11 September 2017 National Monsoon Blues

Can’t Smoke Out Scary Strains

The rains again expose factors plaguing India’s healthcare in rural and urban spaces
Can’t Smoke Out Scary Strains
Futile?
Civic workers spray chemicals along a canal in a Calcutta slum
Photograph by Getty Images
Can’t Smoke Out Scary Strains
outlookindia.com
2017-09-02T10:39:03+0530

How 3 Diseases Are A Major Annual Danger

  • Monsoon typically leads to water-­logging, which is the villain behind the spread of major vector-borne diseases like malaria, dengue and chikungunya
  • The diseases are rampant in Delhi, which has reported 50% new instances of malaria and 400% rise in cases of chikungunya between 2014 and ’16
  • The need of the hour, experts say, is a new system that can counter pathogens from becoming stronger
  • India does chart out ways to resolve the issue, but their implementation mostly fall short of the requirements
  • Rural India has below-par PHCs and CHCs, where accurate and prompt diagnosis seldom happens
  • There have been some progress in vaccines for dengue and chikungunya, but they are mostly at the test stage. Malaria already has a vaccine.

***

As monsoons enter upcountry, Dr Rajesh Kumar’s day in the hospital begins much earlier than usual. At 8 in the morning, he sets out on his rounds, meeting patients, mainly affe­cted with malaria, dengue and chikungunya. An internal medicines physician with Delhi’s Paras Hospital, Dr Kumar ends up spending longer working hours, treating the inmates suffering from the three preventable diseases. “See, water-logging becomes common—and with it comes a surge in mosquitoes,” he says about the July-­September months.

In the capital, dengue took its first victim of the season on August 19 even as the total number of people infected with the tropical disease rose to around 700. Not to be left behind are equally dangerous diseases such as malaria and chikungunya. The national capital alone repor­ted 50-plus cases of malaria this season, while chikungunya has shown a startling 400 per cent increase in just three years between 2014 and ’16.

Vector-borne diseases—those carried by mosquitoes—have been on the rise over the past decade. Worse, malaria, which was considered eradicated in the late 1960s, is back with a vengeance. Others such as dengue, chikungunya and Japanese encephalitis are comparatively new to the country and are showing no signs of an exit soon. So what are the government and other health organisations doing to curb such diseases? Turns out, there is no simple answer. While res­earch and public health measures have been put in, the governmental steps fall woefully short of requirements.

Vector-borne diseases, according to most specialists, lie at the root of the country’s public health crisis. They are a culmination of many factors, says Dr Rajib Dasgupta from the Centre of Social Medicine and Community Health, Jawaharlal Nehru University. “We suffer from a mix of poor sanitation, dismal knowledge (about the diseases) and apathy typical of the public authorities in the country,” he says.

Mosquitoes carrying these dreaded diseases breed in places where water-logging is common and sanitation is seldom paid attention. If one looks at rural India or even peri-­urban parts of the country, this area is huge. According to Dr Jeevan Aggarwal of Delhi’s Fortis, much of the responsibility to curb this problem rests with the government. “Public cleanliness, which is the job of the municipal corporation, is often not addressed because of a paucity of workers,” he notes.

For the authorities, it’s not just a shortage in manpower. There is a lack of well-built infra­structure to tackle issues arising out of heavy rainfall in most part of the country. For instance, statistics show that only 68 per cent of the funds sanctioned by the central government to the natio­nal vector-borne disease control programme have been released, while an ever lesser amount was utilised.

No wonder the government is grappling with problems such as a lack of manpower to clean up roads and water accumulation or build better infrastructure that has the potential for a total eradication of the diseases. According to Dr Kumar, one of the other big issues is the approach taken to curb the problem. “While there might be no paucity of money being spent on controlling such diseases, the approach taken by the government is at best cosmetic and doesn’t look at the picture in long term,” he says referring to the large-scale fumigation carried out by authorities as only one of the measures to prevent the disea­ses. The displacement of populations to different areas in order to prevent such diseases, too, is simply a half-hearted app­roach, experts say.

