To be fair, Odisha has made significant strides in tackling its malnutrition problem. The infant mortality rate has dropped, the under-five mortality rate has decreased, while anemia in children and pregnant women has also reduced. Several tweaks, such as decentralizing the procurement of supplementary nutrition, under the Integrated Child Development Services Program have yielded benefits while the state has also set an example for other states by converging its health, nutrition and WASH (water, sanitation and hygiene) programmes. Larger problems still remain, with a stark difference between its urban districts, and the tribal-dominated rural districts. Stunting ranges from 38.4% in Kandhamal district, to 15.3% in Cuttack while almost half of the children from tribal communities are either underweight or stunted, as per data from the International Food Policy Research Institute (IFPRI). Moreover, nearly 23 per cent of the tribal community lived in remote villages where the governments scheme hardly ever reach. “It is essential to improve the implementation of schemes to reach out to the most vulnerable tribal population,” Suri added. Pramod Meherda, Odisha health secretary didn’t respond to repeated requests for comment.

It is impossible to talk about malnutrition in Kerpai and the adjoining areas without talking about malaria. “Malaria is also an indirect cause of maternal death. We have cases of low-birth babies because of this and there have been related problems,” said Mithun Karmakar, of the National Health Mission at Bhubaneshwar. But little is known about how the two interact and influence each other. The key question: to what extent can malaria lead to stunting (low height for age) and wasting (severe weight loss)? While there are some studies that have reported a link between malnutrition and a higher risk of malaria, others have disagreed. A 2018 review of the literature on malaria and malnutrition argued that “understanding the complex relationship of the immune response of individuals infected with malaria and suffering of malnutrition is crucial to guide specific antimalarial therapeutic approaches in this vulnerable sub-population.”

Suri pointed out that practitioners who work closely with communities “where what is called ‘Malaria-Induced Malnutrition’ is high” treatment for malaria has led to “dramatic improvement in the nutritional status growth pattern of the children.” She also pointed out that an expert consultation in Bhubaneswar (2019) titled “Current Advances in Malaria Management and Implications for Malnutrition” had concluded that there was a statistically significant correlation between malaria and malnutrition and that “the Mal-mal linkage theory is right.”

Back at Kerpai though, the lone doctor has little time to ponder over such questions. The queue outside the small clinic has swelled up by noon, with over 30 patients, mostly mothers with their young children, waiting. Most, like Jayati, have walked several hours. Most have had malaria at least once in their lives, but until recently they had no inkling about the disease or its risks. “If you had asked us some years ago, we wouldn’t have been able to tell you what malaria was, or that it was transmitted through the mosquito,” said Renuka Majhi.

By noon, there were over 30 patients, mostly mothers with their young children, waiting at the clinic. Most have had malaria at least once in their lives, but until recently they had no inkling about the disease or its risks. (Photo: Aniruddha Ghosal)

The Rayagada district has larger challenges that find expression at the queue at the medical centre. Stunting of children less than five years old is at 43.5 per cent, wasting at 23.1 per cent while nearly half of the children are anemic (49.8 per cent) and underweight (42.4 per cent), as per data from POSHAN-IFPRI. Among women, anemia was rampant at 55.4 per cent and the body-mass index of a third of the women (33.1 per cent) implied that they were underweight to the point of malnutrition. The Swasthya Swaraj annual report for 2018-19 noted that among the under-five children, the number had dropped to 47 per cent, but that stunting rates remained high “indicating the chronic, intergenerational undernutrition” and that “neonatal mortality and infant mortality remain unabated“.

The choice between going to the clinic or losing a day's worth of food is also a difficult one. Most, like Jayati, had left early in the morning - a time usually reserved for finding food. As tribal communities are dependent on hunting, food gathering and shifting cultivation for sustenance, Shibu (32) explained, “We only come to the clinic, if we are really sick.” This, Kaushik Sarkar of the global non-profit, Malaria No More said was also when they were at risk from the mosquitoes. “There is a lot of slash and burn farming, they don’t take the (long lasting insecticide) nets with them. So they’re not protected. They become vulnerable.”

Add to this, the increasing number of extreme weather events. Earlier in August, at least eight people died after floods in several of Odisha’s districts. While the state received an average rainfall of 66 mm on August 13, two blocks at Kalahandi and Bolangir district got 400 mm rain in the same time period, while four other blocks received between 300-400 mm rainfall and Kalahandi’s Karlamunda received the highest rainfall in the state — 608 mm, as per a report in Down to Earth. “Everything we had grown was destroyed in the rains,” Jayati told News18, adding that they also often spent nights outside to try and protect their crops.

Bridging the Gap

Much of the government’s hopes for ensuring that their work to stop malaria rests on the distribution of Long-Lasting Insecticide Nets (LLIN). These nets are impregnated with insecticide and are aimed at prevention. But villagers told News18 that most found the nets too impractical. MM Pradhan, of the state vector borne disease control program (SVBDCP) said that the “messaging needed to be different”. “They are for personal protection. They protect not just from mosquitoes, but also other insects and scorpions and snakes. Doctors know the mosquito-malaria connection. But people? They still don’t understand.”

But villagers aren’t convinced. “We barely have space to sleep inside our homes…let alone hang a net,” said Malendra Majhi. He said that after decades of sleeping under the stars, many couldn’t bring themselves to sleep under a net. In lean months, he added, “There are some who have converted their nets into fishing nets. They are great for catching fishes.”

Suri argued that the nutrition and health sectors could simply not afford to work in silos. “Within the framework of maternal and child nutrition, convergence will result in improved coverage -- a low lying fruit, given that the health system is able to reach out to a wide majority of population currently through antenatal care coverage, institutional deliveries and immunization efforts to strengthen governance and accountability.” She pointed out that this was done in Bangladesh in the past decade, “where antenatal care (ANC) and management of sick under-five children were identified by the National Nutrition Services (NNS) as critical health service delivery contacts.”

Back at the clinic though, conversations weren’t about policy -- but the arduous task of getting back home. Reaching these ‘inaccessible’ villages was a key factor, not just in controlling malaria, but also remains crucial for the government in their effort to improve nutrition. The conversations of the patients, as they leave, emphasizes the degree to which remoteness is a factor. Almost tangible, it informs and shapes lives. On paper, there is an 86 kilometer long road that connects Kerpai to Bhawanipatna, the nearest city. In reality, it fades and eventually disappears before reaching the village. A single bus, makes the four-hour trip, once a week. Spasms of construction, along the way, suggest that things could improve in the future.

But the villagers, like Jayati, aren’t very hopeful. They point out that years ago, a building was built in the village which was to become a primary health care centre for the region. But no doctor ever came in those days of extremist violence.

“The world forgets we are here...but we are used to fighting,” Jayati said.

(This story was produced with the support of Internews’ Earth Journalism Network)