India t;iisasters

report

EPIDEMICS: DISEASES

AS DISASTERS

Epidemic selection cri. teria

. The shortlist presented in this ehupter is based on various parametres of epidemics, such as the rule of spread, number of people lIffected, morbidity, rates of dislIbility and death, social and economic disruption, coping diffi-

ulties, and the potential for ross-border transmission.

c. M. Francis Ravi Narayan Rajan R. Patil C. Umesh

Developed nations find it difficult to view epidemics as disasters

Most experts refuse to include epidemics in their shortlist of disasters, costing the world dearly in terms of morbidity, mortality, and hence, human capital.

Today, aid and relief go largely to non-biological disasters while increasingly treatment-immune and mutagenic biosystems wreak havoc in the Third World.

There are two kinds of disasters that concern us: 'disasters waiting to happen' and 'disasters that should not have happened'. Both include natural and human-made catastrophes: the first demands our respect; the second, a measure of rationality.

A disaster is a grave occurrence with ruinous results. This definition WOUld. certainly include epidemics. Policy-makers, however, view them CIS distinct from other disasters, and do not respond with the same promptness reserved for floods, fumines, and tectonic calamities or wars, subterranean mine entastrophes, and oil spills.

Left to fester or incompletely addressed, an 'area-endemic' can become epidemic. With vectors primed for aggression, an epidemic can become pandemic.

Lines of convergence

During a disaster, amongst the first to collapse is the public health system. Hence, governments and agencies often try to reduce the response time and expedite the transport of relief material.

Hell's kitchen: A slum is a pressure cooker for epidemics

OTHER DISASTERS INDIA DISASTERS REPORT

Scientific studies based on mathematical models show that an increase in the global mean temperature by 1-2 degrees would enable mosquitoes to extend their range to neW geographical areas, leading to an increase in cases of malaria and several other infectious diseases-especially in populations living at the periphery of the areas currently prone to these diseases'

Long-~erm psychological trauma is a fallout of epidemics

Besides long-term psychosocial physical trauma, disaster victims are exposed to increased incidence of epidemics. Disasters boost infections such as measles, malaria, diarrhoeal diseases, cholera, typhoid, typhus, and rodent-borne diseases such as the plague.

Economic loss

In 1991, it was estimated that the average nationalloss on account of malaria was Rs 25,000 million.' This includes estimates of the cost of long-

288 INDIA DISASTERS REPORT OTHER DISASTERS

tions are conducive to epidemics ably spread to the countryside.

Agriculture Agro-expansion has impacts on system. The pesticide extravagance vectors and their natural predators. Fol' inured mosquitoes trigger off epidemlos local antidotes.

Changing environments Anthropologists postulate that piggyback on adventure tourists. There i.

filoviruses, and infections such as yellow

get transmitted from wild animals to because of transformations in animal habitatl!

Malaria

The government spreads malaria by policy. V. P. Sharma, former director, Malaria Researcb Centre, DeIhl

History

Incidence of large-scale outbreak of malaria is common in the hills and amongst tribal peoples. Malaria epidemics have been known to decimate settlers and impede cartography in the past. For example, as recently as 1952, of 75 million malaria victims, about 800,000 died. Cases dropped to fewer than 100,000 with the setting up of the National Malaria Control Programme. In 1958, the word 'Control' was replaced by. 'Eradication'. Surprisingly, 1965 registered no malarial fatalities.

In the early 1970s, the programme wound Up.3 Malaria struck 6.5 million people in 1976, killing 59. Emergency measures cut incidence to 2.2 million in 1982.

Current status

The World Health Organisation (WHO) estimated that India had 2.8 million malaria cases in 1995.4 According to the Union Ministry of

Health and Family Welfare, of the 85.92 million blood slides examined till September 1996, 1.73 million were positive. and 0.53 million were P

. [alciparum. The number of fatalities was 1,363.5

The Malaria Research Centre, Delhi, estimates, on the basis of chloroquine consumption countrywide, that about 35.5 million malarial cases are treated every year - in addition to those treated under the National Malaria Eradication Programme (NMEP).