The need of the hour, according to specialists, is to nip the problem in the bud. That calls for the implementation of a new system that can counter pathogens from evolving to become even stron­ger. Also, they want urban development plans to find ways to resolve them. The government, on the other hand, reels out several challenges in implementation. One of them is a growing population in the country, says a research scientist at the National Institute of Virology, Pune. “Rising headcount offsets the measures to curb such pathogens,” he shrugs.

Public awareness, according to the nat­ional vector-borne disease control programme, is vital. For instance, diseases such as dengue and chikungunya are spread by pathogens that breed within a 100-metre radius of people, points out Dr Aggarwal, implying these places can fall within the confines of one’s house.

Vector-borne diseases are a major pro­blem also in countries other than India. Yet their density in India is clear in that the country contributes to 71 per cent of all vector-borne diseases in the world. Several countries have been able to curb such pathogens to controllable limits—the most noted among them being Thailand, Singapore and Bangladesh.

Dr Dasgupta reveals how their strategies do not differ much from that of India’s. “Thailand and Singapore have implemented strategies very similar to those explained on our NVBD programme. Unlike with us, they have done a far better job in implementation,” he says. “As for the integrated vector management system, different government authorities are still haggling over who is to implement it. There is dispute over whether it is the task of the Rural Health Mission or the municipal corporations or the vector-control programme.” The “lone solution”: work in unison.

All the same, certain states have been able to control the situation. Kerala, which  was affected most by vector-borne diseases (the southern state already rep­orted more than 10,500 dengue cases this year), has been fighting the issue through integrated systems involving municipal corporations, ASHA workers and state health programmes in ways that have made it able to device systems of prevention, diagnosis as well as cure.

A bigger problem lies in the diagnosis. One of the most vital aspects of comp­letely curing such diseases is timely det­ection. Local medical facilities such as community health centres (CHC) and primary health centres (PHC) in rural ­areas mostly lack the infrastructure for it. “Symptoms presented in cases of malaria, dengue and chikungunya match those of any regular viral disea­ses because of which patients are misdiagnosed and even mistreated,” says Dr Kumar. Also, there is the problem of villagers having to travel long distances patients to reach CHCs and PHCs.

The other big problem is the poor quality of testing kits. Dengue, for instance, has four different strains—but the cost of testing for each strain is so high that doctors simply test the presence of dengue. “Treatment plans are then devised, based on the doctor’s discretion and expe­rience,” Dr Sengupta says.

There has been some progress made in developing vaccines. Malaria already has a vaccine available, though it is not cleared for use in the country. There has been some progress in the vaccine development of dengue and chikungunya, but both the efforts are at the trial stage. The only vaccine available for a vector-borne disease is that for Japanese encephalitis, and it has been implemented under the universal immunisation programme in select parts of the country.

The disease increases in variety, portending a propensity to affect a larger population. Each year sees a stronger strain of the same pathogen—one that is much more resilient to fumigation as well as treatment. Acco­rding to Dr Kumar, malaria this year is proving to be the biggest killer. “Most cases we are getting this year are fraught with complications such as multi-organ dysfunction, breathing issues or thrombocytopenia (which is the deficiency of platelets in the blood),” he says. The government seems to hush up the spread of the disease. News reports and a number of research have made it clear to Dr Kumar that the larger picture is being withheld from the common people. “If I go by the number of dengue cases we in Fortis alone treated last year, it is evi­dent that only 30 per cent to 40 per cent of the cases are reported,” he says. Adds another doctor of internal medicine: “I was specifically asked by my senior to underreport instances of dengue so as not to create mass panic.”

The number of affected people is incre­asing by every second. In this season, the only governmental approach has been to devise temporary fixes to prevent the disease from spreading. That is no strong sign of India working for a total eradication of these vector-borne diseases.

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