Report of Fact-finding Visit on “Infant Deaths due to outbreak of Japanese Encephalitis / Acute Encephalitis Syndrome” in Malkangiri district, Odisha
The child causalities due to outbreak of Japanese Encephalitis in Malkangiri district were reported in 2011 and 2012. An estimated death of 36 children was reported by District administration in 14 villages of the district within the period of September to 5th December 2012, but the actual scale of causalities was more than that. During that time, being shocked over the news, a 3-member team of Right to Food Campaign, Odisha had visited Malkangiri district from 18th to 20thDec.12 on a fact-finding mission to find out the reasons behind causalities, steps taken by the District administration to check child mortality and as to effectiveness in implementation of food security programmes like MDM and ICDS, two flagship programmes which aim to provide nutritious food to the children and thereby check IMR and MMR in the country. The Fact-finding Report along with host of recommendations highlighting disastrous food insecurity issues, failure of ICDS and MDM programme, chronic hunger among the children and subsequent loss of immunity capacity of the children was presented to Govt. to take steps for increasing nutritional standard of the children through effective implementation of ICDS programme and close monitoring of health and nutritional standard of the children by ICDS and health staff.
After gap of three years, the break out of same disease Japanese Encephalitis ( JE) has caused 60 child deaths in different parts of the districts officially during September and October 16 and many more unofficially. The child causalities highlighted by mass media exposed callous and insensitivity of the district administration and ineffectiveness and break down of health system of the district to deal this dreaded disease. After public reaction and outrage and protest by opposition political parties, the State Govt. took a lot of steps to check health hazard. It was thought of by Right to Food Campaign, Odisha to send another Fact-finding Team to Malkangiri to find out the basic reasons of child causalities, whether any preparedness and preventive measures taken prior to outbreak of JE, nutritional standard of the children, status of implementation of various programme, intervention of the Govt. etc. Accordingly, a four-member Fact-finding Team had visited different parts of the district from 18th to 20thOctober 2016.
- Members of Fact-finding Team
- Pradip Pradhan
State Convener, Right to Food Campaign, Odisha
Member, Advisory Group of NHRC on Right to Food, M-9937843482
- Sri Ashok Patnaik
Advocate and RTI Activist, Malkangiri, M- 9437435399
- Sri Bikash Dandsena
Social Activist, Malkangiri, M-9437970303
- Sri Era Padiami
Tribal Activist, Malkangiri, M- 9437316380
- Objectives of the Visit
- To find out the reasons of huge child deaths- whether it is due to outbreak of Japanese Encephalitis ( JE) or degraded and ineffective health service available in Govt. hospitals or any other reasons.
- To study and document the socio-economic condition of the family of child deaths reported by Govt. and condition of the children before their admission and death in hospitals collecting information from Anganwadi Centres and the people at large.
- To study the capacity and effectiveness of District Hospitals, CHCs to deal such dreaded disease on the pretext that preparedness measures, if any taken on the basis of learning from JE- related infant death hazards of 2012.
- To understand the effectiveness of ICDS programme to check malnutrition among children in Malkangiri.
- To make recommendations to State Govt., Central Govt. and other constitutional bodies about necessary steps required to be taken to check this dreaded disease in the district in the coming days.
- Malkangiri District- An overview
Malkangiri is one of the most backward districts of Odisha and infamous for significant presence of malnourished children and highest number of child causalities in the country. Looking at the history of its development, the district is named after its headquarters town Malkangiri. During the formation of Orissa Province in 1936 Malkangiri was a “Taluk” of Nabrangpur sub-division of Koraput District in Orissa. In 1962 it was upgraded to a subdivision of Koraput District. The present Malkangiri comprising an area of 5,791 sq.kms. got its identity as an independent district with effect from 2nd October 1992 following the reorganization of districts of Orissa as per notification dated 1st October,1992. .Oriya is the main spoken language. The district is divided into two distinct physical divisions. The eastern part is covered with hilly terrain of Ghats, Plateaus and Valleys sparsely inhabited by primitive tribes notable among who are Bondas, Koyas, Porajas and Didayis. The rest of the district is comparatively flat plain broken by a number of rocky wooded hills. Almost the whole of the district is covered with vast stretches of dense forest.
Map of Malkangiri district
The district has seven administrative Blocks i.e., Kalimela, Khairput, Korukonda, Kudumuluguma, Malkangiri, Mathili, Padia and two NACs i.e., Malkangiri and Balimela. It consists of 108 GPs and 928 villages. Literacy rate in the district is 31. 26%. Infant Mortality rate is 55 per 1000 child births in the district. Children suffering from malnutrition are a common phenomenon in the district.