P Jalciparum infection doubled from 21.8 per cent in 1981 to 43.9 per cent in 1991, and has been intensifying since 1994.

Predisposing factors/ecotypes Accelerated transmission of P Jalciparum was recorded during the construction of the Nagarjuna Sagar dam in Andhra Pradesh, the lndravati Project in Orissa, the Upper Krishna Project in Karnataka, and, more recently, the

. Indira Gandhi Canal in Rajasthan."

Ecotypes abound in India: rural malaria in

rain-fed areas; irrigation malaria; urban malaria; development project malaria; migration malaria; and border malaria. Scientists have noted a sharp increase in malaria along highways, irrigation canals, and in industrial regions.'

Control mechanisms

Insecticides

The current WHO Global Malaria Control Strategy emphasises early diagnosis, treatment with anti-malarials, and prevenlive measures such as insecticides IIIH.! insecticide-impregnated bednels."

Impregnated bed-nets

N M EP and the Malaria Research Centre have recently conducted studies in Assam, Orissa, and ~.adhya Pradesh that show that medicated bed-nets are of varyIng effectiveness, depending on III' biting habits of local vectors nnd habits of residents. While lutcrnutional public health collab- 1II'II1ioll promotes them as 'magic bullets'. they are only one of the IIIl1l1y alternatives to be adapted

1991 1992 1993 1994

to local realities."

Expansion of agriculture and irrigation has further compounded the problem

Bioenvironmental control

There is today, a move towards bioenvironmental control, using fish and biocides like Bacillus thuringensis against mosquito larvae. But these are newer prescriptions, pending a better basic healthcare infrastructure and demanding more intensive community participation. Field projects in Goa, Pondicherry, Chennai, Kheda, Kolar, and Hassan have been successful."

Vaccines

A breakthrough vaccine must demonstrate multi-

3

OTHER DISASTERS INDIA DISASTERS REPORT 2 '

Kala-azar is an 'also ran' disease, with its tens of thousands of victims too poor to ensure fat pharmaceutical profits. The only hope centres round an entrepreneurial movement towards herbal medicines

dimensional capabilities to J:aclde multiple hosts, multiple stages of vector lifecycle, multiple antigens per stage, multiple forms of the same antigen etc.

One vaccine under research against the pre-erythrocytic stages of malaria attempts to eliminate infection by blocking the parasite's ingress into liver cells. Other types of vaccines being researched separate the parasite's blood stage, its sexual stages, or reduce the parasite load. It will still take several more years to develop effective vaccines.

Medicinal plants

Quinine; obtained from cinchona, continues to be a potent drug. Artemisia annua, whose active principle is artemisin, has been used for centuries in China. It can be an alternative to chloroquine- and quinineresistant malaria. Several better synthetic deriva-. tives of artemisin, such as arteether and artesunate, have been prepared. 11

Kala-azar

Changing vector ecology of kala-azar is one of the least investigated topics. 12 Dr N. L. Kalra, Malaria Research Centre

History

The first recorded kala-azar epidemic occurred in Bihar in 1882. Thereafter, it recurred in 1891, 1917, and 1933. In 1939, it struck 92 thousand people. By 1960, it was almost eradicated. There were only 196 cases reported in 1961. Between 1953 and 1957, widespread spraying of DDT suppressed the epidemic. By the mid-1970s, the anti-malaria programme began to slip and kala-azar,

290 INDIA DISASTERS REPORT OTHER DISASTERS

which was linked like malaria to eradication through DDT, resurged.

Kala-azar is endemic to Bihar (26 districts), West Bengal (8 districts), and Uttar Pradesh (2 districts). Transmitted by the. sandfly, Phlebotomus argentipes, the disease is characterised by irregular fever, anaemia, and enlargement of the spleen and liver. The vector lives in the damp mud walls of huts and cattlesheds,· common in tribal areas.

Research into the 1977 epidemic indicated that the earlier kala-azar was transforming to post kala-azar dermal leishmaniasis (PKDL). The disease subsided during the 1980s, but resurfaced in 1990. The next cyclical decline, due in 1996, was reversed mainly by transmission control glitches."

