from food shortages during the rainy season. In addition, social distancing is impossible due to the lack of proper latrines and bathing facilities in many households.
During the pandemic, tribal students and parents faced a challenging situation in the area of education also. The non-availability of electricity and internet connectivity were significant barriers to tribal students from taking advantage of online education. COVID-19 drew a clear boundary line between the elites and the nonelites, and between those students who are privileged to have access to better facilities and the opportunity to access study materials, online lectures, and information, and those underprivileged tribal students who had to struggle to obtain their minimum sources of knowledge. Furthermore, students in rural areas may have limited or no internet access, and many students may not be able to afford computers, laptops, or smartphones in their homes. As a result, online education has created a cyber divide between different sections of student communities. According to various reports, most people cannot pursue online learning. K.P. Suresh et al.

HealthCare System in the Tribal Area
Most tribal people live in tribal settlements and hence, were most vulnerable to the outbreak. Generally, tribal people depend on Primary Health Centres and in certain cases, on the taluk and district hospitals for their primary treatment for diseases. In the case of severe diseases, people depend on a far distantly-located Kozhikode medical college hospital for better treatment.
During the outbreak of COVID the health workers were more engaged in COVID prevention and Covid care treatments across the district and the routine medical services to the tribal people were interrupted. In such a situation, the tribal patients suffered rigorously. Moreover, being a marginalized community, they required special care for COVID-19. There was a need for a special tribal health action plan in the context of the COVID pandemic.
Hence, a special plan was framed for addressing their issues. Due to the COVID-19 pandemic outbreak, the district collector established a separate control room for addressing the health issues of the tribal people and for coordinating the COVID-related issues in tribal communities. It was under the control of the district collector, and the members of this Special Cell included the deputy collector (disaster), project officer of (ITDP), TDOs and other senior officers from planning, health, and other Departments. The Cell also included a doctor, four Committed Social Workers (CSW) and a staff from Kudumbasree (a Woman's Self-Help Group) to coordinate the daily activities. It monitored and coordinated the COVID-related issues such as awareness, food shortage, healthcare activities and medical care issues, helping the tribal migrant workers from other states return to their place and be quarantined. After quarantine, with the help of the tribal department, the cell arranged vehicle facilities to help them return to their homes.
The tribal cell also collected COVID and healthcare issues-related data, analyzed the situation, and submitted a daily report , including the COVID-19 infection report (related to COVID treatment, vaccination issues and treatment of tribal patients, and food shortages) to the district collector. In addition, the cell monitored quarantine-related issues such as hostility, transportation, issues related to the COVID care centres (First Line Treatment Centres), food distribution, supply of medicine to the severe and prolonged patients, and ensuring medical care to the tribal patients.
In the second phase of the lockdown, the Cell also focused more on monitoring and coordinating vaccination programmes for above 40 years among the tribal people. The district administration conducted a special vaccination drive for the tribes. There were more than hundred special vaccination centres for COVID vaccination of tribes. In addition, the Cell, with the help of the transport department, arranged transportation facilities, to the tribal extension offices and Panchayaths for smooth transportation of vaccination and for the COVID-infected people from home to First Line Treatment Centres (CFLTC) or quarantine centres. K.P. Suresh et al.

Steps to Prevent COVID-19
The prominent nature of tribal settlements is the clustering of houses within a limited space. Each house is much close to another house. Commonly, five to forty houses exist in a settlement. Paniya settlements are the most populous and congested settlements among them. So, the government popularised three slogans, to prevent the pandemic. These included -Physical and social distancing, Washing the hands using sanitizers, and Wearing masks. However, these preventive measures could not be easily implemented in tribal areas as it was done elsewhere making them accept the preventive measures proved challenging for the Health Department and the Tribal Department. So they adopted several ingenious ways to prevent COVID spreading to tribal people.

