Between October and December 2010, an epidemic of falciparum malaria broke out in Chhattisgarh. The state government reported a statewide total of 32 deaths. In Bilaspur district alone there were nine deaths, of which seven cases were reported from the Jan Swasthya Sahyog hospital in Ganiyari. While gathering evidence in an area where JSS did not have an outreach programme, the JSS Community Health team learnt of 250 deaths in the Kota block of Bilaspur district through a painful process of verbal autopsy. Of these, 200 deaths were confirmed to be from malaria. If these were the number of deaths in one block of one district alone, one could only speculate on the numbers statewide.

What follows are some first-hand accounts given by family members to the JSS team, in cases where at least one person had died.

Six-year old Shyamlal Yadav of village Rigwar had fever and headache for three days. He was going to the Anganwadi regularly where, it would have been his last year. When his body started turning yellow, his parents called a witch doctor to do jhar-phook (chase away the evil spirits possessing the boy), following which they took him to a quack who gave him an injection and the fever subsided for a day.

The day after, a Sunday, Shyamlal’s father Anand Ram returned from the fields to find his son burning with fever and gasping for breath. Panicked, he wanted to take the child to the Primary Healthcare Centre (PHC) in Ratanpur, 25 km away. But the family had no means of transport and the last bus to Ratanpur had already left. The village Sarpanch was kind enough to arrange for a motorcycle. The doctor on duty at the PHC detected malaria and asked Anand Ram to take his son to Bilaspur, a distance of another 30 km. Anand Ram had only Rs 200 with him and pleaded with the doctor to keep his son for the night while he went to arrange for the money, but he had no such luck. As the sun descended on a bone-chilling winter evening, Anand Ram made a last ditch effort to get medical help, but he got the same answer at another private hospital: he had to go to Bilaspur.

Catching the last bus to his village, Anand Ram returned home with a now gravely ill Shyamlal at 8 pm. The boy was coming in and out of consciousness. That night a frantic Anand Ram mortgaged one acre of his land along with the standing kharif crop. With Rs 8000 in hand, the family waited with bated breath by the boy’s side for the sun to rise. At 4 am, Shyamlal asked his mother for some water, and died soon after. The life of a 6-year old snubbed out due to reasons perhaps unimaginable to many frequent flyers, broadband users or anxious faces in the IPL galleries. While accurate estimates are available for projected GDP growth or an impending recession-recovery couplet, for Shyamlal’s distraught family it would have been helpful to know an estimate of the time it takes for benefits to trickle down.

Malaria is caused by Plasmodium parasite which is transmitted by the Anopheles mosquito but we humans determine its frequency and lethality, by our mode of development and the way we handle water resources, and by the way we organise our treatment and control programmes. Offcially India lost 535 people to malaria in 2014, though the Million Death Study estimated it to be 1,50,000 to 2,25,000 annually. Himalayan states are immune to it while the worst hit states are Tripura, Odisha, Chhattisgarh and West Bengal

Three days later, Shyamlal’s uncle’s son, one-year old Tilakram showed the same symptoms. This family was better prepared with money and had rented a car to take him from the Community Health Centre (CHC) on Kargi Road to Bilaspur. But the parents could not convince the authorities to spare an oxygen tank for the breathless infant; Tilakram did not survive the journey to Bilaspur. Sickness and death has left the families of both Shyamlal and Tilakram in a debt of Rs. 10,000, and inconsolable.

Nandini (a year-and-half old) and Anjali (aged five) came from a landless family in village Porimohonda. Both sisters had fever and a PHC near the village detected both with malaria. The family was advised to take the girls to the Ratanpur PHC, 35 kms away, which had more doctors and besides a malaria camp was also running there. Since Anjali was less seriously ill, the parents took Nandini there. This went on for four days. Meanwhile, Anjali finished the course of medicines given by the village PHC, except that her belly was swollen. The parents thought she was better and left her behind to take Nandini to Ratanpur again. But this time, they were told to go to Bilaspur. The distance and the cost of transport, however, made the journey impossible for the family. While still at Ratanpur, they got the news of Anjali’s death.

In panic and grief, the parents rushed back home. One can only imagine the numbing effect of helplessness, hopelessness, angst and grief. A week later, before the mourning for her sister was over, Nandini, too, succumbed to the disease one night.

