10. CAUSES OF PERSISTENCE OF MALARIA IN KORAPUT DISTRICT

10, CAUSES OF PERSISTENCE OF M4LARIA IN DISTRICT:

?he results of malarianetric surveys indicated that malaria is a

persistent problem in Koraput district, responsible for high degree of

morbidity and mortality (chapters: 5-9). There is no doubt that a

canplex interplay of several factors is responsible for this

persistence. Identification of the causes of the persistence is of

vital importance in replaming control measures. Tnough most factors

are interrelated, the possible causes of persistence have been

presented under the following headings: '

(i). technical aspects,

(ti ). hman behavioural aspects, and

(iii). administrative, operational and logistics aspects relating

to the existing control prograrmle.

10.1.1. Susceptibility status of P.falciparm to chloroquine in

Koraput :

Of the several factors responsible for resurgence of malaria in

India, appearance and spread of drug resistant strains of P.

falciparun. has been considered important (Clyde and Be1 jaev, 19841.

Chloroquine resistant strains of P, falciparm have been detected in

many parts of north-eastern India including all the 13 districts of

Orissa (Guha g i., 1979a; Pattanayak g fi., 1979; WK), 1982a;

S h a m , 1984b; Anonpus, 1987a). A majority of P. falciparum cases in Orissa state is reported from the Koraput district (chapter: 4) and

there is only one report of R resistance by in-vivo test frm the I

district (Anonymous, 1987a1. The present status of chloroquine

sensitivity of 1. falciparum in the district was studied both by

in-vivo and micro in-vi tro techniques. Apart from these, the

effectiveness of different regimens for treatment of P. falciparum

cases which are being advocated in the local area (under the national

program) was also evaluated.

10.1.1:l. Study area:

'Ihe study area included four FWCs and the construction site of

hairan irrigation project. 'he malarimtric data in these RIC areas for

3 years (1984-1986) is shown in Table: 59. 'he Muran irrigation project

site was chosen because of the high prevalence of malaria (parasite

rate of 35.9%) with predominance nf P, falciparum (!ll.6\ of all tves).

Apart from this, the construction site served as a focus of malaria and

could play an important role in the dissemination of the disease since

there was a congregation of imnigrant population from several parts of

India. The malaria situation in this project site has been described

earlier (Chapter: 8).

Table: 59

Malaria situation in 4 R-1C areas of Koraput where in-viva chloroquine sensitivity studies were carried out.

Primary health centre (PHC)

Lamptaput Mathili Borigurma Malkangiri Year

API Pf% API Pf% API Pf% AP1 Pf%

1984 36.9 92.2 11.4 91.2 45.1 95.8 20.9 94.8

1985 31.5 86.9 30.5 95.2 21.5 94.0 2R.R 95.1

API: Annual parasite incidence per 1.000 population P f % : Proportion ( % I of E. falciparm cases to total malaria cases

(SOURCE: district malaria authorities)

Page. .234

10.1.1.2. Methods:

Chloroquine is administered to E . falcipaurm cases in the

c m i t y by the following three different dosage schedules, under the

national p r o g r m .

( A ) . A dosage of 6 0 C ~ chloroquine base is given as presunptive

treatment at the time of blood smear collection. The positive

cases are given an additional 600 mg chloroquine with 45 mg

primaquine (adults) for radical cure.

( B ) . In areas which are inaccessible, 600 mg base of chloroquine

and 45 n18 ol prlln~ql~lnn nro hr~ing glvc~n prosl~~ylt ivr~ly rlnl y

once at the time of blood smear collection.

(C). S m cases in the first schedule receive only 600 mg

chloroquine base given presunptively, as the radical

treatment is not imparted due to logistic and other problems

[non availability of drug/ patient/ staff etc.)

To study the effectiveness of these regimens, 70, 43 and 35

persons with P. falciparum infection were treated with the above three

dosage schedules respectively. They were examined for persistence of

parasitaemia in peripheral hlorxl on the 7th day of their receiving tho

drug/drugs.

Page. ,235

In-vivo extended test was done in all the 4 R1C areas and in-vivo

standard test was carried out in !&ran project area. The selection of

cases and the methcdology of the test were as per the WHO

recarmendstions (WH), 1973) . The extended test was carried out in 149

P. falciparm carriers, of w h m 139 ( 9 3 . 3 % ) were followed for 28 days - for peripheral blood parasitaemia. Twenty persons with P, falciparm

infect ion were subjected to standard in-vivo test and 16 of them were

followed up for 7 days.

For the in-vitro study, blood samples collected from 17 P.

falciparm cases ( 11 from Barigtmrma RIC area and 6 from hhran project

area), were subjected to micro in-vitro chloroquine sensitivity test by

using W0 kit following standard procedure IWln, 19R2h). The

chloroquine sensitivity plates, charged with the sample were incubated 0 0

at 37 - 38 C for 24 hours.

lhe blood smears collected for the preliminary screening and

selection of cases were stained with Giemsa stain (Bruce-Chwatt, 1985) .

Bath thick and thin smears were examined and parasite count was done

against 8,000 WBC. The post culture in-vitro test slides were stained

by Rananowsky I and I1 supplied along with the kit.

The standard Dill and Glazko technique was employed to test the

Page. .236

presence of chloroquine in urine before and after chemotherapy in all

patients as per test requirement (Leli jveld and Kortmann, 1970).

10.1.1.3. Results:

The presence of asexual parasites was detected in 18.bb (lJ/70],

9.3% [4/43), 34.3% (12/35) cases who were treated with dosage schedules

A,B and C respectively on the 7th day following the intake of drug/

drugs. ?his indicated that the dosage schedules followed were

inadequate for complete clearance of the parasite.

Of the 139 cases followed for 28 days by the extended in-vivo

study, 11 showed resistance at R level and 2 cases at R level. I I1

Apart from these another case of R was detected but follow-up was I T . -

discontinued from 14th day as the patient bocaae scrinusly i 1 1 ,

necessitating treatment with alternative drug. Cases resistant to

chloroquine were detected in all PHC areas except brig& by this

technique. One case of R was detected by the standard in-vivo test I I

at the Muran project area (Table: 601. The parasite density index (PDI)

per cubic mn of blood for sensitivk and resistant cases on different

follow-up days for the 4 RIC areas and hran is shown in Table: 61. The

results indicated that the fall in PDI for the sensitive or resistant

cases was not uniform in different FliC areas. Arrnng the sensitive cases

the parasitamia persisted until 6th day in Malkangiri, 5th day in

Lamtaput, 3rd day in Mathili and 2nd day in b r i g m and Mran.

Page. .238

Table: 61

Density index of P, falciparun on different days following chloroquine treatment in 4 RE areas and Mihlran (in-vivo test)

Area Days following chloroquine

Cases sensitive to chloroquine

Malkangiri 8.6 7.0 4 .5 4 . 0 5 . 5 1 . 0 1 . 0 0 .0 0 . 0 0.0 0 .0 Lamtaput 7.6 5.2 5.5 7 . 0 4.0 2.0 0 . 0 0 . 0 0.0 0 . 0 0 . 0 Mathili 6.9 4.5 3 .0 2.3 0.0 0.0 0.0 0 . 0 0.0 0 . 0 0 . 0 B o r i g w 8.6 5.8 4.1 0 . 0 0 . 0 0.0 0 . 0 0.0 0.0 0 .0 0.0 &ran 7.7 6 .2 3.9 0 . 0 0.0 0 . 0 0.0 0 . n 0 . 0 0 . 0 0 .0

Cases resistant to chloroquine

Malkangiri 7.6 5.0 4.2 2 .8 4 . 5 4.8 5.7 5 . 3 4.8 7 .5 6.0 Lamtaput 8.3 6.0 7.0 7.0 4.0 0.0 0.0 0 . 0 6 .8 6 . 8 3.8 Mathili 10.0 5.0 7 . 0 0.0 0.0 0 . 0 0 . 0 0.0 0.0 0.0 6.0 W r a n 10.0 1 0 . 0 1 0 . 0 2.0 2.0 1.0 3.0 6 .0 - - -

Variations in PDI was also observed among resistant cases in different

areas.

Of the 17 blood samples subjected to micro in-vilro test. 8

showed growth of schizonts at/ above 5.7 picom1 chloroquine

concentration indicating resistance (Table: 6 2 ) . Six of the resistant

cases were from hhran project area and 2 from B o r i g m R1C area.

All the resistant cases, detected by both in-vivo and in-vitro

tests were treated with Metdkaifin [combination of sulfalene and

pyrimethamine) :

10.1.1.4. Discussion:

An earlier study in Koraput district had show that the dosage of

600 mg of chloroquine failed to clear 11. falciparum in 3.8% of cases

(buha $- g. , 1979b). The present study showed persistence of

parasitaernia in 34.3% of cases with the same dosage schedule ( C of

present study). This indicated that the efficacy of chloroquine in

clearing parasitaemia with the same dosage schedule has declined over

the years.