Tribals constitute the dominant community in the district with a presence of 59.21% of the total population. Most of the tribal people are poor and live in abject poverty. As per Govt. report, 81.88% of the rural people live under Below Poverty Line. The whole district is affected by Naxal violence. Almost all development projects and programme like PDS, ICDS, MDM, NREGA, Integrated Action Plan (IAP), ITDA, OTELP, Banda Development Authority and Didayi Development Authority are being implemented by Govt. to ensure livelihood and provide food security to the people in the district. To curb naxal violence in the district, both Central and State Govt. have also undertaken special development projects for socio economic development of the people in the district by spending crores of rupees.
- Japanese Encephalitis (JE)- What it is ?
Japanese Encephalitis (JE) is a mosquito borne zoonotic viral disease. The virus is maintained in animals, birds, pigs, particularly the birds belonging to family Ardeidae (eg. Cattle egrets, pond herons etc) which act as the natural hosts. Pigs & wild birds are reservoirs of infection and are called as amplifier hosts in the transmission cycle, while man and horse are ‘dead end hosts. The virus does not cause any disease among its natural hosts and transmission continues through mosquitoes primarily belonging to vishnui group culex. Vector mosquito is able to transmit JE virus to a healthy person after biting an infected host with an incubation period ranging from 5 to 14 days. The disease affects the Central Nervous System and can cause severe complications, seizures and even death. The Case Fatality Rate (CFR) of this disease is very high and those who survive may suffer from various degrees of neurological sequeale. (An estimated 25% of the affected children die, and among those who survive, about 30-40% suffers from physical & mental impairment). The children suffer the highest attack rate because of lack of cumulative immunity due to natural infections. Acute Encephalitis Syndrome (AES) is a general description of the clinical presentation of a disease characterized by high fever altered consciousness etc mostly in children below 15 years of age. Acute Encephalitis Syndrome (AES) has a very complex aetiology and JE virus is only one of the many causative agents of Encephalitis. Further it is also
- Details of visit of the Team
The Team members visited three JE- affected blocks i.e. Malkangiri, Korkunda and Kalimela and 10 villages and interacted with cross section of the people, parents of deceased children, Medical Officers of CHCs, Panchayat representatives, Anganwadi Workers, Supervisors, the villagers to find out the reasons of death of children and outbreak of JE. The Team members also visited Community Health Centres at Kalimela and Korkunda and inspected the Wards to understand the health condition of the children being treated. The doctors were very cooperative and explaining details and responding the query. Most of the children admitted in the hospital were visibly malnourished and suffered from fever. The doctors have taken them as suspected AES and kept them under observation.
On 18.10.16, the Team members also met Dr. U.C.Mishra, Chief District Medical Officer, Malkangiri and discussed with him about the reason of outbreak of Japanese Encephalitis (JE). He explained in details about how virus is transmitted from pigs to man through mosquitoes. This disease has broken out due to bad sanitation condition, pigs. He also said that due to malnutrition , many of the tribal children have lost their immune capacity for which their body could not resist this dreaded disease. He admitted that as large number of JE affected children got admitted, they could not handle it and many of them died. Referring these patients to Berhampur became problem for the administration. Because many of them also died on the way. Now they have taken a lot of steps including mobilising doctors, staff nurse from different districts, Sishu Bhawan and engaging them for treatment. Pigs have been kept in enclosures around 3 kms away from human habitation. Fogging and restoration work has been started in affected villages. Dr. S.B.Mohapatra, ADMO carried with him the team members and facilitated their visit to different Wards, ICU, Nutritional Rehabilitation Centre (NRC) where the affected children are treated. It was observed that most of the children admitted in hospital and under treatment are malnourished.
