Disease Control

India cannot eliminate malaria if a large state like Andhra Pradesh cannot count its cases correctly

The state health department does not count results from the Rapid Blood Tests for malaria, even though the national guidelines mandate it.

On July 12, the Union health minister announced a National Strategic Plan to eliminate malaria by 2027. But Scroll.in has found that Andhra Pradesh is systematically under-reporting the number of malaria cases by flouting two central government norms and exercising discretion available to states in some cases. This could undermine the government’s attempt to rid the country of the disease.

The Centre has set year-wise targets for the elimination of the disease in malaria-endemic areas. The targets are predicated on current levels of malaria incidence, which is calculated on the basis of malaria cases that are confirmed by state government records.

However, Andhra Pradesh has been suppressing the number of confirmed malaria cases through three measures.

For one, as the previous story in this series reported, the state health department continues to administer chloroquine to fever patients, which reduces the chance of the malaria parasite being detected in diagnostic tests. This is in violation of guidelines set by the National Vector Borne Disease Control Programme, the central agency responsible for controlling vector-borne diseases like malaria.

Two, as this story elaborates, the state does not count cases detected through Rapid Blood Tests as confirmed cases, despite the National Vector Borne Disease Control Programme approving the use of the test in malaria surveillance. The state solely counts cases confirmed through blood smears tested in laboratories.

Three, even when cases have been confirmed through laboratory tests, when a patient dies due to comorbidities – an additional diseases accompanying malaria – it is at times not counted as a malaria death.

This under-reporting at Andhra Pradesh’s government hospitals is only adding on to the country-wide trend of private hospitals being slack in notifying the state agencies of malaria cases and deaths, say officials.

The undercounting of malaria cases and deaths in the state has come back into focus after 16 people died in Chaparai village in East Godavari after suffering from fever, vomiting and diarrhoea. As a previous story in this series reported, health officials rushed there on June 24 and took 59 people to the hospital. Thirty two people who were tested with Rapid Blood Tests were found positive for falciparum malaria, but only one case was confirmed as positive in the laboratory. This was enough for the government to conclude that the village did not have a malaria outbreak, when other health experts said that 32 positive Rapid Blood Tests cannot be ignored.

Admitting to the underreporting of malaria cases in India, Dr Neena Valecha, director of the National Institute of Malaria Research, said: “A poor surveillance system will be a poor indicator of the disease burden.”

Health experts say faulty data raises questions over how any national plan will allocate resources and prioritise treatment and control of the disease.

Which test gets counted?

Two weeks ago, Bhoyi Devi got a high fever. Devi is 25 years old, six months pregnant and lives in Gannavaram village in Rampachodavaram Adivasi area in the East Godavari district of Andhra Pradesh. She was tested for malaria at the Rampachodavaram Area Hospital.

The first simple test for malaria is a Rapid Blood Test. A drop of a patient’s blood is put on the film of paper inside in the test cassette. The paper is coated with malaria antibodies that react with malaria antigens if they are present in the blood and the results are seen as a line in the cassette window. The test is easy to perform and does not need to be administered by a trained technician.

Devi tested positive for malaria on the Rapid Blood Test. Her doctors at the government hospital immediately started treating her for malaria infection caused by the protozoan parasite Plasmodium falciparum by giving her an artemisinin-based drug combination therapy. Devi responded to the treatment and got better.

Before they had started treating her, the doctors had sent her blood samples for smear test to confirm the malaria infection at a laboratory. Surprisingly, the smear test results came back negative for malaria.

A Rapid Blood Test kit. (Photo: Menaka Rao)
A Rapid Blood Test kit. (Photo: Menaka Rao)

The gold standard for testing malaria is looking at the smear of blood on the microscope and spotting the parasite. This test needs a good medical technician and such technicians are not always available in health centres in remote areas like the hill tracts of East Godavari district.

Keeping in mind the conditions in such areas, the National Vector Borne Control Disease changed its policy on diagnosing malaria in 2013 and allowed Rapid Blood Test results for malaria surveillance. This means that if a malaria infection shows up on a Rapid Blood Test, it must be counted and recorded.

States such as Chhattisgarh, Odisha, Madhya Pradesh, Maharashtra, Karnataka and West Bengal have a policy of recording both laboratory confirmed and Rapid Blood Test diagnosed cases.

“The states have to follow the policy we set,” said Dr Neeraj Dhingra, additional director, National Vector Borne Disease Control Programme. “They get the funds from us.”

But Andhra Pradesh does not follow this protocol. While malaria cases detected through Rapid Blood Tests are treated, they are not recorded unless they are confirmed as positive in a laboratory.

“We do not record a malaria case unless it is smear positive,” said Dr Geetha Prasadini, additional director with the state’s directorate of health. “If someone tests positive on the Rapid Blood Test kit, we immediately test the smear too in the laboratory.”