Control mechanisms

Spraying with caution

The malaria control programme, was redesigned when the vectors became drug-resistant after irregular and untimely over-spraying. The kalaazar combat programme must follow the lines of

the redesigned malaria programme. A piece-meal approach will not help in combating the problem. I ;or example, in 1994, the Bihar government made the agonising bone marrow test compulsory," even though the infrastructure for bone marrow aspiration and microscopy is inadequate.

Changing environment

The humid eastern parts of India, mainly Bihar,

The Plague in Surat

The 1994 epidemic infected 614 people and killed 46

Surat was a sunrise city, its population of 1.5 million having multiplied four-fold over three decades. Its traditional handloom businesses of gold zari-work, changed to powerlooms. International investment in its burgeoning diamond-cutting industry shot up after 1958.

Frenetic growth and haphazard town planning Jed to high-density residential colonies. Increased construction accompanied by a growIng number of slums came up in low-lying, flood-prone areas.

,'. The 1994 Beed earthquake disturbed the territorial equilibrium between city-bred rats and wild rats and fleas jumped hosts. Simultaneously, in Surat, floodwaters from the river Tapi mixed with sewage and flushed the rills lrom their burrows.

The plague caught the city unprepared, without diagnostic apparatus or medical expertise.

are extremely conducive to the sandfly causing kala-azar. New foci have been reported in irrigated tracts in Gujarat, as well as in Jammu and Kashmir, Himachal Pradesh, and Uttar Pradesh. Environmental malformation brought about by irrigation projects and post-Green Revolution deforestation is mainly responsible for the vector adaptation and spread.

The first patients were admitted to hospitals on 19 September. By 29 September, one-third of the population had fled the city. Taken by surprise, research institutions did not have enough serotype samples to identify-by-comparison the type of pathogen.

Meanwhile, on 24 September, three suspected plague cases were admitted to the Infectious Diseases Hospital in Delhi and of these, two tested positive. Panicking, the government invoked section 385 of the Delhi. Municipal Act, 1957. As per this Act, the plague had been declared a dangerous disease and the government was vested the authority to forcibly hospitalise patients. By 29 September, 66 patients, 26 of them locals, were hospitalised.

The plague, as the government saw it, was detrimental to international public relations, the tourism industry, and multinational investments. The financial loss was computed at US$ 1.7 billion.

Open overhead water tanks, water accumulated in plastic or metal containers, and items such as disused tyres favour the breeding of the dengue vector. Urban construction, overcrowding in slums and

1 multi-storeyed

. buildings, and migration lead to the disease becoming an epidemic

OTHER DISASTERS INDIA DISASTERS REPORT 291

Dengue followed ilie 1982 Asian Games, when Delhi was an open strip mine of

mercial buildings, housing colonies, ~d flyovers.' .

In 1996, severe epidemics were reported from 27 countries in the Americas

EastAs~a.lnDelQi;th year, ther ere 10,252 cas.es and 423 deaths from in

of deng!!e. and QHE,.

. .. (\' ,... .' ;~"

Recently, as deng ent into rp.e~tasis, the Delhi High Court took suo

based bla newspaper report. Chastisetl, the Dellii government conducted punitive to-house searches for 'mosquito-breeding receptacles. Civil rights activists move as being invasive and seeking to shift blame from government to citizens.

Capital punishment

Dengue History

Dengue/dengue haemorrhagic fever (DHF) is an urban disease but has spread to villages with increased rural-urban traffic and return migra-

Year 1996 1997

.

. -Infections

16,531 1,177

Deaths 545

tion. It is a complex disease, caused by a virus with four serotypes.

Classical dengue was first identified in India in the 19th century. The definitive DHF epidemic occurred in 1963, causing about 200 deaths and thousands of hospitalisations.

Dengue has a peripatetic footprint: it was reported from regions as disconnected as

" .

lOlA DISASTERS REPORT OTHER DISASTERS

Visakhapatnam in 1968, Ajmer in 1969. V. in 1985, and Delhi in the mid-1980s.

The plague History

The Black Death has been endemic to India for I century. It travelled to Bombay from Hong Kon. in 1896, piggybacking on stowaway rats. In the following two decades, an estimated 33 million people died.