Places visited and persons / officials interviewed by the Team and their response .
|Name of Block||Name of villages/ offices||Person/ officials interviewed||Content of Interview and query made by the team|
|Kalimela||Koimetla village ( Koimetla GP)||Muka Madhi||His daughter Manjun Madhi , one year and eight months got suffered from fever. He carried her to Kalimela CHC. The doctor referred her to District Hospital. No proper treatment was made. He brought back her daughter to home on 6.10.16. She got serious next day. While carrying her to District Hospital, She died on the way on 7.10.16 ( it has not been reported in Govt. list)|
|Kasa Padiami||He admitted his son Bikram Padiami, 3 years old in District Hospital. The Doctors could not treat his son properly. He was told his son to be referred to Berhampur. The doctor asked him to wait. He waited for one day and his son ultimately died in Hospital on 10.9.16.|
|Sukra Padiami||His son Bapi Padiami, 3 years and 9 months old died on 11.9.16 in M.K.C.G. Hospital, Berhampur. He could not avail Hospital Ambulance to bring back his son. Finally he hired private vehicle @ Rs. 22,000.00 to carry his dead son to home.|
|Jaga Madhi||His daughter Ananya Madhi, 3 years old died on 22.9.16.|
|MV-68 Anganwadi Centre||Shyamali Halda, Anganwadi Worker||She reported about 3 malnourished children identified in the centre|
|Kalimela Community Health Centre||Dr. Muktikanta Mallik , In-Charge of CHC||He reported that total of 74 children suspected AES (Acute Encephalitis Syndrome) were admitted within two months Sept and Oct. 16. 40 patients referred to District Hospitals and 34 treated and got cure.|
|Korkunda||Palakonda village ( Sikhpali GP)||Marsha Kabadi||His son Rama Kabadi, 3 years old died in District Hospital on 29.9.16|
|Bira Kabadi||His son Deba Kabadi, 4 years old was admitted in district hospital. The doctors neglected in treatment and did not prescribe any medicine. His son died in Hospital on 21.9.16|
|Nande Madhi||His daughter Debika Madhi, 2 years old died on 21.9.16|
|Deba Kabasi||His son Rame Kabasi, 2 years and 7 months died on 15.9.16 in M.K.C.G. Hospital, Berhampur|
|Irme Madakami, Anganwadi Worker, Palakonda||She gave the list of 3 malnourished children and explained in details about steps taken to refer malnourished children to the District hospital.|
|Jhunurani Mohapatra, ANM||She explained about provision of two meals provided in Anganwadi Centre to all pregnant and lactating women and children upto 6 years of age from 10.10.16 and mass sensitisation programme undertaken by them to maintain proper sanitation in the area.|
|MV-19 , Primary Health Centre ( new)||Dr. Chandan Soren, Medical In-Charge||22 suspected AES cases referred to District Head Quarter Hospital within last two months. On query about reason for death of only tribal children, he said that the tribals are not health conscious and do not maintain proper sanitation around them.|
|Patrel village||Ajay Madkami||His son Aditya Madkami , 3 years and 10 months old is 8 kg suffering from Malnutrition|
|DO||Binod Bihari Takri||His daughter Jhansi Takri, 4 years old died on 29.9.16. She was suffering from malnutrition.|
|DO||Sukanti Karasta, Anganwadi Worker||She provided list of 3 malnourished children identified and necessary steps taken for their recovery.|
|MV-53||Pinku Biswas, Anganwadi Worker,||She was seen managing the centre well.|
|Puspali ( Tarlakota GP)||Puspali Anganwadi Centre||Immunisation programme was going on in the presence of Mathamai rath, Supervisor and Minati Panda, Anganwadi Worker. She provided list of 3 malnourished children.|
|Mahulput||Shyamali Biswas, ANW||She was appraised about non-distribution of egg to pregnant and lactating woman of Jamuguda village. After complaint, she agreed to provide food and egg to them|
|Sangita Panigrahi, Supervisor||During visit, the team spotted her supervising provision of cooked meal to pregnant and lactating woman in the centre.|
|Siraguda||Bipasa Mandal, ANW||Many beneficiaries have not received money under Mamata Yojana for years together|
|Korkunda CHC||Dr. Tanmaya Acharya||He said that total no. of 73 JE suspected children were admitted within two months. Out of it 28 referred to District Hospital.|
|Malkangiri||Tamasa||Muka Madkami||His son Bidesh Madkami , 6 months old died on 7.10.16 in hospital.|
|Padia Kabasi||His daughter Puja Kabasi , 4 years old died in home.|
( MV 68- Malkagiri village 64 – habitation of refuse Bengalis rehabilitated by Govt.)