Health officials in Andhra Pradesh pointed out that the Rapid Blood Test throws up positive results even if a person has been cured of malaria three months before the test was done. But Dr Neena Valecha, director of the National Institute of Malaria Research, called the test a “sturdy” diagnostic tool that is routinely reviewed by the government has a high accuracy rate.

While health officials rely only on positive smear test results for malaria, doctors working in the tribal areas of Andhra Pradesh said that they cannot wait for smear test results before they treat patients. They also do not rely entirely on smear tests to treat the patient for malaria. In the Rampachodavaram agency area where falciparum malaria is endemic, doctors simply look for tell-tale clinical symptoms of malaria.

Dr N Ramaru, a pediatrician working at the Rampachodavaram Area Hospital, said that doctors can distinguish between a viral fever and a malaria fever. Viral fever is consistent while malaria fever is intermittent. Malaria is also accompanied by chills and shivering.

“We have to give artesunate (drug to treat for falciparum malaria) to such patients even if it is slide negative,” said Ramaru. “This is an endemic area and malaria is common at this time of the year.”

Whose death counts?

Sivakumar B, a 17-year-old resident of Malasingram in Araku Valley in Visakhapatnam district of Andhra Pradesh, died on July 6. The boy had had fever for more than a week and his family took him to the largest hospital in the valley – the government-run Araku Area Hospital which is about 15 km away from his home.

The boy’s father Mukundan B said that the doctors told him that Sivakumar was suffering from malaria, typhoid and jaundice, but did not give him anything in writing.

The family of 17-year-old Sivakumar B who died with symptoms of malaria, typhoid and jaundice. (Photo: Menaka Rao)
The family of 17-year-old Sivakumar B who died with symptoms of malaria, typhoid and jaundice. (Photo: Menaka Rao)

“The doctor kept shouting at us,” he said. “But we did not understand. The second injection made his body swell up. We did not feel safe there.”

The family brought the boy home in three days, though he was still sick. Two days later, he died. There has been no investigation into whether Sivakumar died of malaria.

Many deaths, like Sivakumar’s, that occur at home are not investigated for causes or recorded. Some of this is due to an unwritten rule that doctors in the government hospitals in the Adivasi areas of Visakhapatnam and East Godavari district y they have: Do not let a patient die in the hospital.

“If the malaria gets complicated, we send the patient to the Vishakhapatnam or Kakinada (district headquarters of East Godavari) immediately,” said a government doctor from Rampachodavaram Agency in East Godavari district. “Nobody knows what happens to the patient on the way.”

The Visakhapatnam malaria officer claimed that no one has died of malaria in the district this year. The Andhra Pradesh health department too has not recorded any malaria deaths this year.

Two people tested positive for malaria and later died at the King George’s Medical University, Visakhapatnam June and July. In both cases, there were symptoms such as kidney injuries and pulmonary oedema (both known complications of malaria), sources in the hospital said. But these cases were not recorded as malaria deaths.

People who test positive for malaria died due to comorbidities or other complications, said Dr Kalyana Prasad, Visakhapatnam district epidemiologist.

As in the above case, deaths are sometimes attributed to comorbidities accompanying malaria instead of to malaria itself.

Moreover, even though malaria is a notifiable disease, which means that all hospitals must report malaria cases to the government, private hospitals hardly report malaria infections, the officials from the national programme said.

Righting wrong data

Undercounting malaria is India is not new. During the 1990s, the former head of the National Institute of Malaria Research, the late Dr VP Sharma, analysed trends in consumption of the malaria drug chloroquine and estimated that malaria was underreported somewhere between 10 and 15 times.

A 2010 study took into account verbal autopsies of 122,291 deaths in India and showed that the real malaria estimate could be as high as 2,05,000 deaths every year. The World Health Organisation’s estimated that there were only 15,000 deaths in 2006.

Dhingra of the National Vector Borne Disease Control Programme insists that, despite continued data discrepancies, the malaria control programme is on track.

“You will see that the number of cases reported will increase,” said Dhingra. “This is a normal phenomenon when you are moving towards elimination of the disease.”

This is the third part of a series on disease outbreaks in the Adivasi hamlets of Andhra Pradesh. Read the first part here and the second part here.

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

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Swara Bhasker: Sharp objects has to be on the radar of every woman who is tired of being “nice”

The actress weighs in on what she loves about the show.

This article has been written by award-winning actor Swara Bhasker.

All women growing up in India, South Asia, or anywhere in the world frankly; will remember in some form or the other that gentle girlhood admonishing, “Nice girls don’t do that.” I kept recalling that gently reasoned reproach as I watched Sharp Objects (you can catch it on Hotstar Premium). Adapted from the author of Gone Girl, Gillian Flynn’s debut novel Sharp Objects has been directed by Jean-Marc Vallée, who has my heart since he gave us Big Little Lies. It stars the multiple-Oscar nominee Amy Adams, who delivers a searing performance as Camille Preaker; and Patricia Clarkson, who is magnetic as the dominating and dark Adora Crellin. As an actress myself, it felt great to watch a show driven by its female performers.