?he chloroquine sensitivity studies by in-vivo and in-vitro

methods showed that 10% of the cases in the former and 47% in the

latter are rosifitnnt to thr? tlr~~~. I ' . [ i i r l r ! i~~ in l r~~ i r :~~ l invofit ip,nt ion

Page. .241

revealed that all the resistant cases were indigenous. A majority of

cases was f r m Malkangiri and Muran areas. In Borigurma R E area.

though no resistant case could be detected by the in-vivo method, two

cases showed resistance by the in-vi tro te~tulirlue. A v a i lablo reports

indicate that there is no definite agreement between the sensitivity

status of P. falcipaum as measured by in-vivo and in-vitro methods

(Schapire 5 g., 1988).

The resistance of P, falciparum to chloroquine in the locality

could be due to introduction of resistant strains from outside or due

to natural selection. There is a large refugee settlement in Malkangiri

area and these people who are originally from East kngal of undivided

India (present Bangladesh), make frequent visits to eastern parts of

the country (Bengal, Assam etc. 1, where resistant strains are known tu

exist [ S h a m , 1984bl. As already stated Muran project site had a high

potential for spread of malaria [chapter: 81. The fact that a majority

or the resistant cases was from these two areas suggested probable

introduction of resistant 1. falcipartnn strain from outside. However,

the possibility of establishent of the resistant strain due to natural

selection cannot be ruled out due to the following reasons. ?he

parasite in these areas had been subjected to chloroquine pressure

since a long time. Administration of the drug in inadequate dosage

schedules as evidenced in the present study, could have also enhanced

the process of natural selection of resistant strain in the locality.

The variations in PDI even among sensi tive cases suggested a gradual

change in the sensitivity status of P. falciparun in the different RM:

areas (Table: f i l ) .

The spread of the rosislant strains to olt~cr ro~oplive areas

within the district and outside is of great concern considering the

fact that there is substantial degree of human movement for

developnental purposes. Role of human movement in the spread and

persistence of malaria cannot be over emphasized (Prothero, 1984;

Rajagopalan g., 1986) . Malaria surveillance is not carried out

routinely in developnental project areas under the national programne

in Koraput district. Since the migration of labourers from other States

to several project areas like hluran is going to continue for

developnental reasons, i t is essential to establish monitoring centres

at focal points to prevent spread of malaria including drug resistant

strains.

An imdiate change to an alternate drug is not warranted in the

present situation, since a majority of the P, falciparun was shown to

be sensitive to chloroquine by the in-vivo test. Wtakal fin [sulfalene

and pyrimethamine] has been recomnended as the alternate drug in

treating resistant cases in this area (according to PHC medical

officers), which was also used in the present study. Resistance to this

drug has already been detected in India (Chnudhury g s., 1987). In

the present circunstances the use of this drug should be restricted and

quinine could also be used as an alternative.

Page. ,243

10.1.2. Parasite species and strains in Koraput:

Koraput is the only part of India where all fnur human malarial

parasites are prevalent. P. ovale has hitherto not been recorded in any

other part of India (Choudhury, 1985b). Presence of P. malariae, which

is considered to be the oldest/ primitive parasite of man, in all parts

of the district suggested that malaria is prevalent in this district

from time imnemrial. Detection of large number of mixed infections in

this locality indicated high level of transmission. The malaria

situation is comparable to that of Africa. As in the African continent

(Bruce-Chwatt, 1951; 1985; Richard, g g. , 1988a). 11, falciparwn has remained the predominant parasite species in this district even from

early part of the century (Perry, 1914). unlike other parts of India.

In fact, Perry (19141 had concluded that malaria had been introduced to

this locality since several thousands of years. 'Il~e primitive nature of

!he parasite is reflected in its highly evolved state and adaptability

to its environment. The paucity of P. falciparum gametncytes in the

population, particularly in the aborigine tribals of Koraput, unlike in

Punjab (Strickland g g., 19881 and in Rameswaram (Krishnmorthy g

al., 1985) bears a testimny to this adaptation. Perry [1914) had also - observed this phenomenon in Koraput and sought the opinion of Ross, who

believed that this reflected the intensity of malaria and the degree of

its adaptation. Recent studies, have also shown Lllu presence of

dividing forms of 11. falciparwn in peripheral blood (VCRC annual

Page. .244

report, 1989) and such morphological variation in P. falciparm has

been considered to be an indicator of strain difference (Raper fi G . , 1945). Adaptability of the parasite in turn could have resulted in the

high prevalence of asynptanatic parasite carriers responsible for the

persistence of malaria in this locality. Irrportance of adaptability of

parasite has also been highlighted elsewhere (Kondrashin and Kalra,

1989b).

10.1.3. Difficulties in the epidemiological assessment of malaria

situation:

Accurate epidemiological assessment nf malaria situation is an

essential prerequisite for the developnt of appropriate control

measures (UIJ, 1986a; Kondrashin and Aashid, l!Jt17). I n thc course of

studying the epidemiology of malaria in Koraput district which was

essential to bring forth the causes of malaria persistence, it was

found that the present mebods enployed routinely, are inadequate for

accurate assesswnt of malaria situation.

Fever surveys form the basis of malaria surveillance under the

existing national p r o g r m . Spleen survey and mass blood surveys are

not carried out routinely. Classification of endemicities are usually

based on child spleen rate as per the recmndations of W D (Molinequx

et s., 1988). However, several difficulties have been reported in - classifying areas based on spleen rate (Iyengar and Sur, 1929;

Viswanathan, 1951; Pampana, 1969, Bruce-Chwatt; 1985). Genetic factors

may also be influencing the splenic enlargement in a population (Rrabin

et g., 19881. According to Bruce-Chawatt (1985)" . ..there is no fully - satisfactory method of expressing in an arbitrary way the dynamics of

malaria transmission", and he suggested child parasite rate as an

alternative. Viswanathan 11951). while studying the malaria situation

in Jeypore hi1 1s believed that "endemici ty connotes the malariousness

of a place or c m n i t y and the spleen rate according to League of

Nation's Malaria curmission (1940) ....... appears to give, in a broad and general sense, its best measure. The same place presunably having

same inoculation rate manifests different reactions among indigenous

residents...... ..Hence there will be confusion in the determination of

'holoendemic' areas. " He had advocated a classification based on

patterns of age spclcific parehilo rdtn in it18 P I I ) I I ~ ~ I ! ! ~ I I I . lit! II~:IICV~!II

that adult spleen rates are useful in differentiating holo and

superendemic areas. The use of adult spleen rate 1s debatable, since

there may be several reasons for splenic enlargement in adults (Park

and Park. 1985). The "Central cmittee for study of Malaria in India"

had advocated the classification ol rn in lo four types based on spleen

rate in the population, prior to Kampala conference. Iyengar and Sur

(1929), had studied the difficulties in classifying areas based on this

and sho&d that seasonal variations in spleen rates in thesame

population will interfere hith the classification. Gabaldon (19461

believed that indication of the "Condi tion or Constitution" of malaria

was more important than the degree of endemicity. He attenpted to

express it by means of two indices, one of endemicity and the other of

epidmicity and their relationship. This requires estimation of spleen

rates in the population for at least a period of five years. Recently,

a classification of areas based on their intensity of transmission

(basic reproduction rate) has also been prnpnfied /Ml lneaux, 1988).

Incidence and recovery rates from longitudinal studies have been used

for studying the transmission dynamics of disease in course of time

[Bekessey 5 g., 1976; Molineawc and Gramiccia, 1980). However, the measurement of these parameters would need expertise which is always

not available.

These difficulties in accurate assessment of malaria situation

leads to formlation of inappropriate strategy. In Koraput, there are

areas with varying degrees and periods of transmission, all four human

malarial parasi tes are prevalent and there are several vectors, hence

the problem becomes even more complicated.

The persistence of malaria in several parts of the world is

closely associated with human behavioural aspects (Rueben, 1989). The

persistence of malaria in Republic of S m l i a and the adjacent parts of

Ethopia due to migration of people related to traditional pastoralism

(Prothero. 19841 and in Rameswaram island in south India, related to

seasonal h m n movement for the purpose of fishing (Rajagopelan gal.,

1986) are classical examples highlighting the importance of hunan

behaviour in relation to malaria. Hunan behaviour in turn is closely

related to the socio-econanic status of the population (Kondrashin and

Rashid, 1987; Kondrashin and Grlov, 1989; Aul t , 1989). Ilonce, the role

of these factors was studied in Koraput district.

10.2.1. Study area:

b n t y two villages were randomly selected in Jeypore zone for

this purpose. All the villages are located in Boriglsrma PIlC area. Mass

blood surveys (chapter: 5 ) and initial fever surveys (chapter: 6 )

carried out in these villages revealed that all were malarious.

