Pallala Linga Reddy was the first in his family to die this summer. The 23-year-old suffered from vomiting, fever and diarrhoea for a few days before he died on June 6. He was followed by his mother Komanna, 50, who died on June 10 after keeping sick for seven days with the same symptoms. Then, four-year old Ramcharan, Reddy’s nephew, perished on June 13.

The family lives in Chaparai village in Andhra Pradesh’s East Godavari district. Sixteen people died in the village in a span of three weeks from May 30 to June 22. The government heard about the deaths on June 24 when a message reached the office of the Integrated Tribal Development Authority in Rampachodavaram, 150 km away. Rampachodavaram is the headquarters of the East Godavari’s agency area – a term used for the Adivasi-dominated hill tracts in Andhra Pradesh.

“We sent a medical team the next morning,” said AS Dinesh Kumar, project officer of the Integrated Tribal Development Authority. “There were lots of cases of fever, vomiting and loose motion.”

Over the next few days, 59 people from Chaparai, including Reddy’s family, were referred to the area hospital at Rampachodavaram. Of these, 32 tested positive for falciparum malaria in Rapid Blood Test. The test gives preliminary diagnoses with just a few drops of blood. However, when the samples were sent to a laboratory for confirmation, only one tested positive for malaria.

The authorities then concluded that the deaths were not due to malaria. They claimed the Adivasis had more likely succumbed to infections from contaminated food and water, which they blamed on their lifestyle.

Health experts, however, question the dismissal of the Rapid Blood Test results. Dr Neena Valecha, of the National Institute of Malaria Research, Delhi, said the test is a “sturdy” diagnostic tool, which is routinely reviewed by the government and has a sensitivity of up to 95%.

Others question why it took the government so long to detect the outbreak of a disease that killed so many people in such a short period.

Dr Manoj Murhekar, director of the National Institute of Epidemiology in Chennai, said 16 people dying in three weeks in one village was definitely an outbreak of a disease. “While it is theoretically possible for there to be two outbreaks at the same time, my gut feeling is it is one pathogen causing the outbreak,” he said. From the description of the symptoms, Muhrekar surmised that the deaths could have been due to cholera, dysentery or malaria. “A good surveillance system would have caught the cases even before the deaths,” he added.

This family is grieving the loss of Kondala Narasamma, a seven-year-old child who died in the outbreak.
This family is grieving the loss of Kondala Narasamma, a seven-year-old child who died in the outbreak.

Surveillance is not just keeping track of the cases that come to the district hospital but also those reported at community or sub-health centres. But surveillance can take place only if there is a functioning public health system on the ground.

Residents of Chaparai have no regular access to a government doctor or even community health workers. The posts of Accredited Social Health Activist, or ASHA, and Auxiliary Nurse and Midwive, or ANM, for the village are currently vacant.

Isolated village

Like most villages in the agency area, Chaparai does not have a motorable road. It takes a steep trek of 10 km downhill from the village to reach the nearest road from where residents can catch state transport buses three times a day. The nearest primary health centre is in Gurthedu, about 15 km away, but it can take at least three hours to reach there by foot.

Dr K Chandraih, the district medical and health officer, claimed a traditional medicine man had told the villagers not to reveal the deaths to anyone, or else they would die too.

But Chaparai’s residents said when the people began to fall ill, family members and neighbours barely had the time and resources to take them to a doctor.

“Taking the sick people downhill in a palaki [palanquin] is very tough,” said Pallamanga, Ramcharan’s mother, and Reddy’s sister-in-law. Their palaki is a piece of cloth tied hammock-like to a pole. They cannot call the free state ambulance service by dialling 108 because there is no mobile network in the village. The BSNL network can only be caught at the tourist destination of Maredumilli, 50 km away.

It takes a trek of 10 km on this path to reach Chaparai village.
It takes a trek of 10 km on this path to reach Chaparai village.

Pallamanga was sick herself, as was her 11-month old daughter and brother-in-law Panamma Laxmi, all with the same symptoms. “We are still very scared,” said Laxmi.

