The invisible dead


Naxalism and police action are the two biggest known killers in Chhattisgarh. But, there is a third and silent killer. Revati Laul and Anil Mishra report

An unwell region Mallaya Punim, 60, lies on her bed at Timapur village in Bijapur district. Like most, Punim also has a constant fever
An unwell region Mallaya Punim, 60, lies on her bed at Timapur village in Bijapur district. Like most, Punim also has a constant fever
Photos: Vijay Pandey

Anthony Khujur was only 24 when he succumbed to cerebral malaria. His mother Dilo Bai’s staccato narrative, punctured with sobs, tells how doctors did not diagnose the problem that caused his death on 24 August. For his family, Anthony will ever be missed; for the state of Chhattisgarh, he is not even a statistic. Officially there have been no malaria deaths in 2012. Anthony Khujur has slipped between the cracks. He is one of Chhattisgarh’s invisible dead.

Anthony lived in the very green village, Ghutrapara, in north Chhattisgarh. This is not the part of Chhattisgarh that makes it to national headlines. It has no Maoist insurgency and is located in a relatively prosperous district called Sarguja. Ambikapur, the biggest town in the district and not far from Ghutrapara, is a busy trading centre connected by a clear, straight road to Anthony’s village. There is even a practising doctor — Dr Santosh Singh, with an MBBS degree — in the adjoining village, barely a 10-minute walk away. In short, this is not Chhattisgarh’s heart of darkness.

Dr Singh said he’d been treating Anthony for malaria every year for as long as he could remember. This year too, he saw Anthony, treated him and apparently the patient had recovered. A month later, however, he fell ill again. This time his family did not take him back to Dr Singh. When Anthony’s condition worsened, he was taken to the Mission Hospital in Ambikapur where he died. His mother said they had no idea malaria was still lurking in his body. He was being treated for secondary diseases — jaundice and typhoid that stemmed from the original malaria condition. That’s why Anthony is a non-statistic.

Malaria is not just a seasonal predicament in Chhattisgarh. It is its secret epidemic, and kills many more people than the Maoist insurgency. Deliberately or otherwise, everybody is blind to it. So was TEHELKA till 15 June, when this magazine lost one of its own — and an anonymous, unknown health crisis began to haunt us.

TARUN SEHRAWAT was 23, and excited to be on assignment in Chhattisgarh. It was a high-risk assignment, he was accompanying reporter Tusha Mittal into the jungles of Abujmarh in the Bastar region in south Chhattisgarh. This was the inner core of the red zone in the state and a dense and sparsely inhabited forest that, it is said, even Akbar’s army and British surveyors had left alone. Tarun expected to face danger from Maoists. What got him, however, was a more insidious and much more silent enemy.

Tarun returned from Abujmarh and a week later, he developed a fever and soon developed jaundice and typhoid. As his friends and family watched, bewildered, he slid into a coma. A month-and-a-half later, at Medanta in Gurgaon, among India’s best equipped hospitals, doctors finally took him off life support. He had recovered from the malaria. But suddenly, he was hit by a massive brain haemorrhage. Just like that, he was gone.

In the Greek epics, the clue was a ball of wool that Theseus took with him as he entered the labyrinth, rolling it out gradually to help him retrace his steps after he had killed the monster. After Tarun’s death, his colleagues at TEHELKA were left on the other side of the labyrinth, wondering what mysteries and what monsters lived inside, what conditions made malaria and other fevers like the one Tarun suffered from, such a killer. For Tarun’s sake, it was important to enter the labyrinth and interrogate that monster. We owed him that much.

THE MAZE of statistics surrounding malaria in Chhattisgarh is caught in a snare of lies and Stalinist statistics. Falciparum malaria is known all over the world to kill between 1-3 percent of its patients. In the UK, for instance, the Journal of Infection recorded in 2007 that 1 percent of those infected with falciparum malaria had died — that’s 10 of the 1,500 infected. Perplexingly, Chhattisgarh’s reports seem to defy all medical odds. According to data sent to the Ministry of Health and Family Welfare in New Delhi, 1,90,590 people had malaria in Chhattisgarh in 2007. Of these cases, 1,44,766 cases — 75 percent — were falciparum. Bizarrely there were only three recorded deaths — making for a death rate of 0.00002 percent.

