Breaking the cycle of malaria and malnutrition in eastern India

The 30-year-old gingerly stepped onto the weighing scale. “Thirty-one kilograms,” the doctor said and asked her to sit down. Neither of them knew that she was pregnant.

All of four-feet and ten-inches, Jayati (name changed to protect her identity) is the mother of two. It took her four hours to walk from her home, atop one of the many forested hills of Odisha’s Raygada district, to reach the clinic in Kerpai village run by the non-governmental organization Swasthya Swaraj. Her story, like so many others in Odisha’s tribal villages, is also the story of malaria, malnutrition and mothers desperate to break the vicious cycle that is increasingly made worse by a changing climate.

In the past two years, Jayati has made this journey multiple times, for different ailments. In April 2016, she was diagnosed with clinical malaria and was found to be dangerously anemic. Two months later, she got malaria again. In December 2016, she was diagnosed with tuberculosis. In 2018, she gave birth and arrived at the clinic in June 2018 for postnatal care.

“My body aches and I also have a fever,” she told the doctor, who asked the nurse to run a few tests. A little while later, the nurse returned with Jayati, her face ashen. “She’s pregnant and wants an abortion. But she will have to ask her husband first,” the nurse said.

The doctor, who didn’t wish to be named, explained that it wasn’t the history of malaria or tuberculosis that worried him the most. But her weight. “She is severely malnourished,” the doctor said, adding that this wasn’t uncommon in the district. “It is almost the norm,” he said.

The malnutrition, malaria connection

For decades, the tribal districts of Odisha have been synonymous with famine and drought. But malnutrition is not the same as starvation. It is more insidious, impacting the function and recovery of almost every organ in the human body – from loss in muscle function to a weakening of the respiratory system to a direct impact on a person’s immunity. Malnutrition also impacts consequent generations. The weight of the child at birth depends on factors ranging from maternal nutrition to gestation at birth to the mother’s age. It is likely, the doctor at the Swasthya Swaraj clinic said, that Jayati’s parents were undernourished and there is a risk to her child.

“It is a cycle and one which is very hard to get out of. Because it is entirely based on inequality,” the doctor said. Additionally, Jayanti's village is in the heart of the red corridor – the area in India impacted by Left Wing extremism – and officials admitted that doctors were often too afraid to work in the area so for decades health care in the region was ignored.

In August, a special report on climate change and land by the United Nations Intergovernmental Panel on Climate Change (IPCC) in Geneva warned of desertification and degradation due to climate change and said that food security will be impacted. Recently, the Lancet Countdown Report 2019 on Health and Climate Change found that the average yield potential of maize and rice had declined almost 2 percent in India since the 1960s.

In India, malnutrition accounts for 68 percent of the deaths of under-five children and was responsible for 17.3 percent of the total disability-adjusted life years (DALYs) -- a measure of overall disease burden, according to a study published in September. Dr. Shobha Suri, senior fellow with the Observer Research Foundation and an expert in nutrition, stressed the need to break this intergenerational cycle of malnutrition, poverty and disease by improving maternal nutritional status and pregnancy outcomes.

“It is crucial to prioritize adolescent health in order to break the intergenerational cycle of malnutrition,” she said.

To be fair, Odisha has made significant strides in tackling its malnutrition problem. The infant and under-five mortality rates have decreased, while anemia in children and pregnant women has also been reduced. Several moves, such as decentralizing the procurement of supplementary nutrition under the Integrated Child Development Services Program have yielded benefits, while the state has also set an example for other states by converging its health, nutrition and WASH (water, sanitation and hygiene) programmes.

Larger problems still remain, with a stark difference between Odisha's urban districts and the tribal-dominated rural ones. Stunting ranges from 38.4 percent in Kandhamal district, to 15.3 percent in Cuttack, while almost half of the children from tribal communities are either underweight or stunted, as per data from the International Food Policy Research Institute (IFPRI). Moreover, nearly 23 percent of the state's tribal community lives in remote villages where government schemes hardly ever reach.

“It is essential to improve the implementation of schemes to reach out to the most vulnerable tribal population,” said Suri. Pramod Meherda, Odisha's health secretary, didn’t respond to repeated requests for comment.

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It is impossible to talk about malnutrition in Kerpai village and adjoining areas without talking about malaria.

“Malaria is also an indirect cause of maternal death. We have cases of low-birth babies because of this and there have been related problems,” said Mithun Karmakar of the National Health Mission at Bhubaneshwar.

But little is known about how the two interact and influence each other. The key question: To what extent can malaria lead to stunting (low height for age) and wasting (severe weight loss)? While there are some studies that have reported a link between malnutrition and a higher risk of malaria, others have disagreed. A 2018 review of the literature on malaria and malnutrition argued that “understanding the complex relationship of the immune response of individuals infected with malaria and suffering of malnutrition is crucial to guide specific antimalarial therapeutic approaches in this vulnerable sub-population.”

Suri pointed out that practitioners who work closely with communities where what is called "Malaria-Induced Malnutrition" is high have found that treatment for malaria has led to “dramatic improvement in the nutritional status growth pattern of the children.” She also pointed out that an expert consultation in Bhubaneswar titled “Current Advances in Malaria Management and Implications for Malnutrition” had concluded that there was a statistically significant correlation between malaria and malnutrition and that “the Mal-Mal linkage theory is right.”

