infectious disease

Adivasis in Andhra Pradesh repeatedly fall ill with anthrax infections due to government apathy

Regular animal immunisations can prevent the annual outbreak of anthrax in the state.

One night in June, 48-year-old Janni Gundu cried out in pain caused by the large lesions that had come to cover his hands over the past day or two. Despite this, the farmer from Kodupunjuvalasa village in the Araku valley in Andhra Pradesh’s Visakhapatnam district did not want to see a doctor. It was sowing season and he had a lot of work.

Ignoring his protests, his daughter Padma took him to the Araku Area Hospital about 25 kms away. The doctors suspected that Gundu had anthrax and told him to go to the King George Hospital in Visakhapatnam city. Instead, Gundu went to the community health centre at the neighbouring district Vizianagaram and got some antibiotics.

But his daughter Padma, an IAS aspirant and an engineer, began to look for details about anthrax online using her smartphone.

Anthrax is an infection caused by the bacterium Bacillus anthracis that normally infects animals. It is a major cause of fatalities in cattle, sheep, goats, camels, horses and pigs around the world. Humans get this disease from infected animals, either by handling the animal or when exposed to contaminated animal products. Anthrax is not known to spread from person to person.

When four other people in Kodupunjuvalasa were also found to have the same infection, Padma asked a local politician to contact the Integrated Tribal Development Agency headquarters in Paderu to come to the village and help them.

On June 24, the agency sent an ambulance to take the five anthrax-infected patients to the Visakhapatnam Hospital. Two days later, three more patients – one from the neighbouring village Padmapuram – were also taken to the hospital.

Andhra Pradesh has an outbreak of anthrax almost every year, mostly often in Adivasi areas. Anthrax spores remain in soil for long periods of time in areas where the disease is endemic. Cattle that consume grass, water or soil containing the spores become infected. The only way to prevent the spread of the disease is to vaccinate the domesticated animals that come in contact with people.

But officials at the state’s Integrated Tribal Development Agency admitted that they rarely undertake vaccination of animals in all Adivasi areas. Dr Gurunadar Rao, additional district medical and health officer, said that the government conducts anthrax vaccinations once a year in the areas with suspected human anthrax cases.

For instance, the animal husbandry department vaccinated animals in Kodupunjuvalasa and four other villages within a 10-km radius only after Gundu and his neighbours went to hospital with anthrax infections.

“They think that because we are tribals, we need not be treated well,” said Padma.

Janni Gundu, one of eight people in Kodupunjuvalasa village in Visakhapatnam district who got skin anthrax infections this year. (Photo: Menaka Rao)
Janni Gundu, one of eight people in Kodupunjuvalasa village in Visakhapatnam district who got skin anthrax infections this year. (Photo: Menaka Rao)

Misleading claims

The district administration said that the villagers developed skin infections after they ate the meat of a goat infected with anthrax. But the villagers claimed that not everyone who was infected had eaten the goat meat. Besides, all eight suspected anthrax cases were skin infections.

There are three forms of anthrax infections – cutaneous anthrax that causes infection in the skin, ingestion anthrax that is caused by eating contaminated food, and inhalation anthrax that occurs when spores of the bacteria are inhaled. All three forms of the disease are dangerous to different degrees.

According to the World Health Organisation, cutaneous anthrax accounts for more than 95% of the cases worldwide. If left untreated, cutaneous anthrax is fatal in about 20% of cases. Gastrointestinal or ingestion anthrax kills about of those infected who do not get treatment. However, with proper treatment, 60% of patients survive. Inhalation anthrax is the most deadly form of the disease, and only about 10%-15% of patients survive without treatment, while about 55% survive with treatment.

Gundu and his fellow villagers had cutaneous anthrax.

Dr B Balachandrudu, the head of dermatology at the King George Hospital, has seen and treated anthrax infections over many years. Spores present in animal meat die if the meat is cooked in high temperatures, he pointed out.

“Gastrointestinal presentation of the disease is rare in India,” he said.

Little anthrax awareness

Balachandrudu sent the samples of the eight patients to the Defence Research and Development Establishment laboratory in Gwalior, Madhya Pradesh. Seven were confirmed as positive for anthrax, while one patient’s test was inconclusive. All the eight patients were given antibiotics – treatment to which they responded well – and were sent home in a fortnight.

“Every year we get some case or other,” said Balachandrudu. “This disease has been here for hundreds of years and has been treatable with antibiotics for more than 60 years.” He said that the disease can be managed at the primary health centre level and need not be brought to the medical college every year.

Balachandrudu has seen how common and easily treatable cutaneous anthrax is. But for most people, the word “anthrax” conjures up the spectacle of fatal infections linked to bio-terrorism. After the attack and collapse of the World Trade Centre towers in New York in 2001, powdered anthrax spores were deliberately put into letters and mailed through the United States postal system. Twenty two people contracted anthrax by opening these envellopes and five people died.

The more common and less dangerous forms of anthrax around us have got little attention compared to the post-9/11 cases. A number of people in Andhra Pradesh have died of anthrax in the last decade. Some research papers point to the underreporting of anthrax cases.

“Fatality takes place only if there is an accumulation of toxins in the blood,” said Professor Rakesh Bhatnagar of the School of Biotechnology at Jawaharlal Nehru University who has been working on anthrax for more than two decades.

Balachandrudu said that anthrax can be be fatal if there is a co-infection of cholera or malaria. “But there are not many studies done on the subject,” he said.

No preventive measures

While Andhra Pradesh’s health and tribal welfare authorities do not conduct preventive vaccination of animals in adivasi areas, residents of these villages have only intermittent access to any kind of healthcare that could help catch early stages of infection.

