Intolerable Burden of Malaria among Primitive Tribal Community in Odisha: Examining the Fundamental Cause

Introduction

Malaria is one of the foremost public health problems in India. It is an age-old vector-borne disease with considerable risk to mortality and adverse economic implications to the household and the nation as a whole (Dhingra et al., 2010; Kumar et al., 2007). According to the recent world malaria report, India accounts for about 70 per cent of total malaria cases in the South-East Asia region (WHO, 2015). Malaria is popularly called as a local and focal disease mostly clustered in low- and middle-income settings. Almost all the developed countries have successfully eradicated malaria indicating it to be the disease of the poor population. Malaria is an indication of a poor socio-economic and environmental condition highly prevalent among backward communities such as among the aboriginal population (Sharma et al., 2006, 2015; Yadav et al., 2007).

The vast majority of the North-eastern states, Eastern and Central Indian states, particularly the tribal dominant regions are considered as high malaria transmission zones (Narain, 2008). A whopping 80 per cent of malaria cases and deaths are reported from these states, of which Odisha is infamous for the major share of malaria cases and fatality (Patil & Kumar, 2011). The state of Odisha is aggrieved by a very high incidence of malaria, predominantly among the tribal populations for the last several decades. As per the National Vector Borne Disease Control Programme (NVBDCP) data, Odisha contributed 36 per cent of total malaria cases, 47 per cent of falciparum cases and 16 per cent of death due to malaria recorded in the country in 2014. A total of nearly 4 lakhs malaria cases were recorded in Odisha alone in the same period. Therefore, it is ironic to note that Odisha with a population share of 4 per cent of the country is laden with a massive 36 per cent of malaria burden reflecting the state of public health conditions in the state.

The epidemiological outcome of malaria varies in different ecotypes (Kar et al., 2014). Therefore, the situation of malaria is rather complex due to varied socio-economic and environmental conditions India is endowed with. Favourable environment and climatic factors poses a serious threat for malaria elimination challenges despite modest gains in the recent times. Though Malaria has been associated with environmental conditions, rarely has it been understood about the linkages of social determinants of health with malaria causation from a public health point of view. Further, not much has been explored to understand the social determinants of those cases clinically confirmed from hospital-based records as a follow-up study. Therefore, it is useful to understand the social determinants particularly the living and the working conditions of the tribal populations who are highly exposed to the risk of malaria for an evidence driven public health intervention strategy. This study was undertaken to understand whether the living conditions such as the environment and household surroundings and the working conditions of the indigenous person who is infected with malaria possibly contribute to malaria transmission in a malaria endemic zone. Further, we explored the health seeking behaviour of those clinically tested malaria positive cases and the response of the health services system.

Materials and Methods

The study used multi-stage sampling method to select the primary sampling units. At the first stage, one block was randomly selected out of 12 blocks in the district of Kandhamal, Odisha. The selected block was then divided into five different clusters based on geographic proximity of the Gram Panchayats (GPs). Each of the cluster comprised of 4–5 GPs. Further, the central cluster was randomly selected from among five clusters. Two GPs from central cluster were purposively selected based on access to pakka road in the GP, literacy rate and percentage share of total tribal populations. Four hamlets each were randomly selected from a total of 10 and 11 hamlets respectively from the better of GP and not so better of GP based on the aforementioned categories. Kandhamal lies in high altitude zone with inter-spreading inaccessible terrain of hill and likewise, the condition of not so better off GP selected in the study was not connected by a pakka road and there was limited means of communication.