A team of workers visited all the households and enmrated the

population. The nature of houses, the education, occupation and income

status of the family members were recorded. 'Ihe general beliefs and

faiths of the people with respect to health and disease were studied by

questioning a cross section of the population (mstly by observation

and informal discussion). Cultural practice of mud plastering

prevailing in tribal areas of Orissa is one of the) most important

factors which interferes with the efficacy of residual spraying in the

locali ty (Rueben, 19891 and hence, the frequency of this in n o m l

course (without spraying) and on 3rd. 7th. 15th, 21st and 30th day

following spraying was studied in two of these villages. Refusal for

residual insecticide spraying or its poor acceptance is another

important factor which influences the spray coverage (Sham, 1904a;

Rueben, 1989). It is necessary to study the reasons for such refusal if

any, so as to give adequate consideration to these factors in

replanning. For this purpose, a team accompanied the W spray squad

in 7 of these villages and the cause was enquired in the case of

refusal.

10.2.3. Results and Discussion:

10.2.3.1. Socio-economic status:

The total population of the study (22) villages was 15,303 and a

majority (77%) of them was scheduled tribes/ castes. The number of

holdings ranged from 36 to 318 and the population from 144 to 1,455 per

viilage. The family size varied from 2 to 23. A majority (qfisi,) of the

houses had thatched roofs and mud walls and rest (4%) had cemented

walls with tiled or concrete roofs. Many houses (50%) had false

roofings for storage of household articles and food grains. Mixed

dwelling, where both man and cattle live under the same roof was very

commn. The cattle population in these villages rangcri from 138 to 603

and the total cattle enmrated was 4,865.

The literacy rate ranged hetwen 2 and 5% in different villages.

Page.. 249

A majority of the population was labourers (37.9% nules and 24.3%

fmlesl. The nature of work varied from season to season. While most

of t h m w r e engaged in cultivation during paddy season, at other tims

they were engaged in various other types of work, rmst important being

mploymunt under petty contractors (for different constructions such as

roads, buildings, developrental project areas etc.). For these, the

people shifted their families temporarily to the place of work only to

return during cultivation. The daily wage ranged betwen Rs 3 to Rs 10,

depending on the nature of work. When no jobs were available, people

collected various forest produce. Only small proportion (8.8%) w r e

settled cultivators owning land. The monthly i n c m of the villagers

was meagre: 41.7 % earned betwen Rs 100 to 200, 56.3% betwen Rs 201

to 1,000 and the rest (2.0%) above Rs 1.000. Poverty was so grave that

they practically led a hand to mouth existence, which itself was

difficult. They had to work even if they had mild illness (unless they

were physically incapacitated).

The important consequences of this poor socio-ecnanic status are

the following:

[il. Since the villageseare situated far apart and the place of work

is usually far away from the villages [which they invariably

cover on foot, as cmnication facilities are almost

nonexistent), most people leave their villages early in the

nrrning to return only in late evening. They are thereforo

Page. .250

not available at the time of visit of the surveillance workers.

?he present study showed that 28 to 56% of the population is

not available at the time of survey (Chapter: 6). As a result,

persons with mild illness are missed and malaria carriers, who

after having received the presunptive treatment are not

available for radical treatment. This leads to accunulation of

parasite carriers in the ccmnunity and persistence of malaria.

Non-availabilty of villagers is also an important factor

resulting in poor coverage of population in mass blood surveys

particularly in tophill villages. Similarly the insecticide

spray coverage is reduced since many houses are found locked,

even after prior information.

(ii). Tne villagers particularly in remte hilly areas cannot afford

to shift the sick to the nearest PAC, both due to poor econmic

conditions and poor cmunication facilities, This was

responsible for several deaths in tophill villages in Jeypore

zone.

(iii). Poor paying capacity of the people is responsible for lack of

medicare facilities available in the villages, as no private

medical practitioner would like to settle there, unless he

wants to serve the poor.

(iv). As a consequence of low literacy rate and ignorance, the people

Page. .251

continue to have many false beliefs. For example even at this

modern age most people in and around hran believed that the

water of river Muran was cursed and was the Lause of fever

[malaria). Even the so called literate peoplo continue to

believe that Ghosts and certain Goddesses are the cause of

several illness including malaria (details vide infra).

(v). The most important consequence of poor living standards is the

difficulty in achieving comnunity involvement in disease

control p r o g r m s in the locality. For example, free

distribution of bednets to tribals resulted in the villagers

either selling i t or giving it as a dowry (VCRC annual report.

1987). lhe needs and the priorities of the people are

different.

10.2.3.2. Beliefs and faiths of the people:

Tne traditional beliefs and faiths relating to illness have a deep

cultural root particularly among the tribals. Traditionally, there are

three possible causes of illness. They are a) vengeance of divine

beings (Goddesses or 'Thakurani' as known locally) due to the wrong

doings of an individual, bl difficult times related to the planetary

positions and, c ) illness as a result of witch craft or black magic.

lhese beliefs are not only prevalent among illiterate tribals but also

among the 1 iterates. The probable cause (of the three mentioned above)

of illness is decided fran the sympta~tology of the disease or

according to the strongest belief of the person. For example. any

disease with fever and skin rashes (like chicken pox or masles) is

taken to be a definite sign of vengeance of Goddess.

?hese bliefs lead to three different modes of 'treatment'

according to the three possible causes of disease and there are

therefore three types of traditional httalers. The help of a 'PUJARI' or

priest is sought if the illness is believed to be due to divine

vengeance; a 'GUN&RI1 or astrologer is approached i f bad planetary

positions are thought to be responsible and a 'DISHMI' (one who is

believed to drive away evil spirits) is called when witch craft or

black magic is felt to be the source of illness. The tribals approach

the nearest hospital or health care personnel only when all the above

ixthods fail, that too when they can afford to transport the sick.

Of the three traditional healers, the Disharis appear to have

developed s a w systm of their own for the diagnosis and treatmnt of

the sick. They have traditional scripts written on palmyra leaves which

deal with symptmtology and appropriate recipes. They recognize

a1 together 11 typos of tovors. Of these tt~roc a~~pear lo bo related to

malaria and these are described in brief, in the following lines.

(i). Pali or Kampa Jwara: In the local language 'Pali' refers

alternate days, 'Kampa' refers to chills and rigors and 'Jwara'

Page. .253

refers to fever. These are fevers which appear at regular

intervals and are associated with chills and rigors and

possibly fit the classical malarial episodes. Such fevers are

treated with 'Trilinga Panchana' a crude extract prepared by

grinding and boiling barks of Paradi (Aegle marmatos) and

Patuli (Lagerostoemia reginae) , and leaves of Tulsi (Oscimun

sanctml in a castor leaf bowl. 'he decoction is mixed with

black pepper, honey and given twice a day until the fever

disappears.

( i t ) . Bata sa l fsd~u .Iwcltd: 111 \lic:hc ii:v~:rb thu \ U I ~ N : I ~ , ~ ~ I I I ( : r.\bcs i l l

the evening and becomes normal by mnrning. It is associated

with body ache, sweating, headache and burning sensation in the

chest. The treatment for these fevers consists of a mixture of

equal parts of coriander seeds, neem (Azadirachta spp. ) leaves

and Trifala (fruits of three plants: Emblica officinalis.

Terminalia bell irica and Teninalia chebula). This mixture is

taken once a day for three days and during the period of

treatment green leafy vegetables, gooseberry ( ambla) and

brinjal are prohibited. After 7 days the patient is given a

soup prepared from 'Magur' fish (Clarius batrachusl, black

brinjal and raw banana. 'Ihis food is recomnended for treating

anaemia in Rengal. Tt111s i t appears that Bata salisama jwara is

probably related t o lnaluria in association wi t t i sc?vcro anaemia.

Page. .254

(iii). Sannipata Jwara: This is another type of fever which ultimately

results in lowering of body tqerature and usually dreaded for

the high fatality associated with it. I t is also accompanied by

chills, headache in forehead region, deliriun, dryness in

mouth, laziness, congestion in eyes, body pain, dysphagia, dry

cough, sweating and pale colour of palm and foot. These

synptms are suggestive of early stages of cerebral malaria or

other viral fevers. No specific indigenous therapy has been

suggested for these.

There are several reasons why the tribals resort to the above

modes of treatmnt. Primarily they are illiterate and ignorant, and,

resorting to these treatmnts is a tradition followed for generations.

These healers are essentially tribals and a part of the cmunity. They

are easily accessible to any one in the village and their demands are

mstly in kind, which the villagers can afford. Inaccessibility of the

terrain and the possible cost of treatmnt forbids them to approach

hospitals/ dispensaries.

10.2.3.3. The mud plastering practice:

'Il-Ie tribals living in mud wall houses traditionally plaster the

walls with colour~ muds most dt:coratively. This practice has probably

evolved from the need to prevent the appearance of cracks and crevices

in the wall.