a) Mass Awareness Campaign
In the first phase of the lockdown, the tribal and health departments initiated a mass awareness campaign conducted in tribal settlements through audio-visual and social media (Radio Mattioli, T.V., Whatsapp) and created awareness through the field-level workers (including the tribal Promoters, ASHA workers, CSW, TEO and others.). Awareness programmes were also conducted in tribal dialects. In addition, the tribal and health department prepared awareness slogans in tribal dialects and gave maximum publicity through mobile phone and social media among the tribal people. They gave training and awareness to people to maintain social distancing, wear the mask and wash their hands with soap.

b) Food supply
During the lockdown, the tribal department provided tribal people with additional food kits over and above the free rations supplied by the government of India. The food kit contained rice, grams, oil, vegetables, tea, salt, sugar, soap and other essential things. Some local self-governments had also supplied milk among the tribal settlements in their respective limits. The field-level workers (including the Ward members, ASHA workers, Tribal Promoters, Committed Social Worker (CSW), and Rapid Response Teams (RRTs) constantly monitored the field situations and reported the instances of food shortages if any to the tribal extension officer (TEO). The TEOs collected the food kit in the Maveli store and other cooperative stores with the help of social workers and promoters and supplied it to the concerned settlement. Through the tribal cell, the district administration coordinated and monitored the food kit distribution. If there were any lag or complaints from the field, the tribal cell contacted the concerned authorities and solved the issues. The cell ensured that the prompt delivery of the free ration. It was monitored and ensured that there was no scarcity of food grains in settlements.
In the district, for people over 60 years suffering from tuberculosis, cancer and other serious diseases, the Scheduled Tribes Development Department gave a nutritional food kit including all essential provisions. The cell ensured the prompt delivery of the free ration It also ensured nutritional food supply to children up to the age of six and took measures to maintain personal hygiene while delivering food grains and supplying necessary materials for personal hygiene. Due to the outbreak of COVID, the district administration took some preventive mechanisms to check the spread of COVID from outsiders by prohibiting the outsiders except government officials from entering the tribal settlements. In the first phase of the lockdown, this mechanism proved beneficial for reducing the infection rates in the settlements. The tribal youth who work in the nearby towns, the tribal people going outside their settlements, and the people supplying essentials to the settlements were considered as the bridge population, with a high chance of exposure. Tribal people from other states who transited through forests were also considered as high risk people for the spread of COVID. Hence the tribal people who move across the territory frequently were given awareness about the importance of social distancing, hand washing and proper wearing of masks. As part of the special tribal health plan, the health department arranged capacity-building and training for all health staff and tribal promoters.
In the hamlet level, the ASHA/Tribal Promoters should informed the cell when any person enter into the colony should inform the Panchayat Ward Member. They restricted the unnecessary travel of the people till the containment of the pandemic. If anyone from the tribal community became vulnerable to the COVID virus, all the contacts of the patients should be taken to a separate centre (preferably Covid care centres) for quarantine.
Each Panchayath was to identify a building for converting into a Covid care centre to quarantine the tribal persons who were notified as belonging to the high-risk group by the health department. A separate building with clean water and toilet facility, had been kept separately for the women and children and 24-hour security and police patrolling were ensured. Nutritional food rich with vitamins C and B, and locally available traditional food were provided to them and medical camps were organised on alternate days.
A team of community volunteers, LSG leaders, Tribal ASHA and health staff, would visit every house in tribal areas for awareness creation on COVID prevention measures, to ensure supply of medical requirements and to provide psychological support to the people. They were ensured of the visits of the Tribal Mobile Medical Units and provided with integrated services, including COVID diagnosis, communicable disease surveillance and COVID Care Management. In addition, the District administration distributed free reusable masks, soaps and sanitizers to the tribal people to encourage health education and motivation.
