The children dying in India's remote tribal heartland

Warning: This article contains details some readers may find distressing.

Key points

• An investigation by the ICMR-National Institute for Tribal Health Research (NIRTH) tested 10 samples collected from the affected villages on 7 August.
• Parte is a landless farm labourer who earns regarding 200 rupees ($2; £1.58) on a good day, he stated.
• The victims ranged from babies just three or four months old to an 18-year-old, and most were Baiga, one of India's 75 "particularly vulnerable tribal groups", external.
• The nearest state hospital, a 100-bed facility in Birsa, is regarding 70km away.
• On 21 July, Parshuram Dhurwey, a local village council chief, heard that two children in the same household in Bondari village had died.

Warning: This article contains details some readers may find distressing. At regarding 3am one morning in May, Bamita Markam began convulsing.

Notably, the three-year-old had spent days with a high fever and angry red sores on her body. Her mother, Koushila, had first taken her to a doctor. This person prescribed an ointment.

Bamita seemed to recover, then became ill again. A faith healer, called to the house in Matla village, offered her syrups and tablets. Nothing worked. By dawn, Bamita was dead.

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

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

Authorities attribute the deaths to mainly measles and malaria, possibly aggravated by malnutrition and delays in treatment.

They believe eight to 10 deaths were associated with measles, roughly another 10 with malaria, with a number of children suffering more than one infection. The precise cause of every death is less certain.

"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 plenty of children die in such a short time, " Sanjay Uikey. This person has represented the area since 2013, informed me.

But disease is only part of the story. In remote, forested parts of Balaghat, where Maoist insurgency once took root, reaching a health centre can be a challenge in itself.

In the monsoon, the terrain can create that journey harder. Paddy fields glow against red earth and low, forested hills. Narrow dirt tracks wind between fields and mud homes, often becoming slippery and impassable in heavy rain.

For context, the countryside is lush, but the homes are sparse. Most Baiga houses have low mud walls, rough timber and bamboo, and tiled or thatched roofs patched with plastic against the rain.

Some homes are accessible only by these tracks. Doctors investigating the deaths have travelled through the mud in tractors. On a recent visit, we walked almost 2km (1.2 miles) uphill to reach some of the more remote homes. The surrounding jungle was dotted with the graves of children who had died.

Notably, the nearest state hospital, a 100-bed facility in Birsa, is regarding 70km away. For families without vehicles, reaching it can mean muddy tracks, a makeshift bamboo stretcher or a motorcycle – and a day's lost wages.

When Bamita became seriously ill, the family did not obtain her to hospital. It was raining heavily. The tracks were muddy and slippery, and the family had no way of transporting her.

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

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

For some Baiga families, some illnesses – like chicken pox – are seen as the arrival of a disease goddess. This person must be appeased rather than treated. Families perform a seven to nine-day ritual of bathing and offering cool water and neem leaves to the local disease goddess. Plenty of believe that treating the patient before the ritual is completed could cause death.

For weeks, such beliefs shaped how families responded to sick children. Then the scale of the deaths began to emerge.

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 heard of another death. He called local authorities and went to the area. They discovered a grim picture.

"Every other child was sick, " Dhurwey notes. "They had fever, they had rashes. Plenty of were undernourished."

When administration medical officer Nimish Gautam arrived, he identified severely dehydrated children. The first case he saw was a teenage girl with a number of days of fever and rash, whose blood sugar appeared dangerously low. Her family refused to let the health team examine her properly.

"Police were brought in to persuade them to take her to a health centre. The family still refused, " Gautam informed me. "They remarked if we took her for treatment, she would die. So we kept her under observation, and she recovered."

In one village, Dhurwey notes, office-holders forcibly entered homes and took five seriously ill children to hospital. All recovered.

By the time the outbreak became unmistakable to local authorities, children had already been dying for weeks. By September, Dhurwey notes, 10 children aged concerning 18 months to 14 years had died throughout the four villages in his council – Adori, Kundekasa, Bondari and Usri.

For context, the symptoms were frighteningly similar and frustratingly non-specific: fever, rashes, weakness, dehydration and, in some cases, seizures. Some children had scabies, fungal infections or bacterial skin infections alongside suspected measles and malaria. In a district where malaria is endemic, external, fever could mean a number of things at once.

Sagnibai of Bondari lost two children within 24 hours. Her daughter, Lamnin, 12, died on 26 June. Her one-year-old son, Sahil, died the after day. A local healer informed the family it was Mata. They additionally had no capital or vehicle to take the children to a doctor.

Her husband, Samaroo Dhurwey, remembers nights in which the children's bodies seemed to be "on fire". They could not digest food. They died at home.

Mahasingh Parte of Matla village lost two children – a six-year-old girl and a four-year-old boy – within two days of each other. 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 earns regarding 200 rupees ($2; £1.58) on a good day, he stated. Work is scarce in the monsoon, and although a small primary health centre is just 5km away, he had never been there. Poverty and remoteness had stacked the odds against his children.

Notably, the question of what was making children sick became harder to answer as the deaths mounted.

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

Measles is highly contagious, causing high fever, cough, runny nose and red, watery eyes, followed by a rash. Most children recover, but malnutrition can create measles far more dangerous, external, increasing the risk of pneumonia, severe diarrhoea and dehydration, and inflammation of the brain. The infection additionally weakens the immune system, leaving children vulnerable to other infections. Malaria can compound that risk.

But doctors cautioned that malaria did not necessarily follow measles, and not every fever and rash was measles. Instead, a number of infections and vulnerabilities collided.

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

Meanwhile, the Baiga villages are not entirely disconnected from modern India. Seasonal migration takes families to other states for chilli picking and other work. While plenty of families have minimum single-bulb solar-powered electricity, bank accounts and, in some homes, piped water, children watch reels on smartphones.

Yet malnutrition remains widespread, with children often poorly fed. A five-year-old who died lately of measles weighed around 5kg.

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

While young mothers struggle to breastfeed and care for their children, closely spaced pregnancies, premature births and low birth weight can follow. Diet is another difficulty: numerous families rely heavily on rice and lentil soup, with too little protein and dietary variety. Studies on Baiga households have discovered widespread nutritional deficiencies, compounded by poor uptake, external of public services.

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

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

Taken together, the developments around the children dying in India' s remote tribal heartland point to a situation that is still moving, and the coming days should bring more clarity.