When I was told that I will be working in Kalahandi District, I was not surprised initially, as I actually heard of such terms for the first time. However, when I discovered that it was, and still is, one of the most backward districts in India, which is endemic to Malaria; which, in turn, was responsible for high Infant and maternal mortality rates, I understood what I was getting into. My fears were intensified further when I read about “Kalahandi Syndrome”, a term used by social workers in the 1980’s which describing the severe poverty and malnutrition in the area (Banik,1998).
As a medical doctor, I was trained to look at a disease in a curative approach, which involved recognizing the symptoms, investigation and giving the appropriate management. After working in Swasthya Swaraj (my host organization) for a month, I had realized that there are various other factors which act as catalysts to the development of an endemic like malaria. Based on my personal experiences, I will henceforth share some of these factors.
Geographical landscape and climate
Kalahandi district is mostly a hilly terrain and receives heavy rainfalls during the monsoon, extreme temperature (0-48 degrees Celsius) and has high humidity of >60% (Pradhan,et,al., 2016). Heavy rain falls cause accumulation of water which acts as breeding areas for anopheles mosquito. Hence, these climatic conditions are quite favorable for breeding of the mosquitoes carrying malarial parasites, particularly the Plasmodium falciparum type (Pradhan, et. al., 2016).
Almost every child I had seen has severe malnutrition, and I’m not exaggerating. The region was affected by serious droughts and famines in the past few decades. Malnutrition reduces the overall immunity of the body and also causes micronutrient deficiencies such as iron, folate, vitamin B12 which eventually leads to anemia (Alexandre, et.al, 2015; Yip and Ramakrishna, 2002). I had personally seen numerous cases where the child aged anywhere under 5 years of age, having severe malnutrition, positive for Plasmodium falciparum malaria and the hemoglobin levels as low as 2.5 gm%. The normal levels being 11.5-12.5 gm/dl for a child of an age ranging anywhere from 6 months to 6 years (Marks and Glader, 2009).
To make matters much worse, it’s not even in the tribal culture to drink milk. For some unknown reason, there is hardly anyone in the tribal community who consumes milk. This was a shocking revelation to me.
Malaria is particularly dangerous in pregnant mothers as there is reduction in immunity during pregnancy, which makes them more vulnerable to the parasitic infection of malaria, and poses substantial risk to the mother and fetus by increasing the risk of fetal death, prematurity, low birth weight (LBW), and maternal anemia (Schantz-Dunn & Nour, 2009). I had personally heard of numerous stories maternal deaths due to malaria, and I have to admit, some of them were quite disturbing to hear.
Lack of Accessibility
There are literally no accessible roads to several villages. People literally walk several kilometers (10-12 km on average) for work or even while coming to the clinic. It is honestly disturbing to see someone walking several kilometers and comes with simple, non-specific complaints like headache and mild body ache. I’ve also seen men; women and even children carry rations as big as 30-50 kg for several kilometers during the PDS (ration) day.
Over the course of time, I had realized the correlation of accessibility with improving health outcomes. For instance, imagine some in a remote village suddenly felt sick and needed emergency medical intervention; but he/she couldn’t reach the nearest public health centre or a clinic due to lack of access to any means of transport or even a road. This is further evidenced in a research about modes of transport for accessing food by Tenkan, et.al. (2016), where he says that the interaction of an individual with the surrounding physical environment and social structures shapes not only one’s daily life practices, but also one’s health conditions.
With a literally rate of 59.2%, which is way below the national average of 74%, there’s a significant disparity in terms of literacy in the district (National Census, 2011). The illiteracy is very apparent in the tribal community to an extent that they have no formal numerical system. It is a herculean task to train the tribal women in safe pregnancy or menstruation measures. Even in the recent years, there is hardly any progress to educate the future generation. To give an example, I and Mahir (my cofellow here) decided to visit a nearby government school. Well, let’s just say that we were not exactly happy. With the exception of handful of students, there were no teachers, anganwadi workers or even cook. The children prepared their own meals. All the staff were on leave for a festival and left the school unsupervised. The situations of most remote schools are substandard in terms infrastructure, lack basic amenities and function with similar circumstances.