Since the official data can’t be relied on, people working on malaria in the state have had to find other ways of estimating the size of the problem. The State Health Resource Centre for Chhattisgarh, an autonomous public body, relies on another statistic: the Annual Parasite Index (API), which measures the number of people affected in thousands. If an area has an API measure of over five, that’s five deaths in a 1,000 people, then by WHO standards it is considered an epidemic. In Chhattisgarh, the API for malaria is above five in 79 of the 146 blocks across the state. In the forests of Dantewada — 42 blocks have an API of over 10. In some it’s over 100.

The worst affected areas are not just in the Bastar forests, but equally in the comparatively tranquil north. Here the defunct public health system cannot hide behind the conflict. Dr Yogesh Jain runs a non-profit health centre on the outskirts of Bilaspur in the north. His patients are largely tribal poor from the surrounding forests and malaria is a huge concern. In 2010, his centre, the Jan Swasthya Sahyog (JSS), mapped the cases in just one of the 10 blocks in Bilaspur — an area called Konta. Dr Jain and his colleagues counted more than 100 malaria deaths in just that one block. In all 10 blocks, he deduced, there would be at least a 1,000 deaths that year. The official figure for that entire district was just nine.

Raging fevers (Left to right) Five-year-old Rakesh Markaon in Bijapur district has had a constant fever for 3 weeks; A young mother with her two children, both running a fever; and 60-year-old Jimme Kunjam, who says the fever has become a constant companion

Extrapolated for the entire state, the malaria death toll would easily cross 5,000 a year. Dr Jain told us that while Chhattisgarh makes up 2 percent of India’s population, it accounts for 14 percent of the country’s falciparum malaria cases. But the state doggedly refuses to acknowledge this.

On the surface, it would seem an open-and-shut argument. Chhattisgarh is battling India’s “biggest internal security threat”. How can one expect the healthcare system to work? Malaria is a byproduct, by that reckoning, of Maoism. The government often hides behind this logic and leaves its people to ponder a cruel and twisted paradox. Chhattisgarh was carved out of Madhya Pradesh 12 years ago to give the aboriginal communities a homeland, a sense of belonging and access to public services. The ramshackle healthcare system speaks for the failure of that promise one decade on.

The basic failure of the state is its refusal to recognise that if someone in a village in the middle of nowhere is attacked by malaria, she has no place to go. The most rudimentary health system is at least a two-hour walk away. And it is run not by doctors, but “multipurpose health workers”. These are people trained as midwives and in basic medicine, from rural backgrounds. They are in charge of a cluster of villages. One pair — a man and a woman — run what is called a subcentre that caters to about 3,000 people.

In Kanker — a model district in Chhattisgarh, where roads and electricity are both present — TEHELKA met Devli, who works in the sub-centre of Mitaghamri village. The ceiling is weighed down and leaking water. The creaky and damp wooden bed is entirely unfit for her to deliver babies, so she sends most pregnant women that come to her straight to the district hospital. This is definitely not the place for a seriously ill person. Yet this is the only health facility in a radius of 30 km.

Three women health workers in Kanker in different geographies had similar stories to tell. One was recently divorced, another was a single mother — but all three walked 15-20 km each day to remote villages to distribute medicines and check on their patients. In one such village, TEHELKA arrived in the midst of torrential rain. It was beautiful and lush but the road had vanished. “The Naxals have dug up this road,” the health worker said. “When we go into a village for the first time, they ask us who we are and what we’re doing and demand medicines from us. They also fall ill like everyone else.”