Check post and testing facility was set up at every entry point and near tribal health outposts/PHCs, for the tribal people. It provided testing facilities for COVID suspects and for the bridge population A WISK (Walk-In Sample Kiosk) was set up in such places so that the concerned people need not be transported to distant places for testing. A primary health centre medical officer was appointed to coordinate these activities with the help of the district administration and tribal and health departments. In tribal areas, people with mild symptoms were admitted in the CFLTCs. The tribal promoters and social workers were fully engaged in completing this mission. The social workers from tribal departments went to the tribal settlements and gave awareness to the tribal people who were not cooperative with the vaccination. The major causes of denying vaccinations were fear of injection and the belief that vaccination is the cause of death and impotence. Therefore, the Tribal department arranged special vehicles Discussions : A report from one media regarding COVID said: "In May, the infection spread was high in the tribal hamlets of Wayanad, Kannur and Kasaragod districts.
There were days when the TPR climbed to more than 50%." (The News Minutes, 2021) The then Medical Officer of Wayanad District said: "In the first wave, we could control the spread; as a result, there were very few cases. However, after that, the rules were relaxed, and just like in other places, the infection started spreading among the tribal communities too. So we mainly shifted people testing positive to Domiciliary Care Centres (DCC); we did not allow home quarantine.
The Tribes in Kerala lead a community life, which can contribute to COVID-19 spread. In Wayanad, the spread among tribal people was mainly due to gatherings for funerals, weddings and other ceremonies, for which people would visit other colonies; She also pointed out that the funerals became super-spreaders in the district." The words of tribal youth show another reality of tribal life during the pandemic.
"He said various other factors were addressed while discussing COVID-19 management among tribal communities; for example, only that person who tests positive is taken to the DCC. In addition, most families live in a two-room house. There is no facility for them to quarantine themselves, as there is no door between the rooms, which are separated only by curtains. Usually, there is just one bathroom and not even enough space for them to move around inside the house." "More than two families live in many of these tiny houses because some do not have a proper house. Many houses in the colonies are leaking, and some families spend nights sitting on chairs holding their children as their houses are leaking; our homes are built close to each other in a small area, just like cluster house" Words of Paniya youth -K.P. Suresh et al.
Tribal Healthcare System in Kerala during the Pandemic ___________________________________________________________________________________________________________ 92 "We appreciate that the government provides food kits, but the lentils we get are not part of our food culture. So how long can we be forced to eat it? We never buy lentils in our daily groceries. We mainly depend on vegetables and tubers. So people would go out to earn that." The COVID-19 created global uncertainty for the entire people across the world. Generally, tribal people are considered the weakest group in society. The tribal people in the district faced many difficulties during the pandemic; both men and women had lost employment opportunities and economic security. It led to an economic crisis in the life of tribes. Most women and children had faced malnutrition, hunger, domestic violence, psychological problems and other difficulties. In the case of education, they suffered a digital divide in online education. In the health sector, the tribal people depended on government agencies for getting medical assistance during the lockdown period. The routine medical camps and check-up system ran out during the pandemic. COVID-19 protocol and restrictions were the major obstacles to delivering health interventions and services to the field level. The government realized the hazards to the tribal people during the pandemic and took positive steps to meet the situation The state government and the district authority initiated many steps to address the specific issues faced by the tribal peoples during the COVID-19 pandemic. In this paper, we have discussed the various programs implemented for the tribal people with the help of the Health Department, ST department, local self-government and other departments during the Covid pandemic.

IV. Conclusion
COVID pandemic created a global health crisis across the world. The entire health care system was challenged to deliver their services to the society. The tribal people, who have been most vulnerable to external pressures, could not escape from the affect of pandemic. Wayanad, the most tribal concentrated district in Kerala had successfully used the health care mechanism for COVID prevention in tribal areas. Information technology services were also used for the delivery of the health care services to the tribal people. Telehealth systems were used for queering the diseases in tribal sector during the pandemic period. The district administration could effectively use the intervention of the health department and other government agencies to deliver and strengthen the tribal health care services during the COVID outbreak in Wayanad.