The series is woven around a troubled, alcohol-dependent, self-harming, female journalist Camille (single and in her thirties incidentally) who returns to the small town of her birth and childhood, Wind Gap, Missouri, to report on two similarly gruesome murders of teenage girls. While the series is a murder mystery, it equally delves into the psychology, not just of the principal characters, but also of the town, and thus a culture as a whole.

There is a lot that impresses in Sharp Objects — the manner in which the storytelling gently unwraps a plot that is dark, disturbing and shocking, the stellar and crafty control that Jean-Marc Vallée exercises on his narrative, the cinematography that is fluid and still manages to suggest that something sinister lurks within Wind Gap, the editing which keeps this narrative languid yet sharp and consistently evokes a haunting sensation.

Sharp Objects is also liberating (apart from its positive performance on Bechdel parameters) as content — for female actors and for audiences in giving us female centric and female driven shows that do not bear the burden of providing either role-models or even uplifting messages. 

Instead, it presents a world where women are dangerous and dysfunctional but very real — a world where women are neither pure victims, nor pure aggressors. A world where they occupy the grey areas, complex and contradictory as agents in a power play, in which they control some reigns too.

But to me personally, and perhaps to many young women viewers across the world, what makes Sharp Objects particularly impactful, perhaps almost poignant, is the manner in which it unravels the whole idea, the culture, the entire psychology of that childhood admonishment “Nice girls don’t do that.” Sharp Objects explores the sinister and dark possibilities of what the corollary of that thinking could be.

“Nice girls don’t do that.”

“Who does?”

“Bad girls.”

“So I’m a bad girl.”

“You shouldn’t be a bad girl.”

“Why not?”

“Bad girls get in trouble.”

“What trouble? What happens to bad girls?”

“Bad things.”

“What bad things?”

“Very bad things.”

“How bad?”

“Terrible!!!”

“Like what?”

“Like….”

A point the show makes early on is that both the victims of the introductory brutal murders were not your typically nice girly-girls. Camille, the traumatised protagonist carrying a burden from her past was herself not a nice girl. Amma, her deceptive half-sister manipulates the nice girl act to defy her controlling mother. But perhaps the most incisive critique on the whole ‘Be a nice girl’ culture, in fact the whole ‘nice’ culture — nice folks, nice manners, nice homes, nice towns — comes in the form of Adora’s character and the manner in which beneath the whole veneer of nice, a whole town is complicit in damning secrets and not-so-nice acts. At one point early on in the show, Adora tells her firstborn Camille, with whom she has a strained relationship (to put it mildly), “I just want things to be nice with us but maybe I don’t know how..” Interestingly it is this very notion of ‘nice’ that becomes the most oppressive and deceptive experience of young Camille, and later Amma’s growing years.

This ‘Culture of Nice’ is in fact the pervasive ‘Culture of Silence’ that women all over the world, particularly in India, are all too familiar with. 

It takes different forms, but always towards the same goal — to silence the not-so-nice details of what the experiences; sometimes intimate experiences of women might be. This Culture of Silence is propagated from the child’s earliest experience of being parented by society in general. Amongst the values that girls receive in our early years — apart from those of being obedient, dutiful, respectful, homely — we also receive the twin headed Chimera in the form of shame and guilt.

“Have some shame!”

“Oh for shame!”

“Shameless!”

“Shameful!”

“Ashamed.”

“Do not bring shame upon…”

Different phrases in different languages, but always with the same implication. Shameful things happen to girls who are not nice and that brings ‘shame’ on the family or everyone associated with the girl. And nice folks do not talk about these things. Nice folks go on as if nothing has happened.

It is this culture of silence that women across the world today, are calling out in many different ways. Whether it is the #MeToo movement or a show like Sharp Objects; or on a lighter and happier note, even a film like Veere Di Wedding punctures this culture of silence, quite simply by refusing to be silenced and saying the not-nice things, or depicting the so called ‘unspeakable’ things that could happen to girls. By talking about the unspeakable, you rob it of the power to shame you; you disallow the ‘Culture of Nice’ to erase your experience. You stand up for yourself and you build your own identity.

And this to me is the most liberating aspect of being an actor, and even just a girl at a time when shows like Sharp Objects and Big Little Lies (another great show on Hotstar Premium), and films like Veere Di Wedding and Anaarkali Of Aarah are being made.

The next time I hear someone say, “Nice girls don’t do that!”, I know what I’m going to say — I don’t give a shit about nice. I’m just a girl! And that’s okay!

Swara is a an award winning actor of the Hindi film industry. Her last few films, including Veere Di Wedding, Anaarkali of Aaraah and Nil Battey Sannata have earned her both critical and commercial success. Swara is an occasional writer of articles and opinion pieces. The occasions are frequent :).

Watch the trailer of Sharp Objects here:

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This article was published by the Scroll marketing team with Swara Bhasker on behalf of Hotstar Premium and not by the Scroll editorial team.