Once bitten never shy

In India, the inevitable has happened this year too. Dengue fever has struck again. Delhi and some other states of the northern belt are feeling the heat, the capital being the worst hit. There are reports that the infection has also spread to Maharashtra and Kerala. So far more than 1200 cases of dengue have already been confirmed and more than 40 persons have succumbed to this virus in the country. The current outbreak is yet to peak and is likely to linger on for next few weeks. To compound the problem, a sister disease of dengue fever called chikungunya fever has also ravaged the southern peninsula and is now heading north. The eastern parts of the country are being re-visited by the brain fever Japenese Encephalitis, JE after creating havoc early this year in the same region.

Not that diseases like dengue fever, JE, malaria and chikungunya have been reported only in last 2-3 years. Data released by the ministry of health and family welfare clearly shows that since 1996 the number of cases reported for some communicable diseases such as dengue fever, JE, malaria and even filaria have been consistently on a higher side as compared to the immediately preceding decade.

All these diseases are grouped under 8220;vector borne8221; diseases 8211; in all these instances, the vector happens to be a tiny mosquito. It hardly matters whether the mosquito is Aedes dengue fever, chikungunyya fever, Anopheles malaria or Culex JE, filaria.

Since dengue is under focus currently, let8217;s examine why India has to undergo this annual torture. Almost all of these factors discussed below can safely be presumed to be applicable to most of the other re-emerging infections, especially the mosquito borne diseases.

Mosquitoes breed in water 8211; be it clean stagnant water in and around the homes Aedes or clean stagnant water in larger water bodies Anopheles or collections of dirty water Culex. As for the bites by mosquitoes, it8217;s directly related to the phenomenon of increased breeding and larger density of mosquitoes as well as bites by them. To my mind the underlying causes for this are:

n Management of water: shortage or wastage

n Lack of public awareness about breeding and protection from bites of mosquitoes

If there8217;s shortage of water, as is the case in most of India especially in the metros, people tend to store water however possible, often leaving storage containers uncovered, inviting mosquitoes to breed. If there8217;s wastage of water due to leaking taps, water supply lines or around wells and handpumps, as also is quite common, the water collects, again creating breeding grounds for mosquitoes. This process is clearly aided by a poor or often non-existent water drainage system 8211; more so in urban slums and villages.

Water shortage and wastages are directly related to the phenomena of ever increasing population, rapid urbanization and industrialisation, un-planned and under planned towns, cities and villages, unchecked and unplanned construction activities, poor sanitation, deforestation, so on and so forth. Poor water management is often coupled with lack of awareness in general public about breeding of mosquitoes and protection from their bites.

As public health education is largely the responsibility of the governmental public health system, the obvious conclusions are that health care workers as well as the state health departments are not fine tuned to meet this need.

Poor or delayed response to outbreak or epidemic threats can be attributed to poor health infrastructure personnel and facilities, practically non-existent disease surveillance and monitoring of communicable diseases including mosquito borne disease. The health care providers are not trained enough to have the eyes and ears of 8220;epidemiologists.8221; Clearly, the fault lies with the training of doctors, nurses and all levels of health care workers 8211; more notably those working at the village and sub-centre levels. This includes instituting adequate prompt and curative treatment.

What can be done? As prevention is definitely better, cheaper and more effective method to control any disease, the issues raised above need to be addressed as part of a comprehensive response to management of health. Health isn8217;t the health department8217;s responsibility alone. A multi-sectoral and multi-faceted response is required to meet the challenges of frequently occurring outbreaks. A segmented or isolated approach won8217;t succeed. While strengthening disease surveillance, the training of health care providers in medical and paramedical schools needs tailoring as per community health needs. The health infrastructure has to be strengthened so that the outbreaks can be managed even by smaller, peripheral hospitals. In the current outbreaks, a premier medical institute like AIIMS could8217;ve been saved from a large rush only if smaller local hospitals in and around Delhi were more responsive. Civic agencies, rather than adopting a callous attitude, have to 8220;really work8221;. Government-citizen partnership, through well-coordinated community participation efforts, need to be enhanced. Public health education strategies have to be streamlined. Rather than ad-hoc, knee jerk reactions, they have to be implemented through innovative, client friendly approaches.

Unless India really tones up the basic public health system, it will continue to suffer every now and then. And becoming super power will remain a pipe dream.

The writer is professor, community medicine at the All India Institute of Medical Sciences, New Delhi.