On September 16, Bira Kabasi’s three-year-old son Debo fell ill. He had fever and convulsions.

For the wiry farmer who lives in Palkonda village in Malkangiri, this triggered a painful memory. Three years ago, his daughter, Rupa had come down with similar symptoms. “She also had a warm body and was shivering,” he recalled. “We didn’t take her to the hospital. We thought she would be fine if she slept.” The child died within hours of taking ill.

When his son came down with similar symptoms, Kabasi did not want to make the same mistake. He rushed Debo to the only government hospital in the district, located in Malkangiri town, 17 kms away. “We took an autorickshaw,” he said. There were no doctors at the hospital. “I even went to their house.” Three hours passed before the hospital staff admitted Debo. He died the next day.

Kabasi has decided that he will never go to the hospital again.

“I spent the little money I had at home, but the child died,” he said with tear-filled eyes. “Nobody, not even the doctors could do anything.”

Bira Kabasi at his home in Palkonda village in Malkangiri, Odisha.

Malkangiri, the southernmost district of Odisha, also one of its poorest, has been reeling under an outbreak of Japanese encephalitis this year. The viral infection, which is transmitted by mosquitoes, causes encephalitis, or brain inflammation, that results in fevers and seizures that can rapidly turn fatal. Since 2012, there has been evidence that the virus has been circulating in the district, and doctors suspect it is responsible for the deaths of many children.

This year, 93 children admitted to the district hospital have died of encephalitis. Kabasi’s son was one of them. In his case and 31 others, blood tests have confirmed the presence of the Japanese encephalitis virus. Investigations are underway in another 61 deaths.

Not enough doctors

Underlying the deaths of children in Malkangiri is a weak and ineffective public healthcare system, plagued by the lack of hospitals, and the absence of doctors.

For a district spread over 5,971 sq kms, which is roughly four times the size of Delhi, home to 660,000 people, Malkangiri has just one large government hospital with only nine doctors. As the only tertiary care hospital in the district, it is responsible for handling complicated cases that are referred to it from the primary and community health centres located in the villages.

The district hospital has 125 beds and 44 sanctioned posts for doctors of which 35 are vacant. Six posts meant for child specialists and intensivists trained in critical care have remained vacant since they were created in 2012.

Of the 103 sanctioned posts of doctors in the district, only 37 have been filled. Not just doctors, the district does not have enough nurses, the workers who form the backbone of the healthcare system. Only 43 of the 122 sanctioned positions for nurses are filled.

With such a shortage of doctors and nurses, none of the operation theatres in the community health centres are functional. Dr Mohammad Hussain who works at the community health centre in Kalimela in Malkangiri said, “We open the operation theatre only when a surgeon comes to perform family planning operations. Otherwise it is shut for most of the year.”

An unused operation theatre at a community health centre in Malkangiri. Photo: Priyanka Vora.

When children started dying in the villages from high fever and convulsions, health workers and families skipped the community health centres, and brought ailing children directly to Malkangiri’s district hospital. Short-staffed and lacking the infrastructure to treat them, the doctors sent the children to the Maharaja Krishna Chandra Gajapati Medical College and Hospital at Berhampur in Ganjam district, about 320 kms away. Many of the children died on the way.

Three-year-old Rama Sodi died of Japanese encephalitis on September 14. The child was one of the first victims of the illness and died on the way to the hospital in Berhampur. Ten days later, the state government started posting doctors from other districts on a two-weeks deputation to Malkangiri.

The district hospital in Malkangiri had just one paediatrician when the outbreak started in September. “We immediately alerted the superiors and got some doctors to our hospital and started a paediatric intensive care unit,” said Dr KK Sarkar, joint director of health for Malkangiri.

Since then, a batch of six to seven doctors from other districts has been stationed in Malkangiri at any given time. Every two weeks, a new batch of doctors comes in.

The hospital had to borrow ventilators from a medical college to treat children with the infection. “We are purchasing some monitors and ventilators,” said Dr US Mishra, the chief district medical officer of Malkangiri.

Relatives, not hospital attendants, ferry patients on stretchers inside the hospital. Photo: Priyanka Vora.

