Long-winding queues of people sitting late into the night outside Government health centres in Kolkata. The haunting image, from a visit to the city a couple of months ago, is reality for several people across the country.
Hospitals beds are packed to capacity and intensive care units not available — the rush, we are told, is because of dengue and malaria patients.
Anti-repellent creams and lotions are in short-supply at chemists and the most popular anti-mosquito device is the trusty, old-fashioned mosquito net.
Though the Centre has managed to get a grip on polio, and is making some effort to get a handle on tuberculosis, there is still much ground to cover when it comes to vector-borne diseases such as malaria, dengue, chikungunya or Japanese Encephalitis (JE).
And adding a fatal turn to the disease is the resistance that patients are developing to medicines used to treat malaria, for instance, a fall-out of the irrational use of these drugs. There are no specific drugs to treat the other mosquito-borne illnesses, though there are vaccines against JE.
But not all ills can be solved by popping a pill. That the Government needs to take a wider, more integrated view of public health, rather than a narrow disease-specific approach, is a view rapidly gaining currency among health-activists working in different parts of the country.
Urban development, the laying of roads or agricultural policies, for instance, need to be laced with an impact study of how it would affect public health as well.
Otherwise, the fogging that municipal corporations undertake in different cities to control mosquito breeding will come to no good, as pools of stagnant water continue to dot plots where the next high-rise is being built. Administrators, in a hurry to make their cities the next Shanghai, London or Manhattan, seem to be losing sight of the impact on the health of their residents.
There are enough scientific resources in the country to help plan urban or irrigation projects, ensuring that they do not leave behind breeding grounds for disease, says Anurag Bhargav, physician and epidemiologist, working in Uttarakhand.
Simple solutions
Simple things make the difference, he says. But presently, prevention has broken down and the focus is largely on treatment, where drugs are available. An overarching strategy to tackle vector-borne diseases is required, he observes.
Interventions are needed at schools and in residential areas. Even among the educated, there are those who think greenery causes malaria, he says, illustrating the prevailing ignorance.
The cost of ignoring public health is escalating, he says, pointing to the resistance patients are developing to malaria medicines. So, the next time they get the disease they could die, as the medicine will not be effective. Other features being witnessed with malaria, are that it is migrating to newer locations as people do, and the incidence of a more virulent form of malaria is increasing, he observes.
Tricky numbers
The prevalence of vector-borne illnesses, as estimated by Government, does not reflect the real picture, or the view from the ground. And this was borne out by a study published in Lancet in 2010, that said that the number of malaria-deaths was grossly understated. A reason for this is that malaria deaths in India take place at home and hence go unrecorded. The study pegs malaria deaths in India at over 1,50,000. The World Health Organisation’s number was 10,000, while authorities in India had estimated malaria deaths at over a 1,000, in 2010.
The range is a “mockery in the harshest way,” says Yogesh Jain of Jan Swasthya Sahyog. It is difficult to estimate the mosquito-borne disease burden in the country, as public infrastructure does not exist to capture prevalence and deaths.
In Bilaspur district of Chattisgarh, he says, when they estimated that 300 people died of malaria, the official numbers were nine. “Malaria death starts where political influence ends,” he observes.
Plotting the numbers is tricky as these diseases are cyclical and surface about every three years. These diseases generally peak between October and December.
In fact, public health parameters being as bad as they are, it is a wonder that epidemics have not broken out in the country, says public health activist Sunil Kaul. “We are getting away with a lot,” he says, adding that there are enough laws in the country, but as always the implementation is off the mark.
Integrated approach
Kaul pitches for a shift from the present illness-specific vertical programme, calling instead for a comprehensive health outlook. This helps focus resources on the problem of a particular location, he observes, since health is a State subject. Otherwise, there is a mismatch between funds released from the Centre for a particular reason, while the State may require funds for something else. Things improve when norms are followed, even with 50 per cent efficiency, he adds.
Public health expert Srinath Reddy agrees: “No vertical programme, however well designed, can fit into a weak public health system”.
Kaul further points out, drug resistance in patients is a fall-out of poor implementation and irrational use of drugs. Doctors treat patients, but are unable to ensure that they take the full course of medicines. Patients too stop taking medicines the moment they feel better, again leading to a situation where the virus or microbes adapt and stop being affected by a medicine — leading to resistance.
In cities, patients can still be treated. But in interiors parts of, say, the North East, blood samples need to be sent to Kolkata, he points out, and this may not be possible all the time. And as a result, doctors may treat dengue, for instance, empirically.
Mosquito-borne diseases are best dealt with by the public healthcare infrastructure in terms of surveillance and other steps; once identified, it needs intensive intervention, says Kaul.
Monitoring water stagnation, improving nutrition and personal protection (including mosquito nets), hand-in-hand with public-health consciousness, can cause a serious dent in the prevalence of mosquito-borne diseases — provided there is political interest in tackling the problem.