With no cases of the plague reported since 1967, the government disregarded a warning in 1989 by the Plague Surveillance and alarms posted by the seventeenth Inter-State Plague Co-ordination Meeting in 1993 that rodent positivity for plague infection was rising.

Japanese encephalitis

In recent years, the disease has appeared to spread into new parts of Asia, perhaps as a result of increased rice field agriculture.

The World Health Report, 1996

History

Detected in India in the early 1950s, Japanese encephalitis (JE) became a full-fledged epidemic in 1970. West Bengal had five outbreaks between 1973 and 1982 resulting in 555 deaths. In 1980, 530 persons died in north Uttar Pradesh, while 177 died in 1982. Karnataka was hit by the disease in 1982.

According to the Union Ministry of Health and Family Welfare, JE is a priority menace. The 1997-8 annual report gave provisional figures of 2,406 episodes and 582 deaths. JE has struck 24 states and union territories. 11

Caused by an RNA flavivirus that plugs into the central nervous system, JE is transmitted mainly by culex mosquitoes thriving in ricegrowing regions. The vector's reservoirs are a variety of animals, mostly porcine. The mortality rate for JE varies from 10 to 50 per cent. The morbidity rate is about 50 per cent; survivors are left with motor paralysis, brain defects, and speech impairment. The long-term effects include personality disorders and reduced learning ability.

Control mechanisms

The control constituents of Japanese encephalitis nrc at the National Institute of Virology, Pune, the National Institute of Communicable Diseases, Delhi, and the School of Tropical Medicine, Calcutta. But JE expert Jacob John says, 'There is no policy on Japanese encephalilis immunisation.'

Diarrhoeal diseases (including cholera)

History

Acute diarrhoeal diseases are responsible for 23 II) :\3 per cent of deaths in children less than 5 years old. But reliable data on morbidity and mortality are unavailable, as diarrhoeal diseases ( xccpt cholera) are not 'notifiable'.

Diarrhoea episodes plateau at about 500 millioll a year. Most are mild and only about 1 per 'Cllt of the 10 per cent dehydrated need in-patient trcuunent. Underlying causes of diarrhoea Include multiple infections, malnutrition of child IIlId mother, and premature birth.

Unfortunately, there is no comprehensive advice on the use of ORS, guidance and education regarding diarrhoea, or its treatment and pre-

vention, although

most households

h VC the required ingredients to treat it.

'l'ording to the WHO, about 70 per cent of

U I)llik fatalities in 1990 were due to diarrhoea. lending causes for the remaining deaths were umonia, measles, malaria, and malnutrition. Ih. lurrcased the demand for integrated health

facilities.

As basic preventive measures, WHo suggested the promotion of breast-feeding, improved water and sanitation facilities, and personal and domestic hygiene. In many settings, adequate breast-feeding was found directly proportional to a 2.5 to 4 times lower rate of mortality, and milder cholera and Shigella infection.

WHO estimated in 1994 that in the developing countries, 75 per cent had access to water, but only 35 per cent to sanitation. The runs were responsible for a quarter of preventable illness.

Cholera

History

Juvenile diarrhoeal diseases have multiple agents

Between the sixteenth and nineteenth centuries, cholera epidemics were called 'the hand of God'.

In AD 1503, Portuguese author Gasper Correa Prodded by a wrote in his book Lendas da India that 20,000- 'rapid results

odd soldiers in the army of the Zamorin in regime', private practitioners, although aware of oral rehydration . salts (ORS), pre-

; ..

Calicut had perished. He described a cholera epidemic in Goa 40 years later. Cholera epidemics raged through Madurai in 1609, the Arcot district of Aamboo valley in 1777, and Ganjam in 1781.

By 1880, the Indian railways that fostered industrialisation also exposed the country to the . cholera epidemics that gestated in fairs, pilgrimages, and political rallies. In 1879, about 300,000

scribe a variety of medicines, including syrups and

injections, to all pilgrims who attended the Kumbh mel a at

Haridwar carried the infection as far as Lahore, loose motion cases

250 kilometres west. A year later, a cholera epidemic struck the North-West Frontier Province. It found its way to Bombay in 1881. In British India, cholera fatalities between 1817 and 1821 numbered 18 million."