After the selection of the hamlets, all the health facilities providing fever related treatment such as Community Health Centre, Sub-Centre, Multipurpose Worker, Anganwai Centre, private diagnostic centres and quacks were identified. The majority of the populations sought treatment for fever case in these facilities. The identification of the facilities was based on informal discussions with the village gatekeepers. Malaria positive cases were identified based on blood sample examination from the medical records of the selected facilities. Malaria positive cases reported two months preceding the study, that is, from 1 February to 31 March 2009 from the selected hamlets were screened. Two months’ reference period was taken in order to understand the most recent cases as well as to minimise recall bias of the respondent. A total of 53 malaria positive cases were identified from the selected 8 hamlets. Data collection was carried out from 10 April 2009 to 15 May 2009. Fourty two cases out of 53 were interviewed. Of the 11 cases not interviewed, four households were locked, four households reported more than one case of malaria and in three households only minor individuals (aged less than 18) were present at the time of interview owing to a response rate of 79 per cent. The study respondents comprised of persons diagnosed with malaria aged 18 or above but in case of a minor patient, an elderly member who often took care of the patient during the time of illness was interviewed.

The tools used for data collection was pretested in the nearby GP. The tools used in the study included: interview schedule administered to the patients (N = 42) including a few open-ended questions in it, semi-structured interviews with the health providers including the doctors, ANM (Auxiliary Nurse Midwifery), MPW (Multipurpose Health Worker), private practitioners and the quacks (N = 9) and five case studies of the households (one from a diseased household, two case studies of households with multiple cases of malaria and two case studies of other households). The interview schedule was translated into local language, that is, Odiya. The findings presented in this study are mainly drawn from the interviews conducted with the patients diagnosed with malaria, health care providers and from the general observations while interacting with the village gatekeepers. Data were processed and analysed using SPSS 13. Frequency distributions of the key variables are presented and a synthesis of observations and interactions with the village gatekeepers, health care providers as well as patients are used to explain the context.

Results

Nearly two-thirds of the patients detected with malaria were below the age 15 indicating that the disease prevalence was somewhat higher among the children. Notably, of all the malaria positive cases, nearly 40 per cent of the prevalence was among the children below six years. The majority of the households were nuclear family. Around 80 per cent of the households obtained a BPL or Antyodaya ration card. The remaining did not obtain any ration card although their economic condition was poor. One of the reasons given for not obtaining a ration card was that such households were newly set up after their marriage and hence have applied for a ration card or planning to apply. The majority of the household members were illiterate. There were 55 per cent of households where not even a single member in the family was able to read and write in any one language. Around half of the households (45%) reported that at least one member of their family studied up to primary level of education (Table 1).

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Table 1.

Profile of the Patient and Their Family

Age of the patient	%	N
Less than 1 year	9.5	4
1–5	28.6	12
6–14	26.2	11
15–34	11.9	5
35 and above	23.8	10
Sex
Male	52.4	22
Female	47.6	20
Type of family
Nuclear	81.0	34
Extended	19.0	8
Household having a ration card
Yes	81.0	34
No	19.0	8
Education level of the family
All members illiterate	54.8	23
At least one member with primary level education Total	45.2 100	19 42

Source: Primary survey

Living Conditions

Basic amenities in the hamlets as well as in the households were grossly lacking. None of the hamlets had a pucca road. The hamlets were devoid of electricity and telephone network. Kerosene lamp or dubi (it is a locally prepared lamp made out of a small tin container with a stick like nob facing outside. Kerosene is stored in the container and a wick made of old cotton cloth is soaked in kerosene and inserted in the nob) was the main source of household lighting. The dubi leaves a lot of smoke and illuminates dimly. However, it is the cheapest and oldest form of household lighting in this area. Firewood was easily available and all the households used firewood to cook. The oven for cooking was often inside the household. However, during the summer season the tribal households generally cooked outside, adjacent to their home. Majority of the houses were on the hilltop and were made out of mud and wood with a mud floor. The houses were painted red from a distinct soil that is mixed with water and painted the wall using old clothes. Cow dung was used to mop the floor. Generally, the house had two entrances. The back entrance was rather smaller than the front entrance and there was hardly any window in the house. There was no separate kitchen as such and most of the houses had one or two living rooms. The cowshed was often adjacent to the house. Most of the houses had an open veranda in front of the house where the kids played and the clothes were kept for drying. There were no toilets and water supply in any of the hamlets. The inhabitants generally went for open defecation. Women folk would go early in the morning, much before the dawn to avoid the sight of men. Those who went in the day light would go for defecation far off but those before dawn went near their houses. Open well followed by hand pump were the primary source of drinking water in the study hamlets. Nearly 12 per cent of the households used stream water for drinking purposes (Table 2). Majority of the house disposed garbage near the house or in the field which was also not very far away from the house. Leaving only 3 households, all other houses were located near the forest of which around 29 per cent of the households were near a jungle or thick forest. Almost all the houses had gutter near the house where water stagnated. More than 70 per cent of the households had cowshed adjacent to the house. Although majority of the respondents slept inside a dwelling, around 12 per cent slept outside of the dwelling. It was found that because of lack of space inside the house the respondent slept outside their dwelling, generally in the veranda. The majority of the houses were kacha house (64%), constructed using mud and wood. Houses categorised as hut were built with mud and wood but the roof of it was made up of hays or leaf. Where as, semi-pucca houses were those with at least two of the three components (walls made of bricks, concrete roof or asbestos cement sheet roof, cemented floor).