Study of n o m l frequency of mud plastering in two villages showed

that floors are plastered alrmst daily, indoor walls almost every week.

and, outside walls and the cattle sheds on ceremonial occasions [Tahle:

63). A total of 130 hunan holdings and 71 cattle sheds were observed

for a period of 30 days after residual spraying of WT in the villages.

It wi16: notd Llrat wi tl1111 a wuuh U4lb ol itla I I U I I ~ ~ I CIWUI l 1 1 1 p d11d 249 01

the.cattle sheds and by the end of a month all human dwellings and 87%

of the cattle sheds were plastered [Table: 64). The important reasons

for mud plastering were religious and cultural practice [89%1, bad

smll of DDT (6%) and bed bug nuisance (4%).

1 0 . 2 . 3 . 4 . Reasons for refusal of residual insecticide spray:

In the 7 villages, direct supervision at the time of spraying

shaved that in 33% of the holdings there was refusal. The following

were the important reasons for the refusals: religious causes [43%,

si:ice most tribals do not permit any outsiders to enter Into their

'PUJA' or prayer rooms), apprehensions of bedbug nuisance following

spray (24%), belief that spray has no use ( 9 % ) , bad smell (681,

presence of sick in the family (6%) and fear of spoiling stored food

grains (4%).

It appsars that ignorance and loss of faith together with poverty

are the important causes of human behavioural problems in Koraput area.

Even after three decades of organized antimalaria programs people

Page. .256

Table: 63

hbd plastering frequency for different surfaces of the holdings by the villagers in B o r i g m RIC area of Jeypore zone.

W d plastering frequency s h m as % of of holdings covered

Sl. Nature of Daily Twice a Weekly Fort- M n - (hce in Cere- no, surface Week nightly thly 3 months monial*

1. Floor 64.3 31.5 4.2 0.0 0.0 0.0 0.0 2. Indoorwall 0.0 76.2 14.7 3 .5 1.4 0.7 3.5

(Lower portion) 3. Indoor wall 0.0 25.9 42.0 4.2 2.8 1.4 23.8

(Upper portion) 4. Outsidewall 0.0 4.2 12.6 8.4 1.4 0.7 72.7 5. Cattle shed 0.0 0.0 1.3 0.0 0.0 11.8 85.5

* Only on cerwonial occasions irregularly

Page. .257

Table: 64

Proportion of hunan dwellings/ cattle sheds mud p1,lastad on different days following residual insecticide spraying

Follow up Nunber No. completely No. Partially Total plas- day Surveyed plastered(%) plastered(%) tered(%)

Hunan dwell ings :

Cattle sheds :

have no idea what is being done and for what? The comnunication gsp

between the health planners/ implementers and the tribals is too wide.

?he problem and difficulties of the villagers are rarely thought of

and therefore never given due consideration in planning and

implementation of the programncs. Health education by appropriate

methods and approaches involving people who are acceptable to the

comnunity may be useful. Involving local leaders irrespective of their

educational status from the time of planning right upto and during

implementation have to be considered. l n c m generating schemes, where

disease control becomes a by-product need to be evolved. Such

p r o g r m s have been demnstrated in the control of malaria in villages

elsewhere in India [Rajagopalan and Panicker, 1985; Hajagopalan and

Panicker, 1986: Rajagopalan $. , 1987). Mu1 t i-disciplinary

approaches to elevate the socio-economic condi t ions of the c m n i ty

with long term goals, improvement of comnunication facilities,

organization of labour and work are all necessary to alleviate the

suffering of the people.

10.3. ALMINISIRATIw, OI'EWI'IONAL AND IXK;lSI'ICS ASIWI'S HOLATlNG TO

I M P W A T I O N OF MISTING STPA'IEGY:

After the initial spectacular success [Pandi t. 19701, Malaria

eradication became an unassailable goal in India and elsewhere due to

several reasons. This has been a major subject of discussion in the

last two decades. The international and national issues relating to

Page. .Z59

this have been highlighted in several publications (Huff, 1965:

tiabaldon. 19btl; Jef fery. 1976: Hay, 1977: Ilas and Hajagopalan, 1978;

Gabaldon, 1978: Kalra, 1978: Bruce-Chwatt, 1979, Farid, 1980; Downs,

1981: Gusnmo, 1982; Cabaldon, 1983: Clyde and Deljaev, 1984; Choudhury,

1985a: S h a m and Mehrotra, 1986: S h a m , 1988: Rajagopalan, 1989:

Onori, 1988; Reuben, 1989). Pdministrative bottlenecks, operational and

logistic problems have been blamed at large for the failure in

eradication. All the above authors have focussed their attention on the

problem of resurgence except Downs ( 1981 I , who considered persistence

to be a major problem. While resurgence would mean reappearance after

initial successful control, persistence is a condition where even

initial success itself was difficult to achieve. In India, there were

several areas where malaria persisted. rather than resurged. As per one

estimate, in 9% of the total area of India, malaria persisted, since

indoor residual spray failed to control malaria in such areas, even

after 12-15 years of continuous application and these areas were never

brought under the maintenance phase of the W ( S h a m and Mehrotra,

1986). The reasons for continuous occurrence of malaria in such areas

lllny not bo 1110 silll~c oa in areas of ar:lual rt:surRcrlct:, slnco In caur! of

resurgence the strategy was useful but vigilance was inadequate and in

persistence the strategy itself may have failed or i t was not

implemented appropriately. In the whole of Koraput district, the indoor

residual sprays have never been interrupted since its initiation in

1953, and yet malaria continues to persist at high levels. Hence, the

existing malaria control strategy and the problems relating to its

implemen ta tion need to be examined.

Page. .2fi0

Malaria control in Koraput was initiated on a regular basis since

1953, when the area came under the MVCP, and then under the MG' from

1958. The modified plan of operations was introduced along with other

parts of India in 1977.

It is well known that malaria is essentially a local problem

(Huff, 1965: Gabaldon, 1969: Downs, 1981) . According to Sir Gordon

Cove11 [1949), the then Director of Malaria Institute of India "The

first point 1 want to etlphasize is that very wide tlilference exists

between malarial conditions obtaining in different localities. In the

study of malaria problems and in the formulation of control programnes,

action based on generalizations is likely to be followed by most

disastrous consequences. It has been well said that the most hazardous

of human tendencies is the drawing of general conclusions from limited

experience and in no instance is this more applicable than in the

planning of malarial control measures.. . ... Each locality has its

special problens, which lnust be Stlltlied with utlrlost care before

antimalaria measures are put into force, for method rvhichhas been

found successful in one place may be utterly useless, and even actively

harmful in another". A separate strategy for malaria control had never

been evolved for Koraput district as such. Hence from the point of view

of persistence, this was the first important 0bSe~ation. 'Ihe present

study in Koraput indicated that,

I . ?he physiography and meteorological conditions within the

district vary widely, so does the n~alarla sltuatlon (chapter:

5, 6 6 7).

[iil. The endemicity of malaria was different in different zones, in

different groups of villages within the same zone and even in

villages within the groups.

(iii]. The seasonality of parasitaemia was different in Malkangiri

zone when compared to Jeypore zone.

(iv). Age specific patterns of parasi taemia suggested that the level

of imnunity in the population varied in different areas,

resulting in different levels of fever and parasi taemia in the

population. The difference in 1, falciparum density index

between the synptmtic and aspptuinatic population in

different groups of villages in the two zones also suggested

this.

(v). All the lour human malarial parasites are prevalent in the

locality. The distribution and the abundance of parasite

species varied in different areas indicating different

malariogenic potentials.

Page. .262

(vi). Oevelopnental areas like Muran project site are inportant foci

of malaria dissemination.

The vectors of malaria and their efficiency were also diverse in

different areas. 2. f luviatilis, the most important and efficient

vector in Koraput is abundant in tophill villages of both Jeypore and

Malkangiri zones, where its survival is high due to the conducive

envirorn~ent. In Jeypore zone, the density of An. annularis was high in

foot hill villages and that of &. culicifacies in riverine villages

(VCRC, Annual Report. 1YRY). I t is well known that the ecology of these

vector n~osqui toes are different and hence their control (Rmchandra

Rao, 1984).

The above factors need careful consideration in developing

awropriate strategy in different areas within Koraput district.

Recently there has been enphasis on developing malaria control strategy

based on the epidemiological assessn~ent of local malaria problem, and

for this it has been advocated to consider village as a unit (MU,

1986a ; Kondrashin and Rashid, 1987: Greenwood, 19891.

The present strategy consists of the following:

(i) , fortnightly fever surveillance for detect ion of parasite

carriers.