Bilaspur remained silent in the distance. The parents’ lives are now caught between the grinding blocks of memories, and a debt of Rs 15,000.

Manglu Ram Gond, aged 40, from village Berapat had fever for 8 days. His brother took him to the CHC on Kargi Road about 20 km away. He was detected with malaria, given saline, and asked to go to Bilaspur. His brother rented a car and took him to the medical college in Bilaspur where he was admitted and his treatment begun. The brother was asked to get some medicine from an outside pharmacy, but he did not have money. He tried to call people in their village to get money by morning. But Manglu Ram did not wait that long and passed away in the early hours.

His brother rented a car again, this time to take Manglu’s body back to his four-year old son and his six months pregnant wife, who was also running a fever. She was taking paracetamol to control her fever, but by the time her brother-in-law returned, she and her unborn baby were dead. The brother took the two acres of land left behind by Manglu to offset the expenses incurred and raise the four year old boy who found himself orphaned for reasons he might think were not preventable.

In official records, the causes for the above deaths would not be recorded as malaria, and certainly not poverty in an era of 10% growth, or the inability to travel 30 km in the age of 3G, or substandard PHCs when medical tourism is a formidable industry in India.

The doctor-patient ratio or physician per 1,000 population are good indicators of human resource in healthcare. But for the poor who are mostly reliant on the government for their health needs, “population per government allopathic doctor” seems to be a more reliable parameter. According to CBHI data, India has 11,455 population per allopathic doctor. The worst performing states according to this parameter are Maharashtra (28102), Chhattisgarh (24,711), Uttar Pradesh (21,122) and Bihar (20,207).

Malaria deaths start where political power ends, said a friend who works for malaria control among the poorest in our country. These deaths and many more are but grim reminders of the disempowerment that people far from resources feel and pay for with their lives.

Today, according to official figures in India, 2 million people get malaria every year in India and about 700 people die of it. The World Health Organization estimates 15 million cases in India annually, with 20,000 deaths every year. The Million Death Study estimate pegged the number of deaths at about 150,000 to 225,000 annually, though this was contested bitterly by the department of vector borne diseases control in India.

The majority of malarial deaths take place at home, and thus would not be counted as being caused by malaria. The government’s figures are restricted to laboratory reports from its health facilities. Even if there is high likelihood of a death being malarial, unless there is a positive smear report for malaria, that death is not recorded as being due to malaria. But most people go to private doctors or other care providers for treatment and few suspected to have malaria actually get tested for it––treatment is usually presumptive. We are working without complete information. And little or no efforts are being made to improve the reporting of malaria cases and deaths.

In absence of correct information about malaria deaths, flawed and ineffective policy decisions are made. In 2010 when Chhattisgarh and other central Indian states witnessed a major epidemic of malaria with arguably over a few thousand deaths, of which at least 200 were reported by JSS from a single development block in Bilaspur district, the official statewide count of malarial deaths stood at 42! It is no wonder then that the Bilaspur Malaria Department’s annual report for 2010 said that this was like any other previous year in terms of morbidity and deaths.

Map the worst-affected states in India, and you also map the poorest. Ironically, these states are rich in natural resources even as the people are desperately poor. Jharkhand, Chhattisgarh, Madhya Pradesh, Odisha and Assam are high-burden states for falciparum malaria.

This deliberate underreporting, and hence the subsequent flawed response to it, is not only unfair to those who have died but it also obfuscates facts about who are the ones who continue to die from malaria. The government’s own data suggests that of all the falciparum malaria cases, 50% occur among the tribals – who comprise only 8% of the country’s population – and they account for over 90% of all those who die of malaria.

In 1948, Rudolph Virchow had insisted that, "Medical statistics will be our standard of measurement: we will weigh life for life and see where the dead lie thicker, among the workers or among the privileged."

Among the diverse socio-economic groups in our country, tribals or adivasis bring up the rear on all social, nutrition and economic indicators. It is no wonder that this inequity and injustice expresses itself through a disease called falciparum malaria. Malaria is only a manifestation of the structural violence that adivasis, other forest dwellers and those who live on the fringes continue to suffer from.

Excerpted with permission from Jan Swasthya Sahyog.