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Table 2.

Living Conditions and Working Conditions

Type of house	%	N
Pucca	2.4	1
Kacha	64.3	27
Semi pucca	16.7	7
Hut	16.7	7
Location of the house
House near forest	92.9	39
House near gutter	97.6	41
House near jungle/thick forest	28.6	12
Place of sleeping
Inside a dwelling	88.1	37
Outside a dwelling	11.9	5
Distance of the cowshed from the house
Beside the house	71.4	30
Away from the house	16.7	7
Do not have	11.9	5
Place of defecation
In the field	57.1	24
Forest	33.3	14
Jungle/thick forest	7.1	3
Toilet	2.4	1
Primary source of drinking water
Open well	47.6	20
Hand pump	40.5	17
Stream/river	11.9	5
Garbage disposal
Near the house	54.8	23
In the field	40.5	17
Forest	4.8	2
Occupation of the household head
Agricultural cultivation	69.0	29
Daily wage	23.8	10
Food gathering	7.1	3
Total	100	42

Source: Primary survey

Health Seeking Behaviour

Nearly three-fourths (71%) of the respondents reported having sought first line of treatment for fever from the sub-health centre, either from the ANM or the MPW (Table 3). It was found that the majority of the serious fever cases received treatment in the nearby CHC. However, CHC seemed the last resort after all other facilities including the quacks were tried out. There was a common understanding among the tribal populations that injection was more effective than the tablets. In particular, the quacks were responsible for imparting these understandings because they were able to demand more money for an injection than tablets. Sadly, the tribal populations tended to believe that more cost meant better treatment and hence they were willing to pay for injection as compared to the medicine. Further, the respondents perceived freely distributed medicine provided by the ANM or MPW as less effective. Of the 42 malaria positive patients, 30 of them reported that their fever lasted for more than 5 days. It indicates that the tribal populations either do not take fever seriously or delay seeking treatment as a result fever lasts longer. One of the respondents narrated her experience:

“I got fever in the morning but it did not seem serious, so I went to work in the field. After I came back from the work, although I did not feel well, it was too late to go for getting medicine from the ANM centre. The next day, I did not go to work but my husband went to work. I thought I would go and take medicine but I was too weak to be able to manage alone. After my husband came, it was again very late to go and get medicine. However, my husband went to get medicine from the ANM. After he got the medicine I took it and thought I would get well, therefore, I sent my husband to work the following day. To my fate, the fever did not reduce and I started vomiting and had a very severe headache. As usual my husband came back home after his day’s work was over. Upon his arrival he went to the nearby village, where there was a petty grocery shop that used to sell medicine. The shop was closed but my husband requested the shop keeper to give him medicine for fever as I was very serious. He brought two different medicines and I took them. However, my fever did not reduce at all. By then, my husband decided to take me to a doctor at the CHC. My husband and two other cousins of my husband carried me in the morning to the nearby bus stop which is around 7–8 kilometres from here. Somehow, they managed to put me in the bus that was too crowded. The doctor told me that I would have got brain malaria (it refers to malaria pf case) and gave injection to me. He also took blood sample for testing. After taking the second injection, I was feeling better. The doctor also wrote a few tablets to buy from the chemist, which my husband did. I was very weak for a long period of time. It took me almost a month to come back to my previous state of health”.—Excerpt from a case study.

