Return Of The Killer Diseases

WHEN the rains came pouring down on Rajasthan last year, Ista Ram of Bijrar village in Barmer district danced in his courtyard. At last the gods had smiled upon the desert. As village wells overflowed and gushing streams eddied along the sand dunes, the people celebrated the prospect of a plentiful harvest. There was only one minor nuisance in that season of plenty. The clumps of mosquitoes that floated on the surface of the water or buzzed around the villagers’ heads seemed to multiply with every passing day. Ista Ram travelled to neighbouring Ranigaon where his son Mangal lived. But a terrible shock awaited him.

Ista Ram had expected a joyful meeting with his only son. Instead he discovered that Mangal and his family had all died the previous day. The wails of grief that emanated from every hut told a terrible story. The rains had brought a mysterious enemy to Rajasthan: malaria falsiparum or brain malaria.

Malaria was not altogether unknown in these parts. Indeed, the high fever and shivering fits were known to be easily curable with the tablets of chloroquine available from local dispensaries. But this time the disease seemed to have taken on a different form. The fever was accompanied by a severe headache and unless the patient received heavy doses of quinine within 24 hours, he succumbed to the illness.

According to unofficial estimates, almost 9,000 people died last year in Rajasthan alone and the killer is on the prowl again. This year, of all the blood samples tested for the falsiparum parasite by a local NGO—Society for Uplift of Rural Economy—more than 40 per cent have tested positive and 30 people have already died.

Man, it seems, is losing the battle against viral diseases. Malaria, which had almost been eradicated in the ’50s is now incurable in its new fatal form. A new strain of cholera—cholera 0139—has become a reg -ular post-monsoon killer. According to a Voluntary Health Association of India report, one-and-a-half million people die of all water-borne diseases every year, although the Government insists the fig-ure is much lower. Leprosy, dismissed in past Ministry of Health reports as a dying disease, is getting out of control in parts of Bihar and Tamil Nadu. Kala Azar, successfully eliminated in the first decades of Independence, has reappeared. And tuberculosis, long held to be a disease of the poor, is emerging in epidemic proportions among the urban middle class. More than half a million people die of TB every year, both in cities and rural areas.

From Barmer to Dhanbad and from Delhi to Bombay, the message is clear: as we set out on the road to modernity, old scourges are haunting new India. And as Dr P.V. Unnikrishnan of the Voluntary Health Association of India observes: "India is facing an epidemic of epidemics."

The process of industri-alisation itself has, paradoxically, led to the reemergence of pre-industrial diseases. Only this time they are deadlier. The explosion of industrial activity, construction in the cities, the proliferation of slums and the mobility of populations have changed the way in which human beings live. And as man has changed, so has the bacteria that lives off him. "In the constant struggle between science and microbe, the pace of mutation of lethal bacteria has become much faster than the rate at which doctors are able to keep up with medical research," says Dr V. Ramalinga-swami, professor emeritus at the All India Institute of Medical Sciences.

The rather questionable impact of development processes on public health is perhaps best illustrated in Rajasthan. Here the Indira Gandhi canal has cut a green swathe through the countryside but the consequent supply of fresh water has created greater opportunity for the proliferation of the malaria-carrying mosquito. Dr S.M. Mohnot of the School of Desert Sciences argues that the widespread construction of tanks using cement instead of the locally produced limestone has led to seepage which, in turn, has led to the breeding of the anopheles mosquito that carries the dreaded falsiparum parasite.

Tanks continue to breed mosquitoes and spread the disease. Yet, local health-care centres are as primitive and unhygienic as they were before the epidemic began last year. If rural folk are unable to withstand the onslaught of the virus, urban dwellers are at even greater risk. The congestion in cities, lack of clean water, exposure to industrial effluents and fast-paced lifestyles mean that the city resident is even more susceptible to infection than his rural counterpart and at times it can go undetected and prove fatal. For instance, dengue haemorrhagic fever is often confused with less lethal forms of fever because of its similar symptoms. The fever is highly infectious and can spread from slums to high-rises through servants or vendors. "The microbe doesn’t recognise class barriers," Ramalingaswami remarks wryly.

In Delhi, another ancient scourge is wreaking havoc on middle-class certainties. Dr Deepak Bawa, who practises in the elite Defence Colony area, says the city is facing a TB epidemic. "Affluent people tend to think they cannot get TB. But I have known people with businesses worth Rs 100 crore-Rs 200 crore who have been infected. When people start losing weight or are easily tired, the chances are they have got it. But because of the stigma, they don’t like to admit to the possibility," says Bawa.

