Koushila Markam holds a photograph of her daughter, Bamita, who died aged three.

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

At about 3 AM one morning in May, Bamita Markam began convulsing. 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, who prescribed an ointment. Bamita seemed to recover, then became ill again. A faith healer, called to the house in Matla village, gave her syrups and tablets. Nothing worked. By dawn, Bamita was dead.

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"She cried a lot," Koushila recalls. "She convulsed all night."

The family tried to make 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, officials 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."

Atilal Dhurwey holds a framed photograph of his 17-year-old brother Rooplal, who died in June. Rooplal died days after developing a fever and rash. Officials attribute the deaths mainly to measles and malaria, possibly aggravated by malnutrition and delays in treatment. They believe eight to ten deaths were associated with measles, roughly another ten with malaria, with several children suffering more than one infection. The precise cause of every death is less certain.

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"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," said Sanjay Uikey, who has represented the area since 2013.

Context

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 make 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.

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 nearly 2 km (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.

Behru Markam lives with his wife and four children in a mud hut. His daughter, Preeti, died of a suspected measles attack. The nearest state hospital, a 100-bed facility in Birsa, is about 70 km 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 get her to hospital. It was raining heavily. The tracks were muddy and slippery, and the family had no way of transporting her.

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"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, some illnesses - like chicken pox - are seen as the arrival of a disease goddess, who 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. Many believe that treating the patient before the ritual is completed could cause death.

Developments

The Dhurwey family home in Bondari village is nearly 2 km uphill from the nearest road. 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 officials and went to the area. They found a grim picture.

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

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