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Table 3.

Health Seeking Behaviour

Places where first treatment sought	%	N
Quacks	4.8	2
Private clinic	14.3	6
ANM/MPW centre	71.4	30
CHC	9.5	4
Places where all treatment sought*
Home remedy	57.1	24
Quacks	38.1	16
Private clinic	33.3	14
ANM/MPW	83.3	35
CHC	31.0	13
Duration of fever
Less than two days	7.2	3
Three to five days	21.4	9
More than five days	71.4	30
% households used mosquito net	45.2	19
% household sprayed DDT	28.6	12
Recent episode of fever in the family	52.4	22
Correct knowledge of malaria transmission Total	28.6 100	12 42

Source: Primary survey.

Note: * indicate multiple answer questions, N will not be rounded off to 42.

There is a general practice in the locality to go and ask for medicine for fever or any other health concerns in the ANM centre without taking the patient along. The locality is generally inaccessible and often the health centres are situated far away. Hence, it is inconvenient for the patient to walk a long distance when there are no other means of communication. At times there were evidences that the village shop keepers sold medicine. A person with illness would go to the shop keeper and ask medicine for the illness he or she is suffering from, for example, if the patient asks medicine for fever then the shop keeper would sell chloroquine, paracetamol, etc. Those who perceive fever to be serious go to the community health centre to consult a doctor. The majority of the respondents did not have correct knowledge about the mode of malaria transmission. Some of them thought that by drinking water from the spring one can get malaria. Further, less than half of the households did not use mosquito net. In fact, at a few instances, there was only one mosquito net at home and hence some slept under it and some did not. Dichlorodiphenyltrichloroethane (DDT) was generally sprayed at a regular interval but only a quarter of the houses reported spraying of DDT since last six months preceding the survey. Apart from the positive case for which information was gathered, more than 50 per cent of the respondent reported that at least one other member in the household had fever during three months preceding the survey.

Response of Health Services Systems

Malaria control programme was one of the most desirable and timely interventions soon after the independence of India by the government of India. National Malaria Control Programme (NMCP) witnessed periodic changes in strategies under different nomenclature, such as National Malaria Eradication Programme (NMEP), National Anti-Malaria Programme (NAMP) and at present, the NVBDCP. Enhanced malaria control project (EMCP) and intensified malaria control programme (IMCP) were two significant projects greatly influenced strategies in the malaria control programme. These projects were supported by the external funders such as the World Bank and global fund to fight AIDS, TB and malaria (GFATM). Although some progress has been recorded in parts of Odisha, yet malaria continues to pose serious challenges. In several ways, treatment of malaria cases reduced case fatality but the incidence of malaria in Odisha particularly among the tribal populations has not changed much. In spite of the state of Odisha contributing to the maximum number of malaria cases as well as death on account of malaria, the state has made very little progress to control malaria. Malaria, the disease of the poor is proved by the fact that Odisha is the second poorest state in India with nearly 40 per cent of the population belonging to tribal and dalit communities.

It was interesting to observe that the MPW is popularly known as the malaria worker in the villages. He, being a male member was more acceptable in the communities because he could manage to commute with a bicycle or motorcycle in the hilly region where there are no adequate roads. On the other hand, it is considered unusual for a female member to ride a cycle or motor cycle in the area, particularly among the married women. Therefore, female frontline community health workers such as the ANM are not better positioned to reach out especially in the hilly region. Moreover, one of the ANMs raised her concern that almost all of her days in the week are earmarked for one or the other health programme. Amidst packed schedule she has to make home visits and therefore it gets very difficult. Similarly, ANMs with newborn baby find it very difficult to make home visits particularly in the hilly region.