In the midst of ignorance and prejudice, doctors too sometimes fail to diagnose TB. When young Sharmila Desai of New Friends Colony contracted a tubercular infection in the knee, it took a long time for the doctors to diagnose what was really wrong. Says her brother Rattan Desai, a chartered accountant: "They suspected all kinds of things before they came up with the right drugs which could control the infection. But by then my sister had already been through an operation and been in bed for six months. We had also spent a great deal of money. I guess they don’t think that people like us could have TB."

Incomplete medication is one of the main reasons why viruses become drug resistant. Often a disease spreads easily or has a fatal outcome because of the incorrect usage of drugs. Taking the full course of medication is essential for the treatment of TB, or the virus can familiarise itself with the drug, fight it and stay alive in a drug-resistant form. Thus, the next person who gets TB contracts a much hardier form. "The days of popping pills, feeling better and then discontinuing the medicines are over. Such practices only lead to a more virulent relapse," Bawa points out.

The human immune system is being rendered increasingly useless against the new strains of disease. Cholera Vibrio or cholera 0139 is a new strain that has struck parts of India after first emerging in Bangladesh in 1992. Contaminated water and inadequate civic amenities foster its spread. The danger posed by this strain is that even those who have had an earlier version of cholera are not immune to it. In fact, once infected, they are likely to contract it again.

The re-emergence of so-called eradicated diseases is an indictment of the health-care system in the ’90s. Today, there is a critical need to give equal emphasis to public health. Unnikrishnan argues that the undue importance given to AIDS has greatly contributed to the lack of preparedness.

Industrialised countries have freed themselves from sicknesses that continue to plague the Third World. And for the giant pharmaceutical companies, it is no longer lucrative to produce improved drugs for TB or malaria. Most of the money available from donor countries for medical research is earmarked for AIDS research and there are hardly any funds available from the Government to find newer cures for older ailments. The figures are telling. Only 849 people have died of AIDS in India which has some of the largest concentrations of TB and leprosy patients. "Let’s face it, AIDS is a white man’s problem," says Unnikrishnan.

The situation became particularly grave because early successes made the authorities complacent. In the ’50s, combating primitive pestilences was top priority. Mass spraying of DDT, awareness campaigns and the setting up of surveillance centres in villages were carried out on a war footing.

However, after early advances in eradicating small pox, controlling malaria, and restricting the spread of TB, government efforts began to flag. Today, primary health centres lack basic equipment such as microscopes or slides to examine blood samples. Teams of medical personnel who should carry out door-to-door checks during the epidemic seasons have long ceased to exist. No initiatives have been taken to ensure that the value of spraying chemicals such as DDT is understood at the village level. In the ’90s a WHO report observed: "The ignition wire of construction-related stagnant water and the gunpowder of migrant labour creates an explosive form of malaria." But as living conditions worsened, no effort was made to maintain public health standards. Among South-east Asian countries, India spends the least on public health, only 1.6 per cent of total government expenditure.

The politicisation of health care is another reason that the battle against old infections has been lost. Patna-based ortho-paedic surgeon Dr B. Mukhopadhyay narrates an incident in south Bihar. A Norwegian leprosy eradication agency had tried to establish a centre there. It was a purely medical body with no missionary objectives. But in a situation where there is cash to be made from contagion—that is, where centrally allocated funds for leprosy eradication are being siphoned off—there is no inclination to control, let alone eradicate, a disease. So the organisation was driven out on charges of proselytism.

The rise in leprosy cases is a tragic result of the breakdown of the health-care system. The disease is almost completely curable but due to lack of information, equipment and motivation on the part of the health authorities, today it is widespread in several parts of the country. There are 1,167,900 cases of leprosy in India.

Today, after nearly half a century of Independence, two million Indians die in epidemics before they reach the age of 10. Bureaucratic hair-splitting has meant that health still remains a state subject and is not given national priority. M.S. Dayal, former health and family welfare secretary, says that problems arise because areas of jurisdiction are not properly demarcated. "You can’t tell us to provide clean water because clean water is the responsibility of the Ministry of Urban Development, not ours." But Dayal admits that often there is a gap between what is said and done. Faced with widespread administrative apathy, India continues to sit on an epidemic bomb.