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By N P Chekkutty Two reasons are attributed to the return of many epidemics to Kerala, a state that had achieved developed-country status in all the major human development indices: erosion of the grassroots-level public healthcare system that once thrived on government support, and dysfunctional municipal systems that do not deal effectively with waste-disposal
Outbreaks of seasonal epidemics like dengue fever, chikunguniya and Weil’s disease in Kerala during the last few monsoons, which have affected millions of people across the state, have caused serious concern about a crisis in public health in Kerala. Politicians, policymakers and public health workers are now unanimous in their view that the famous public healthcare system that helped Kerala achieve developed-nation status in all the major human development indices like life expectancy, infant mortality, etc, is now being seriously challenged. With the onset of the monsoon this year, which started in early June, came a chikunguniya epidemic that practically immobilised the entire state. Over 1 million people were treated at various hospitals across Kerala. According to local newspapers, over 100 people died of chikunguniya in the two months of June and July although official agencies like special teams of experts deputed by the Union health ministry dispute claims that the deaths were due to the epidemic. Experts at the Centre as well as public health organisations like the Kerala Sastra Sahitya Parishad and the Indian Medical Association are united in their view, however, that urgent steps are needed to address the widespread and regular occurrence of epidemics in Kerala, during the monsoon months. Two major reasons are attributed to the return of epidemics in a state that had practically banished such scourges more than a quarter of a century ago: erosion of the grassroots-level public healthcare system that once thrived on government support, and dysfunctional municipal systems that do not deal effectively with waste-disposal. The decline in the grassroots level healthcare system has been evident over the last few years and the recent National Family Health Survey 3 (NFHS3) is an eye-opener: It says that the proportion of children between one to two years who received all required immunisations was 81% in Tamil Nadu, but dropped to 75% in Kerala. The total fertility rate (average number of children per couple) is 1.8 in Tamil Nadu while it is 1.9 in Kerala. The infant mortality rate (IMR) in Kerala, which had reached a low of 10 per 1,000 in the mid-’90s now stands at 15, according to NFHS data. These are some recent statistical indicators – from government sources -- that illustrate the decline of Kerala’s health sector. The decline has been attributed to the erosion of primary healthcare centres as the focus of the healthcare system. Now the focus has shifted to specialty hospitals and referral centres. Doctors serving the government sector, especially in rural areas, are leaving to join the mushrooming private hospitals. Added to this is the accumulation of wastes and the failure of the public systems to cope with it. The changed mood is visible to even a casual visitor. National highways now resemble public dumping grounds, and most of Kerala’s rivers and waterways are clogged with stinking bags full of chicken and other animal waste. In Kochi, the fastest-growing city in the state, the situation has, in fact, become unbearable. Because of the huge piles of garbage in the streets and a breakdown in the municipal system, schools in some areas were forced to declare a few days holiday in July. Dr T Jacob John, former head of the virology division at the Vellore Medical College in Tamil Nadu and an acknowledged authority on virology in south India, is one of the people concerned about the fact that many epidemics are staging a comeback in Kerala. Epidemics that, he says, were weeded out in the early-’70s thanks to easy access to modern medicine through an effective public healthcare system. Experts say that in the mid-’80s there were regular outbreaks of dengue fever and chikunguniya. Also, new and virulent species of carriers like the Aedis Egypti mosquito whose spread has been aided by large rubber plantations that now proliferate even in the midlands. Along with them came the widespread use of plastic and its indiscriminate disposal, with no public action to put in place an effective recycling mechanism. Added to this was the breakdown in a once-efficient public healthcare system, with the decline in government support to public health and an increasing tendency towards privatisation of healthcare taking it beyond the reach of poorer sections of society. At a seminar on the threat of epidemics in the state, organised by Malayala Manorama, the state’s largest newspaper network in Kottayam recently, Dr Jacob John pointed out that the dengue virus and the Aedis Egypti mosquito were the main sources of epidemics in the mid-’80s. Weil’s disease, a waterborne disease spread through rats, was reported in Kerala in 1987, and has since become one of the major causes of death during the monsoons. A decade later, by 1995-96, Kerala witnessed the return of cholera and malaria, epidemics that were almost non-existent in the earlier two decades. During this period, cholera was reported from Alapuzha, a coastal district, and malaria from the northern district of Kasargode. Added to this was an outbreak of Japanese encephalitis, another virulent disease caused by mosquitoes, in the Kottayam and Alapuzha districts. It was this sudden and widespread outbreak of a number of epidemics that spurred the government to set up the State Virology Institute in Alapuzha, a place that has emerged as the epicentre of a number of diseases. The Institute took steps to identity outbreaks of diseases in any part of the state, urging doctors to send in postcards with warnings. The scheme worked well in the initial years. In Kottayam, during the 1990 monsoon, an outbreak of cholera was quickly detected. What helped contain it was an early-warning system that worked and ensured that efficient preventive measures were taken, say health workers who participated in the campaign. Doctors and health workers assert that the Kottayam experience was an example that proved the efficiency of coordinated efforts by grassroots health workers, the three-tier panchayati raj system, and the administration. Four years later, however, when a hepatitis virus struck the same district, the system failed. This time, the authorities asserted that there was no serious threat and no major outbreak, even as dozens of patients were admitted to hospitals. The point of origin of the epidemic was the Medical College Hospital in Kottayam. No steps were taken to tackle the outbreak in the initial stages. Over 170 doctors and para-medical staff became infected; two doctors later succumbed to the disease. Dr Jacob John points out that by the time (January 2005) it was confirmed that the cause of death was the hepatitis A virus, the situation had reached epidemic proportions. He is of the view that had the authorities taken adequate preventive steps and warned the public about the possibility of an outbreak, and ensured a supply of clean water, this calamity could have been averted. Doctors and health workers believe that public campaigns and mass-based preventive methods are the best way to tackle epidemics, as in most cases the diseases are caused by poor health awareness and lack of proper water supply and sanitation. For this to happen, a vigorous effort to revive government agencies like primary health centres is necessary. (N P Chekkutty is a senior journalist based in Kozhikode) InfoChange News & Features, August 2007
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