Beneath the health workers, who are paid Rs 10,000- Rs 20,000 a month, is the army that Chhattisgarh sees as the bedrock of its health system: the mitanins. These 60,000-strong foot soldiers of Chhattisgarh’s health battle are all unpaid volunteers and all women — the word “mitanin” meaning female friend. A decade ago, they were introduced to fill gaps at the lower end of the health system in the newly carved-out state. They were taught basics like advising women in the villages to breast-feed their babies, eat a balanced diet and also keep the surroundings clean. Whether mitanins can take upon themselves the entire responsibility of fighting off malaria is, of course, quite another question.

TAKE THE case of Kovasi Bhime, the mitanin in the village of Jaigur in southern Chhattisgarh’s Behramgarh. At 28, she is hunched and bent over from losing her nine-year-old son Ashu to an undiagnosed fever a month ago. “It came upon him suddenly,” the distraught mother said, “so we rushed him to the village witch-doctor.”

Bhime is a mitanin, trained to tell the village to go to a proper doctor, to take a blood slide on the glass plates given to her in the medical kit and send it to the primary health centre for testing, to not rely on shamans. It’s this voluntary worker, the key to the healthcare system, who in her darkest hour reconciled to the default resource of the others in her village: the local witch-doctor.

It would be unfair to stereotype Bhime. Like her, the over two dozen mitanins we met and interviewed across the state are proud of their work. “We are the warriors, the Durgas of our village,” said one. But Bhime’s story also speaks of the limitations of the system. In a state where the malarial parasite is so densely present that it is killing thousands, can the edifice of the government’s curative and preventive measures rest entirely on a force of volunteers?

Further in the state, in the village of Injaram, in Dantewada, lies the reason why malaria is Chhattisgarh’s big state secret. Boddu Raja is the vice-president of the Dantewada District Panchayat, a man of considerable influence and money, but even he could not save his 14-year-old daughter, Boddu Lalita.

Lalita had complained of fever on 5 April. Her Class VIII exams were approaching and so Raja took her straight to the hospital and had a blood test done. It showed up as normal. But perplexingly, the fever wouldn’t go away. Doctors working on malaria say this happens often. A thick smear test i s required to identify the malarial parasite — Plasmodium Falciparum. If you’re not looking hard for it, you won’t find it.

But Boddu Raja was determined. He took his daughter to the community health centre in Konta. And then to many more hospitals across the border in Andhra Pradesh — to Bhadrachalam, then Kottagudam, then Rajahmundhry and finally Khammam. It was only in Rajahmundhry that the doctors diagnosed Lalitha with malaria. But it was too late. She died on 4 August. Her reports were buried with her according to tribal custom, making Lalitha one more of Chhattisgarh’s invisible dead.

Boddu Raja is a prominent Salwa Judum leader — the parallel force set up and then disbanded by the state, after it failed to deal with “the greatest internal security threat”. As a Judum member, he is prime target for the Maoists. So he has been living in a camp in Injaram, away from his native village in Aserguda. But even police protection, money and the ability to travel far to save his daughter could not help him. It’s the reason why deep in Chhattisgarh, faith and witch-doctors triumph over reason and medicine. But the comfort of ceremony in the absence of effective science is misconstrued by administrators and perhaps even the media as mere ignorance and tribal custom.

IT’S THIS cynical cover-up and blind-sightedness that is evident in the district of Sarguja in the north of the state. Whilst interviews with numerous health workers on the ground revealed a list of over 70 fever deaths in the district this year alone, Chief Medical Officer Dr Shamsu Doha looked surprised. He quoted a below-average index for malaria in the district. “There is not a single block in Sarguja where the malaria level is more than an API of two,” he insisted, quoting the Annual Parasite Index.

“We believe it’s over five,” TEHELKA said. “That makes it an epidemic.”

An unconvinced Dr Doha summoned the District Malaria Officer, Dr Anil Prasad. “Sir, it is above 5.5 across Sarguja,” said an embarrassed Dr Prasad.

Exposed now by his subordinate, Dr Doha attempted a cover-up that gave away his real opinion. “These tribals have a history of alcoholism. That’s what exposes them to disease,” he summed up. Dr Prasad chipped in as well: “Eighty percent of these tribals are alcoholic. They don’t eat much, but they drink. So they become hyper-glycaemic and therefore die of malaria. Alcoholism is the reason they don’t get themselves treated for malaria.”

