How Tripura Goofed Up In Its Battle Against Malaria

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Tripura, the smallest state in the Northeast, has been in the grip of a malaria outbreak for the past two months. At least 120 people have lost their lives since the first malarial death was reported on 26 May; 85 of them died in hospital, while the rest succumbed to the disease without any medical treatment. As of now, nearly 40,000 people are being treated for malaria across the state and deaths have been reported from five of the eight districts. But, as a TEHELKA report (Losing the fight against malaria by Ratnadip Choudhury, 5 July) had pointed out, the Manik Sarkar government’s efforts to battle the outbreak are hamstrung by a fatal flaw: though the entire state had been declared resistant to first-generation anti-malarial drugs such as chloroquine in 2009, those drugs still comprise the bulk of the medicine procured by the government.

That the government seems utterly lost in the face of a disease that is known to be endemic to the Northeast betrays not just lack of foresight but also apathy towards the wellbeing of the people.

The epicentre of the current outbreak lies in Dhalai district bordering the Chittagong hill tracts of Bangladesh. The district has always been highly vulnerable to water- and vector-borne diseases. TEHELKA visited the worst-affected Gandachara subdivision to find out why the government has failed to contain the epidemic- like situation despite having everything at its disposal — doctors, paramedics, information of drug resistance and, above all, funds.

Gandachara town, headquarters of one of the remotest subdivisions in Tripura, is a four-hour ride (115 km) from state capital Agartala through the Kalajhari mountain range. Girachandrapara, one of the worst-affected villages, is another one- hour ride through muddy hill roads, followed by a one-hour trek. Eight residents lost their lives to malaria between 26 May and 10 June, and almost everyone in this village of 160 tribal families is afflicted by the disease spread by the sting of the female anopheles mosquito.

Though Tripura has a literacy rate of 94.65 percent, among the highest in the country, hardly anyone in Girachandrapra can read and write properly. No wonder, few villagers could understand the malaria-awareness posters that were put up in the village, even though they were in the local tribal language Kokborok.

“Eight lives had been lost before we came to know of the outbreak,” says Gandachara Sub-Divisional Magistrate (SDM) Bhaskar Dasgupta. “We immediately rushed medical teams to the village and they started sending patients to the Gandachara Civil Hospital.” The hospital was soon full of malaria patients and a makeshift medical camp had to be set up at the SDM’s office.

“It was horrific,” recalls Dasgupta. “There was an acute shortage of medical staff and medicine. We started treatment on a war footing and could somehow bring the situation under control, but we could soon be back to square one if a broader action plan is not implemented.”

At Girachandrapara, there are no roads, no electricity and no source of clean drinking water. The villagers drink water from the same rain-fed rivulet where they bathe and wash utensils and clothes, and that is also where the larva of anopheles mosquitoes breed. The villagers eke out a living by growing rice and vegetables on the nearby hillocks, using the indigenous slash-and-burn method of cultivation called jhum. Perhaps, that is where they are most exposed to malaria-carrying mosquitoes.

“Malaria and enteric diseases are very common here. I have had malaria twice,” says Dhanaram Tripura, 39. “The doctors don’t come here, nor do the paramedics. We are poor and would have to go hungry if we don’t go to work even for a day. In fact, we went to the hillocks where we practise jhum cultivation even the day after my two-year-old nephew Bishwaram succumbed to malaria.”

Indeed, when the Dhalai district administration sent vehicles to the remote villages, many tribals afflicted by malaria refused to be taken to hospitals because they could not afford to miss even a day of work. The administration had to give some cash and arrange free meals for family members of patients in Gandachara so that they don’t leave the hospital until fully cured.

Malnutrition is common among tribal children in Tripura, and so they become easy targets of the killer disease. Half of those who died in the current outbreak were children below 10 years.

“Across the world, malaria is still prevalent in regions afflicted by extreme poverty. It’s the same in Tripura’s tribal belts, where the people are deprived of their basic rights,” explains Chandrakanto Molsom, an activist from World Vision India, an NGO that has been organising health camps across Dhalai district, detecting malaria patients and transporting them to the hospitals. “We have run out of test kits and medicine, and there are many remote areas where no healthcare team has reached yet.”

In the absence of medical facilities, tribals from remote villages still follow superstitious practices and are dependent on quacks. “It’s different only in areas where the people have got some education,” says Dhanaram. “We, on the other hand, have no option but to follow the customs we have been handed down from our ancestors and depend on village quacks.”

In the past two months, around 40 people died after being treated in their village by quacks. “Most of these deaths could have been because of malaria. There is little awareness about the disease and patients are usually taken to hospitals only in the final stages,” says Gandachara Sub-Divisional Medical Officer Dr Arijit Sinha. “The tribals seem to have more faith in quacks.” But Sinha shies away from talking about the rickety healthcare infrastructure in the state that could be forcing the tribals to depend on quacks. The state boasts of new hospital buildings, but has an acute shortage of beds, equipment and medical staff.