OTHER DISASTERS INDIA DISASTERS REPORT 293

In recent years,

cholera outbreaks have been reported in Jammu and Kashmir, Madhya Pradesh, Delhi, the North-East, West

. Bengal, Orissa, Andhra Pradesh, and Tamil Nadu.

Cholera biotypes Classical cholera epidemics and pandemics were caused by the Vibrio cholerae 01 type. In 1961, the EI Tor biotype (detected in 1905) eInerged as the cause of the seventh cholera pandemic, which originated

in Indonesia. The eighth pandemic started in southern India in 1992, with a new strain called

Pulse polio programme:

Only 1 ()() per cent coverage will work V cholerae 0139,19 which spread swiftly through-

Of the two types of vaccines - oral polio vaccine (OPV) and enhanced inactivated polio vaccine (EIPV)India prefers the inexpensive and mildly invasive OPV. The disadvantage is that 3 cases of vaccineassociated paralytic disease will occur for every 10 million doses of OPV

out the Indian subcontinent and its vicinity. After having peaked in 1993 with 9,000 notified cases, 0139 is now retreating.

Contributing factors

In a microstudy in Vellore following the 0139 outbreak, the factors responsible included faecal contamination of the riverbed, improper maintenance of riverbed Cartesian wells, irregular chlorination, and sewage contamination of the superannuated pipelines."

Poliomyelitis History

In 1994, the WHO listed that 75 per cent of polio cases in the world were found in the Indian subcontinent. In 1988, India committed itself to polio eradication by AD 2000.

Combating polio

Poliomyelitis is caused by one of three types of paralytic viruses belonging to the enterovirus group. The viruses infect only humans and are transmitted primarily through the faecal-oral route, but they can ride on coughs and sneezes. _ Polio is seasonal; it needs heat and humidity. Each type renders its victims immune to itself

294 INDIA DISASTERS REPORT OTHER DISASTERS

but not to the other two. The virus invades the motor-neurons of the spinal

and/or the brain stem.

Vaccine:

Of the two types of vaccines, oral polio VU':CJn •• (OPV) and enhanced inactivated polio vacoln' (EIPV), India prefers the inexpensive and mildly invasive OPY. Unfortunately, three cases of vilecine-associated paralytic disease will occur for every 10 million doses of OPV.

EIPV (injectible), on the other hand, costs more but carries no risk of vaccine-associated paralysis. It produces sufficient serum antibody to prevent, the virus from entering the nervous system via the blood stream but offers significantly less intestinal immunity.

More than 90 per cent of the cases occur among children less than two years 01d.21

Strategy for eradication

Measures to control polio are punctual immunisation coverage, national immunisation days, surveillance of acute flaccid paralysis, network of laboratories to detect wild polio virus, and transmission severance campaigns."

The pulse polio programme, along with National Immunisation Days, was initiated in 1995. On 7 December 1997,122 million children under five years of age were reported to have received the polio vaccine." A year earlier, while 100 per cent coverage was claimed, actually 93 per cent received the vaccine." WHO pegs the figure for 1995 at less than 90 per cent."

Tuberculosis

History

In 1910, the director general of Indian Medical Services drew the attention of the Government of India to 'consumption'. In 1916, Dr A. Lancaster was deputed by the Indian Research Fund Association to study the issue. In a 1935 tuberculin survey in the Deccan, Dr P. V. Benjamin, one of the architects of the Indian TB programme, noted positive reactions in 8.2 per cent of village children below 15 years of age and 11.6 per cent in small towns.

Tuberculosis was a big problem among Partition refugees. Today, stark examples exist in India's Tibetan settlements and ghettos. The Tuberculosis Association of India, established in

Tuberculosis kills one Indian every minute

ing for policy leverage, the irrelevance of the formulation to ground realities, lack of emphasis on strengthening primary healthcare systems, and further verticalisation when better integration was needed."

1939, initiated a Seal Campaign in 1950. The BCG vaccine was administered on a mass scale a year later. The National Tuberculosis Programme was kick-started in 1960. The lower-tier District TB Programme was initiated in 1962 and now covers 85 per cent of the country's districts.