Back in Kerpai, though, the lone doctor has little time to ponder such questions. The queue outside the small clinic had swelled up by noon with over 30 patients, mostly mothers with their young children, waiting. Most, like Jayati, had walked several hours to get there. Most have had malaria at least once in their lives, but until recently they had no inkling about the disease or its risks.

“If you had asked us some years ago, we wouldn’t have been able to tell you what malaria was, or that it was transmitted through the mosquito,” said Renuka Majhi.

The Rayagada district has larger challenges that find expression at the queue at the medical centre. Stunting of children less than five years old is at 43.5 percent, wasting at 23.1 percent while nearly half of the children are anemic (49.8 percent) and underweight (42.4 percent), as per data from POSHAN-IFPRI. Among women, anemia was rampant at 55.4 percent and the body-mass index of a third of the women (33.1 percent) implied that they were underweight to the point of malnutrition. The Swasthya Swaraj annual report for 2018-19 noted that among under-five children, the number of those underweight had dropped to 47 percent, but that stunting rates remained high “indicating chronic, intergenerational undernutrition” and that “neonatal mortality and infant mortality remain unabated.“

The choice between going to the clinic or losing a day's worth of food is also a difficult one. Most, like Jayati, had left early in the morning - a time usually reserved for finding food. Tribal communities depend on hunting, food gathering and shifting cultivation for sustenance, said Shibu, a 32-year-old in the village who has a small farm and does odd jobs as a construction worker. “We only come to the clinic if we are really sick.”

This, said Kaushik Sarkar of the global non-profit Malaria No More, was also when they were at risk of getting bitten by mosquitoes. “There is a lot of slash and burn farming, they don’t take the (long-lasting insecticide) nets with them. So they’re not protected. They become vulnerable," Sarkar said.

Add to this vulnerability the increasing number of extreme weather events. Earlier in August 2019, at least eight people died after floods in several of Odisha’s districts. While the state received an average rainfall of 66 millimeters on August 13, two blocks at Kalahandi and Bolangir district got 400 mm of rain in the same time period. Four other blocks received between 300-400 mm rainfall and Kalahandi’s Karlamunda received the highest rainfall in the state — 608 mm, as per a report in Down to Earth.

“Everything we had grown was destroyed in the rains,” Jayati told News18, adding that they also often spent nights outside to try and protect their crops.

Bridging the gap

Much of the government’s hopes for ensuring that their work to stop malaria succeeds, rests on the distribution of Long-Lasting Insecticide Nets (LLIN). These nets are impregnated with insecticide and are aimed at prevention. But villagers told News18 that most found the nets too impractical.

“We barely have space to sleep inside our homes…let alone hang a net,” said Malendra Majhi. He said that after decades of sleeping under the stars, many couldn’t bring themselves to sleep under a net. In lean months, he added, “There are some who have converted their nets into fishing nets. They are great for catching fishes.”

MM Pradhan of the state vector-borne disease control program (SVBDCP) said that the “messaging needed to be different.” 

“They are for personal protection. They protect not just from mosquitoes, but also other insects and scorpions and snakes. Doctors know the mosquito-malaria connection. But people? They still don’t understand.”

Suri argued that the nutrition and health sectors could simply not afford to work in silos.

“Within the framework of maternal and child nutrition, convergence will result in improved coverage -- a low lying fruit, given that the health system is able to reach out to a wide majority of the population currently through antenatal care coverage, institutional deliveries and immunization efforts to strengthen governance and accountability.”

She pointed out that this was done in Bangladesh in the past decade, “where antenatal care and management of sick, under-five children were identified by the National Nutrition Services as critical health service delivery contacts.”

Back at the clinic, though, conversations among patients weren’t about policy but the arduous task of getting back home.

As they leave, patients emphasize the degree to which remoteness is a factor. Almost tangible, it informs and shapes the way they live. On paper, there is an 86-kilometer-long road that connects Kerpai to Bhawanipatna, the nearest city. In reality, it fades and eventually disappears before reaching the village. A single bus makes the four-hour trip, once a week. Spasms of construction, along the way, suggest that things could improve in the future.

Reaching these "inaccessible" villages is a key factor not just in controlling malaria, but for the government's effort to improve nutrition.

But the villagers, like Jayati, aren’t very hopeful. They point out that years ago a building was built in the village that was to become a primary health care centre for the region. But no doctor ever came in those days of extremist violence.

“The world forgets we are here...but we are used to fighting,” Jayati said.

This is Part 3 of a four-part series examining how climate change is impacting the spread of deadly diseases in India. The complete interactive package first appeared on News 18 on 30 Dec. 2019. Each piece was produced with the support of Internews’ Earth Journalism Network. Production and graphic visualization was done by Fazil Khan.

• Chapter 1: How climate change has altered the rules of Odisha's battle against vector-borne diseases
• Chapter 2: How the fight against malaria reached a fever pitch in Odisha
• Chater 4: From Sri Lanka to India: What India can learn from the world about combating dengue, malaria

Banner image: Children are among those who are most at risk from vector-borne diseases, particularly malaria, say experts / Credit: Aniruddha Ghosal