Lack of medicines and crucial medicinal nets is leading to reinfections and disease spread, especially among vulnerable Adivasi communities.
Malaria Crisis in Odisha: A Tale of Neglect and Struggle
On a sweltering June morning, Sumit Sisa felt extremely cold. His head hurt, and he had spiked a fever. After a day of struggling with fever, muscle aches and no relief, Sisa, 25, who lives with his wife and a toddler in a thatch and clay tile hut in Bonda Hills in the Khairput block, roughly 80 km from Odisha’s southernmost Malkangiri district, visited the nearest primary health centre in Mudulipada, a kilometre away from his home, alone.
At the primary health centre, the doctor conducted a Rapid Diagnosis Test. This meant a drop of blood was taken from Sisa’s finger and immediately placed on a test strip. A few drops of a solution were added, and a couple of minutes later, two red lines appeared on the strip. Sisa tested positive for falciparum malaria – for the third time in the last three years.
According to the National Vector Borne Disease Control Programme, India has recorded over a million laboratory-confirmed cases of malaria every year (except in 2013). Since then, the programme recorded a drop in cases from 840,000 in 2017 to 180,000 in 2022. Malaria is a vector-borne life-threatening disease caused by the Plasmodium parasites that are transmitted to people through the bites of infected female Anopheles mosquitoes which carry the parasite. The two major Plasmodium species causing malaria in India are Plasmodium falciparum (Pf) and Plasmodium vivax (Pv), and these are unevenly distributed across the country. Plasmodium falciparum is more lethal.
Government data show that across the country, since 2008, Plasmodium falciparum infections have accounted for over half the malaria cases in the country. In densely forested areas, this proportion is even higher – 77% in 2019 – research shows. Home to about 3.5% of India’s population, Odisha, with about 40% forest and tree cover and hot and humid climatic conditions, is highly conducive to malaria transmission. The state contributes to about 40% of India’s falciparum malaria burden, and 30% of deaths. Estimates suggest that 91.5% of malaria cases in Odisha are caused by P. falciparum.
Testing positive for P. falciparum malaria meant that Sisa had to be immediately treated with Artemisinin Combination Therapy for three days, and a single dose of Primaquine. Artemisinin Combination Therapy is provided across 19 other states and Union territories in India that are resistant to chloroquine, another antimalarial for preventing and treating the disease, as per the guidelines of the National Vector Borne Disease Control Programme. Instead, Sisa was given a paracetamol tablet, a drug used to treat mild to moderate pain and fever, because the health centre did not have Artemisinin Combination Therapy and Primaquine in stock.
“I was shivering when I reached the health centre,” Sisa recalled. “After the blood test, they gave me paracetamol, probably to bring down the fever, and asked me to go to a community health centre in Khairput as they didn’t have the medicines for malaria.” Instead, Sisa travelled 12 km, crossing various stretches of forest and minor rivers down the hill, to reach a private clinic, where the treatment and medicines for three days cost him Rs 600. “I knew that the CHC would have referred me to some other hospital, and it was 3 km farther than the private clinic. I didn’t want to delay the treatment, so I got myself treated at the private clinic,” Sisa said.
The lone primary health centre, situated in the midst of hilly Mudulipada, serves around 12,321 members of the Bonda community scattered across 32 remote hilltop villages in the Kondakamberu mountain range of the Eastern Ghats in Malkangiri. Found only in these 32 villages, the Bonda tribe is one of the 13 Particularly Vulnerable Tribal Groups living in the isolated mountainous range of Odisha, with limited access to transportation, connectivity, and healthcare. Considered vulnerable due to their stagnant population, low literacy levels and mostly pre-agricultural economy, the Bonda tribe suffers from many health diseases, including diarrhoea, tuberculosis and malaria.
In 2023, Odisha topped the list of states for malaria cases, marking a resurgence in the state despite government efforts to control the disease through various measures. The rise in cases is attributed to frequent drug supply shortages, particularly in remote tribal areas like Mudulipada, and disruptions in the distribution of long-lasting insecticidal nets across the state. As a result, malaria cases in Odisha rose 80% since 2022. The state reported 41,971 cases and four deaths in 2023, and accounted for over 18% of the country’s total malaria cases.
“For the last two months, we have been facing a significant drug shortage at the Mudulipada health centre, and we had to refer patients to the CHC [community health centre] in Khairput,” said Champeswar Panigrahi, a medical officer at Mudulipada’s primary health centre where Sisa had first visited for malaria treatment. Panigrahi was quick to add that the health centre never refers patients to any private clinic or hospital. “Although Mudulipada sees a high number of malaria cases, especially between May and July due to the monsoon, last year we received fewer,” Panigrahi said, adding that authorities used the 2022 case figures to estimate the medicines required, and the supply ended up falling short because of a spike in cases.