Padma complained that Kodupunjuvalasa village has no primary health centre. The village has an Accredited Social Health Activist or ASHA, but the Auxiliary Nurse and Midwife or ANM manages to come to the village only once a month. The ANM did not visit the village in June when the anthrax infections occurred.

After the incident, many officials including the State Health Minister Kamineni Srinivas visited the village.

“We complained about the lack of drinking water,” said Padma. “He told us: ‘Do not tell me about problems. I have only come to see the patients.’”

We welcome your comments at
Sponsored Content BY 

Removing the layers of complexity that weigh down mental health in rural India

Patients in rural areas of the country face several obstacles to get to treatment.

Two individuals, with sombre faces, are immersed in conversation in a sunlit classroom. This image is the theme across WHO’s 2017 campaign ‘Depression: let’s talk’ that aims to encourage people suffering from depression or anxiety to seek help and get assistance. The fact that depression is the theme of World Health Day 2017 indicates the growing global awareness of mental health. This intensification of the discourse on mental health unfortunately coincides with the global rise in mental illness. According to the latest estimates from WHO, more than 300 million people across the globe are suffering from depression, an increase of 18% between 2005 and 2015.

In India, the National Mental Health Survey of India, 2015-16, conducted by the National Institute of Mental Health and Neurosciences (NIMHANS) revealed the prevalence of mental disorders in 13.7% of the surveyed population. The survey also highlighted that common mental disorders including depression, anxiety disorders and substance use disorders affect nearly 10% of the population, with 1 in 20 people in India suffering from depression. Perhaps the most crucial finding from this survey is the disclosure of a huge treatment gap that remains very high in our country and even worse in rural areas.

According to the National Mental Health Programme, basic psychiatric care is mandated to be provided in every primary health centre – the state run rural healthcare clinics that are the most basic units of India’s public health system. The government provides basic training for all primary health centre doctors, and pays for psychiatric medication to be stocked and available to patients. Despite this mandate, the implementation of mental health services in rural parts of the country continues to be riddled with difficulties:

Attitudinal barriers

In some rural parts of the country, a heavy social stigma exists against mental illness – this has been documented in many studies including the NIMHANS study mentioned earlier. Mental illness is considered to be the “possession of an evil spirit in an individual”. To rid the individual of this evil spirit, patients or family members rely on traditional healers or religious practitioners. Lack of awareness on mental disorders has led to further strengthening of this stigma. Most families refuse to acknowledge the presence of a mental disorder to save themselves from the discrimination in the community.

Lack of healthcare services

The average national deficit of trained psychiatrists in India is estimated to be 77% (0.2 psychiatrists per 1,00,000 population) – this shows the scale of the problem across rural and urban India. The absence of mental healthcare infrastructure compounds the public health problem as many individuals living with mental disorders remain untreated.

Economic burden

The scarcity of healthcare services also means that poor families have to travel great distances to get good mental healthcare. They are often unable to afford the cost of transportation to medical centres that provide treatment.

After focussed efforts towards awareness building on mental health in India, The Live Love Laugh Foundation (TLLLF), founded by Deepika Padukone, is steering its cause towards understanding mental health of rural India. TLLLF has joined forces with The Association of People with Disability (APD), a non-governmental organisation working in the field of disability for the last 57 years to work towards ensuring quality treatment for the rural population living with mental disorders.

APD’s intervention strategy starts with surveys to identify individuals suffering from mental illnesses. The identified individuals and families are then directed to the local Primary Healthcare Centres. In the background, APD capacity building programs work simultaneously to create awareness about mental illnesses amongst community workers (ASHA workers, Village Rehabilitation Workers and General Physicians) in the area. The whole complex process involves creating the social acceptance of mental health conditions and motivating them to approach healthcare specialists.

Participants of the program.
Participants of the program.

When mental health patients are finally free of social barriers and seeking help, APD also mobilises its network to make treatments accessible and affordable. The organisation coordinates psychiatrists’ visits to camps and local healthcare centres and ensures that the necessary medicines are well stocked and free medicines are available to the patients.

We spent a lot of money for treatment and travel. We visited Shivamogha Manasa and Dharwad Hospital for getting treatment. We were not able to continue the treatment for long as we are poor. We suffered economic burden because of the long- distance travel required for the treatment. Now we are getting quality psychiatric service near our village. We are getting free medication in taluk and Primary Healthcare Centres resulting in less economic stress.

— A parent's experience at an APD treatment camp.

In the two years TLLLF has partnered with APD, 892 and individuals with mental health concerns have been treated in the districts of Kolar, Davangere, Chikkaballapur and Bijapur in Karnataka. Over 4620 students participated in awareness building sessions. TLLLF and APD have also secured the participation of 810 community health workers including ASHA workers in the mental health awareness projects - a crucial victory as these workers play an important role in spreading awareness about health. Post treatment, 155 patients have resumed their previous occupations.

To mark World Mental Health Day, 2017, a team from TLLLF lead by Deepika Padukone visited program participants in the Davengere district.

Sessions on World Mental Health Day, 2017.
Sessions on World Mental Health Day, 2017.

In the face of a mental health crisis, it is essential to overcome the treatment gap present across the country, rural and urban. While awareness campaigns attempt to destigmatise mental disorders, policymakers need to make treatment accessible and cost effective. Until then, organisations like TLLLF and APD are doing what they can to create an environment that acknowledges and supports people who live with mental disorders. To know more, see here.

This article was produced by the Scroll marketing team on behalf of The Live Love Laugh Foundation and not by the Scroll editorial team.