Page. .263

(ii). Chmtherapy, and

(iii). indoor residual insecticide spraying

10.3.1.1. Probltnn relating to the strategy of case detection:

Tht, strategy of case detection through fever su~veillance alone

was found to be inadequate in Koraput, since a majority of parasite

carriers rained asynptmtic and a large proportion of them were

gametocyte carriers (chapters: 5 6 6; Figure: 2 8 ) . The routine fever

surveillance cannot detect asynptorxitic parasite carriers. Together

with inadequate cher~utherapy [chapter: 10.1), this is responsible for

the maintenance of high parasite load in the c m n i t y and thereby

persistence of the problem.

10.3.1.2. Problen~s relating to chemotherapy:

The strategy advocatetl by the M' for chelrotherapy of malaria

cases ( S h a m , 1984a) serves the purpose only partially. The present

study clearly showed thal the efficacy of the drug regirwns in parasite

clearance has declined over the years (chapter: 10.1). In areas, where

mala~ia is stable with very high levels of transmission, i t is ideal to

undertake mass prophylaxis/ mass chemotherapy, prior to peak

transmission period (Pampana. 1969; Males, 1988) and this will be of

great value in liquidatln~ the paras1 le load particularly in

aspptmtic persons. However, this is not carried out in Korapot

district. The methods employed for effective distribution of drugs

through trained village health guides (WG) are particularly useful in

remote villages. Though such methods are there on paper, their

functioning is poor (vide infra). The NMEP guidelines r e c m n d

prophylactic treatment of labour force which is moving from one area to

another ( S h a m , 1984a). As far as Koraput is concerned, there is no

malaria control activity in any of the developlent project areas. Ihus,

it is evident that the strategy of chemotherapy. has not been tailored

to the local needs and the existing strategy itself is not being

implemented in its totality.

10.3.1.3. Problems relating to residual insecticide spray:

The strategy of residual spraying with adulticide is aimed at

interrupting transmission by killing freshly fed resting msqui toes,

best described as ' Interception' (Gabaldon,l983). I t is unfortunate

tlint 1111 ontrx~x~lo~lcnl sl~~rly, wt~atsor~vr!r ti;rs 1m'nr1 carrinrl o11t ~lnco the

very inception of the strategy in Koraput district. Even after 3

decades of spraying, the inpact or rule of this rroasure, which alone

accounts for about half the budget of whole control program (Ray

al., 1989), has not been evaluated properly. -

Recent studies indicated that . An, culicifacies and &.

annularis were resistant both to LBn' and 14iC in this locality, but, An. fluviatilis, the most efficient vector in the district was still

susceptible to DET, BHC andmalathion (VCRC unpublished data). I t had

been deimnstrated that drastic reduction in malarimtric indices

resulted following DDT spraying for control of &I. fluviatilis in

Rayagada part of the district [Weeks, 1 9 5 1 ) . Hence the strategy of

residual insecticide spraying might still be an important and efficient

wthod of malaria control, but needs improvement in its impltmntation.

The entire district of Koraput was unr1f:r ULlT spray from the

beginning of the national program (1953). In 1972, DDT was replaced

with BHC in 26 of the 42 RCs. m e reasons for the switch over are not

mntioned in the records of the malaria office of the district. Since

entmlogical studies were never carried out, whether the change was a

conssquence of recmndations of any visiting team or was initiated on

a trial basis or was a outconie of short supply of DDT or excess supply

of BHC are not known: this practice however, continues even now [last

18 years!). A simple analysis of data available at the malaria office

s h m d that the EW: areas are continuing to record higher API cunpard

to WT areas (Table: 65).

Health being a State subject under the Indian constitution, each

State is theoretically free to modify the guidelines of the W to

suit to the local requlrmnts. In practice, this opportunity is not

utilized in Orissa unlike in Andhra Pradesh (chapter: 10.4).

Table: 65

Canparison of malaria situation in WTI BHC sprayed PHC areas in Koraput district.

Year DDT Area EHC Areas

API P f % API Pf %

Average 17.85 87.72 29.24 90.86 (1981-1986)

API: Annual parasite incidence per 1,000 population PfB: Proportion ( 8 ) of P. falciparm cases out of total

parasite carriers

The spray men lack adequate training and, the mxxlng and spraylng of lnsect~cldes 1s faulty. The practrce of mud plastering the walls make lnsectlclddl spray 1nefEecLlvr (Sections: 10.3.1.3 & 10.2.3.31.

10.3.2.1. Administrative problems:

The organization and administrative schemes relating to

antimalaria operations in the district is shown in Figure: 52. ?he

Chief District MBdical Officer [CtMJJ is responsible for the

implementation of all the health programs in the district, including

malaria control. 'll~e District Malaria Officer [W) assists the CLM) in

malaria control and is directly responsible for the operations. He is

assisted by Assistant Malaria Officer (MU) and Malaria Inspectors

(MI). All health p r o g r m s including malaria control are finally

routed and implemented through the Medical Officer, Primary Health

Centre (PHM). The DM3 gives directives to and co-ordinates with the

P H M for all anti-malaria activities. At the tail end of the

organization are the mu1 tipurpose workers IhW), who directly interact

with the ccmmunity in implementing all health activities. Apart fran

malaria surveillance, the other activi tics include family planning,

imnization, registration of births 6 deaths, public health activities

like reporting of disease outbreaks such as gastroenteritis etc. The

multipurpose workers are supervised by multipurpose supervisors. Each

PHC has a laboratory technician who is responsible for slide

examination, and maintenance of all records relating to case detect ion.

The district organization (for ant!-malaria measures) is linked

to the state organization as follows: the state malaria operation is

headed by the Joint Director [Malaria and filariasis), who receives

guidelines f r m the NMEP and gives directives to district authorities

(to CIM)) through the Zonal Malaria Officers [Few districts put

together form a malaria zone and there are three such zones in Orissa).

?he modus-operandi of antimalarial activities in the district is

described in brief. The multipurpose workers are to carry out malaria

surveillance by fortnightly fever surveys and impart presunptive

treatment. The technician stains, examines the blood smear slides and

reports the positives. ?he Multipurpose Supervisor/ Malaria Inspectors,

with the help of MPW impart radical treatment and they should undertake

epidemiological investigation of all malaria cases. The PHUKJ

coordinates all these activities and procures the drugs, stains, slides

etc. from the W. The other activity is the residual insecticide

spraying. Yearly two rounds of DUT or 3 rounds of B K have to be

sprayed depending upon the FtiC area. Tne insecticides are transported

from the state headquarters to the district and the IM) receives the

same and transports to the PHC. ?he IM) prepares the spray schedules.

He also receives the contingency money for spray operations. ?he PHUKJ

has the technical responsibility of spray operations. Actual operation

is carried out by spray squads which consist of one Superior Field

Worker [SFW) and five Inferior Field Workers [IFW) with two stirrup

punps. The SFW is the squad leader. For two such squads there is one

platoon leader to supervise the work. Usually the MW of the particular

section works as the platoon leader. R e Malaria Inspector (MI) and

Wl t ipurpose Supervisor (WS) are to supervise the spray operationr in

general. Overall, the MI is responsible for actual spraying in the PHC

areas allocated to him. The SW and IWs are supposed to be trained in

the spraying technique. The SFW has to give prior information to all

villagers about spraying and supervise the appropriate preparation of

DDT and technique of spraying, motivate the villagers to accept

spraying and advise them not to plaslrr thc? wal Is, wri to tho stencil on

walls and keep all records of day to day operations (coverage, refusals

etc. 1.

'he administrative problems which arise in the above setup are as

follows.

(11. While at the state and district levels the health p r o g r m s

still remain vertical, at the grass root level the programne is

implemented horizontally by the Mllhis, There are separate

divisions and officers for malaria/ family planning/ public

health/ t~~herculosis etc., but a1 l those actlvl ties are carried

out in the field only by MRlls. Cepending on the pressure and

priorities of local authorities, one is bound to neglect one or

the other work. In concept, the emphasis on implementation of

malaria control through the primary health care delivery system

is extremely good (W, 1984: Fyakalyia, 1989) . However, one has

to consider the feasibility in relat-ion to different areas. There

Page. .271

are certain general problems relating to feasibility of MW

scheme in Koraput district (Rajagopalan and Das. 1988). 'lhe area

is vast and the terrain is difficult, there are hardly any

cmnication facilities and the health problems are too many.

Hence the actual work load of the MW is several times greater

campared to his counterpart in the other districts. Since a

majority of the population consists of aborigine tribals, who are

poverty stricken, their priorities are different [also have their

own beliefs, faiths, cultural practices: vide supra), i t is

expected that MPNs have to spend a great deal of time to collect

right information and carry out their work.

(ii). There is a gross imbalance in authority and responsibility. ?he

M W s play a pivotal role in surveillance. Though activities of

all MPNs are same, they come under three categories: a) W - family planning, h) MPN - public health and c) MPW - malaria. 'These three ca tcgories were originally assigned to different

duties when the programnes were vertical, but presently all of

than perform the s;ul!e type of work. Wt~ilo their responsibilities

are same at present, their disciplinary authorities are different

(Figure: 52). This is because the funds for their salaries and

other allowances are drawn from different heads and budgets.