Discussion

We investigated the living conditions and the working conditions of a primitive tribal populations who were clinically tested malaria positive. Additionally, health seeking behaviour of those infected with malaria was explored. The vast majority of the tribal populations who were tested malaria positive lived in an environment close to forest which is conducive for excessive mosquito breeding. Almost all the households lacked basic amenities including appropriate road connectivity, electricity supply, safe drinking water, sanitation facilities, a pakka house, etc. Their living conditions in these kinds of settings are such that it is ‘natural’ to get exposed to mosquito bites that make them susceptible to malaria. The majority of the populations did not have adequate access to health care services. Although many relied on primary level health care, delay in seeking healthcare is a grave concern was the norm at most of the instances. All the fever cases were treated with radical treatment in spite of the lack of evidence to prove the presence of malaria parasite among the patients. It was observed that the health workers at the sub-centre although took blood sample to investigate malaria parasite, it took at least two weeks to know the result of the blood examination. Therefore, blood examination hardly provided any benefits for treating fever case. The introduction of rapid diagnostic kit (RDK) made it possible to know about the presence of malaria parasite instantly but often the health workers at the primary level did not have enough supply of it or used it only for the socio-economically well-off population. On the other hand, there are evidences of chloroquine resistance. As a result, treatment plans have been changed recently to act against malaria parasite. The majority of the malaria positive cases were observed among the young populations, suggesting the young populations to be at higher risk of malaria compared to others (Sharma et al., 2004, 2006).

The first point of contact for treatment was mostly with the primary level health worker, often the MPW. Although a few of the respondents reported that they did not trust the community health worker such as the ANM or the MPW, however, they were hardly left with any option as a result community-level health workers were the first point of contact in the majority of the cases. Studies in the past reveal that often the patients did not trust the community-level health workers and hence sought treatment from quacks or traditional healers and those who had access went in the private hospitals (Das & Ravindran, 2010; Vijayakumar et al., 2009). In a setting such as the current study area, where roads and communication are paralysed, frontline health workers’ role is key. Moreover, male health workers, that is, MPW have been identified as the ones mostly contacted for fever cases.

Although this study sheds insights into understanding how the lack of basic public health provisioning is characterised by the inability to improve malaria conditions in an endemic zone, yet the findings of the study need to be taken in light of a few limitations. The primary aim of the study was not to generalise the findings of the study but to understand and depict the deplorable public health scenario available to the Kondho communities living in the hilly region, devoid of basic mode of communication and the surroundings conducive to malaria. The study considered only those fever cases who availed services from any of the existing health facilities. A household-based survey would have provided a comparative picture to understand the social determinants of those who reported malaria positive cases and those who did not. Nevertheless, hospital-based survey information is not only a rich source of information but also is supported by clinically diagnosed case rather than self-reported morbidity. Although the study is supported by information collected through case studies and in-depth interviews with the health care providers, the study heavily relies on the information gathered from the 42 respondents, that is, rather a small sample size.

Conclusion

Case fatality due to malaria is declining but not the incidence. Due to resistance of chloroquine, more radical drugs are currently prescribed. The policy and programme need to focus on malaria control with a vision for basic public health provisioning of prevention and promotion of health rather than excessive emphasis on treatment. Investment on malaria prevention is subsumed by malaria treatment. Basic public health provisioning of sanitation and hygiene including housing is grossly neglected. The results of the study indicated that the environment in which the tribal populations live are prone to mosquito breeding. Most of the inhabitants live in a house built in mud and beside a cowshed. Together with continuing curative care for malaria—more emphasis is needed on prevention of malaria due to the susceptible surroundings in which the community live. Community, civil society and the government need to work in tandem to improve the living and working conditions of these primitive communities. Community-based model for malaria prevention may be worked out with participation from the population. Measures such as cleaning of the household surroundings, distancing cowshed from the house and other mosquito breeding places needs to be encouraged together with a better healthy habit message. Every individual must be promoted and educated to use insecticide bed net. The study observed that often the tribal populations sought treatment from the health sub-centres. Therefore, it is essential to strengthen primary health care delivery with appropriate diagnostic and treatment facility at the sub-centre level. There is also a greater need to invest on the alternative systems of medicine for malaria treatment.