- List of Malnourished children collected from Anganwadi Centres and identified by the team during visit
|Sl.No||Name of Block||Name of village||Name of malnourished children with age|
|1||Kalimela||Koimetla||Rasmita Padiami, 1 year and 8 months old|
|2||DO||DO||Radhika Madi, 3 years and 7 months old|
|3||DO||DO||Bimala Madi, two years and 11 months|
|4||DO||Palakonda||Tami Padiami, 2 years old daughter of Aite Padiami|
|5||DO||DO||Santu Kabasi, 2 years and 10 months old|
|6||DO||DO||Surya Kabasi, 11 months , Father- Bimal Kabasi|
|7||Korkunda||Potrel Village||Mangul Madi, 2 years And 3 months , son of Sama Madi|
|8||DO||DO||Sabar Padiami, 1 year and 3 months , son of Dabe Padiami|
|9||DO||DO||Ganga Padiami, one year and 3 months|
Jamuna Padiami, one year and 3 months, twin of Munda Padiami
( Tarlakata GP)
|Kasa Beti , 1 year and 8 months|
|11||DO||DO||Rita Madkami, 2 years and 2 months|
|12||DO||DO||Jangi Kuasi, 2 years and 7 months|
- Analysis of the problems aggravating health hazards and JE epidemic
- Child death is not new phenomena in Malkangiri district. Every year thousands of children died of fever, malaria and other small ailments. The information obtained under RTI from the office of CDMO, Malkangiri on 3.11.12 has exposed that from 2007-08 to 2011-12, around 7400 children have died due to contraction of various diseases like Epilepsy, ATI, LBW, Diarrhea, Ashthma, Fits, Burning, UND, Septicemia, Birth Asphyxia, Fever related ailments and Boll cancer etc. it means in normal period, thousands of children mostly tribal children died of minor ailments, The death due to outbreak of Japanese Encephalitis in 2012 and 2016 has only aggravated the situation exposing the ineffectiveness of health system of the state.
- While visiting the Anganwadi Centres, CHCs, District hospitals and interacting with Anganwadi workers, it was observed that most of the children who have died or under treatment are malnourished. More than 95% of JE-affected children are tribals and all of them are malnourished. It is interesting to be noted here that among the affected tribal children, most of them are girl children. Due to chronic hunger and lack of food, the tribal children have suffered from malnutrition. A malnourished child is easily susceptible to any disease. Because, their immune capacity gets lost. As a result, they have succumbed to dreaded disease like Japanese Encephalitis. As reported by health experts, the children are highly vulnerable to this disease. Malnutrition among the tribal children can be attributed to extreme poverty, lack of employment opportunity or less accessibility to food and ineffectiveness of Govt. programme. During interaction with the villagers, they were asked about daily consumption. All of the replied that they consume rice and jungle leaves (forest leaves) as their staple food and sometimes rice and dal. It shows horrible food insecurity situation among the tribals. As they could not get any work, they could not earn to feed their children. The employment generation programme implemented by district administration has failed to provide employment to the tribals. During interaction with the villagers of Koimetla village, it was found that the NREGA labourers have not been paid their wages since 7 months.
- It was observed that ICDS programme is badly implemented in Malkangiri district. For example, the beneficiaries of Jamuguda village under Tarlakota GP have not been getting egg and food for years together because of 2 km distance from Anganwadi Centre. The Anganwadi Worker has not taken any proactive step or extra initiative to ensure food/ THR to them. The Team also came across a lot of complaints relating to distribution of substandard Chhatua. Many beneficiaries are not consuming it and using it for food of pigs. Under Mamata Yojana, the beneficiaries like lactating woman have not been paid money for years together across the district. Either ICDS programme have miserably failed to ensure nutritious food to the children and P & L woman or has it been ineffective to address malnutrition among the children which requires further study or review of the project in Malkangiri.
- Though a number of children died due to Japanese Encephalitis (JE) during 2011 and 2012, the administration could not learn anything and remained callous and indifferent to take steps for prevention and control of the disease in the district. It is worth to mention here that Ministry of Health and Family Welfare, Govt. of India decided in 2011 to implement National Programme for Prevention and Control of Japanese Encephalitis/Acute Encephalitis Syndrome in the country. This programme is implemented with cent percent Central Govt. support in 171 JE-prone districts of 19 states. Though Malkangiri has been affected from 2011, the year of beginning of National programme, the State Govt. has precariously failed to influence the Central Govt. to be part of the National programme. It is also fact that the State Govt. has not even tried to be linked with National Programme to combat this dreaded disease, despite of its ineffectiveness and incapacities to deal it. It has happened due to inept political leadership and insensitivity bureaucracy of our Govt.
