When Pola Madhi was returning from the district hospital of Malkangiri with the body of his seven-year-old daughter, the health worker of his village discreetly handed him a bag. It contained a mosquito net.

“I also got this,” said Madhi, holding out a tube of a popular brand of mosquito repellent.

Ninety three children have died in this district in southern Odisha since September from encephalitis, or brain inflammation, that doctors suspect has been caused by the Japanese encephalitis virus. The virus is transmitted from pigs to humans by the Culex mosquito. So far, laboratory tests have confirmed 158 cases and 32 deaths on account of the Japanese encephalitis virus.

Madhi’s daughter Aarti was one of them.

The child came down with fever on the morning of September 24. “Her eyes looked strange,” said Madhi. He put the gasping child on a motorcycle and rode on a bumpy gravel road for about an hour to reach the district hospital. By evening, Aarti was dead.

Madhi has three children of which two were infected with the virus. While Aarti succumbed to the illness, her younger brother, five-year-old Sanjeeb, survived it. “He was not as ill as Aarti,” the father said.

The Madhis belong to the Koya Adivasi community and live in a village called AB Colony. In the backyards of their mud and brick homes are wood pens used for rearing pigs. The village is surrounded by verdant paddy fields. These fields, which hold water for months, are breeding grounds for mosquitoes.

Villagers in Malkangiri returning to their homes from the fields. Photo: Priyanka Vora

Malaria is endemic in the district. According to the National Vector Borne Disease Control Programme, Malkangiri recorded 18,687 malaria cases in 2014, which went up to 29,610 cases in 2015. Between January and September this year, the district had already recorded 27,077 malaria cases.

Public health experts say the high incidence of malaria itself calls for better mosquito-control measures. Both the Anopheles mosquito that spreads malaria, and the Culex mosquito that transports the Japanese encephalitis virus, breed in dirty water. The most effective measure against them is clearing accumulated water once a week. Spraying indoor residual disinfectant is another way to kill the mosquitoes, said experts. In addition, mosquito nets can provide protection.

Such measures could have prevented the outbreak of Japanese encephalitis.

Pola Madhi and his neighbours at AB colony village in Malkangiri. Photo: Priyanka Vora.

Administrative lapses

The National Vector Control Borne Disease Control Programme in Odisha is responsible for preventing and controlling mosquito borne diseases such as malaria, dengue and Japanese encephalitis. The Malkangiri division of the programme has 25 employees, with 17 of the 31 posts of health workers entrusted with carrying out vector control activities lying vacant.

For a district spread over 5,791 square kilometers, only two fogging machines were available to spray insecticide in 2,220 villages.

After the Japanese encephalitis outbreak, the state government has rushed more fogging machines to Malkangiri. “We now have 60 fogging machines,” said district collector K Sudarshan Chakravarthy.

The other common preventive measure – distributing mosquito nets – was also put into action after the outbreak.

The last time mosquito nets were distributed in the district was in 2014. That year, the state government gave 16,000 insecticide-treated mosquito nets to villagers living in two blocks – Kalimela and Pandripani. Villages in six other blocks did not receive any mosquito nets.

It is the Union government’s responsibility to supply these nets, said Dr Madan Pradhan, joint director, health services, Odisha. But it failed to do so.

Between 2015 and 2016, not a single mosquito net was distributed in Malkangiri by either the state government or the Centre.

Following the outbreak this year, 12,412 mosquito nets have been distributed, but they are not the long-lasting nets which are supplied by the central government. The long-lasting nets have insecticide incorporated in their fibre and are more effective. “An untreated net is just a barrier between the human and the mosquito, but an insecticide treated net will kill and repel mosquitoes,” said Johnny Oommen, head of community medicine at Christian Hospital in the town of Bissam Cuttack.

Ajit Kumar, who heads the National Vector Borne Disease Control Programme in Malkangiri, said the district is still waiting for those nets.

A woman in Malkangiri who lost her child in the current outbreak. Photo: Priyanka Vora.

Punishing people

Palkonda village in Malkangiri’s Korukonda block is home to more than 1,000 families. Five children here died of Japanese encephalitis. In the third week of September, soon after these deaths, electricity to the village was cut off.

“We cut the electricity as the villagers were refusing to leave their pigs in the pigsty that we had built outside the village,” said Chakravarthy, the district collector. District health officials had tested pigs in the area and confirmed that they were carrying the Japanese encephalitis virus. They believed the outbreak could be controlled by moving the animals out of the villages. A pigsty was constructed two kilometres away. But the villagers did not use it.

