While the area is a hotbed for malaria, with tribals being the most vulnerable due to extreme poverty, the state has failed to meet the lack of health workers, essential medication and preventive measures.
Pangi Deevena is an eight-month-old adivasi infant. She is the daughter of Pangi Chinni and Pangi Venki of the Balijipeta village in the Vanjari panchayat of G. Madugula mandal, located in the fifth schedule area of Andhra Pradesh’s Visakhapatnam district. She was diagnosed with the deadly falciparum malaria and had high fever for ten days. “We cannot give her the medicines we have since she is too young. She should be shifted to the Paderu area hospital immediately and kept under observation. Any further delay and the disease will reach the brain and the baby will die,” said Dr. M. Chandrashekar of the King George Hospital (KGH). He had visited the village as part of a medical camp conducted by the Rural Development Service Society (RDSS) and Srujanavani, NGOs based in the district.
The scene at the camp was paradoxical – extreme adversity of the human condition nestled in the lap of bountiful nature. Twelve-year-old Salimiti Banni Babu, from Kakarapalli village, was trembling while a disoriented seven-year-old, Pangi Sailu from Devarapalli village, sat listless in a corner. Both were shivering, like the howling vertical columns of rainwater sprayed by winds that one witnesses in the forest tracts (known locally as the agency) during the monsoon. There is a rhythm to it and death dances to its howling tunes here, year after year.
Tribals, young children most vulnerable
The sheer intensity of the destruction was first fully noticed only in 1999. Over 4,000 tribals died that year due to chali jwaram (cold fever) and what the vernacular media calls visha jwaram (poison fever) that had struck the Visakhapatnam Agency area. In a paper titled ‘Health Care Services in Tribal Areas of Andhra Pradesh: A Public Policy Perspective’, published in the Economic and Political Weekly in 1998, K. Sujatha Rao, a senior bureaucrat in the state, observed that of all the people who die of malaria in the state, 75% are tribals. There are normally 18 victims of malaria for every 1000 tribals. She furthers observeD that 50% of these victims were children under the age of five. The Telugu Desam Party (TDP) was in power at the time.
Now nobody questions the government during these ‘normal’ times. That would be too harsh. But when an ‘extraordinary’ situation – like the one in 1999 – occurs, a few questions must be raised. Over 2,500 tribals died in the year 2005. But that time, the TDP was in the opposition. When the Congress government tried to play down the number to just seven deaths, the TDP filed a complaint with the National Human Rights Commission (NHRC). In response to the ‘grave’ human rights concern expressed by TDP leader K. Yerran Naidu in his written complaint, the NHRC requested retired IAS officer K.R. Venugopal to investigate the matter and prepare a special report, what came to be known as the KVR report.
Crucial observations in KVR report
One important detail, among the many mentioned in the KVR report, is the slide positivity rate (SPR) for G. Madugula, which according to a senior entomologist is 1.84 and to constitute an epidemic, the SPR should be 5% and above. SPR is the percentage of the total number of positive slides for malaria out of the total slides examined. Out of the 32 slides examined during the camp, 20 tested positive. And all of them belonged to the particularly vulnerable tribals groups. Nineteen of the falciparum variety and one of the vivax variety. The SPR was 62.5, so does one call this a ‘super-epidemic’?
The medical camp at Kimmudupalli and Balijipeta was visited by a total of 218 people from as many as seven villages of G. Madugula mandal — including Devurapalli, Mullagaru, Balijipeta, Gedhara Banda, Kimmudupalli, Kukurapalli and Pidikonda. One might say the sample is too small. But many patients could not come due to the incessant, heavy rain, lack of communication and, most importantly, because of being too weak to walk up and down a hill or two. Therefore, the number of those suffering from fever and ill-health could well be even higher. “It is an epidemic of unimaginable proportions. Malaria here is an endemic problem. Nobody can deny it,” said Dr. A. Prudhvi Raj from KGH, the other doctor in the camp. In fact, as the KVR report notes: “Every one case represents 50 hidden or unreported cases in the community.”