- Malkangiri district is extremely backward and poverty-stricken district in the country which has drawn attention of the policy makers several times. That’s why a good number of development projects and special tribal welfare programme is undertaken for improvement of socio-economic condition of the people. Crores of rupees are sanctioned for implementation of various project. On the other hand, the District Hospital and CHCs and PHCs are seen ill-equipped with lack of infrastructure, vacant of post of Doctors, ANMs and Para-medical staff for years together. If proper treatment had been offered to the patients in a coordinated way, life of many innocent children could have been saved. Whatever staff and para-medical staff are available in the district, they are not working properly. ANM, male and female health workers hardly visit the field. There is no monitoring of health programme and activities of medical staff by the higher authorities. The patients are not provided proper treatment in Hospitals rather got neglected and died.
- The insensitivity of the district administration to deal critical health hazard situation and lack of preparedness has aggravated the problems resulting in huge child causalities. After hue and cry in mass media, the district administration took a number of preventive measures at village level to counter spread of disease by putting para-medical staff in different locations, conducting massive awareness programme among the people, fogging, keeping pigs in enclosures at distance place from human habitations and offered fantastic treatment in hospitals to check child causalities. If this kind of arrangement had been taken earlier, the magnitude of child causalities could have been avoided.
In view of the above problems, the team endorsed the following recommendations to make Malkagiri a district of zero child causalities.
- The State Govt. should constitute a Judicial Commission headed by a retired High Court judge along with medical expert as members to make a thorough investigation into magnitude of causalities of only tribal children due to outbreak of Japanese Encephalitis, factors responsible for it, reason of susceptibility of tribal children to this dreaded disease. The recommendation of the Commission should be carried in letter and spirit.
- The Team is of the view that the malnourished children have been susceptible to this disease. There is high malnutrition among the tribal children in every village across the district. the children who have died or under treatment inspected by the Team are seen and examined as malnourished. So to save the precious life of the tribal children requires intervetion of the Govt. to check malnutrition among the children. The food insecurity and extreme hunger has resulted in children suffering from malnutrition. ICDS programme which has mandate to increase nutritional standard of the children has precariously failed due to its bad implementation, huge corruption and irregularities in distribution of Chhatua ( Take Home Ration). The team felt that the provision of Rs. 6.00 for food per head per day in Anganwadi centre is not at all sufficient to meet nutritional need of the tribal children. secondly, though it is not sufficient, but whatever is given is again misappropriated by Anganwadi workers and other ICDS officials. There is a chain of misappropriation of ICDS fund from top to bottom. So, it is recommended that ICDS programme needs to be revamped with allocation of required fund in context of Malkangiri district along with independent monitoring team to be put in place to moitor its implementation.
- As the outbreak of Japanese Encephalitis has assumed alarming proportion in Malkangiri, there is urgent need to cover this district under National programme launched by Govt. of India for Prevention and Control of Japanese Encephalitis/Acute Encephalitis Syndrome . So that with cent percent support from Central Govt., Japanese Encephalitis disease can be controlled. So, the State Govt. should be engaged in dialogue with Central Govt. for coverage of Malkangiri district under the said programme.
- A number of tribal welfare programme under various schemes, tribal sub-plan schemes supported by Central Govt. and State Govt. with allocation of huge fund is implemented in Malkangiri. Despite huge funding, why the Primitive Tribal Groups like Didiya, Bonda are suffering. Time has come to examine why these programme have failed to bring any changes in life and livelihood of tribals. Why their socio-economic condition is still disastrous. Whether the programme are itself defective or it is badly implemented by unscrupulous officials. It needs to be studied by experts in context of Malkangiri and their recommendations should be carried out in letter and spirit.
- The medical system of Malkangiri should be revamped and well-equipped with appointment of doctors, para-medical staff making it effective to provide free health service to the patients.
- There must be independent grievance redressal and monitoring mechanism in place to monitor the implementation of various welfare programme meant for tribals. The report of the monitoring should be taken into consideration by the higher authority. Time-bound grievance redressal system should be put in place and massive sensitisation programme to be conducted among the tribals across the district.
- The Japanese Encephalitis epidemic is just like disaster. It requires trained personnel to deal this disaster situation. The team recommended that the officials should be trained on disaster management to take preventive measures to counter any epidemic in the district.
- Governance system with transparency and accountability in implementation of various programme should be enforced at every administrative level ensuring participation of the beneficiaries.
Pradip Pradhan Sri Ashok Patnaik
State Convener, Right to Food Campaign, Odisha Advocate and RTI Activist, Malkangiri
Member, Advisory Group of NHRC on Right to Food M- 9437435399
Sri Bikash Dandsena Sri Era Padiami
Social Activist, Malkangiri, Tribal Activist, Malkangiri,9437979303 M- 9437316380