To improve the health indicators, health education is an integral part of health programs. To promote health education, literacy plays a significant impact (World Bank, 2017). According to research studies, there is correlation between literacy and health outcomes; where a person with lower literacy levels is more likely to have worse health outcomes compared to someone who is more literate (DeWalt, et.al., 2004).
As a medical doctor, I was trained to cure a disease by identifying the symptoms and giving appropriate treatment. However, my experience of working in Kalahandi, especially the tribal community taught me that multiple factors influence the health outcomes of a particular place or a community. These factors could be as simple as not having a functional road or transport to not having adequate nutrition. This, to me, is an extremely important learning as I feel that I’m starting to understand malaria in a broader context and my role in working with Swasthya Swaraj.
Alexandre, M., Benzecry, S., Siqueira, A., Vitor-Silva, S., Melo, G., Monteiro, W., Leite, H., Lacerda, M. and Alecrim, M. (2015). The Association between Nutritional Status and Malaria in Children from a Rural Community in the Amazonian Region: A Longitudinal Study. PLOS Neglected Tropical Diseases, 9(4), p.e0003743.
Banik, D. (1998). India’s freedom from famine: The case of Kalahandi. Contemporary South Asia, 7(3), pp.265-281.
Census2011.co.in. (2017). What is literacy rate of Kalahandi (Kalahani) district of Orissa in 2011 census ?. [online] Available at: http://www.census2011.co.in/questions/419/district-literacy/literacy-rate-of-kalahandi-district-2011.html [Accessed 25 Sep. 2017].
DeWalt, D. A., Berkman, N. D., Sheridan, S., Lohr, K. N., & Pignone, M. P. (2004). Literacy and Health Outcomes: A Systematic Review of the Literature. Journal of General Internal Medicine, 19(12), 1228–1239. http://doi.org/10.1111/j.1525-1497.2004.40153.x
Marks PW, Glader(2009). Approach to Anemia in the Adult and Child. Hoffman F, Benz EJ, Shattil SJ, eds. Hematology: Basic Principles and Practice. 5th ed. Philadelphia, PA: Churchill Livingstone; Chap 34:439-46.
Pradhan, A., Anasuya, A., Pradhan, M., AK, K., Kar, P., Sahoo, K., Panigrahi, P. and Dutta, A. (2016). Trends in Malaria in Odisha, India—An Analysis of the 2003–2013 Time-Series Data from the National Vector Borne Disease Control Program. PLOS ONE, 11(2), p.e0149126.
Schantz-Dunn, J., & Nour, N. M. (2009). Malaria and Pregnancy: A Global Health Perspective. Reviews in Obstetrics and Gynecology, 2(3), 186–192.
Tenkanen, H., Saarsalmi, P., Järv, O., Salonen, M. and Toivonen, T. (2016). Health research needs more comprehensive accessibility measures: integrating time and transport modes from open data. International Journal of Health Geographics, 15(1).
World Bank. (2017). Education is Fundamental to Development and Growth. [online] Available at: http://blogs.worldbank.org/education/education-is-fundamental-to-development-and-growth [Accessed 25 Sep. 2017].
Yip R, Ramakrishnan(2002) R. Experiences and challenges in developing countries. J Nutr; 4:129–132.
The reading gave me a kind of deja vu to my recent visit to the tribal villages of Jharkhand. Although the situation is not that worse there, but the health condition still remains an issue with a huge percentage of population suffering from anaemia. When I came to know that the tribals there hardly consume milk, I was left wondering if one should make any efforts to counter this habit, or let it continue as a act of preserving the tribal culture.
Thanks Sandeep for such amazing insights! This will keep me pondering for months ahead. I can’t put to words the kind of respect I have for you! Keep inspiring us my man!
A lot of the tribal communities do not consume milk as they see it as a right of the calf, not theirs. Same goes with their treatment with most natural resources – rivers, forests etc. They will only take what is essential for survival. Milk clearly, does not feature in their list. It will be very interesting for organizations working on nutrition and health to see how they can work in sync with the tribals and the choices they have made for their way of life, just like how they do with nature. Very well written piece 🙂
So well written Sandeep! I was hoping one of you (Mahir/You) will write this piece to let us know why Kalahandi specifically has a problem of Malaria. Looking forward to knowing Kalahandi better through Mahir and your blogs.