A system that fails entirely to deliver appropriate medical care is run by people who knock tribal traditions and invent fables to cover their ignorance. Dr Doha and his staff are unfortunately not an aberration. There is a similar apathy in the upper echelons in Raipur. Pratap Singh, Health Commissioner of Chhattisgarh, says: “This year, there have been no reports of serious cases of malaria so far.” One almost wonders if there are questions left to ask.

A malaria task force was set up by the state government in 2011. According to Singh, what it’s done so far is to draw up a set of guidelines. TEHELKA probed this further with Dr Singh. Did the guidelines say anything about whether DDT or a superior insecticide should be used, given that the Indian Council for Medical Research had told the Chhattisgarh government that 80 percent of malaria-affected districts are now resistant to DDT? The health commissioner’s answer is remarkable: “I’m not part of the task force, I haven’t got the minutes of their last meeting, so I don’t know what these are.” Incidentally, the task force has met only once in 2012, just before the monsoon set in.

Army of the ill Of the 120-strong CAF at Bijapur, 50 had malaria in 2011
Army of the ill Of the 120-strong CAF at Bijapur, 50 had malaria in 2011

IF ONLY Pratap Singh saw the tragedy of Podium Joga, from the same village as Boddu Raja. Joga had a violent fever in April. And his first instinct was to go to a doctor at the Konta Community Health Centre in Sukma. But not even a blood test was done and Joga died on 14 April. At the other end of the state, in Bilaspur, health worker and activist Praful Chandel’s tone became indignant as he spoke of how so many tribals choose to visit doctors but the system fails them.

Chandel works with Dr Yogesh Jain at the Jan Swasthya Sahyog in Bilaspur. In 2010, a man from a small interior hamlet brought his son with a raging fever to the primary health centre in Ratanpur. The doctor took one look at the boy and said his was a severe case of cerebral malaria and could only be treated in Raipur. The father pleaded for time, for just one night, till he gathered the money and means to take his son in the morning.

He agreed to take full responsibility for his child. All he asked of the doctor was for his son to be put on a drip or some emergency treatment at the primary health centre for the night. But, the doctor refused. So the man put his boy on the carrier of his bicycle and they travelled back to their village 10 km away. His son died that night. It was not that his father was an ignorant tribal from the “interiors” who had no faith in modern medicine. Modern medicine had failed him.

If the tribals are “ignorant” and therefore bound to die, what about the Central Reserve Police Force (CRPF)? Companies of CRPF troops are sent to camps across Bastar to fight Maoists. At the 168 CRPF camp in Timapur — the mouth of the Bastar forest and conflict zone — there was a malaria death in 2011. Om Pal Yadav, 28, had a raging fever. But no blood test was done. His colleagues tell us they weren’t aware then of this silent killer lurking in their midst. No one figured out in time that he even had malaria.

After his death, the camp woke up to the epidemic. Now, every jawan in the camp takes chloroquin tablets twice a week — as did the TEHELKA team before heading out to Bastar. It’s a preventive but not a magic potion. What is really needed is a rationalised system of preventives. This calls for regular spraying of the right insecticide across the region. Leave out one part of the territory and the germ becomes insecticide-resistant and is back with greater ferocity.

The jawans spray DDT in their camp regularly. However, their work lies outside, in the jungle, where they are subject to the arbitrariness of the State and the gaps in the spraying regimen. This year, they say, two jawans with violent fevers have already been shipped out. And the malaria season has only just begun.

At the Community Health Centre in Behramgarh, Registered Medical Officer (RMA) Suryakant Kashyap confirms that malaria is the biggest cause for concern. Ninety percent of all cases he sees turn out to be malaria. For an outpatient department that sees 100 patients every day, there are two RMAs and two medical officers. There is an acute shortage of staff because no one wants to be posted here.

