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Controversy over malaria estimates reveals sickness in health infrastructure by Aman Sethi

All epidemiological data in Chhattisgarh are ‘guesstimates'

Underestimation of malaria mortality figures

Public hospitals ill-equipped to handle severe cases

Last week, the medical journal Lancet published the results of a malaria survey undertaken by researchers as part of the Million Deaths Study, an ambitious programme that strives to document the causes of nearly one million deaths in India from the period 1998 to 2014.

As per the survey 2,05,000 Indians die of malaria every year as compared to the World Health Organisation estimate of 15,000. These implications have prompted a fierce debate on the methodology behind either estimate.

Doctors and malaria researchers in Chhattisgarh believe that the underestimation of malaria mortality figures is indicative of the broader problem in Central India's disease surveillance infrastructure. Chhattisgarh for instance, reports some of the highest malaria incidence rates in the country, coupled with relatively low mortality rates.

If one goes by numbers alone, Chhattisgarh appears to have made remarkable progress in controlling malaria, reducing malaria fatalities from 63 deaths in 2000 to zero deaths in 2007. According to the figures provided by the State, a total of 137 people have died of malaria since 2000. In Orissa by contrast, 283 persons died of malaria in 2004 alone.

International comparisons are equally flattering. According to 2007 data from the Journal of Infection, the United Kingdom reports between 1,500 and 2,000 cases of malaria every year, with a 1 percent mortality rate. In 2006, Chhattisgarh reported 1,44,766 cases of falciparum malaria, and three deaths – a mortality rate of 0.00002 per cent.

Either Chhattisgarh's malaria intervention programme is among the finest in the world, or the State is unable to gather epidemiological data. Doctors interviewed by this correspondent believe that the latter was the case.

“All epidemiological data in Chhattisgarh are ‘guesstimates' at best,” said a senior doctor at the National Institute of Malaria Research (NIMR), Raipur, who requested anonymity as he was not authorised to speak with the press.

The only independent study tracking malaria's deadly march through the State was conducted at Shaheed Hospital in Durg district in 2008. “Of the 426 malaria cases admitted in our hospital from October to December 2008, 113 contracted severe malaria and 18 patients died,” said Saibal Jana, lead author of the study. These 18 deaths were observed in one hospital in one district alone. However, the government figures from the same period indicated a total of 5 malaria deaths for the entire State.

“We admit that there is underestimation of malaria deaths in Chhattisgarh. But we do not know the extent of the underestimation.” said Jai Prakash, Chhattisgarh Programme Officer for malaria.

Humans contract malaria when bitten by the female Anopheles mosquito. In India, malaria is of two strains – the relatively mild Plasmodium Vivax and the virulent Plasmodium Falciparum. Once the parasite enters the bloodstream, it incubates in red blood cells before destroying the host RBC. The damaged RBC form tiny clots, cutting off blood supply to vital organs like the liver and kidney. Death often occurs from the failure of one or multiple organs.

Adivasi deaths

“You can say that Chhattisgarh's Adivasis die due to Plasmodium Falciparum, but it would be equally correct to say that they die due to the absence of timely health care, the absence of adequate public transport that allows them to reach hospitals and malnutrition that lowers immunity,” said Yogesh Jain, one of the founders of Jan Swasthya Sahyog, a community health project in Bilaspur.

Dr. Jain said “public hospitals in Chhattisgarh are ill-equipped to handle severe malaria cases, and have inadequate blood banks, almost no dialysis facilities, and are unable to check blood glucose levels of patients.” Low blood sugar was an important reason for death in malaria, especially in pregnant women, he said.

Thus, the pyramid of primary health centres, community health centres and district hospitals that is unable to treat patients, is incapable of preparing blood smears to check for malaria, rigorously recording epidemiological data and sending it for State and national level data collation.

Dr. Jain points out that the absence of epidemiological data is reflective of the complete disruption of Chhattisgarh's health system.

The absence of data cripples future malaria interventions as researchers have little idea of the scale of the crisis. For instance, the NIMR is currently involved in a WHO study to evaluate the efficacy of mosquito nets embedded with insecticide as a method to control malaria. However, researchers are unable to choose an appropriate test site as there is little district or block-level data of malaria incidence in the State.

“Earlier this year, we wasted 1 month testing the nets in a village which had no mosquitoes,” said a senior researcher. “This time we hope to be luckier.”