Malaria is a major public health and social problem in India, leading to high morbidity, mortality, economic loss, people missing work and absenteeism in schools. While studies are required to arrive at the exact economic cost of malaria in India, the fact remains that the disease is regrettably unchecked in parts of the country.
As per the National Vector Borne Disease Control Program, 1.13 million malaria cases were reported in India in 2015. While between 2000 and 2015 there was a 45% drop in malaria prevalence, 80% of the remaining burden is confined to geographies inhabited largely by India's tribal populations. While a state or two in India may be on the brink of eliminating malaria in the foreseeable future, Odisha, Madhya Pradesh, Chhattisgarh, Jharkhand, Maharashtra and the Northeast are far behind. These states bear the largest share of India's malaria burden and specifically the killer falciparum malaria. Eight percent of India's population, largely the tribal residents of these states, account for 46% of the total malaria burden, 70% of falciparum malaria and 47% of malarial deaths in the country.
While between 2000 and 2015 there was a 45% drop in malaria prevalence, 80% of the remaining burden is confined to geographies inhabited largely by India's tribal populations.
These states have some common factors binding them: high maternal deaths, malnutrition, and sickle cell disease. Inaccessible and remote forested or hilly landscape, rainfall and water stagnation, lack of qualified healthcare professionals and health posts, weak mobile phone and internet connectivity further exacerbate the problem. Furthermore, there are numerous slow-flowing and perennial streams in these areas—a breeding ground for vectors like Anopheles Fluviatilis. There are also other predominant vectors in tribal areas. Plasmodium falciparum is the principal species mostly seen in forest fringed areas in districts in aforementioned states inhabited by tribal populations. There are districts in parts of Odisha and Maharashtra affected by malaria, with an annual parasite index (API—a measure for confirmed malaria cases or morbidity in a year) of more than 10. The unrest here renders the health system even more ineffective. All these factors make addressing malaria in tribal areas a unique challenge.
At the turn of the millennium, there was a global shift towards insecticide treated nets, long lasting insecticidal nets, rapid diagnostic kits (RDK) and new treatment regimen using Artemisinin-based Combination Therapy (ACT) that ushered in hope. These developments however failed to reach the most affected areas. Even today some regions face an inadequate supply of RDK for early detection of malaria, poor supply of ACT during the high prevalence seasons and suboptimal coverage of indoor residual spray.
Rapid diagnostic tests (RDT), excellent for early detection, have been found to be less effective for detecting people with low parasitemia, a problem which is prevalent in some tribal areas. RDTs are however more widely available than microscopy tests, making it necessary to use.
Despite improvement in surveillance over the last few years, the actual burden of malaria is yet to be known—there is poor coverage, low examination of blood smears, weak reporting systems and no reporting of malaria-related data from the private sector. In the absence of such formal functioning health care systems, tribal communities often confine themselves to traditional practices and healers.
Smart partnerships and social capital with innovative financing, technical inputs, research, product and process innovations can make a significant difference.
But these problems in the context of tribal population are not insurmountable. Malaria was almost conquered in India in the 50s and 60s with appropriate measures and commitment. With evidence-based practices, innovations, advancement in science and technology, research and development and new approaches to address the poor practices and health-seeking behaviours of tribal people, controlling malaria seems achievable. Smart partnerships and social capital with innovative financing, technical inputs, research, product and process innovations can make a significant difference.
The approach is twofold. On the one hand the state has the mandate to invest, scale up, monitor and evaluate to ensure better quality of care and, on the other, development partners can take the risk to innovate and generate evidence which can inform policymakers to plan and chart courses of action while investing effectively and efficiently in a solution.
This financial and social commitment will not only dispel malaria from regions inhabited by tribal populations but will be effective in lifting the general standards of the healthcare system to combat other diseases and conditions. This investment will earn high returns from neglected communities and their future generations through better health, improved productivity and better attendance and performance in school. Targeting malaria in ethnic communities will significantly reduce overall malaria burden in India.
To conclude, the immediate call for action to mitigate malaria in tribal regions in India will require the adoption of multiple strategies and an integrated approach. Foremost is the strengthening of the surveillance system and bolstering it with the support of IT and mobile technology. GIS mapping will capture the disease burden and enable state machinery to take timely action. Secondly, early detection and treatment of all cases, including afebrile (without fever) cases, is imperative, with attention to pregnant women and children. Thirdly, mapping of the actual requirement of anti-malarial drugs for remote tribal pockets and making those available is essential in meeting the treatment gap. Ensuring immediate distribution of long-lasting insecticidal nets, repellants and indoor residual sprays, and simultaneously educating and promoting their adoption, is critical in bringing change in tribal villages and hamlets. Lastly, research on the health of ethnic communities along with investment in the development of tomorrow's drugs and insecticides is a must for future action.