The government has set up a system of ordering rapid testing kits for malaria. These are meant to be distributed to the volunteer force of mitanins in villages, trained for the job. But the kits and much needed medicine — chloroquin — are in short supply. When someone has a violent fever, this volunteer mitanin is expected to do the impossible, for free. To make a blood slide, walk many kilometres on foot and hand it over to the multipurpose worker in time for them to walk many more kilometres to the primary health centre for testing. By the time this impossible chain is completed, the slides have melted in the heat or been tarnished in the rain or are simply too old to be of any use. Kashyap was only one of many doctors, mitanins and health workers to confirm this.

Loss and pain (Left to right) Wife of 24-year-old Anthony Khujur, who died on 24 August; Kawal Sai Paikara of Chiranga village holds up his dead brother Krishna’s picture, a victim of malaria

Along the highway, not far from the Behramgarh hospital, TEHELKA saw jawans from the 15th Indian Reserve Battalion of the Chhattisgarh Armed Force (CAF) on duty. They were checking the road to make sure there were no mines, a routine operation in preparation for a VIP to pass through. One of the jawans, Sanwar Mal, 25, said he gets malaria every two months. The jawans also spoke of how of the 120 in their camp, 50 were down with malaria in the past year.

THE CAF jawans were on a highway that leads to Sarkeguda and, further, to Kothagudem village. This is now called the “killer road” by locals after an encounter with the CRPF on 28 July, where many believe that innocent civilians were killed. Kamla Kaku, a fiery health worker from the village, sees red when she describes the encounter. The state didn’t care for its people even before the Sarkeguda massacre, she says. After 28 July, they feel completely abandoned.

In this village, Kaka Samaka took her three-year-old son Manoj, down with a fever to the Basaguda Health Centre. Officials there asked her to come back in two days as they had no medicines. No blood slide was done either.

‘Tribals have a history of alcoholism. That’s what makes them prone to dying of disease,’ says Sarguja district Chief Medical Officer Dr Shamsu Doha

If there is a fatalism to Chhattisgarh’s malaria scourge, it is not surprising. The other side to disease is starvation. According to Dr Jain, it always peaks in November and December. That’s the time when the harvest has ended and grain stocks in individual homes are gone. Hunger attracts malaria like nothing else.

As proof, Markam Raju in the Kothagudm village held desperately onto her three-month-old girl. The baby was hysterical and her wailing made her ribs stick out even more from her shrivelled, severely malnourished body. Her cries stopped abruptly as she gasped for breath. The effort to breathe was so loud and agonising, it was worse than the crying. She hadn’t been named yet because her parents were more concerned with keeping her alive.

Callous method Young boys at Lalitpur village mixing DDT powder with their hands
Callous method Young boys at Lalitpur village mixing DDT powder with their hands

In the jungles of Bastar, the struggle for survival is inextricably wound up with the conflict. There’s the double fear of being taken hostage by Maoists or having to deal with them and being labelled a Maoist. Health workers here are not ordinary healers, they are enormously courageous individuals.

But at the other end of the state, in safe, non-Maoist Sarguja, the government and the authorities have no excuse and no cover. In these villages, if the mosquitos are kept at bay, fewer people would fall ill. Like the rest of the system, this part of the machinery is also deeply dysfunctional. Medicines and malaria testing kits are in short supply. Mosquito nets are inadequate. This year, the district authorities realised only after the rains had begun and the mosquitos had begun to breed that they were 100 metric tonnes short of DDT. Eventually, the DDT had to be brought in from neighbouring Odisha.

In Lalitpur village of Seetapur district, three young boys were hard at work spraying DDT. They insisted they were 19, but looked not a day over 14. They had been primed that a team of journalists was coming to see DDT being sprayed. Even so, they were mixing the DDT powder with their bare hands. “Our gloves are torn today.” The cover only magnifying the callousness of those who put them to work. These are frontline soldiers of the war against malaria.

