* The district surveillance unit, a crucial line of defence that is meant to save children from the kind of cocktail of illnesses that are alleged to have killed them in Madhya Pradesh’s Balaghat, was run by a data manager.* The post of District Epidemiologist, critical for surveillance, outbreak investigation and data analysis, was vacant. There was no District Public Health Laboratory and the post of microbiologist was vacant.* The most affected village Kundekasa has been without an ASHA worker for over a year, leading to a “major gap in active case detection, community mobilisation and follow-up”.These are some of the damning findings in an investigation carried out by the Centre’s National Joint Outbreak Response Team (NJORT) into the deaths of approximately 32 tribal children in Balaghat since June, The Indian Express has learnt. The children, aged between one and 13, reported symptoms such as high fever, rashes, red spots, stomach pain and ulcers.Read | Remote location, reluctant parents: Madhya Pradesh battles odds amid outbreak that left 6 kids deadWhile the team visited Balaghat in August, the deaths have become a political crisis for the BJP government now after Leader of the Opposition Rahul Gandhi’s visit to the affected families last week. His visit followed that of Cockroach Janta Party leader Abhijeet Dipke to Balaghat in mid-September.The Mohan Yadav government earlier maintained that the number of deaths was eight, with around 100 children falling ill, in August in four remote, Baiga tribe-dominated villages. Yadav also visited Balaghat on August 29.However, the NJORT report, which was submitted to the Union health authorities in September, shows that the deaths were not the result of an isolated failure or one identifiable disease but of a health system weakened at almost every stage, from detecting sick children in villages to maintaining vaccination records, from laboratory coordination to tracking deaths, and from referring severely ill children to bigger hospitals, and ensuring that they actually got appropriate care. It found evidence of measles alongside malaria and smaller numbers of dengue, chikungunya and enterovirus infections, in what it called a mixed febrile illness cluster.Story continues below this adRead | ‘Total government failure… will raise issue in Parliament’: Rahul Gandhi visits BalaghatThe report, which did not put a number to the estimated deaths, also spoke of “gaps in data collection, reporting and sharing between surveillance, laboratory, immunization and nutrition programmes”. The lack of a common repository meant “even getting a timely, well reconciled, line list was a challenge”, said the NJORT.Dr Shatrughan Dahiya, Chief Medical and Health Officer of Balaghat, told The Indian Express that their investigation indicated around 12 deaths since June of symptoms mentioned above. However, the government had earmarked 32 cases for compensation, he said.The case studiesDuring their field visit from August 13 to 18, the NJORT examined three deaths in detail (a fourth family declined to participate).One of those who died was a four-year-old boy from Kundekasa. The report said he developed rashes, fever, oral ulcers, loss of appetite and seizures, before dying at home on August 6. This was three days after an ASHA worker visited the house, and advised the family to take him to hospital, which was not done, the report said.Story continues below this adSimilarly, the NJORT said, a three-year-old girl from Kundekasa died at her maternal grandmother’s home on July 22, before she was taken to hospital. In her case too, an ASHA worker and a multi-purpose worker had visited the family and urged them to take the child for malaria testing, which they did not do.The family reportedly attributed the illness to “Maata”, to be treated by traditional methods. Apart from delayed formal care, the NJORT said the death was a result of such cultural beliefs, plus incomplete vaccination documentation and the absence of a laboratory diagnosis.In case of the third investigated death, the team said the three-year-old girl from Bondari was brought to District Hospital, Balaghat, on August 9, after her family sought treatment from a traditional healer approximately 35 km from their village. At admission, the three-year-old weighed only 4.9 kg, and had a height of 66 cm. She died at the hospital on August 11.The NJORT said the child was vulnerable due to “marked nutritional deficit”, but did not establish a cause for the death.Nutritional gapsStory continues below this adOverall, the team recorded 604 children as severely acutely malnourished and 1,985 as moderately acutely malnourished across 357 anganwadi centres in the Birsa block sectors.While earlier field teams reported that visible wasting or severe wasting was found in roughly 20-25% of the children surveyed in Baiga, the report said “only around 30-35% of children were enrolled in the Poshan Tracker”, and that the weekly weighing of children by anganwadi workers was not being done regularly.(Poshan Tracker is a government digital system for monitoring nutrition and child development services delivered through anganwadi centres. It helps frontline workers identify children who are malnourished and track them over time.)The report found that joint visits by auxiliary nurse midwives, ASHA and anganwadi workers were irregular, affecting coordination of maternal, child-health and nutrition services, and that there were “significant discrepancies” between measurements recorded in the Poshan Tracker and those seen during the NJORT field verification.The testsStory continues below this adThe NJORT tested 64 samples for measles, of which 25 tested positive. In the case of malaria, of the 32 samples tested by the National Centre for Disease Control, 27 were positive. Dengue testing was positive in 2 of 28 samples, chikungunya in 1 of 28 and enterovirus in 2 of 24.All five water samples tested for adenovirus (which causes a range of symptoms) were positive, while eight of nine samples tested for coliform bacteria were positive, though the report said these “do not establish a single cause for the entire cluster”.On the gaps identified by the NJORT, Dr Dahiya said these were of “staffing”, and were being addressed. “Malnutrition has been one of the major issues in the area. There was a supply-chain issue, but we are now focusing on ensuring that nutrition reaches the children continuously. We have treated approximately 3,500 children at their homes. Apart from this, around 750 children who were in critical condition were treated. Overall, we have been able to save around 800 children who were in critical condition.”The government earlier said four Block Women Development Officers had been posted to Balaghat, and 14 sub-health centres and community health centres were being established in the region.Story continues below this adDuring his visit, Gandhi called the deaths the result of “total, 100% government failure”, and said the children suffered from illness and malnutrition, with even basic government support absent in the area.Sanjay Uikey, the local MLA who belongs to the Congress, said: “Our estimates say the death toll is over 40. It’s only after much pressure that the government has announced compensation for 30-odd families. Our hope is that the push by the Health Department is long-lasting and not a temporary fix.”