Quoting official figures, a New Indian Express report from June 30 mentions: “Malaria is rampant in the three districts and the number of cases is more than the last years. In Visakhapatnam district, so far 1,680 cases were registered against the 2,000 cases registered last year. In Vizianagaram district, 880 malaria cases were registered last year while the figure reached 900 till now. In Srikakulam district, so far 370 cases were registered.”
Deaths due to ‘ignorance’ of tribals: TDP
The serious health situation in the north Andhra forest region was back in focus after the death of 16 adivasis over a period of three weeks – from Chaparai village, Boddagandi panchayat and Y. Ramavaram mandal of the neighbouring Rampachodavaram Agency in East Godavari district. Although the current TDP government initially tried to pass it off as a case of ‘ignorance’ on part of the tribals, many independent reports confirmed that this is not the case. “We believe that most, if not all, of these deaths at Chaparai were due to falciparum malaria. In fact, our view is that there is a malarial epidemic sweeping the fifth schedule region stretching from Paderu division in neighbouring Visakhapatnam district through the Rampachodavaram and Chintur Agency areas of East Godavari district,” said A. Ravi of the Human Rights Forum.
Ravi added: “The government is seeking to obfuscate this reality by trying to pass off the Chaparai deaths as due to adivasis having eaten rotten meat at a marriage gathering and also because of consumption of contaminated water from a local hill stream. This is clearly not the case. A reprehensible attempt is also being made to portray the adivasis as being ignorant, superstitious and unwelcome of medical intervention. This narrative is being pushed to gloss over official failure.”
After looking into Integrated Tribal Development Agency (ITDA) numbers of the cadre strength of the medical and health institutions of Paderu division, the KVR report notes: “The point deserving of emphasis is that the sample years I have taken were 2001-2002 to 2004-2005 – i.e. four years saw three years of governance by the TDP and one year of governance by the Congress-I. Specifically, with reference to the points made in the complaint to the commission, the only comment needed is that this is a classic case of the pot calling the kettle black.”
With the kettle now broken, the pot is trying to blame the victims.
KVR report recommendations being ignored
Regarding the state of health infrastructure, nothing seems to have changed. For instance, 13 out of the 56 sanctioned posts for multi-purpose health supervisors, 11 out of the 58 staff nurses, 15 out of the 40 pharmacists and others are lying vacant. In fact, a quick research on the ITDA website reveals the massive vacancies in the health personnel. It seems the only change is in the name of basic health unit in every village — the community health workers (CHWs) are now called accredited social health activists.
Shockingly, some of the villages do not have a CHW. Vanthala Ramesh, from Devurapalli village, said, “There are no CHWs in Kimmudupalli and Mullagaru. The anganwadi in Mullagaru exists only on paper. And wherever there is a CHW, she is heavily burdened and poorly trained. She is paid only 400 rupees and most of them haven’t even been paid for the last six months. How can one expect them to go on? Even they like us are poor and have to earn a living.”
The KVR report notes: “As seen during my field investigation, the so-called honorarium of Rs 400 per month for these community health workers is not being paid to them every month at all. In fact, they are being paid this small honorarium once in six months. That is absolutely unacceptable and must be destructive of all motivation. My investigations revealed hunger in the households of the community health workers themselves and they have to go and do agricultural labour work for their own living. A hungry, labouring CHW, who is paid her honorarium once in six months, is hardly going to be the person who will spread health education amongst other hungry tribals in a terrain like the agency areas of Andhra Pradesh and fight endemic malaria.”
The multi-purpose health assistant (F), also called ANM, at the sub-centre, K. Varalakshmi (name changed), in one of the villages, seems to be clueless. “The other ANM who is on a leave must know the details. I have come here only a few months back. The tribals don’t come to the sub-centre with their health problems. So I go to their villages which are highly inaccessible. But, more often than not, there is a communication problem. I don’t understand their language,” the ANM said. When asked to show the complaints she registered over the last 15 days, she revealed that the sub-centre does not maintain a register.
The fact that the ANMs are hired as ‘temps’ and are moved every six months does not help either. “These health personnel are hired on a contract basis. On top of that, they are never paid on time. So they don’t show commitment towards their job. But if they are hired on a permanent basis and still not paid on time, then they would at least continue to do their jobs decently for fear of losing their jobs,” points out Ramarao Dora, a senior journalist and tribal rights activist from Paderu.