In a sense, the story of malaria is one of poverty. Districts and villages that are the most economically backward are where malaria is most rampant

THERE ARE ways out of the abyss. The State Health Resource Centre (SHRC), set up initially with some ActionAid India Society assistance and European Union funding in 2002, has made some strides. The mitanin programme is managed by SHRC. Even if it is a voluntary force, full of flaws, the training has gone a long way in getting women to breastfeed their children, in getting some amount of blood slides into hospitals to detect malaria and in educating villages in the benefits of the use of mosquito nets. The linkages between the SHRC workers and the rest of the public health matrix are however, absent.

Outside the government, exemplary work is being done in pockets of the state. In 1983, when Chhattisgarh was still part of Madhya Pradesh, a few progressive doctors decided to focus their attention on healthcare for the neglected. They included Dr Binayak Sen and Dr Saibal Jana. The hospital they built in Dalli Rajhara, deep in Chhattisgarh’s mining country, is the stuff of local legend. Shaheed Hospital was set up by workers and for workers and is still run by a trust made up largely of workers. Dr Sen lived with these mine workers when he moved to the region. Today, patients at this hospital get treated for as little as Rs 3-5. You’ll find them squatting in the passageway outside the OPD, the hospital trying to accommodate as many as it can. It isn’t a perfect system. But those who come to the hospital get the attention and level of care they need.

The hospital’s very existence makes a larger political point. If you are concerned for the poorest, you are likely to design a healthcare system that is functional. And if it is possible for daily wage workers from the Bhilai Steel Plant to set up and run their own hospital efficiently, then why can’t the government?

At the other end of the state, Dr Jain and his team run their NGO, the Jan Swasthya Sahyog (JSS) in Ganiyari, outside Bilaspur. The 10-acre health facility is a happy hub with wards surrounded by green spaces. The doctors also fan out to look after the tribal and rural poor in their villages. Camps are run regularly. For over a decade now, an innovative mechanism of collecting blood samples has been in place. One person is appointed in each village to collect slides of people with fever. The slides are packed into a soap dish and handed to a schoolchild getting onto the morning school bus. People from JSS are appointed to stand at the point where the bus stops and collect the soap boxes. The slides are examined on priority and the results are sent back by the afternoon bus.

“On grounds of equity, if someone in a city deserves a physician or a nurse who knows how to manage malaria, so does a person in a village. So how can we accept a structure that assumes that at the village level these can’t be provided?” In asking this, Dr Jain stabs at the heart of darkness. He asks a question families of so many unsung, unknown victims of Chhattisgarh’s malaria epidemic are also asking.

THE STORY of Chhattisgarh is also the story of Odisha — which has nearly double the cases of malaria and deaths. Sudarshan Das, who runs the Human Development Foundation, says there is the shortage of political will to tackle “the three Ms” killing people in the state — malaria, malnutrition and mortality. The malaria map of India extends across the red corridor from Chhattisgarh to Odisha to Jharkhand. It’s also spread across five of the eight states in the Northeast; Mizoram having the worst malaria indices in the country. On closer inspection, the districts and villages that are the most economically backward and destitute are where malaria is most rampant.

This has made the telling of this story even more difficult. In the end, it comes down to that blinding circular logic: the poor die because they are poor. If you’re at the bottom of the socio-economic ladder and live in nowhere land, you will die of some disease or another. In Chhattisgarh it is likely to be malaria; in Kerala, it could be dengue; in Rajasthan, meningitis; in Uttar Pradesh, Japanese encephalitis. The only criterion is poverty, everything else is merely detail.

But by accepting this logic, by failing to travel with Anthony Khujur, we are allowing the cycle to continue. Most malaria deaths occur because the State is absent. It is no coincidence then that these are states where other actors have taken over — Maoists, the ULFA, the NLFT, the NSCN-IM. An alphabet soup of resistance in the country’s most disease-prone areas. Where the fabled ignorance of the tribals is trotted out to blind everyone to the structural violence of the State. Disease and death so obvious and present that they remain hidden from view. Tarun Sehrawat’s death forced us at TEHELKA to see what we have been missing all along. The invisible dead now speak through him.

Revati Laul is a Special Correspondent with Tehelka.
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