Despite the hospital’s poor infrastructure, Mishra blamed the disease for the high mortality. “There is no drug to kill the virus,” he said. “What we can do is provide supportive treatment.”

A doctor posted to the hospital on deputation said that he can do very little to save the lives of the children with the limited medical infrastructure that the hospital has. “These children come in a bad state,” he said.

“And we can’t live here,” he added.

A senior doctor from the health department in Malkangiri commented wryly: “No one will work here for more than two weeks. People are not ready to come for even two weeks.”

Dr Mohammad Hussain joined the community health centre in Kalimela in October. “I was supposed to join here last year but I didn’t want to. It is a red zone,” he said, referring to the Maoist presence in the district. In the last week of October, 24 alleged Maoists were killed in a gunfight with the security forces. Government employees, including health workers, are reluctant to venture into the villages, even those that are far away from the arena of conflict. “Government officers are always a target,” said Hussain.

Dr Hemant Kumar Singh who was deputed to Malkangiri from Cuttack for two weeks. Photo: Priyanka Vora.

The problem of access

Located at the intersection of Odisha, Chhattisgarh, Andhra Pradesh and Telangana, Malkangiri is part of a hilly and forested region, which is underdeveloped in terms of infrastructure. The roads leading to the district are broken and bumpy. There is no railway network.

When the state health minister Pradip Kumar Amat visited the district in October to check for the district’s preparedness, he flew from the state capital, Bhubaneswar, to the base camp of the Border Security Force in Malkangiri. “His aircraft had to be refilled midway, because Malkangiri is so far from Bhubaneswar,” said a local official. “This district is like it is not in Odisha.”

Most roads leading to villages are unpaved, making it difficult for ambulances to reach the doorsteps of patients. Photo: Priyanka Vora.

In 1971, the Balimela dam was built on the Sileru river that flows through the district. As a result, villages in the lowlands were submerged under water, and those on the highlands were cut off. Since then, no bridge has been built to connect those villages, and the isolation has helped a Maoist insurgency take root, which has further compounded the area’s infrastructural problems.

Adivasis living in some 150-odd villages on the other side of the reservoir – the region known as the “cut-off” area – are not under the scanner of the health system. “We really don’t know what goes on there,” admitted a senior official from the district administration. “Even if children are dying of Japanese encephalitis, we would have no clue.”

Local politicians have claimed that more than 150 children have died in the district since September but government records put the death toll at 93.

Activists point out that only cases that have come to the district hospital have been recorded. There is little information coming from the villages across the reservoir, and even in the rest of the district, several cases may have escaped the attention of the health authorities.

“Many children don’t come to the hospital,” said Ashok Patnaik, a right to information activist from Malkangiri. “Their deaths are not being taken into account.”

Nowhere to go

Years of neglect on part of the administration has left villagers in Malkangiri weary of the public health system. This year’s encephalitis outbreak is the first time that sick children have been transported from their hamlets to hospitals in ambulances.

Unkepmt wards at the district headquarters hospital in Malkangiri. Photo: Priyanka Vora.

In the first week of October, when Muni Singa Podiami’s three-year-old daughter Debe developed convulsions, she refused to take her to the hospital. She took her to the faith healer instead.

Podiami lives in Pedawada village in Kalimela block. The health worker of the village, Priti Ranjan Devra, eventually managed to coax her to take Debe to the hospital.

On October 10, the child died in the intensive care unit. “Other villagers had warned me against taking my daughter there,” said Podiami.

“They put my daughter in the cold room,” she continued, referring to the intensive care unit, “and she simply died in the cold.”

Fearing a similar outcome for her second child, who had the same symptoms, Podiami refused to admit him at the hospital. “I ran away from there,” she said.

Many like Podiami will continue to run away from the hospital until the administration builds their trust by making healthcare facilities available regularly and closer to their doorsteps.

Muni Singa Podiami. Photo: Priyanka Vora.

The next story in the series looks at what makes Malkangiri’s children vulnerable to diseases – a constant state of hunger and malnutrition. You can read the other stories 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.