Stemming the spread

Technology and hygiene are powerful weapons in the community armoury when combating malaria, encephalitis and their like

C ovid-19 is a recent killer but in India’s backward regions, communicable diseases such as encephalitis, malaria and typhus have held deadly sway for years. Last summer more than 160 children died of acute encephalitis syndrome (AES) in Bihar’s Muzaffarpur district. The tragedy showed up India’s weak rural healthcare system, and the need for bolstering it.

The battle against communicable diseases occupies sizeable space in the Tata Trusts’ spread of programmes in healthcare. This includes plugging gaps in village-level healthcare systems, building the capabilities of local health workers, providing medical resources in rural regions and educating communities about sanitation and hygiene.

Gorakhpur district in Uttar Pradesh, which was the centre of an AES blight, and South Odisha, a region that was once home to 40% of India’s malaria cases, are two places the Trusts have devoted special attention to.

The Gorakhpur initiative started in 2018, about a year after the district’s count on AES accounted for two-thirds of Uttar Pradesh’s tally of 4,000 cases and 600 deaths. Project Prayaas, operational in two sub-districts of Gorakhpur, was aimed at tackling the menace of a neurological disorder that affects the brain and nervous system and poses a greater risk to young children.

AES is caused by a cluster of diseases such as Japanese encephalitis, dengue and typhus, and is transmitted through viruses, mosquitoes, rats and unclean water. Prevention is the panacea here and this can be done best through community awareness sessions, improved hygiene and sanitation, and a nimble medical response system. These are aspects that Prayaas concentrates on.

Red is for stop

The backbone of the programme are Ashas (or accredited social health activists), community workers who are at the frontlines of the Indian government’s National Rural Health Mission. Prayaas trains Ashas to identify AES cases through a simple diagnostic method called the ‘traffic light protocol’.

The protocol helps them recognise ‘red’ or serious AES symptoms (fever, delirium and mental confusion) early so that the affected get treatment in time. The Ashas of Gorakhpur have tracked more than 12,900 AES cases and have been instrumental in getting some 26,650 children vaccinated.

About 74% of the children covered under the project are now immunised against Japanese encephalitis and mosquito nets treated with insecticides help keep sleepers safe. Just as important in the project is the decentralisation of care for victims. “Since the Ashas track patients with fever, cases are reported early and this is a big help,” says Avinash Choudhary, the chief medical superintendent at the Uska Bazaar community health centre.

Prayaas has three mobile medical units (MMUs) to extend the healthcare safety net to villages. With a doctor, a nurse, a pharmacist, a lab technician and equipment to conduct 50 tests, the units speed up the identification of cases and treatment in remote areas. Each doctor at an MMU sees around 2,000 patients every month.

Prayaas also works to deal with dengue and typhus as these diseases often escalate into AES. Dengue is countered through a community campaign for cleanliness, pushing villagers into the habit of checking for standing water or garbage, which are breeding sites for mosquitoes. Last year, this campaign reached out to 12,000 homes in 50 villages.

The Prayaas team works closely with panchayats (village councils) to improve water drainage and spray larvicides to reduce mosquito breeding. The intensive efforts on different fronts have brought down Gorakhpur’s AES death toll drastically.

As with AES in Gorakhpur, so with malaria in South Odisha, with its rough terrain and a tribal population that is particularly susceptible to health disorders. In 2016, the Trusts partnered the Odisha government to minimise malaria deaths in three districts of South Odisha: Kandhamal, Rayagada and Kalahandi. The goal was to bring deaths from the disease to zero and reduce positive cases by 40%.

Drop zone

The implementation partner for the Trusts here is the Livolink Foundation and a robust community outreach effort is the chosen way. The zero deaths target was reached three years ago and new cases have dropped by 87% since 2017. The success in Odisha was a factor in India becoming one of only two countries to reduce malaria cases in the 2017-18 period.

The strategy in south Odisha focused on regular screening of residents in 310 malaria-endemic villages. Support is delivered by a unique team of people — village health volunteers — and technology has been brought into play.

Livolink has screened nearly 125,000 people, tested about 40,000 and treated in excess of 10,000. “Earlier, villagers would spend a lot of money to get malaria treatment, mostly from quacks,” says Bharat Hikabadi, who heads the Raskola panchayat. “Now people get free treatment at their doorstep and blood tests are done twice a year.”

Public awareness

The fight against malaria is now being intensified by screening migrant workers and testing family members of patients to stop potential transmissions. Public awareness campaigns are the cornerstone of the programme. Audio spots on All India Radio, a short film on local TV channels and awareness sessions in 350-plus schools have helped spread the message.

More than 8,500 community meetings have been organised under the project, about 1,600 mosquito breeding sites have been destroyed and some 23,000 mosquito nets have been distributed.

Science plays an effective role in the programme. The Trusts have funded genetic studies of local tribal communities to understand their vulnerability and rapid-detection tests have been developed. The Trusts have shown that technology, hygiene and community awareness are a winning combination against communicable disease.

A village health volunteer does a malaria test in south Odisha

Village volunteers to the fore

S outh Odisha is home to tribal communities living in hilly terrain, with hamlets that can be reached only after hours of walking through forests inhabited by snakes and wild animals. Health awareness is poor and disease rates are high here and that has complicated the challenge for the Tata Trusts and its implementation partner, the Livolink Foundation.

The solution to reaching remote tribal communities and educating them has come in the form of village health volunteers (VHVs), a cadre of locals aged between 20 and 35. Trained through the Indian government’s National Vector Borne Disease Control Programme, there are 263 VHVs and they are at the frontlines of the initiative, first responders in villages where there are no regular health workers.

VHVs keep medicines handy, organise early testing and treatment, and do follow-up visits.

“We have a trained volunteer named Salman Mallick in our village,” says Bhima Budu Majhi, a resident of Budabiormaha village in Kotagarh sub-district. “We go to him for free diagnoses and treatment, and he conducts community meetings to build awareness among us. We no longer have malaria in our village and we are really happy about that.”

In 2019, the Trusts put technology tools in the hands of the volunteers. They have been trained to use a tablet-based app to enter data that helps Livolink monitor the quality of malaria interventions in remote areas. The tab-based system has been rolled out in 223 villages, all of them healthier than before and far better connected to the world beyond.