Strains of the deadly cerebral malaria parasite flourish even as
The family's relief was short-lived, for the fever returned—only to disappear again. The second blood test, like the first, was negative. Dutta's uneasiness however persisted and he decided to go in for a third test. This time round, he tested positive for malignant malaria. Two days later, a week after the first hint of fever, Dutta died.
Was it possible to save Dutta? Perhapsnot. But speedier treatment and easier access to the complete pharmacopia of anti-malaria drugs could have given him a fighting chance, says his doctor. The debate now hovers around the question: how to combat the growing menace of Plasmodium Falciparum, whose strains can cause cerebral malaria, and which is gradually edging out its benign and nonfatal counterpart, P Vivax?
The P Falciparum strains now account for 40 per cent of all cases of malaria, against 10 per cent two decades ago. The epidemic has also become more widespread. This year the disease raged through Calcutta and its neighbouring areas, the North-east and Orissa, besides the border areas of Rajasthan and, to some extent, even Bombay.
Dutta was one of the three influential persons, including Ananda Bazaar Patrikadirector Audhip Sarkar, and former MLA and minority leader Wilson d'Roz, who died of cerebral malaria in Calcutta within the space of a fortnight. These deaths highlighted the fact that while the original parasite has evolved into a more dangerous and lethal predator, the methods of combating it have failed to keep pace. The parasite's pernicious strains are resistant to the treatment of the standard anti-malaria drug chl-oroquine, which necessitates the development of a whole new arsenal of drugs against the parasite, say private practitioners.
It is the ultimate leveller, affecting the rich and poor alike. Divya, an advertising executive who lives in Bombay's posh Malabar Hill area, recently came down with the virus. In the absence of a blood diagnosis, she was treated for typhoid and her condition deteriorated until, in desperation, she was put on quinine, the strongest anti-malaria drug currently available in India. She survived. Assamese journalist Rabijit Choudhary was not as lucky. His blood tested negative for malaria and treatment was deferred until it was too late to save his life, even with quinine.
As the spate of malaria deaths rises, doc-tors are demanding improved diagnostic techniques and access to more anti-malaria drugs. While country-wide figures for fatalities in the last two months are not available, some 500 people are estimated to have died in the North-east alone.
But despite the alarming spread of the epidemic, the Ministry of Health and Family Welfare has yet to wake up to the menace. It is not as if the P Falciparum strain is a new phenomenon. Says Dr A.K. Bannerjee of the Woodland's nursing home in Calcutta: "Cases of drug-resistant malaria parasite were common inAssam in the mid-1970s." But even two decades later, quinine remains the only defence against the drug-resistant strains of P Falciparum, which are immune to conventional medication.
Citing one reason, Dr Saupayan Dutta, who treated the late singer, says that the Government has failed to train laboratory technicians suitably and hence, incorrect diagnosis of blood samples is fairly common. Mass blood tests are most often useless if the slides are not examined with adequate skill and care. With cerebral malaria, an incorrect or delayed diagnosis could mean death. And doctors cite numerous instances of the parasite showing up only in the eighth blood test.
While the situation grows serious, the ministry steadfastly refuses to import new anti-malaria drugs developed abroad. Complains paediatrician Dr Jaidev Rai: "I can't understand why potential life-savers like mefloquine, halofantrine and artemesine are not made available at least through government outlets." He cites the case of a child whose virulent case of P Falci-parum proved resistant even to quinine and who survived only because the doctor was able to access imported mefloquine.
Government health specialists are hesitant about using even the anti-malaria drugs available in India. The patient, they say, should preferably wait for a blood analysis before taking chloroquine, the standard anti-malaria drug. Only if the drug fails to work, should he be put on quinine. Further, each case has to be treated individually and there may arise occasions when immediate treatment with quinine may be required. Primaquine and metacalffil are the other alternatives for treating non-resistant malaria.
The new line of anti-malaria drugs, however, are currently available only on the black market. Dr Arup Dutta, urologist at Calcutta's Belvue nursing home, specialises in treating complex cases of malaria and strongly feels that mefloquine—priced as high as Rs 1,500 per course—should at the very least be made available to poor patientswho cannot afford black market rates.
And though doctors agree there is considerable merit in the ministry's argument that the import of new drugs may lead to their widespread misuse and may further lead to the development of even more resistant strains of the parasite, Dr Bannerjee offers the following counter-argument: "We are not saying put them on the open market. But there is nothing wrong in having them made available to patients strictly on prescription through government agencies."
Dr Saupayan Dutta outlines a similar problem. In the singer's case, he was unable to use mefloquine on his patient because he had a heart problem. "But," says he, "I had no access to or working knowledge of artemesine and halo-fantrine, which are far less toxic and have fewer side-effects. Authorised outlets should definitely stock these drugs."
In Calcutta, where hundreds of patients throng the malaria clinics set up in government and charitable hospitals, panic buying of chloroquine, primaquine and quinine has created an acute shortage of anti-malaria drugs. They are being used as preventives rather than curatives—precisely the kind of indiscriminate use health experts fear.
Articulating a forceful argument against the use of such drugs is Dr Amitabh Nandy of Calcutta's School of Tropical Medicine. According to him, the malaria parasite, like all life forms, tends to adapt itself to hostile environments. "Long-term exposure to any chemical results in the parasite mutating in a way that beats the drug. Multi-drug resistant malaria is rampant in South-East Asia." The doctor does not recommend chemo-prophylaxis even for high-risk groups like infants and pregnant women.
The Director General of Health Services, Dr A.K. Mukherjee, argues against mef-loquine, citing the case of an English child who developed "a serious blood disorder" after using the medicine. He acknowledges, however, that the most promising drug is artemesin, which is both effi-cacious and inexpensive and widely used in China. While he prefers to wait until clinical trials by the Central Drug Research Institute are complete, Health Ministry sources point out that Cadilla and Rhone-Poulenc have already conducted successful government-approved trials. So why the delay here?
Whatever the outcome, it appears that the ancient scourge—mentioned by physicians as far back as in fifth century BC—is here to stay. echoing that feeling strongly is Mukherjee whose prophecy, "we expect the incidence of P Falciparum to increase in the next decade", has deadly ring of truth.