Malaria’s Double Threat: Understanding The Interplay With Sickle Cell Anaemia In Rural India

Delving into the connection between Malaria and Sickle Cell Anemia in India's rural spaces unravels a complicated interaction.

?? Dr. Ankur Jain and Shyamal Santra

“I would like to play with my friends”

The girl had just returned from the hospital to her small hut in the tiny village of Rajpur, Madhya Pradesh. She was eager to jump, but she had to give up and take rest as her physical strength didn't permit her. Over the last few months, she has been undergoing treatment in a hospital for sickle cell disease, and last month she experienced a high fever, which was diagnosed as malaria.

"When I was seven months pregnant, during a camp organized at our Arogya Ayushman Mandir, I was screened and informed by the attending Didi that I am a carrier of the 'Sickle Cell Trait,' and my husband was also tested and found positive," narrated the mother of the girl Laxmi. "My daughter Sumi was diagnosed soon after birth, during a routine check-up."

"Often, I experience a crisis in my body," Laxmi tearfully explained, "from hands to feet, and sweating. My husband and I can't do hard work. Anyway, we were managing our small farmland. Now, Sumi has a fever that none of us had experienced earlier, and she had to be hospitalized. We have taken a loan from neighbours; let us hope for the best."

Malaria: Decoding The Untold Threat

Globally Malaria is a public health concern, a potentially life-threatening disease caused by a parasite from the Plasmodium genus. This parasite is spread through the bite of a female Anopheles mosquito. It is estimated that in every three minutes, four people die due to malaria. In 2022, an estimated 249 million malaria cases were reported in 85 malaria-endemic countries, which is an increase of 5 million cases compared to 2021. Despite the reduction in reported cases in India in 2022, India accounted for 66% of cases in the region. About 95% population in the country resides in malaria-endemic areas and 80% of malaria reported in the country is confined to areas consisting of 20% of the population residing in tribal, hilly, difficult, and inaccessible areas. According to a WHO report, approximately 44% of cases have been reported to be disproportionately contributed by approximately 27 high-burden districts. World Malaria Report highlighted those states like Odisha, Chhattisgarh, Jharkhand, Meghalaya, and Madhya Pradesh accounted for a significant portion of malaria cases in India, with these states contributing to nearly 45.47% of malaria cases and around 70 per cent of falciparum malaria cases.

The government of India is committed to eliminating Malaria Cases by 2030, and has implemented the National Framework for Malaria Elimination 2016-2030. The framework has emphasis on early diagnosis and prompt treatment, vector control, community engagement, and inter-sectorial cooperation, to achieve the national malaria elimination goal of 2030. The reported annual malaria cases in India during 1990-2000 were 2.38 million, which dropped to 0.73 million cases annually during 2011-2022. The goal is to achieve zero indigenous cases of malaria in the country by 2027 and to sustain elimination by 2030.

In the same geography of India- central, western, and southern parts, Sickle Cell Disease (SCD) has a high prevalence. SCD is a genetic disorder where the red blood cells have an abnormal half-moon shape. It not only causes anaemia but also pain, reduces growth, and affects many organs like the lungs, heart, kidneys, eyes, bones, and brain. The prevalence of sickle cell anaemia varies, with estimates suggesting that it ranges from 5 to 40% among tribal populations. India is reported to have the second-highest burden of the disease globally, with over 2 crore people carrying sickle cell traits and approximately 14 lakhs suffering from sickle cell disease. About 1 in 86 births among the Tribal population have SCD . "In 2023, the Government of India initiated the National Sickle Cell Anaemia Elimination Mission to tackle this challenge, aiming to eliminate sickle cell diseases as a public health concern in India by 2047.

The Interplay Between Malaria and Sickle-Cell Anaemia

The coexistence of malaria and sickle-cell anaemia in rural India presents a complex intersection of human health and genetics. This interplay between the two conditions poses a dual threat to individuals in these communities, necessitating a deeper understanding of their relationship for the development of effective health strategies and interventions at different levels.

Malaria's Impact on Rural India

Malaria, caused by Plasmodium parasites transmitted through the bite of infected Anopheles mosquitoes, has plagued rural India for centuries. Its impact goes beyond health, affecting socioeconomic growth and development. Rural communities, with limited access to healthcare facilities and education, bear the brunt of the disease. The prevalence of malaria in these areas is not only a result of environmental and lifestyle factors but also hinges on genetic predispositions among the local population, such as the trait for sickle-cell anaemia.