Thus the DM) is the disciplinary authority only for the W/ WS

of the malaria division. ?his results in different groups of W/

Page. ,272

WS, being more loyal to one programne than to the other. The

P W M is the controlling authority for all lvPWs and has to

take work from them in the field, but has no authority over

them. One can only report matters.

According to the priorities of the authorities, money is

allotted in tlme for some prograrnnes only. For example family

planning receives the highest priority and therefore staff

under thls division receive their salary and other m l m n t s

in time. Whereas, for the workers in other divisions, it is

delayed inordinately. In 1987, the then Uvfl reported that his

staff had not received their allowances for over two years.

This has resulted in frustration among the workers.

Iiii). ?he other factor relating to administrative policy is that

there are incentives and disincentives for some p r o g r m s but

not lor r~i,~larla c.c~nlro1. For cx;ali11lc, a MI"# is glvorl f lr~ancial

incentive for motivating people to accept farnily planning and

in case one fails to motivate the required nmber of persons,

not only one is asked for explanation but also liable for

disciplinary action. This is not only true for MPWs but also

the PHCM)s.

(iv). In the whvle administrative structuce and in implemntation of

Page. .273

the program, the representation of the comrmnity is conspicuous

by its absence. The comnunity has no opportunity to put forth its

views, priorities etc. The whole system is based on primary

health care concept, where c m n i t y is expected to play a major

role (Ghai, 1985). 'The need for community involvement for malaria

control has been discussed elsewhere (Rajagopalan and Das, 1988).

Iv). It needs to be further examined, whether the health personnel,

responsible for implementing malaria programnes are suitable for

the job. In Orissa state, the post of I30 is held by medical

of ficers, who are gynaecologistsl paediatricians/ surgeons etc.

They accept the posting, because of promotional avenues, but try

to get transferred as soon as they join. It was not surprising

that in Knraput, there were 5 dlffnrnnt DMls in 4 yoarfi

(1986-1989). The other factor is that the LM)s appointed, rarely

have any practical experience in malariology, which makes them

dependant on their subordinates. In many other states like Andhra

Prarlcsh, Tan111 NaOu etc, tho pofit ol is occupied by

entomlogists and who have years of experience in practical

malariology.

(vi). There is no in-built system of training under the present

organization. No one in the organization has ever seen

P , malariae, hence i t is impossible for anybody to recognize the - - same, lhough 1. malariae was recorded in this area in pre-IUT era (Perry, 1914, Senior White, 192tl ) and in the present study,

not a single case was reported from the very inception of the

national program. Discovery of 1. has added to this

problem. Training of spray squad in practical aspects of the

operation is extremely important, but none of the SnVs or IFWs

are trained. (During a spray operation one IFW was found applying

WI' on d wound in 111s leg, since he thought that WrI' anyway is a

mdicine ! ) . The IFWs are invariably tribals who work for daily

wages. Since they are nos tly i 1 l i tcra te and ignorant. their

training is of utmost importance. According to a review cornnittee

report "training provided is inadequate and insufficient to meet

the needs of the country and there is an urgent need to

strengthen training at all levels" (Anonymus, 1985a).

(i ) . Resources:

Resources are of vital importance for any control operation. The

entire national programne was funded by the central govermnt until

the fourth five year plan. Fran the fifth five year plan period

(1975-80) the national programne is a centrally aided scheme with 50:50

Page. . 275

cost sharing between the centre and the states. During the period

1980-85 while the NMEP (centre) expenditure was Rs. 300 crores, the

total expenditure of all states put together was only Rs. 194 crores

(Anonpus, 1985a). It is obvious that many states (of which Orissa is

one), could not meet their 50% share. The resources generated by

different states varies. Depending upon what priority malaria control

progranrne receives, the money is allocated. ?his has resulted in poor

quality of operation in backward states like Orissa.

lhe broad heads of expenditure of national progrrurme indicates

that about 50% expenditure is incurred on insecticides (which is met by

the centre). 30% on establishnent, 15% on drugs and rest on equipnent

and transport (Anonyous, 1955a; Ray g g., 1959). The establishnent

and operational costs are to be met by the States, which when

inadequate result in failure of logistics. The annual expenditure of

a:~tin?alarial operations of Koraput in different years (1981 - 19851, is

shwm in Table: 66. I t is evident that there is no specific allocation

lo necl operalional costs.

Shortage of funds has led to change in strategy in Koraput

District. The authorities have decided to undertake spray operations in

the sections (groups of villages] which record API 10 or more per

1,000 population. The lower limit of which, according to the national

p r o g r m guidelines is 2 per 1,000 population (Sham, 1984al. Malaria

does not recieve the priority that i t deserves.

Page. .277

Reviewing the spray operation in Orissa, Ray g c, , (1989) write "Despite the highest priority accorded to the supply of insecticides to

Orissa and operational plan drawn up by February each year, i t is only

on rare occasions (such as in 1986) that first round could start fran

the beginning of May. As a rule, it has been delayed every year by

weeks and scmetimes over a month and prolonged over a long period. In

view of this, the second round is delayed flnd has of ten to be stopped

when the operation has gone beyond the transmission season". They

reported that the failure was primarily due to lack of funds.

(ti). Staff position (as per latest information in 1989):

One of the three posts of MU in the district is vacant since

1987. Of the 75 sanct toned posts of Surveillance Inspector

(Wltipurpose Supervisor) 5 are lying vacant from 1977. 14 post of

Surveillance workers out of 283 allotted are also lying vacant from

1978. Two posts of I.aboratory Technicians out of 45 are vacant since

1977. Nunber of sections were increased from 283 to 529 in 1983,

however there was no corresponding increase in the post of MW3. An

individual worker covers a population of 9,104 against reccmnended

5,000 in difficult areas in general (Anonpus, 1985a; S h a m , 1984al.

Considering the hilly terrain, the absence of cmunication facilities

and the nature of the population [mostly tribals), the task of

surveillance worker is of a tall order.

Apart frau the MlWs, there are village t~oalth guides ( W I G ) , who

are trained at PHC and given free medicines to be distributed to the

villagers in remote areas. They are supposed to collect blood smears

from all febrile cases in the village and impart presunptive treatment.

According to the data available there are 647 VHGs in Koraput district.

however in a year each VHG collected only between 12 and 22 smears on

an average. Every WG is paid Rs. 50/- per mnth and thus the programne

spends Rs. 388,200 for these guides in a year. In reality, these VHGs

take advantage of remoteness of the area and ignorance of the people

and carry out illegal private practice using the supplies from the R1C.

&st VHGs are selected on political grounds and the R 1 0 cannot

improve the situation.

[iii). Equipnents and supplies:

In one PHC (out of the 421 , there is no supply of electricity. Of

the 42 microscopes in the district, 11 are under repair for over 5

years arid there are no facilities and funds for repair of lnicroscopes

nor any now rnicroscopes supplied. None of the laboratory technicians

are trained on maintenance or repair of microscopes. lhe total nunber

of sprayers (stirrup pmpsl required for the district is 277 and there

were a total of 537 punps, of which only 162 were functional. There is

M provision for repair of sprayers as well. The IM) office requires

one truck, two jeep trucks and two jeeps. On official records, it has

two jeep trucks and two jeeps, all of which are off the road and only

one jeep truck is in repairable condition, for which the repair is not

undertaken due to lack of funds. The required amount of drugs and

insecticides for the district and armunt supplied by centre/ state in

1985 (Latest information available) is shown in Table: 6 7 , 'This clearly

shows that the supplies are inadequate.

(ivl . Supervision and impact assessment :

'There is hardly any supervision of tho control operations. The

illW and I l ~ c dlstrict authorities Ihcrr~selvcs are not well trained in

practical malaria operations. When they themselves cannot recognize the

parasite in peripheral blood, i t is difficult for them to cross check

the findings. While the n-1UvDs are hardly aware of the technicalities

of spray operations, they are responsible for over all supervision of

all operations. The number of villages under a PHC is large Ie.8. 328

in Borigumna PHC), hence i t is improper to expect the MI to visit all

these villages for supervision. During initial stages of national

prograrrlte stenciling on tl~c? wall by survoillar~r,c workers was a nust and

regularity of his house visits could be ascertained from the same, but

this practice has been given up in Koraput. Supervision could still be

done by surprise visits, mass blood survey and looking for P.

falciparm gametocyte rates etc., but no one seems to have the time to

do it due to other preoccupations. In fact, a review cmittee report

reads "The lack of knowledge on the exigencies of antimalaria practices

m n g the district medical officers and PHC doctors is also a major

Page. .280

Table: 67

Supply of different items against their requirements for malaria control operations in Koraput district.