“We have an average of one doctor per health facility, but they are not evenly distributed. And when there is an outbreak, it is difficult to handle the surge of patients,” says Dhalai District Medical Control Officer Dr Padmaram Jamatia. “That is why we focus on prevention. But the prevention mechanism failed this time.”

As the incidence of malaria peaks in June and July in the northeastern states, the preventive exercises usually begin in April. But this year, the Tripura government woke up to the problem too late. “It was very hot and humid this year and the grassroots health workers were not doing their duty properly. That’s why we could not control the outbreak of malaria initially and many lives were lost,” says Health Minister Badal Chaudhury. “We have suspended 50 health workers and now things are under control.” What he does not say is that it was 29 May — three days after the first malaria death was reported — when his ministry sent orders to the districts to start malaria-prevention exercises.

“Preventive work such as spraying of DDT was started late,” admits Ajit Sharma, a vector-borne disease consultant in Dhalai district. “We could spring into action only from the first week of June, while most people had already got infected in the period from 20 May to 30 May.”

Moreover, even after the spraying of DDT started, only 30-35 houses in remote areas were covered in a day, far too slow to arrest the spread of the malaria vector.

These loopholes, however, pale in significance when compared with another fact. TEHELKA has accessed documents that expose how the Tripura government under-utilised Central funds and also procured the wrong drugs to fight malaria.

A letter from the director of the National Vector-Borne Disease Control Programme to the Tripura government reveals gross under-utilisation of the grant-in-aid released to the state for 2013- 14. Tripura was provided 87.07 crore, of which it could spend only 13.47 crore by December 2013. “The funds were underutilised because little work was done despite repeated reminders from the Centre. There were almost no campaigns in the malaria-prone zones of the state. The little that was spent went towards providing salaries to the staff of the National Rural Health Mission (NRHM) and meeting the running cost of the offices,” alleges Dr Ashok Sinha, state spokesperson of the Congress. “In the past few years, the local media has been reporting that the health department and the NRHM are not purchasing adequate anti-malarial drugs.”

Sinha has lodged an FIR against three top health department officials — Health Secretary M Nagaraju, Director of Health Services Dr SR Debbarma and NRHM State Mission Director Dr Sandip Namdeo Mahatme — accusing them of negligence in their duties. “In a review meeting on 28 May, Chief Minister Manik Sarkar flayed the State Health Mission for not utilising the funds, but did not take any tough action,” says Dr Sinha.

Last year, the Union health ministry had laid down a specific protocol for treatment of malaria in highly endemic zones such as the Northeast. The National Drug Policy on Malaria, 2013, clearly states that malaria caused by Plasmodium vivax should be treated with chloroquine, while a combination of drugs called ACT-SP should be used for the more dangerous type of the disease caused by Plasmodium falciparum. But, as Plasmodium falciparum is showing resistance to ACT-SP in most parts of the Northeast, including Tripura, the protocol now clearly suggests the use of another combination of drugs called ACT-AL.

In the light of these clear guidelines, what did the Tripura government do?

On 5 April, the Director of Health Services floated a tender for medicines for 2014-15. Documents show that that order was for 10 lakh tablets of chloroquine and only 500 tablets of ACT-SP, even though the National Drug Policy clearly stated that these drugs would be useless in the Northeast due to resistance. And the Tripura health department did not order for ACT-AL, which has been recommended especially for the Northeast. “If you look at the government records for that past five years, you will find that every year, an average of 94 percent malaria cases are caused by Plasmodium falciparum and only 6 percent by Plasmodium vivax. It was clearly illogical of the Tripura government to buy 10 lakh tablets for treating vivax malaria and only 500 tablets for falciparum treatment. And even these 500 tablets would be of no use in the state as the falciparum malaria here is resistant to ACT-SP,” says Dr Sinha.

So, it was a deadly combination of factors that led to the malaria outbreak in Tripura. No preventive measures were taken in April as the grassroots health workers were negligent and the government woke up to it only towards the end of May. Low rainfall and extreme humidity provided the climate-trigger for the outbreak in May. People had started dying before the government realised that it could be staring at an epidemic-like situation. And in the first week of June, the hospitals did not have ACT-AL drugs that could have helped cure the disease.

“We were giving chloroquine to patients infected by falciparum, even though we knew that it would not work,” reveals a junior government doctor working in Longtorai Valley. “We had no stocks of ACT-AL and the poor tribals could not buy expensive medicines from the market.”

Last year, Tripura recorded only seven malarial deaths, but the alarm bells had started ringing. Of 7,396 cases that were reported, 6,998 had been caused by Plasmodium falciparum. So why did the government continue to procure the wrong drugs? Despite TEHELKA’s attempts, no one from the health department was willing to talk about this. However, that there had indeed been a criminal goof-up became clear when the health department issued a fresh tender on 27 June for the procurement of ACT-AL.

Meanwhile, the tribals in villages like Girachandrapara are terrified of another bout of the disease — it would mean not just the loss of more lives, but also entire families might have to go hungry if the bread-earners end up in hospital.

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