The children dying in India's remote tribal heartland

The children dying in India's remote tribal heartland

At around 3am one morning in May, Bamita Markam started convulsing.

The three-year-old had already spent days with a high fever and angry red sores across her body. Her mother, Koushila, first took her to a doctor, who gave her an ointment.

Bamita appeared to get better, then fell ill again. A faith healer, summoned to the home in Matla village, gave her syrups and tablets. Nothing helped. By dawn, Bamita was dead.

"She cried a lot," Koushila recalls. "She convulsed all night." The family tried to get her to drink water. At one point she vomited blood. After midday, they buried her in a jungle.

Bamita's death was among at least 32 child deaths recorded since May in a group of remote villages in Balaghat district in India's Madhya Pradesh state, officials say. The victims ranged from babies only three or four months old to an 18-year-old, and most were Baiga, one of India's 75 "particularly vulnerable tribal groups"

Rooplal died days after he developed a fever and rash.

Officials say the deaths were mainly caused by measles and malaria, possibly worsened by malnutrition and delays in treatment.

They believe eight to 10 deaths were linked to measles, roughly another 10 to malaria, with several children affected by more than one infection. The exact cause of each death is less clear.

"I have never seen an outbreak like this. My father was a two-term lawmaker, and I have served three terms, but neither of us has seen so many children die in such a short time," Sanjay Uikey, who has represented the area since 2013, told me.

But disease is only part of the picture. In remote, forested parts of Balaghat, where Maoist insurgency once took root, getting to a health centre can be difficult in itself.

During the monsoon, the landscape makes that trip even harder. Paddy fields shine against red earth and low, wooded hills. Narrow dirt paths snake between fields and mud houses, often turning slippery and unusable in heavy rain.

The countryside is green and dense, but the homes are scattered. Most Baiga houses have low mud walls, rough timber and bamboo, and tiled or thatched roofs patched with plastic to keep out the rain.

Some homes can be reached only by these tracks. Doctors investigating the deaths have travelled through the mud in tractors. On a recent visit, we walked nearly 2km (1.2 miles) uphill to reach some of the more isolated homes. The jungle around us was marked by the graves of children who had died.

Behru Markam lives with his wife and four children in a mud hut. His daughter, Preeti, died in what was believed to be a measles attack.

The nearest state hospital, a 100-bed facility in Birsa, is about 70km away. For families without vehicles, getting there can mean muddy tracks, a makeshift bamboo stretcher or a motorcycle - and a day's lost wages.

When Bamita became critically ill, the family did not take her to hospital. It was raining heavily. The tracks were muddy and slippery, and they had no way to transport her.

"If I was able to take her to hospital she might have lived," Koushila says.

Her other daughter, Ankita, keeps asking what happened to her sister. The six-year-old has been told what many children in these villages are told: "Mata aa gayi" - the goddess has arrived.

For some Baiga families, certain illnesses - such as chicken pox - are viewed as the arrival of a disease goddess, who must be appeased rather than treated. Families carry out a seven to nine-day ritual of bathing and offering cool water and neem leaves to the local disease goddess. Many believe that treating the patient before the ritual is finished could cause death.

For weeks, such beliefs shaped how families responded to sick children. Then the scale of the deaths started to become clear.

On 21 July, Parshuram Dhurwey, a local village council chief, heard that two children in the same household in Bondari village had died. The next morning, he learned of another death. He contacted local officials and went to the area.

They found a bleak scene.

"Every other child was sick," Dhurwey says. "They had fever, they had rashes. Many were undernourished."

The family followed a faith healer's instructions. "He said don't take them to hospital," Parte recalls.

Parte is a landless farm labourer who said he earns about 200 rupees ($2; £1.58) on a good day. Work is scarce in the monsoon, and although a small primary health centre is only 5km away, he had never been there. Poverty and isolation had stacked the odds against his children.

As the deaths increased, it became harder to determine what was making the children sick.

An investigation by the ICMR-National Institute for Tribal Health Research (NIRTH) tested 10 samples collected from the affected villages on 7 August. Six were positive for measles; four were negative.

Measles is highly contagious and causes high fever, cough, runny nose and red, watery eyes, followed by a rash. Most children recover, but malnutrition can make measles much more dangerous

The infection also weakens the immune system, leaving children open to other infections. Malaria can add to that danger.

But doctors warned that malaria did not necessarily come after measles, and not every fever and rash was measles. Instead, several infections and vulnerabilities came together.

"Sometimes there is no single factor behind the deaths," Gautam said. "There are malnourished children and there's zero health education and hygiene at home."

The Baiga villages are not completely cut off from modern India. Seasonal migration takes families to other states for chilli picking and other work. Children watch reels on smartphones, while many families have single-bulb solar electricity, bank accounts and, in some homes, piped water.

Even so, malnutrition remains widespread, with children often poorly fed. A five-year-old who recently died of measles weighed about 5kg.

Gautam believes malnutrition is fuelled by early marriage and motherhood, with some girls becoming mothers at 16 or 17, while their bodies are still developing.

Closely spaced pregnancies, premature births and low birth weight can follow, while young mothers struggle to breastfeed and care for their children. Diet is another issue: many families depend heavily on rice and lentil soup, with too little protein and variety in what they eat. Studies of Baiga households have found widespread nutritional deficiencies, made worse by poor uptake

The gap between services on paper and reality on the ground was stark: the state response came weeks after the deaths began, while health teams struggled to reach families and persuade them.

Once the outbreak was identified, health workers began screening door to door in the affected villages. Mobile medical units carrying oxygen, nebulisers, suction equipment, malaria tests and medicines visited more than 20 affected villages.

One mobile doctor, Neeraj Sharma, says teams regularly saw more than 50 patients a day, about half of them children. They carried out 10 or more malaria tests daily, sometimes finding two positive cases a day.

More than 6,200 patients - mostly children - were eventually treated at home, according to Gautam. More than 630 were referred to district hospitals. About 600 went back home, while around 30 remain admitted.

Vaccination became an emergency measure. Although official records suggested 90-95% coverage in some areas, health workers found children without records and families unwilling to vaccinate.

Authorities therefore offered the measles-rubella (MR) vaccine to all children under 15, regardless of recorded status. Of about 40,000 children identified in Birsa, roughly 27,000 had been vaccinated, Gautam said. Of the area's 180 villages, about 67 are predominantly Baiga and among the most vulnerable.

But vaccination is only one part of the protection children need. Broader questions remain about whether basic nutrition and other health services are reaching those most at risk.

The outbreak has now eased. Officials say the last child death was more than two weeks before their late-September assessment, while teams continue to visit villages. In Kundekasa, a medical camp that once saw about 120 children a day was seeing fewer than 10.

Back in Matla, Bamita's mother talks about the child who would ask for money for snacks, play with her sister and run inside whenever cars came near because vehicles frightened her.

"I had hope she'd study and make something of herself. I never regretted I didn't have a boy," Koushila says.

Then she looks at Ankita, the surviving sister.

"I want more kids," she says. "I feel alone. Ankita is alone. She keeps crying for her sister."