A May 2021 paper in BMJ Global Health noted that malarious regions in Odisha have reported 79% asymptomatic infections and 30% of subpatent infections, which are undetectable by the current Rapid Diagnosis Test kit. This suggests that a significant number of people with malaria in these categories remain undetected. Asymptomatic cases involve individuals infected by the parasite but without symptoms, while subpatent cases have the parasite in their blood at levels insufficient for detection through testing. The existing Rapid Diagnosis Test kits for malaria screening are based on a protein called HRP. A May 2022 paper in The Lancet points out the inability of Histidine-rich protein II (HRP II)-based Rapid Diagnosis Tests in detecting P. falciparum strains with HRP2 and HRP3 deletions. The paper also identified prevalence rates of P. falciparum with HRP2 and HRP3 gene deletions ranging from 0%-8% in Odisha and other highly malaria-endemic states. This means that the present estimates for using the tools for clinical screening and Rapid Diagnosis Test for malaria, likely underestimate malaria cases considerably.
“Merely focusing on vector control is not enough; reduction of parasite density, or cleansing a community of malaria parasites is also necessary, as it decreases the chances of patients contracting the disease again and of spreading the infection to others,” said John Oommen, a community health doctor at the Christian Hospital, Bissamcuttack in Rayagada district of Odisha, who has worked for over three decades with community-based malaria control. “In many cases, patients show no symptoms but yet are harbouring malaria parasites from a previous infection, which can still be transmittable and even dangerous,” Oommen added.
Sisa could not ask the doctor why he has contracted malaria thrice and – as a farmer who works year-round growing millets to sustain his family of three – he could also not visit the private hospital after he started feeling better in four days. “The clinic is far and takes time and money to reach so I could not go there again though I wanted to,” Sisa told IndiaSpend. “I am tired of falling sick of malaria every year.”
Shortage of Life-Saving Nets
Since his most recent malaria infection, Sisa has resorted to actively using his semi-torn, soiled long-lasting insecticidal nets every time he goes to bed. “I got this net almost five years ago, and we could barely use it for the first month,” Sisa said, pointing toward the net, which had been hand-stitched by his wife after a rat gnawed it. “I’m not sure if the net is even working now because it used to feel very hot sleeping under it. Now it feels like a normal net,” he added.
Indoor Residual Spray and the use of insecticide-treated mosquito nets are long-term measures that target adult mosquitoes, recommended by National Vector Borne Disease Control Programme as part of the Integrated Vector Management strategy. The programme is gradually shifting towards reducing areas under Indoor Residual Spray and increasing coverage with a new type of insecticide-treated net, long-lasting insecticidal nets, which remains effective for up to three years. Against the backdrop of widespread chloroquine resistance in Odisha, particularly among pregnant women, long-lasting insecticidal nets have proven to be the most effective preventive measure against malaria. As far as insecticide-treated nets go, though, Odisha has been experiencing frequent shortages. For instance, between June and August this year, Odisha received 140,000 long-lasting insecticidal nets instead of the 500,000 originally planned. This forced the state to rethink the net distribution strategy, so it could accommodate distribution for priority areas including Malkangiri, Nabarangpur and Kalahandi – the top three districts for malaria cases in 2023. As a result, the overall distribution was delayed and a lot of people had to go without them for months, despite the anticipated monsoon rains.
Long-lasting insecticidal nets are currently being distributed in phases, with a primary focus on high malaria burden districts. However, inadequate coverage has resulted in a high number of households without access to nets. According to the 2019 District Level Household and Facility Survey, while 100% of the population is covered by malaria services in many parts of Odisha, coverage gaps persist. A survey conducted by the Malaria Consortium in Odisha found that more than 75% of the population was covered by long-lasting insecticidal nets but the coverage was lower in districts like Malkangiri where access to healthcare is limited. The challenge of inadequate coverage has been exacerbated by the delay in distributing nets to all eligible families in malaria-endemic areas.
“For several months, malaria transmission continues to be high in Odisha, even though long-lasting insecticidal nets are being distributed at different phases,” said a State Health Department official who did not want to be named. “This may be due to the shortage of nets or inadequate and incomplete net coverage,” he added. The official also noted that in remote tribal areas, effective net coverage remains an issue, leading to higher malaria transmission rates.
The Way Forward
Despite the high burden of malaria in Odisha, health experts believe that improving access to timely diagnosis and treatment, investing in malaria surveillance, and enhancing vector control measures can significantly reduce the incidence of the disease. Targeted interventions for vulnerable populations, such as the Bonda tribe in remote areas, and increasing access to preventive measures like long-lasting insecticidal nets are crucial in controlling and eventually eliminating malaria.
With the onset of the monsoon and the rise in malaria cases, there is an urgent need to address the challenges faced by remote communities and ensure that resources reach those who need them the most. By strengthening healthcare infrastructure, improving drug supply chains, and increasing community awareness, Odisha can work towards mitigating the impact of malaria and safeguarding the health of its vulnerable populations.
author Jyoti Thakur