Trapped in terrain: how a range of factors complicate Gadchiroli’s fight against malaria

This year, over 2,060 malaria cases have been identified here and three deaths have been reported so far, said Avishyant Panda, District Collector, Gadchiroli. The district reports malaria deaths every year – 13 in 2022; 12 in 2023 and 14 in 2024. The year 2021 saw the most cases in the last five years – 12,326, though only eight deaths were reported that year. Over the last five years between 2019 and 2024, a total of 51 deaths have been reported, as per the data provided by the malaria task force.

Starting April 1, this year, Gadchiroli launched a comprehensive malaria eradication plan. A Malaria Eradication Task Force was initiated under the Public Health Department and chaired by Dr Abhay Bang, a public health expert and the Founder and Director of Society for Education, Action and Research in Community Health (SEARCH). Chief Minister Devendra Fadnavis also announced to allocate Rs 25 crore for the initiative through the Tribal Development Department.

“This year, the rain started in May. Usually, rain starts in mid-June. And so, small water collections have occurred in the forest everywhere. Hence, mosquito breeding has started much earlier. That is why the task force has cautioned the district administration that there is a likelihood of an early upsurge in malaria cases this year. And we have to be prepared to face a rise in cases this year on a war footing,” said Dr Bang.

Terrain and other key challenges

The district faces several geographical and environmental challenges – 76 per cent of Gadchiroli is covered by forests and hills, hindering development. Dense forests, rivers, and hilly terrain create ideal conditions for mosquito breeding, say sources.

High transmission of Plasmodium falciparum (PF) – one of the two primary species of malaria parasites commonly found in India – is frequently observed, particularly in tribal blocks, and malaria demonstrates persistent and perennial transmission, with peaks occurring in July-August, according to the task force data.

While Plasmodium falciparum is known to cause more severe and potentially fatal cases of malaria, Plasmodium vivax is generally considered milder.

Panda told The Indian Express, “The district is working on the availability of drugs and logistics for which we are specifically targeting three talukas that get cut off.”

Distribution of LLINs by members of the task force. (Express Photo)

“In malaria-positive cases, there has been a difficulty regarding whether to take blood smears. Every year, nearly 10 lakh blood smears have to be taken in the district. But really, microscopy of 10 lakh blood smears is a Herculean task. Then, a backlog develops. Hence, the task force has decided that all fever cases should be instantly examined by what is called RDT, Rapid Diagnostic Test. So, within 15 minutes, the result is available. And if it is positive for malaria, the patient is treated. So, every fever case must be tested by RDT as a regular practice,” informed Dr Bang.

He added, “There is an implementation committee to carry out this plan, under the chairmanship of the collector. So, this has not remained merely a health department programme. The collector, zilla parishad CEO, and the health departments are all involved, with the collector chairing it. The implementation would therefore involve various other sectors of the administration as well.”

Socio-cultural factors

There are other socio-demographic and cultural factors contributing to the issue. Ninety-seven per cent of the population lives in rural and tribal villages, which are often scattered and difficult to access. Locals often prefer traditional healers or pujaris for fever, leading to delayed malaria diagnosis and treatment. Risky practices such as outdoor sleeping and non-use of long-lasting insecticidal nets (LLINs) further increase the risk of malaria. Poor socio-economic conditions, low literacy, and lack of hygienic conditions are also contributing factors.

“We are trying to increase the testing efforts and routine surveillance. The RDK (Rapid Diagnostic Kit) method is being used for diagnosis in the field, and when a case is found positive, the first anti-malaria dose is administered. IEC (Information, Education and Communication) activities are also being carried out in Marathi and Madia languages,” Panda said.

“A school IEC programme is also being launched, with nodal teachers being appointed, even in ashram schools, because these are also used as shelter homes during floods. It is also being ensured that the school IEC programme benefits the parents as well,” Panda said.

‘Some never reach institutions’

Talking about factors associated with delay in treatments, Dr Bang said. “There are several delays. There are various superstitions linked with fever in tribal areas, and people usually don’t seek help immediately. They first go to the pujari. Then the pujari does his process, and so two–three days, sometimes even five days, are wasted there. From there on, most of the patients can actually be treated in the village itself by the ASHA workers (Accredited Social Health Activists) or the ANMs (Auxiliary Nurse Midwives).”

“But a small percentage, maybe 5 to 10 per cent, have more severe malaria and they need hospitalisation. So they are appropriately selected and referred to the hospital for treatment. There are delays that occur at every level. Besides, some people never reach institutions. And so certain measures have been decided on how we can avoid this,” Dr Bang said, adding that the task force also plans to seek pujaris’ cooperation to tackle this issue.

