After Parvati Nimwal completed grade ten she was married off and moved to her husband’s village. Kandala is in Madhya Pradesh’s Alirajpur district, and has the lowest literacy rate in the country.
For the village leaders, her arrival left no room for argument. She was the most qualified to be their doctor, and help them tackle the scourge of malaria. Parvati was made an Accredited Social Health Activist (ASHA), given a few week’s training and the equipment and mandate to diagnose and treat malaria, and other general ailments. She is one of one of 900,000 such woman workers – India’s barefoot doctors who work in places the public health system cannot access (and everywhere else too).
She doesn’t know the name of the medicines she prescribes for malaria – at least, not on questioning, she laughs. She’ll have to check the textbook that the Ministry of Health and Family Planning gave her. While doubts have been cast over the efficacy of ASHA workers, there’s no denying that they’d made their impact: the death toll from malaria has been in steady decline. In 2005, it was 963. For 2016, it’s 242. The plan is for nationwide wide eradication by 2030.
Dr. A.C. Dhariwal is director of the National Vector Borne Disease Control Programme (NVBDCP) – India’s nodal agency for coordinating the war on Malaria. After 13 years of implementing community healthcare across India, he says:
ASHA are the ones who have transformed our Malaria programme.
“It’s volunteer work,” he adds. “Renumeration is performance based. If they examine a fever case for malaria, then they would get 15 rupees. If a malaria positive case comes, and she gives complete treatment, then she would get 75 rupees.”
As malaria cases decline, ASHA workers have been given other responsibilities – like facilitating safe childbirth, and promoting condom use.
Malaria’s socioeconomic costs
Cumulatively, malaria has cost India 1.9 million disability-adjusted life years – years lost due to being ill from the disease. The financial incentive to fight malaria is huge – a 2007 study estimated that for every rupee spent on the National Malaria Control Program, a dividend of 19.7 could be expected back. The economic cost was estimated at $1.94 billion.
Malaria is one of the top four causes of poverty worldwide, as the disease of the poor – and part of its lethality is its ability to strike at regions that are isolated from health services and hygiene. This link was stated as far as as 1909, in Rickard Christopher’s study of malaria among the tea planters in West Bengal: “One of the chief causes leading to increased intensity of malaria in the Duars is the fact that at the commencement of their life in the district all new coolies [tea workers] are placed under the disadvantages imposed by the present labour system.”
This divide is greatest in India – 90 percent of malaria deaths happen in rural India. The regions it strikes hardest each year are Orissa, Meghalaya and West Bengal. A 2015 study found that regions with tribal populations were more likely to suffer fatalities from malaria – contributing nearly half of all malarial deaths in the country.
Initiatives that successfully tackle malaria can have benefits in other areas as well.
Maureen Momin is the district community process coordinator for Meghalaya’s West Garo hills district – the state’s deadliest region for malaria. It’s her job to recruit and report on ASHA volunteers in the area – and she has to pick which one is doing the best job.
Sleni B. Marak is an ASHA from the Soragre village – 34 kilometres from the nearest town of Tura. The Garo tribe form the local community, brewing wines and growing brooms. Before ASHA started here in 2006, Soragre’s pregnant women were unregistered, and outside any form of pre-natal care. Sleni alone managed to end the practice of home deliveries in the village, and convinced up to 48 children to attend immunization programmes – even though the programmes were held nearly 50 kilometres away.
Her ‘Param Vir Chakra’ moment happened on a rainy day – when the region was flooded – and a Pinky Sagma fell unconscious while pregnant with a second child. Sleni carried her in a stretcher across the flooded Ganol river to the Mission hospital at Tura, 14 kilometres away.
Regions like West Garo have a high prevalence of the lethal ‘P. Falciparum’ strain of malaria which can kill patients who don’t get treatment 24 hours from the time symptoms start to appear. In villages where the nearest hospital can take that much time to reach, community health providers make the difference between life and death.
Time to retrospect on malaria?
While India’s performance might seem admirable compared to where she started off – around one million cases in 2016 today versus 75 million in the period following 1947 – the numbers may not be telling the whole figure. A Lancet study found up to 20 times more deaths due to malaria than the NVBDCP’s estimates.
Inspiration for malaria eradication comes from India’s very own neighbourhood, and a country that has similar ecology, climate as well as a landscape ravaged by civil war– Sri Lanka, who eradicated the disease in 2016. They weren’t the first in the region to do so – Maldives beat them to that.
Tackling malaria means state programs cannot afford complacency. Strains that are immune to one of the most common treatments have already emerged, and threaten regions like the North-East. “There is historical evidence that achievement against malaria is often fragile and any kind of complacence may lead to resurgence at any time,” writes Dr. Dhariwal.
Turning to history reveals India as a key battleground for the disease since ancient times – a similar disease is mentioned in ancient texts from thousands of years ago, and it was in Bengal that the link between mosquitoes and malaria was discovered (a find that won its scientist, Ronald Ross, the Nobel Prize in Medicine in 1902).
The day the war against malaria is won will be a victory – not just of medicine, but of institutions, community and mankind.
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