Who'll bell the pig?

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By In the wake of the scare over swine flu, T.V. Jayan turns the spotlight on the way India has consistently neglected to build up a system of disease surveillance and disease control
  • Published 31.05.09

For over six months the paediatrician kept waiting for the elusive phone call. Vipin Vashishtha, who is with a private hospital in Bijnor in Uttar Pradesh, had been told by officials of the National Institute of Communicable Diseases (NICD) in New Delhi that he would be informed about a seminar that would once and for all settle doubts about a mystery disease that had been killing scores of children every year, mainly in the western parts of the state. The call never came.

Vashishtha had a particular interest in the subject. Though the disease, known as Saharanpur encephalitis, had returned to haunt people year after year for the last two decades, health officials were clueless about its origin. It was widely believed that the disease — which killed nearly 125 children in 2007 alone — was caused by an unknown virus.

Then about two years ago, Vashishtha and a team of virologists, found that the culprit was not a virus, but an abundantly growing wild weed that children eat. The weed — coffee senna (cassia accidentalis) — tastes like a pea, but is poisonous. The meeting that the NICD was scheduled to convene was meant to examine the data that Vashishtha and others had collected. But, of course, it never happened.

Mysterious outbreaks of diseases have been killing thousands of people in India. But, despite the swine flu scare — the first case in India has been reported from Hyderabad — the country is strangely careless when it comes to disease surveillance. If Saharanpur encephalitis remains a big blot on the Indian disease surveillance system’s ability to identify and contain an unknown fatal disease, the chikungunya outbreaks in recent years expose yet another chink in the system: an urge to hush up the real magnitude of disease outbreaks.

While governments at the Centre and in most affected states have so far maintained that chikungunya in India has not claimed any lives, a team of researchers from the Indian Institute of Management (IIM), Ahmedabad, found last year that the city alone had hundreds of deaths that could be attributed to the viral epidemic in 2006. Their study showed that Ahmedabad registered 2,944 more deaths than the average during a four-month period when the outbreak had peaked.

Dileep Mavalankar, professor of public health at IIM and chief author of the study, says the Indian public health system lacks the resilience to catch early signals of an epidemic. “I fail to understand why we do not have an institution like the (American) Centers for Disease Control and Prevention even after 60 years of independence,” says Mavalankar. “We have a Central Bureau of Health Intelligence under the Union health ministry which is fossilised. Deaths, natural or otherwise, are reported to the home ministry. Besides, institutions like the NICD which normally investigate outbreaks hardly have ready access to real-time data.”

Health experts, who have been warning governments about diseases, are unhappy with the lukewarm response to findings. Take the case of Saharanpur encephalitis. A researcher with the National Institute of Virology (NIV), Pune, told The Telegraph on condition of anonymity that it couldn’t isolate any virus from samples collected during 2004 and 2005. But public health officials associated with central agencies continue to maintain that it is a sort of viral encephalitis.

The experts stress that it’s not just a question of lives; an epidemic is a heavy economic burden too. A new study by Mavalankar’s team early this year showed that the actual cost of chikungunya and dengue, another disease spread by the same type of mosquitoes, to the Indian economy during 2006-2008 was anything between Rs 2,600 crore and Rs 14,800 crore. “We calculated only the immediate cost of these mosquito-borne diseases. The emotional and economic burden of long-term illness and deaths are outside the scope of the study,” he says.

The health experts expect the government to initiate a series of steps to meet the threat of mysterious diseases, but there are few signs of that. “We do not have an operating public health system,” stresses Jacob T. John, who is credited with setting up the first medical virology department at the Christian Medical College (CMC) in Vellore.

The major problem is that health comes under both the state and central governments. While the Centre is responsible for disease control, disease treatment is under the states. “There is an urgent need for India to “reengineer” its centre-state equation and responsibilities relating to public health and health care,” says John.

Such a system will also address impending problems of emerging diseases by detecting signals and responding immediately.

Citing the Saharanpur fever example, John says the Indian public health system is not geared to do systematic investigations. “The emperor has no clothes, although he is described as being clothed in fine silk.”

Every year, different parts of the country witness unknown diseases that strike, kill a few and vanish. Such outbreaks need to be studied more seriously and modes of transmission identified early so that India can be prepared when they surface again, says Priya Abraham, who heads the medical virology division at CMC.

Preparedness, clearly, helps — as Gujarat saw recently. In February, Modasa, a highway town in Sabarkantha district, was hit by an outbreak of an unusually virulent strain of hepatitis B, which killed 69 people. NIV researcher Vidya Arankalle, who isolated the virus, says it mutated to a lethal one, killing the infected very quickly.

However, the state health department swung into action quickly by vaccinating all 60,000 people in the town, and limited the spread. “All of them have received three shots each over the last three months,” says Sudhir Gandhi, deputy director of health (epidemics) in Gujarat. Nearly three lakh people living in nearby areas have also been vaccinated against the disease, which is said to have spread through infected needles and syringes. The state also immediately arrested the doctors who were found to be recycling syringes. Cases have become sporadic ever since.

But the success stories are few and far between. The problem, Mavalankar believes, is that the government seeks to showcase a healthy India. “It is a conspiracy to project India in a good light. Medical data are often manipulated and misreported to show to the world that everything is fine here.”

Yet, as Jacob John puts it, India will not get the respect it deserves unless it takes the health of its people seriously.