Required SUPP~S by State Govt, of India Purchase

Tab. chloroquine 30,00,000 Tab. jlrinlaquine 30.00.000 Tab. quinine 2,OO.OOO Inj. quinine (vials) 2,000 Inj. chloroquine (vials) 1,000 Micro slides in gross 500 DDT (75% W P ) in MT 125 BHC (50%) in MT 450 Dizinon in Kgs. 200

(SOLIRCE: District malaria authorities. 1985)

Page. ,281

factor in the degradation of the anti-malaria programne, particularly

in states with limited resources and high to very high ~nalariogenic

potential" (Anonymus, 1985a).

There is no inbuilt system for impact assessment. In the mnthly

review meetings (held at the CIM) office) emphasis is given on targets

ol fanily planlilng rillhcr than n~alarla. k s t III1m use thc opl~ortuni ty

to get their files [relating to funds, supplies allowances etc. 1 mving

in the CCM) office. No control progranme will be successful, without

vigilance.

( v ) . Intersectoral collaboration:

Collaboration is necessary for control of malaria particularly in

developental project areas. Several governmental and other agencies

(irrigation/ power/ industries departments, and malaria authorities

etc.) are involved in these areas and coordination amng these is

essential to take appropriate preventive measures. However, there is no

intersectoral collaboration worth the name. Malaria control activities

are virtually nonexistent in any of the developnental project areas.

Tne present study in Muran showed that such areas are potential source

of spread of malaria.

(vi). Studies on some operational aspects in one PHC area:

Page. ,282

Detailed studies were also carried out on some operationa

aspects in B o r i g m PHC area and the results of these are discusse

below.

a]. Cqarison of surveillance carried out in the 22 villages in

B o r i g w PHC in the present study suggested that about 45% of mlaria

cases are being missed in a year, under the national program (Table:

35, chapter: 61. There are several problems resulting in ineffective

surveillance under the national programne. Actual dour to door visits

are not made every fortnight, since the target population is high i t is

not feasible to do so in difficult terrain. The work load of W s is

too high, he collects slides mostly from villages in and around, the

one in which tie stays. These findings corroborate with the observations

lnade cerlier 1)y a review coli~nittee (Anonyms, lY85a).

b). There is only one technician for slide examination in the

1IIC. According to Uorl jiulrrla IJHC dala, 111(? teclmlclan tiad examined

18,963 slides in a year (1985). Keeping in view of holidays (comnuted

and other leave not included), the technician would have worked for 255

days, examining 70 to 75 slides per day on an average. Since there is

no other technician, he also carries out other routine investigations

for the out and inpatients as directed by the P H O (includes routine

hemgram, urine/ blood examinations etc.). He has a primitive

monocular microscope, which has not been serviced for years. Hence, i t

is not surprising that he failed to,dotect many positives. If

surveillance was done properly, since 40% of the population have at

least one at tack of fever in a year and one could expect a total of

44,000 slides [total population of the PHC = 107.652) to be collected

in the PHC. To examine these slides, at least four full time

microscopists (and good rnicroscopesl will tm required [in conparison to

slide examination rate of approximately 40 slides per day per person in

the present study).

c]. For a case with P, falciparum infection, 45 mg of primquine

is given as radical treatment, which is usually 6 tablets of 7.5 mg. In

1984, the district authorities did not receive any 7.5 mg. primquine

tablet but received 2.5 mg tablets. In this case, an adult case with P.

falciparun~ infection has to cunsune 1 8 tablets for radical treatment.

The tribals suspect the same for a medicine, that might sterilize them.

Hence they were reluctant to consune the tablets. The stocks of

pl imaquine surlplied arc of ten discoloured and of poor quality. There

were several occasions, vjheri the HI0i.U had con~plained about this to the

LM) and the CIM).

d). Since there is no routine method of collecting blood smear

slides on regular basis from the hlPWs, these are brought to the PHC

irregularly, either when the PHUvD visits the village or when W s

visit the PHC. Hence the slide examination and radical treatment get

delayed.

el. To study insecticidal spray coverage, in 7 villages a team

accarpanied the spray squads and supervised the spray operations. In

these villages tho villagers wcre motlvatcd by tho taam to accept the

spraying. In four other villages, the team did not participate in the

supervision but visited the villages, the day following the visit of

the spray squads. In these villages details of unsprayed holdings due

tn rolusnls nnrl Inr:knd holrliri~s worc nr~tnd nrtrl all t t l ~ ! hr~lrlinfls worn

physically verified for the purpose. To estimate the actual requirement

nf 1)1T, avt:riljit, sprayahlc surface ares of tho holrling~ wr3rp rlntorminod

by randomly sampling 10% of the holdings in the village. The results of

spray coverage study are sumnarized in Tables: b f l and b!l. In 4

villages, where spray was undertaken without supervision, only 4% of

holdings were completely sprayed. The spray coveraee in the villages

where direct supervision was done, 35.79, 1 4 . 5 % of the total holdings

wc!ro canpletely sprayorl in 1st and 2nrl rounrls respr?r:t ivt?ly. In the

second round both refusals as well as absentees wcre higher due to

[:r~i t~r,i~l~!~rr;~~ of I~iirvr!sL 1 1 1 ~ f ~ l ! r , ~ t r t l wl [I) sltr tty r~[lr!r,tI ir~r~.

1 ) . 'The UUI' allull~a:rrt is usually 1rt~de lor a village or1 tlte basis

of its population, i.e. 5 Kg/100 population/round; but actual

consunption depends on the spray surface. In the four villages, the

amount of DDT requirement was worked out to be 170 Ibs of 50% WDP and

207 Ibs of 75% WDP against an allotment of 130 Ibs of 50% WDP and 232

lbs of 75% WDP. All the 5 punps were discharging DIJT at rates much

higher (Kange 1,020-1.2(iU ml/n~inute) than desirable (between 738.4 to

Page. ,287

922.4 ml/ minute). The n-r of spraymen engaged was found to be less

than allotted. Instead of five squads, only four were working.

Supervisory staff like the MI or h.BW w r e not present. 'this reflected

on the poor quality of the operation.

10.4. W I A C m O L MFASURES IN T W DISTRICTS OF AVER4 PRADESH,

ARIOININC KORAPUT DISIRICT:

The malaria control operations in the two districts adjoining

Koraput was also studied to compare with the situation prevailing in

Koraput. For this purpose repeated visits were made to the districts

and apart fron~ collecting ma1arirmn:lric data, rletailud discussions were

held with the W s and other staff concerned with malaria operations.

' l ' l ~ ! ~~~nlariri~~u'trir. ~I:I~;I II~v [ ? II~!I!II ~~r~!sc~nl~;fl f!arlicr lct~apter: 4 ) . The

organization pattern, strategy and control operations in these two

adjoining districts of Ar~dhra Pradesh are presented in brief below.

(i). From the organization point of view, the whole set up in Andhra

Pradesh is more comprehensive [Figure 53 and 54). The posts of

Additional Director (Malaria), Eeputy Director [Malaria),

Assistant Director (Entmlogy) and Health Supervisors (HS)

oxistlng in Andhra I'radesh are not there in Orissa. The posts of

Doputy Director (Malaria), IM), and NvQ are occupied by

MIYISTRY OF HEALTH FAMILY *ELFME I - GOVT. OF & . D m PRADmH I-._

; I

i 1 1

DIRECTOR OF HEALTH kUD I F M L Y WELFARE I

ALL UIYT. HUSPITAIS EXCLUDING I 1 TEACHING t Ia5PITAIS lOISTF3CTl , ADDITlONAL DIRECTORS ( 9 Nffi .1 1

T A L U K I S P E C W S T ETC. 1 16 MEDICAL AND 3 M L I I M S m $ T N E AC6)

I I

ADDITIONAL DIRECTOR (HAUWIAI (MEDICAL I

I I

OEPUTI DIRECTOR (MALARIA ( 2 xffi.) lOXE FOR C N I R A L MALARIA LABORATORY

AND DTHRI FOR E.WOMOLOGY1

HEALTH o f n c ~ ~ s I3 TO 5 MEDICAL1 --.

',A[ MEDICAL UYIVERSITY I * TEACHING HUSPITALS I

- > - - - - - - - - Work Channt?l -

- Adminismtive C o n W l .. . .. -. p a r t i a l AdminisVahve ConWOL :

' ., - - v * C 6 s

&ST- DIRECTOR (EKmMOLOGy 6 Na5.)

FIGURE: 53. The arganizational and administrative echele of anti-lalaria operatiooe in Andbra Pradeah.

Page. .290

entmlogists. In Orissa, the post of Chn is occupied by

medical personnel.

The CM) is the disciplinary authority for the staff under him.