There has been no ASHA worker in Chaparai since 2014. The ANM who had been handing out basic medicines such as paracetamol and anti-diarrhoeal drugs was transferred out on May 30 this year. Another ANM, Balamma Revula, was given temporary charge of Chaparai from June 12. She takes care of 23 villages and could only visit Chaparai on June 23. So for nearly a month – the time during which they fell ill – Chaparai residents were left to fend for themselves.

Auxiliary nurse Balamma Revula has been given temporary charge of Chaparai.
Auxiliary nurse Balamma Revula has been given temporary charge of Chaparai.

Even on June 23, Revula did not inform the authorities about the deaths. “There is no phone network till about 60 km,” she said. “I did not have the time to go to Gurthedu.”

“Nobody [from the government] asked us anything about the deaths,” said Abhayi P, whose mother Seemanna died of the same symptoms on June 15, two days after taking ill. “They are asking us now.”

Flip flop

The first statements made by ministers and state officials, including AS Dinesh Kumar, attributed the deaths to food and water contamination, particularly to the Adivasis eating infected meat.

They pointed to the Gangalamma festival during which sacrificed animals are served at community lunch. Some state officials claimed the people died after eating at a wedding feast.

“We do not eat rotten meat,” countered Andhala Pandamma, a 60-year-old Chaparai resident when asked about this allegation.

Officials also attributed the illnesses to consumption of country liquor brewed by fermenting mango and jackfruit seeds and of dried meat hung inside houses to be cured by smoke generated while cooking. They even said they had found an animal carcass in one of the streams from which Chaparai’s residents drink water directly.

A villager shows the pipe from which they source water.
A villager shows the pipe from which they source water.

However, two weeks after the deaths were reported, Kumar admitted that there could not have been so many deaths due to food and water poisoning. “We think they died because of viral fever,” he told Scroll.in. “Luckily, there is no malaria in the village.”

Kumar speculated that viral fever coupled with dehydration caused the deaths. “The Adivasis also believe that only rice starch water should be fed to sick people once in the morning, apart from herbs,” he added. “They were not fed food or water.”

Understandably, health activists in the region are not satisfied with this explanation. “If people died of viral fever, is it not their responsibility to investigate what kind of fever it was?” said Dr PVV Satyanarayana, who runs a subsidised hospital for the Adivasis in Rampachodavaram. “If it is cholera, should they not find out?”

Muhrekar said: “The Rapid Blood Test that has been provided by the programme to detect cases at the community level is fairly sensitive. One cannot ignore a finding like that.”

VS Krishna, general secretary of the Human Rights Forum in Vishakhapatnam, led a fact-finding team to Chaparai that concluded that most deaths, if not all, were caused by malaria, since many residents had tested positive for malaria in the Rapid Blood Test.

The Human Rights Forum has accused the government of seeking to “obfuscate this reality [of deaths from malaria] by trying to pass off the Chaparai deaths as due to Adivasis having eaten rotten meat and contaminated water from a local hill stream...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.”

Villagers were given mosquito nets after the deaths.
Villagers were given mosquito nets after the deaths.

Kumar has ordered an enquiry into the deaths. A team led by Shriram Chandramurthy, a revenue divisional officer who is not a public health professional, visited Chaparai, accompanied by doctors from Rangaraya Medical College, Kakinada.

But this kind of enquiry is not appropriate for an outbreak of disease, said Murhekar. The National Institute of Epidemiology has prepared a checklist for public health officials. “In such cases, the district nodal authorities should have sent a rapid response team including an epidemiologist, physician, microbiologist, and entomologist to the site,” he said.

Murhekar also said that in such remote areas, the government should identify one resident who can inform the government in case of a disease outbreak. This could be a teacher, anganwadi worker, or anyone who can respond.

“If the information was provided earlier, at least some deaths could have been prevented,” he said.

This is the first part of a series on disease outbreaks in the Adivasi hamlets of Andhra Pradesh. The next story looks at whether malaria cases are being under-reported.

This reporting project has been made possible partly by funding from New Venture Fund for Communications.