Sunday, December 9, 2007

Kerala: Crisis in Public Health System

Kerala Witnesses Return of Epidemics

By N P Chekkutty

The outbreak of seasonal epidemics like dengue fever, chikun guniya and Weil’s disease in Kerala during the past few monsoons, affecting millions of people across the State, has raised serious concern about a crisis in public health. Politicians, policy-makers and public health workers are now unanimous in their view that the famous public healthcare system that helped Kerala achieve a developed-nation status in all major human development indices like life expectancy, infant mortality, etc, is now facing serious challenge.

With the monsoon season this year, which started early June, came the chikun guniya epidemic that practically immobilized the entire State with more than a million people being treated in various hospitals. According to newspapers, over a hundred deaths have taken place in the two months of June and July owing to chikun guniya, though official agencies like the special teams of experts deputed by the Union Health Ministry, have disputed claims that they were caused by the epidemic. But the Central experts as well as public health organizations like the Kerala Sastra Sahitya Parishad and the Indian Medical Association are united in their view that urgent steps are necessary to address the widespread occurrence of epidemics as a regular phenomenon in Kerala during the monsoon.

Two major reasons are attributed to the return of the epidemics to a State which had practically banished such scourges more than a quarter century ago. First, the decay of grassroots-level public healthcare system that thrived on the support of Government and the dysfunctional municipal systems with the result of accumulation of wastes, most of them non-degradable items like plastics almost everywhere. The national highways now resemble a public waste dumping ground and most of its rivers and other waterways are clogged with reeking bags full of chicken and other animal wastes thrown in. The situation became unbearable in Kochi, the fastest growing city in Kerala: Because of the huge accumulation of wastes in the streets as the municipal system broke down, schools in some areas had to declare holidays in July for a few days.

Dr T Jacob John, former head of virology division at the famous Vellore Medical College, in Tamil Nadu, who is an acknowledged authority in virology in south India, points out that epidemic is a phenomenon making a comeback in Kerala. He says that with easy access to modern medicine through an effective public healthcare system, the State had weeded out such occurrences by early seventies.

Experts point out that the return of the scourges became a major concern from the mid-eighties with regular outbreak of diseases like dengue fever and chikun guniya with the appearance of new and virulent species of carriers like Aedis Egypti mosquitoes. The large-scale rubber plantations which has now spread even to the mid-lands helped the appearance of these guests. 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 of a once efficient public healthcare system with a decline in Government support to public health and the increasing tendency of privatization of healthcare taking it beyond the reach of the poorer sections of society.

At a seminar on the threat of epidemics to the State organized by Malayala Manorama, the State’s largest newspaper network at Kottayam this week, Dr Jacob John pointed out that dengue virus and Aedis Egypti mosquitoes were the primary sources behind the outbreak of various epidemics from mid-eighties. The Weil’s disease, a water –borne disease spread by affected rats, was reported from Kerala from 1987 and it has been one of the major causes of death ever since during the monsoon season. A decade later, by 1995-96, Kerala witnessed the return of cholera and malaria epidemics which had been almost non-existent in the earlier two decades. In this period, cholera epidemic was reported from Alapuzha, a coastal district, and malaria from Kasargode, a northern district. Added to this was the outbreak of Japan Encephalitis, another virulent disease caused by mosquitoes, in districts like Kottayam and Alapuzha.

It was this sudden and widespread outbreak of various epidemics that spurred the Government to set up the State Virology Institute in Alapuzha, a place that had emerged as the epicenter of such diseases. The institute had taken steps to identity the outbreak of any such disease in any part of the State, urging the doctors to use a post-card to give them warning.

That worked beautifully in the initial years: In Kottayam during the 1990 monsoon, an outbreak of cholera was noticed. What helped contain this outbreak was an early-warning system that worked and ensured efficient preventive steps, according to health workers who participated in the campaign. Doctors and health workers asserted that the Kottayam experience was an example that proved the efficiency of coordinated effort of grass-roots’ health-workers, the three-tier panchayat raj system and the administration.

But four years later, as hepatitis virus struck in the same district, the system failed as authorities took a negative line. They asserted that there was no serious threat. It was a massive faux paus, as the authorities denied any major outbreak, while dozens of patients were being admitted to the hospitals. The point of origin of the epidemic was the Medical College Hospital at Kottayam, but there was no step to tackle it at the initial stages. More than 170 doctors and para-medical staff were infected and two doctors succumbed to the disease. Dr Jacob John pointed out that when by January 2005, it was confirmed that the cause of deaths was Hepatitis A virus, it had reached epidemic proportions. He is of the view that if the authorities had taken preventive steps and cautioned the public about the possibility of an outbreak and ensured supply of clean water, such a calamity could have been averted.

Doctors and health workers feel that a public campaign and mass-based preventive methods are the best in fighting epidemics as in most cases the diseases are caused by poor health awareness, lack of proper water supply and sanitation. The media in the State had taken a leading role in such campaigns, but many health workers and activists feel that the media has been taking a largely negative role in recent years. According to Dr K P Aravindan, a senior doctor at the Kohikode Medical College and leader of the Kerala Sastra Sahitya Parishad, major newspapers had spread alarming reports about even minor issues. He also pointed out instances where media and some cultural leaders taking a negative stand against polio vaccination and the mass consumption of tablets against elephantiasis, a disease widespread in the coastal region. The sensational nature of media reports and the irresponsible attitude of a section of intellectuals against science and rationality is a mater of concern in the State. The recent chikun guniya season was a classic example of a media-created scare: The newspapers went to town with screaming headlines and the State came to a grinding halt for weeks together.

(Originally published at

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