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--- - t I.ici- i,li. Bengal has done comparatively better in terms of infant mortality, deliv\ff/est VV enes at medical institutions, children's full immunization, etc., yet, the increase -:: -he incidence of corrtmunicable diseasesin \)fest Bengal is a major cause of worry. iccording to official data, the incidence of communicable diseasesin the state has i:-irplv increatedbetween1995-6 and 2000-1. For all the major health indicators except infant mortality, the record of -::::khand has been abysmally poor. Despire the non-availability of secondary data .. communicable diseasesinJharkhand (only the data for malartais available),media =lrlrts and other sources indicate , hlgh ra;teof occurrence of communicable dis-ses. )falaria is a menace forJharkhand - in 2001 ftom a sample of a little above r'- rr.000 sJides, examination results found more than 15 percent positive cases of :::l;na of which 60-85 percent $,ere casesof plasmodiumfalriparam a fatd, disease. Both the states suffer from absolute levels of inadequacy in terms of public :,e-r.L-J:r services. In rWestBengal each Primary Health Centre serves a population of *--'t-4, on average.In Jharkhand this figure is 47,769.(rhe government norm is to :.: !p one PHC per 30,000 persons in general and per 20,000 persons in Hilly and -:-lrJ areas). The same is the case for the Heaith sub-centres. Each Sub-centre in \,J7est :o:real serves,on average,a population of 7,104. trorJharkhand the figure is 5,659. r1e government norm is to set up one sub-centreper 5,000 persons for the gener,r' :opulation and one per 3,000 persons in Hilly and Tribal dreas). -lharkhand's case is paticular\ disadvantaged for a large part of the state is cov::-c \vith hills and it has a much higher tribal population Q7 percent) than West :ci.s'al (7 percent).

A 5 r : w r , f n " 4i a f t { l i t Dt t i 0 5 and Medical Treatment: One maior cause for concern is the reliance on unqualified medical ptactitioners (JMPs) - populady known as quacks for medical treatment. These quacks include unusual degree holdets @egistered Medical Practitioners, whose degrees are allegedly bought from various institutions); Flealth Ailments homeopathic degree holders (who practice allopathic medicine); non-matriculates who cannot even read the names of medicines (since they are written in English) and depend upon the medicine dealers'guidelines (who label the medicines, for the bena efit of the "doctors", with the names of symPtoms of the drseases particular medicine is used for) and also some medicine shop ownefs. We have even come acfoss a man who possessesa ce*ifrcate fuom avetefinary training progfamme, but provides medical tfeatment to humans. In Dumka the extent of such dependence is much higher - 62 percent. In Birbhum 29 percent reportedly sought medical tfeatment from quacks. While in Dumka 12 percent and 11,percent relied upon the public health services and private qualified doctors respectively, in Birbhum the respective figures ate 33 percent and 29 percent. The main feasons for dependence upon quacks (despite many being awate of jholabala, and their incompetence - in Dumka they are derogatorily caIledjholdanga, so on) by the poor afe (1) poor functioning of the public health services and (2) inabiJity to bear the cost of medical treatment at ^ pnYate qualified doctor's clinic / nursing-home/hospital. The cost factor is very important. \fhile the private doctors are understandably the most expensive sources of medical treatment, the unfortunate rca[ty is that the cost of medical treatment at the public health institutions is higher than that of the private unqualified (quack) sources. Public health services have almost ceased to be free - only four percerit of the patients who visited the public health services in Birbhum and 0.23 percent in Dumka got completely free treatment. In terms of getting all the prescribed medicines from PHC/Hospital only 14 percent in Birbhum and 1.3percent in Dumka have been benefited' In sharp contfast to the popular belief (mainly of doctors and a part of acade' mia) that rural people in generai and tribals in particular depend mainly upon witch doctofs, magic healers or herbal practitioners, u'e found vefy fsy, who have depended urholly upon such sources.Even those who resorted to such services did so due to reasons of financial stringency or problems of accessibiliq'to the public health services. Medical treatment not only involves high costs but also high risks because of many different forms of gross medical abuse (perpetrated not only by quacks but also by qualified doctors). For example, in Dumka, the indiscriminate use of saline . drips (for alrriost evefy soft of ailment) is a common phenomenon and in Bitbhum the most visible form of abuse is over-medication (use of rnultiple antibiotics and other drugs, use of the same combination of dtugs prepared by different companies, and harmful medicines,etc-)' use of urlnecessary