Full-scale Indoor Residual Spraying at high-risk areas in Gadchiroli. (Express Photo)

“I recently held a meeting on anti-superstition practices with the police and revenue machinery. Here, malaria patients are often taken to pujaris. We have almost 2,000 pujaris in the district, so we have mapped them, and we want to start a programme where pujaris encourage people to go to medical facilities rather than treat them on their own. Deaths occur when medicines are not administered in time,” said Panda.

Dr Bang adds, “Of all the malaria deaths reported in Gadchiroli, nearly half of them are in children below 15 years of age. And world over, children are more vulnerable to malaria and to more serious forms of it.”

Small villages, manpower shortage

Three hundred villages lack Accredited Social Health Activists (ASHAs). There are also long-standing vacancies in vital manpower positions like Multi-Purpose Workers (MPWs), Auxiliary Nurse Midwives (ANMs), and technicians.

“The peculiarity of the Gadchiroli district is that, especially in the tribal areas, village sizes are very small. There are nearly 100 villages with a population of less than 100. So, for Gadchiroli, the ASHA norm has been relaxed by the Government of Maharashtra, and smaller villages are allowed to be included. So, an additional 191 ASHAs will be recruited for this need,” informed Dr Bang. He also informed that 200 positions for multi-purpose workers were filled recently.

He added, “Yet, nearly 100 villages remain where you can’t imagine having an ASHA because the population includes hardly 10 to 15 homes. So there, we have decided that a resident in the village who is literate will be trained to use RDT and diagnose malaria.”

Identifying villages that are more prone

In 2024, 159 villages were classified as Category A (Annual Parasite Incidence (API)&gt;50), indicating a very high malaria burden. Additionally, 357 villages were Category B (API 5-49.99), and 1,183 villages were Category C (API <4.99). Across six tribal blocks, 19 Primary Health Centres (PHCs) are classified as High Malaria Endemic with API>2, affecting 3.2 lakh people. Similarly, eight PHCs across six non-tribal blocks are High Endemic with an API >2, affecting 1.3 lakh people. This makes a total of 27 priority PHCs.

Bhamragad, a tribal block in Gadchiroli which alone had over 174.3 API in 2021, contributes over 40 per cent of the cases in the district. Dr Supriyalakshmi Totiger, Deputy Director, Community Health Research at SEARCH, and a member of the Malaria Task Force in Gadchiroli told The Indian Express, “Bhamragad has very thick central Indian forest. With that kind of ecosystem, you tend to find a lot of breeding sources easily available in the natural ecology, so removing mosquitoes and reducing mosquito density is difficult in such places. That is a major contributor to malaria in Bhamragad.”

In Gadchiroli, PV and PF in the context of malaria refer to Plasmodium vivax (PV) and Plasmodium falciparum (PF), respectively. These are the two primary species of malaria parasites that are commonly found in India. Plasmodium falciparum is known to cause more severe and potentially fatal cases of malaria, while Plasmodium vivax is generally considered milder.

Taskforce sets 2027 target

“The last stage in malaria elimination is eliminating it in tribal regions. The task force identified 29 PHCs (Primary Health Centres) as high-risk areas in six tribal blocks and eight PHCs in non-tribal blocks. This covers around the population of 4.75 lakh, which is high risk. Hence, Bhamragad tops the list, followed by Etapalli and then Dhanora,” said Dr Totiger.

“One of the powerful strategies in tackling malaria, also recommended by the World Health Organization (WHO), is the use of LLINs, that is, long-lasting insecticide-treated bed nets. Under the Malaria Mukta Gadchiroli Abhiyaan, the task force will distribute 5 lakh LLINs, so that every family will have one mosquito net per person,” informed Dr Bang.

Collector Panda added, “For identified high-risk areas, we are conducting full-scale Indoor Residual Spraying and LLINs distribution. Fifty thousand LLINs have been procured and distributed so far.”

The task force aims to achieve zero deaths due to malaria by 2027 and an API of less than one. The task force has also been supported by the Bill & Melinda Gates Foundation, Foundation for Disease Elimination and Control of India under Sun Pharma, Godrej Foundation, Indian Council of Medical Research (ICMR), and the National Institute of Malaria Research (NIMR).

“The main season of malaria starts from July onwards. So, we have to wait and see what happens this year. It depends so much on the climate, rain, etc. Worldwide, malaria occurs cyclically. Every five or six years, you get an upsurge. The last upsurge was in 2021. So, one would expect, as a part of the natural cycle, another upsurge in 2026 or 2027,” Dr Bang said.