“Every time we go to her she gives us a paracetamol for a headache and a chloroquine for fever, if there are any medicines at all, that is. She is as clueless as we are. The villagers see no point in visiting the sub-centre,” added Ramesh. Regarding the shortage of drugs, the ANM said, “The drugs are supposed to be distributed to the sub-centres from the PHC at Gemmela. The supply of chloroquine, the anti-malaria drug, has been lacking since the last three months.” Given that the onset of monsoon is the crucial period from malaria, the paucity of the drug can only be called criminal neglect.
The antimalarial operations, like spraying alpha cypermethrin and distribution of mosquito nets, have also not been undertaken properly. “Neither pichkari (spraying) nor the distribution of mosquito nets by the panchayati has been done in the last three years in any these villages,” said Machakonda Babu from Kimmudupalli village. Usuall, three rounds of spraying should be done. In June, September and a special round in March. “But it has not been done. They have only started doing it now,” added Babu. The KVR report notes: “Spraying is done only in the houses and cattle sheds but not in the other places like nalas, drains or stagnant pools of water.” Either spraying is delayed or not done at all.
Potable drinking water facilities are inadequate in most villages of the panchayati. All bore wells are coughing up muddy water. “The ‘gravity’ scheme is working only in Vennelakota and Thadipalem. It has been set up in Balijipeta but hasn’t been working properly,” lamented Babu.
Poverty, malnutrition worsening spread of diseases
These are the most visible governmental failures. But there is a larger force at play which traps the tribals into submission. As the KVR reports notes, “Poverty is the main problem of the area. For eight months in a year, the tribes go hungry, as any agriculture is possible in this area only for four months in a year. Malnutrition is the main cause of the absence of resistance to the epidemics. Malnutrition and malarial fevers peak at the same time, which are the months of May to August.” It further notes: “Even according to the government’s own statistics, out of the 1,26,013 households in the ITDP area of Paderu, 1,17,834 households are living below the poverty line. Effectively, the entire agency area lives in dire poverty. Of all the poor households, 57,975 households have been determined to be amongst the poorest of the poor. The desperate nature of poverty in this area requires no further acknowledgement.”
Dr. Raj acknowledges this. “Nearly all the 218 people that visited the camp today are underweight. Malnutrition is very conspicuous creating anaemic conditions which, like we are seeing, leads to various others diseases like typhoid, TB etc.”
Possible solutions
In such a context, expecting the government to unpack the poverty spiral is a far stretch. But with proper planning of measures and committed implementation, things can change. “See, first, we have to ensure there is war-like preparation. Each PHC should be able to treat, in an emergency situation, 14,000 people. Second, proper training should be given to the CHWs and time-bound fast-track treatment should be given at every level starting from the anganwadi to the sub-centre all the way up to the PHC,” he said.
“If this infrastructure is in place and is held accountable, then early-diagnosis, which is the most crucial bit, to cure malaria, which is a preventable disease can happen. But even inexpensive para-kits (for malaria diagnosis) are not available. Therefore, this cycle of the epidemic will continue and precious lives which could easily be saved will be lost,” he added.
Responding to the health minister’s statement that good doctors are unwilling to work in the agency areas, he said: “All this is politicking and diverting the issue. In our age of privatisation, it is too much to expect our doctors to be service-oriented. But that is where the government needs to come in. If it can create a good health infrastructure, there still are doctors who are willing to work here.” It has been 12 years since the KVR report came out in response to a complaint by the TDP. May be they should dust the report and revisit its recommendations.
Finally, what will be the fate of Deevena, Sailu, Babu and all those other children, the future of this nation? “Only the personal intervention of the ITDA project officer can save their lives. This is what our so called ‘system’ has come to. Life is not a right anymore but the personal charity of the official,” lamented Dora. Until all this materialises, death will continue to dance here. And in this age of hyper-nationalism, no award will be returned by our intellectuals, no candlelight vigils will be held, no government employees and movie stars will donate their day’s salary. Not that those are unimportant but the adivasis lives are equally important. But then, perhaps, this is our ‘nationalism‘.
Pavan Korada is a freelance journalist based in Vizag, Andhra Pradesh.