There are also other kinds of abuse, like not exercising due care and vigilance (particularly in cases of childbirth and surgery - both in private and public instituof dons). One patient had to have his leg amputated due to the carelessness the doctors and the subsequent wrong treatment meted out to him. Gender discrimination can be seen very cleady from the factthat 62 percent of the patients in Birbhum who remained medicall;r untreated were women. In Dumka this figure is 75 percent. Gender discrimination is also evident from the fact rhat nrore men than women w-eretreated in public health centres and by private qualified sources, while the maiorrry of the patients treated by quacks comprised womefl. The Delivery of Public Health Services: V/hile in Dumka all the PHCs visited

*.ere ill-equipped and functioning poody (part of the premises of some PHCs have er-en become permanent shelters for different domestic animals and for the homeiess,vagrants and beggats), in Birbhum no such uniformity was found. Some of the PHCs we visited have been working very well and some were not. The functioning oi the PHCs, it seems,depends upon the motivation of the doctors and other health staff. Nfhile in one PHC we had to wait fbr five hours for an interview with the Block \fedical Officer of Health since he was completely engaged with patients (on that particular day there were more than 500 out-patients!), in anothet PHC we found the Block Nledical Officer practicing in his private chambers during wotking hours. There was a board displaying the timings of his private practice (8 am to L am), x'hich matched exactly with the working hours of the out-patients' department, in clear violation of medical edricsand servicerules. Private practice by government doctors is a major phenomenon in both the dis-!ncts, though less at the PHC level at Dumka (probably for the vztong reasoris nanv people complained that the PHC doctors spent most of their time in their :radve places, far away from theit postings). In both the districts hower,'et, alarge rnajority of the government doctors posted in the hospitals engaged in privzte ptacace. Often many of them were tbund at their private clinics during duty hours. The case of services delivered at the sub-centre level by health r.vorkersis simoler. V4rile in Birbhum 37 percent of the respondents acknowledged that a health ";rorker had visited their homes during the year preceding the sur-rey,in Dumka the ::{ure was 26 percent. The reported visits were often made aftet very long intervals - sometimes just once a yeat. In Bitbhum only 46 percerit of the pregnant women teceived iron folic tablets ind 70 percent received tetanus injections. In Dumka the respectiye figures were 27 :.ercent and 26 percent. Onlv 19 petcent of the respondents in Birbhum and 10 percent in Dumka said that a fzmtlv planning worker had visited their homes during the -;ear preceding the survey Neady 50 percent of the respondents in both the districts who have ever visit:d public health institutions (PHC/hospital, etc.) expressed dissatisfaction over the sen-ices delivered. Manv complaioed that the doctors and health staff did not even ;lcrk with them.

Despite many problems, the condition of the public health institutions was found to be relatively better in Birbhum. N7hile almost all the TB patients in Bitbhum received treatment from public institutions, this was not the case in Dumka, rvhere almost all the TB patients sought treatment from private qualified soufces. This has its financial implications as well - in Bitbhum the average cost of treatment for TB was Rs. 1,270,in Dumka it was Rs.2,003. In both the districts the implementation of programmes related to the prevention of communicable diseases(malaria, diarrhoea, etc.) has not been confitmed by our respondents. of health ailments: The maior implication of health ailments is While the poorest section of people (below Rs. in terms of financial loss or J,iability. Birbhum had to spend 18 percent of thek annual income 16,000 annual income) in Implications on health care,in Dumka it was 12 pefceflt. Twenty-ofie pefcent of the respondents in Birbhum and 37 percent in Dumka said that they had to borrow money at interest rates of 50 to 120 percent per annum for medical treatment. Many were forced to sell their properties - both movable and immovable - to pay for tfeatment of in order to repay loans incurred for medical expenses. The high cost of medical treatmeflt has, in sodre cases, reversed positive changes. Such changes include mortgaging or selling of land that had been allotted under the land reforms programme, working for lower wage rates against contractual loans taken for medical treatment, etc. in Birbhum and the renunciation of the achievements made through political movements in terms of lowering the rate of interest and reducing exploitation by moneylenders in Dumka. The vicious cycle of health ailments, loans taken, loss of wages, loss of Property and poverty and hunger is a very common rciltty for many families. Besides the financial implication, one major negative impact of health ailments is on education. Many children simply carrnot attend school because of illness. It is also a major cause for dropping out (both becauseof ill health and also becauseof other consequences,like engagement in income generating work to repay loans taken for health cate, engaging in farm work to compeflsate for parents'or elder\ relatives' illnesses. etc.).