“We would take the pigs in the forest in the morning, and the villagers would bring them back in the night,” said Dinesh Biswas, the local health worker.

Chakravarthy said the administration even threatened to cancel the pension and ration-cards of the villagers. “It was our last resort. We could not allow the pigs to be in the village knowing that they are spreading the disease.” He claimed the electricity was cut-off during the day and restored in the evening, but villagers said the power cut lasted two days.

The threats worked, said Biswas. After the electricity was cut, “the villagers started cooperating”.

Dr KK Sarkar, the joint director of health in Malkangiri, expressed exasperation: “These villagers treat pigs like their children.”

But the Adivasis, who rear pigs for their livelihood, explained that leaving their animals unsupervised in the forest was not an option. “You are better off if you have more pigs,” said Debendra Kabasi, a 35-year-old man for whom the outbreak has been doubly hard: he lost his daughter, and the family now faces economic hardship. “I could sell the pigs and get money, but this Japaani [Japanese encephalitis] has ruined that.”

District officials, who failed to put preventive measures in place earlier, are now scrambling for solutions. The next measure that the administration is planning, said Sarkar, is to put the pigs under mosquito nets.

Poster about Japanese encephalitis transmission in a village in Malkangiri. Photo: Priyanka Vora.

Poor communication

Activists said that only if the government had paid more attention to Malkangiri and put children like Aarti under mosquito nets, the outbreak would have not assumed such proportions. “The government never conducted any awareness programme in the district to educate tribals about the need for vector control,” said Pardip Pradhan, an activist working on food security in Malkangiri, Koraput and Jajpur districts of Odisha.

Even in cities like Mumbai and Delhi, many residents are averse to allowing insecticide control officers inside their homes to scan spaces for mosquito breeding. In the last few years, city corporations have had to conduct awareness campaigns to explain the phenomenon of mosquito borne illnesses, and to build support among the community for the preventive measures being taken.

In Malkangiri, activists say the district administration chose an easy way out. Health workers forcibly entered homes in the affected villages and sprayed insecticide. Once they left, residents plastered the sprayed walls with cowdung. Health officials then switched to spraying the insecticide on the outer walls, which is not an effective way to keep out mosquitos.

Worker spraying insecticide residual spray at a home in Palkonda village in Malkangiri. Photo: Priyanka Vora.

As children were dying, said Pradhan, what was needed was community outreach. “It is only when the tribals know why the government is doing what it is, will they cooperate,” he said.

But the gulf between the administration and the villagers was too wide to bridge.

Silver lining

An unexpected fallout of the Japanese encephalitis outbreak is that malaria cases that may have escaped the radar of health authorities are getting detected.

Following the deaths of children in September, the district administration started conducting screening camps in the villages. “All ASHAs [Accredited Social Health Activists] have been asked to refer any child with fever to the hospital in the district headquarters,” said Chakravarthy, the district collector.

The camps have helped detect several cases of malaria. Dr Santosh Mishra, a senior paediatrician at the district hospital, said, “There are two wards for Japanese encephalitis patients but more number of children have been admitted to the paediatric ward with malaria.” At least 19 of the 25 children in the paediatric ward at the hospital in the last week of October were undergoing treatment for malaria.

A school girl undergoing treatment for malaria at district headquarter hospital in Malkangiri. Photo: Priyanka Vora

In Palkonda village, 23 children with symptoms of fever and headache were taken to the district hospital by ASHA workers. Villagers said this kind of attention was unprecedented. “So many cars have come to the village because of Japaani,” said Ganshyam Tripathi, a resident of Palkonda. “Kuch to badlaav aayega”. Something will change.

But doctors in the district headquarters do not share the same confidence. Overwhelmed by the influx of both encephalitis and malaria cases, a senior doctor said the district hospital was able to manage only because the state government had deputed doctors from other districts as a temporary measure. “Once they go, the quality of care will be poor like before,” he said.

The next story in this series looks at the abysmal state of the public healthcare system in Malkangiri, a district with just one large government hospital staffed with nine doctors. You can read the first part of the series here.

This reporting project has been made possible partly by funding from the New Venture Fund for Communications project, which receives support from the Bill & Melinda Gates Foundation.