'I'lle stall 118s b w n reallr~cated in sur;l~ a way lllat there is a

concentration of personnel in the difficult areas [agency

areas: chapter: 4). In Vishakhapatnam district, over 80% of

111alaria cases are reported from the agency areas. For a

population of 4.23.000 there are 2 AM)s and 9 HSs in the agency

area, whereas for a population of 20,00,000 in the plains

(where malaria problem is less), only one lnl3 and 6 HSs are

posted. Similar reallocation has also been made ill East

Godavari district. Thus the target population to be covered in

fortnifihtly survr?illance in the hilly tribal areafi was

Z,839/worker in Vishakhapatnam and 2,22Z/worker in East

Godavari (against over 9,00O/worker in Koraput).

(ii). The whole programne is being implemented vertically with

unipurpose malaria workers in entire Vishakhapatnam and Agency

areas of East Iiridavari district.

( iii). l'hnre is no stirirtng~! nl resourcfls, hr~ricr? thr? Ingist ics are met

with adequately. The required quantities of insecticides and

drugs are supplied prooptly. Vehiclbs are repaired in a central

workshop. New vehicles are allotted when required. Both the

districts were allotted new Jeeps and mini trucks in 1988. The

contingency money is also reported to be adequate.

lv) . '1'111, surv<!i 1 18itif:1- CII t ivi 1105 a r e r~f!rinr~~~!ri 9:1t l~rr~~,lr~rl ly. 'r'h~!r~!

are several reasons for this. The strict enforcenent of

slt,nciling by a I;clverrunr1nt order (failure trl write thc stencil is

taken as absence), and adequate supervisory staff make this

possible. Sinc;. the scheme of unipurposa workers is being

followed, high quality discipline has been enforced. Apart from

routine fever surveys, mass and contact surveys are also carried

out regularly to detect as many parasite carriers as possible.

'U IU NlU< ICII. tllusl! tlistricts (11,lrl ir.t~larly 111 agunc.y areas) is

much higher compared to Koraput (chapter: 4 ) . The proper

allocalion of staff and lowering of target por~ulation with

adequate supervision has enhanced the quality of surveillance. In

Vishakhapatnam district, a local tribal accori~panies the

surveil lance worker to relnote inaccessii~la areas as a helper,

also giving the worker a sense of security and company. The

malaria surveillance workers ordinarily give only chloroquine/

primaquine tablets, but the villagers in r m t e areas have

several c m n ailments for which they seek treatwnt from these

workers. Hence in Vishakhapatnam district, all malaria workers

have been trained to treat nine caman silmnts. This has

resulted in better acceptability of the workers by the villagers.

Page. ,292

Incentive in the form of rewards to 10 best surveillance workers

lles also resullud 111 Ilealll~y cunpetitive spirit.

lv). Coverage in chwtherapy has been improved substantially by

opening backlog c:lc?arlng centres for rapirl slide t!xnminat ion in

agency areas. Two extra technicians are posted in these centres,

who are not attached to any PHC. Apart from this, there are extra

technicians (5 in Vishakhapatnam and 6 in East Godavari) at the

headquarters attached to the DvD. These technicians share the

load of slide examination during the peak transmission season (at

the time of necessity they are deputed to the field) and perform

cross examination of slides during other times. Hence the radical

treatment is not delnyud. Apart from trrstnsnt of parasite

carriers detected routinely, in high risk areas (where population

nlov~wnt is hiah) Ina';s r.l~eln~theral~y or contact chtrrr~therapy [all

family members of a parasite carriers) are being carried out in

East Godavari district to liquidate parasite load in the

camiunity.

(vi). The spraying schedules are adhered to strictly and this has been

possible since there is no failure in logistics. Though there are

normally two rou~ds of UUT spray, additional selective rounds of

sprays [sonetimes two) are carried out in high risk areas. In

Page. .293

Vishakhapatnam district, the UvC has enforced that either a

holding is completely sprayed or not at all. Health supervisors

lave to be present on the spot throughoul the spray season in

respective villages. This has resulted in high degree of

coverage ranfling From R5-91% of holding3 in thr! trlhnl arms.

Howevw. the problem relating to mud plastering still exists.

In East I;odavari district , apart from indc~nr residua! :.praying,

larviciding of breeding habitats in and around the problematic

villages by 'Abate' is also carried out. The selective rounds

of spray and larviciding operations indicate the role of local

;~uthori ly in tlr?r:irlirlji thr! stratt!gy in a flcxit~l~? 1rIijrlnr:r.

(vii 1 . ilolti thr! (iislr; cis \lave I J ~ O I I I ~ ! I I I ~ r1!1:1 t ;nfi t o I;I~IIIII~ II I ~ grat Ion.

Labour force frnln several adjoining districts including

Korap~~t, IrlrJvr3 1r1 t111,s1: Lwn 11istrir:ts lrlr t~t~rtlbr~o cuttlng (since

there are two paper mills one at Bhadrachalam and the other at

Rajnundry), road building etc . (Ray t &., 1989). The local

authorities have taken cognisance of this factor. In East

Godavari District, the labour m v m n t is highest in

Maredumalli and Y . Ramavaram PHCs. Analysis of data for 6

nlonths (January to June, 1986) showed that out of the total 236

parasite carriers detected in 12 sections (which involve labour

ll~~vr!ll~~ll~ 1 , 21!1 ( 0 2 ,fit) r;,lSl!S wt!rr! il'11111 vl 1 iagl!5 wl ttl ~ L I ~ J U P

camps/ rnovmnts and the rest 1 7 ( 7 . 2 % ) w r e from villages

where the population was static. 1n'~. Hamavaram W, during

Page. ,294

the same period, out of 300 parasite carriers 293 (97.07%) were

from villages with labour movmnt. According to the PHC

authorities and the LM3, a majority of the labourers was from

Malkangiri area of Koraput district. In Vishakhapatnam district

similar prnhlerns existed in Ramn[~achodavaraun I'IIC. In both

districts, the authorities have taken steps to manitor labour

nmvmnt at strategic points and all labour cmps are under

surveillance by special teams. Blood examination of all

labourers is done imdiately after arriving and before

departing the areas. All incoming labourers are given

presumptive dose o f ctllnroquine. Apart from this, the state and

district authorities keep vigilance on malaria situation in

bordering areas, Tho (rr~verment n f Andtira Pradesh has invited

malaria authorities from neighbouring states and districts for

reviewing the ~ n a l n r i a situation in bortlor art:ns ( 0 such

wetings ware convenrd t~r.twen 1985 and 1 9 8 H l .

(viii). There is s m degree of intersectoral collaboration in

Vishakhapatnam district. Apart from the malaria control

organization, Integrated Tribal Ddvelopent Authority [ITIN) is

also actively involved in the agency areas (these areas record

about 80% of all malaria cases in the district; chapter: 4 ) .

Both the organizations work in close collataration. The ITIN

conduct& a socio-economic survey of the entire agency tract

Page. .295

utilizing the services of the malaria surveillance workers

(during 1985-86) and its d~velopwntal programs are based on

the data collectuci by these wrlrkwrs. l't~r! 1'IW [lrrovides the

funds (medicines etc.) for the "9 ailment treatment" p r o g r m

by malaria wr~rkllrs. TIIH assistance in ttil! fonn of loans etc.

are given to the villagers by the I W , only when the malaria

worker certifies about the genuineness of the request. This has

boosted the image of the workers thereby obliging the villagers

to cooperate with tlio~n. Apart from this, th~? IIW also provides

the funds for payment of daily wage workers who accompany the

malaria workers to remote villages. Further, the district

collectors of thest! two districts have ensured that family

planning is rlorie only for those who sr!uk by choice in the

tribal areas. Ibis relaxation enables the I?ICM)s to concentrate

on public health ar:L ivi t II! ~ includlrlg malaria.

(ixl. A malaria training cenlre has been established at Krishna Dev

Peta in Vishakhapatnam district. This centre is located in the

foothills in a tribal agency area, which involves labour

m v w n t . Hence practical training on all aspects of malaria is

possible. This field training centre is well equippd with

modern audiovisual tools. This centre is the only one of its

kind in Andhra Pradesh, where trai~ing is imparted to all

staff, from surveillanct! workers to PHC medical officers.

Page. .296

The situation in these two districts, adjoining Koraput showed

that malaria control (if nnt eradication) is possible in hilly and

difficult areas, provided. there is will to do good, adequate resources

are available, and, the local authorities are given a free hand in day

to day operations. The success depends basically on individuals, who

have not only technical hut also managtrial skill. The importance of

the role of the local authorities in achieving disease control is well

known (Gusmao. 1982).

However, with all these encouraging results obtained, the foci of

transmission have not been cwnpletely eliminated from these areas. For

this. several factors such as the degree nf asynptnmtic parafii te load.

efficiency of local vectors, resistance status of parasite to drug and

vwtor t o i nst!c:t l[ ; i ~ i ~ ! III'OII ~;1roIt11 ci~r~sifif!rat ion. 1'111!r1! is IIO in bull t

system of in~pac t assessn~ent of different methods. Entomological

studies carried out were far from adequate.