Report of Fact-finding Visit on “Infant Deaths due to outbreak of Japanese Encephalitis / Acute Encephalitis Syndrome” in Malkangiri district, Odisha

1. Introduction

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 5^th 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 18^th to 20^thDec.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  18^th to 20^thOctober 2016.

2. Members of Fact-finding Team
3. Pradip Pradhan

State Convener, Right to Food Campaign, Odisha

Member, Advisory Group of NHRC on Right to Food, M-9937843482

1. Sri Ashok Patnaik

Advocate and RTI Activist, Malkangiri, M- 9437435399

1. Sri Bikash Dandsena

Social Activist, Malkangiri, M-9437970303

1. Sri Era Padiami

Tribal Activist, Malkangiri, M- 9437316380

3. Objectives of the Visit
4. 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.
5. 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.
6. 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.
7. To understand the effectiveness of ICDS programme to check malnutrition among children in Malkangiri.
8. 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.

4. 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.

5. 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

6. 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.)

7. 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 \and Jamuna Padiami, one year  and  3 months, twin of Munda Padiami
10	DO	Puspali village ( 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

8. Analysis of the problems aggravating  health  hazards and JE epidemic  

3. 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.

 

1. 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.

1. 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.

1. 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.

1. 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.

1. 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.

Recommendations

In view of the above problems, the team endorsed the following recommendations to  make Malkagiri   a district of zero   child causalities.

1. 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.

6. 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.

1. 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.

1. 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.

1. 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.
2. 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.

1. 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.

1. 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

M-9937843482 

Sri Bikash Dandsena                                                                                       Sri Era Padiami

Social Activist, Malkangiri,                                 Tribal Activist, Malkangiri,9437979303                                     M- 9437316380