The relationship between malaria and sickle-cell anaemia is a double-edged sword. On one side, carriers of the sickle-cell trait have a survival advantage in malaria-endemic regions, presenting a lower risk of contracting severe forms of the disease. On the other, individuals with sickle-cell anaemia face lifetime challenges, including pain, infections, and delayed growth. This condition also places a significant burden on the already strained healthcare systems in rural India and has its socio-economic arenas.

Address the duel issues of Malaria and Sickle Cell Anaemia required collaborative actions exploring all possible spaces including Social-Economic and technological (SET) realms bringing different stakeholders and also exploring possibilities to integrate, supplement, and complement the strengths of both national programs and collaborate to create a 'Neighbourhoods of Care' involving local community, Frontline Workers and Local Administration; integrating fragmented services offered by the various health and social security schemes to better support activities of seeking, providing, receiving, managing, and promoting care. Such an effort is organized based on the Point of Care (PoC).

Managing Sickle Cell Anemia And Malaria: What Is The Government Doing?

The Government of India promoted Self-Help Groups (SHGs) for the realisation of socio-economic development through DAY-NRLM, intending to organise the rural poor women into SHGs, and, continuously nurture and support them to take economic activities till they attain an appreciable increase in income over a period of time to improve their quality of life and come out of abject poverty. These groups are federated into Village Organisations (VOs) at the village level and further into Cluster Level Federations (CLFs), creating an institutional architecture that can be leveraged for disseminating useful information, generating awareness, and for behaviour change communication. Around 60 per cent of the rural population, in these most backward and tribal districts, has been covered through SHGs, and, thus provides a unique platform for last-mile access with key messages. The platform has in-built five touchpoints viz. SHG, VOs, Cluster Level Federations (CLFs), households and communities, can be leveraged to reach the target beneficiaries with key health and nutrition interventions to increase awareness and access to entitlements through convergence. To overcome the language barrier localising the messages blending with the traditional tribal folk media would help appeal and trigger the behaviour modifications.

Establishing community-level institutional response for improving the health status of tribal population: From the learning from the COVID response integration of PRI-SHG-Frontline Workers (ANM-ASHA-ANM) can establish a mechanism at the habitant level for identifying, tracking and referring 'high-risk' cases to save lives and the following strategies and approaches can be adopted. Building capacities of the Sarpanch and PRI representatives would help to create local champions and ambassadors to spread the messages in the local community to combat SCA and Malaria.

The interventions can be seen in various spares, such as:

1. At home - supports the people living in these areas to adopt scientific practices like using of bed nets etc. Helps the families with early detection and following Care Plans based on individual life stages and conditions; accessing social security and protection schemes; improving living conditions etc.
2. At the community level - empower people to participate in planning, execution, access, and monitoring of community assets that serve as service delivery points (like Anganwadi Centre, managing water sources, etc. integrating services including diagnostics and preventive treatments at Village Health Nutrition and Sanitation Days.
3. At health facilities - Work with the health workers and Administrators to improve the infrastructure and make diagnostics and treatment available at the local level.
4. Frontline first: Frontline workers (ASHA-ANM-AWW) play a critical role in reaching out and delivering essential services, particularly in hard-to-reach communities with few resources. Innovation is required to enhance their skills, equip them with supplies, kits, and tools, and create a community coordination system for increased awareness and improved delivery of essential health services.

Managing Sickle Cell Anemia And Malaria: What Is The Government Doing?

The Government of India promoted Self-Help Groups (SHGs) for the realisation of socio-economic development through DAY-NRLM, intending to organise the rural poor women into SHGs, and, continuously nurture and support them to take economic activities till they attain an appreciable increase in income over a period of time to improve their quality of life and come out of abject poverty. These groups are federated into Village Organisations (VOs) at the village level and further into Cluster Level Federations (CLFs), creating an institutional architecture that can be leveraged for disseminating useful information, generating awareness, and for behaviour change communication. Around 60 per cent of the rural population, in these most backward and tribal districts, has been covered through SHGs, and, thus provides a unique platform for last-mile access with key messages. The platform has in-built five touchpoints viz. SHG, VOs, Cluster Level Federations (CLFs), households and communities, can be leveraged to reach the target beneficiaries with key health and nutrition interventions to increase awareness and access to entitlements through convergence. To overcome the language barrier localising the messages blending with the traditional tribal folk media would help appeal and trigger the behaviour modifications.

Establishing community-level institutional response for improving the health status of tribal population: From the learning from the COVID response integration of PRI-SHG-Frontline Workers (ANM-ASHA-ANM) can establish a mechanism at the habitant level for identifying, tracking and referring 'high-risk' cases to save lives and the following strategies and approaches can be adopted. Building capacities of the Sarpanch and PRI representatives would help to create local champions and ambassadors to spread the messages in the local community to combat SCA and Malaria.