TB kills 500,000 Indians each year: about 3.5 million of the 14 million patients are highly infectious. An estimated 2.5 million new patients are introduced every year." According to the WHO, 1.3 million cases were reported in 1996 alone." Of children less than five years old, 2 per cent are infected, as against 55 per cent of adults who are 35 years and above.

Drugs

It is feared that a 'liberal' drug policy would lead to unfair competition, withholding of supply, and misuse of patents. TB patients are increasingly becoming treatment-resistant because of over-medication, irregular treatment, and cocktailing of mutually contra-indicated drugs.

The TB control programme, initially understaffed, today suffers from under-utilisation of

A physician is one who pours drugs of which he knows little into a body of

which he knows less.

Voltaire

Sero-positive and AIDS cases in India

State Screened Positive AIDS cases
Andhra Pradesh 73.275
169
485
Andman & Nicobar Islands 10,588
Bihar 8,790 24
Chandigarh 55,104 184
Punjab 1,488 65
Delhi 314.213 1.244
Daman & Diu 250
Dadra & Nagar Haveli 160
Goa .61,689
Gujarat '374,078
Haxyan~ 13.951
Himachal Pradesh 13.951
Jammu & Kashmir 3,981
372.602
Kerala 44.547
Lakshadeep 755 7
Madhya Pradesh 93,062 390
Maharashtra 370.897 37,841 102.30
28,128 4,807 175.90
24.838 83 3,34
11,070 51 3.05
7,011 389 55.14&
Orissa 81,573 201 2,4
Pondicherry 76,370 2,406 31.5'0
Rajasthan 21.014 2,341 11.14
Sikkim 187 3 16.04
Tamil Nadu 687,934
Tripura 4,234
Uttar Pradesh 75,545
West Bengal 157,083
Total 3,131,470 Treatment

A moderately infectious patient can infect about 10 individuals in one year. Approximately 60 per cent of TB patients accept treatment without question - cough syrups, placebos, vitamins, esoteric potations, injections. About 35 per cent go to public health facilities; five per cent seek no treatment at all. The success rate of the classical regimen of 18 months is 50 percent and 52 per cent complete chemotherapy.

A new methodology in The Revised National Tuberculosis Control Programme (RNTCP) is based on the WB loan-supported, six-month-long Directly Observed Treatment Short Course (DOTS), which is monitored by a, healthworker.

Some health policy

researchers question the

RNTCP's rationale, raising j sues of systems optimisation, epidemiological and sociologieul analyses, coverage, loan r payment, and replicability.

thers have highlighted the unethical use of external fund-

OTHER DISASTERS INDIA DISASTERS REPORT

An important element neglected by

, government and other agencies are private practitioners, including village medicine men and herbalists, the first point of contact for 70 per cent of India's populace. Their skills must be regularly upgraded by continuing education, seminars, and refresher courses, and by their inclusion in all control activities

trained personnel. There are infrastructural bottlenecks in indenting, auditing, and complex medicine outflow. Although the RNTCP claims a 74.5 per cent cure rate, healthworkers and field staff estimate it at 40 per cent.

Priorities

Greater emphasis is laid on clinical and curative aspects than on pre-emptive control and prevention. There is a misplaced prioritisation of the second line of drugs, ,rather than on' case-tracking, case-holding, regimen compliance, and motivation. An 'essential drugs' list must be drawn up'.

crores a: year as human hours due to TB. She Course Chemotherapy envisages the cost ' treatment dropping to Rs 1,500 per patient und RNTCP. One million sputum-positive patien could be treated for Rs 150 crores per year.

Economic impact: cash down

It is estimated that there is a loss of Rs 1,000

296 INDIA DISASTERS REPORT OTHER DISASTERS

AIDS/HIV

History

The Human Immunodeficiency Vir (HIV) detonates into metastasis aft a dormancy period of up to 10 yea! demolishing the immune syste:

AIDS, HIY's full-blown avatar, fatal.

HIV infection was first detected India in 1986 and the first AIDS ca surfaced a year later. Thereafter, tl hyper-mutagenic disease explod among sex workers, drug mainline] truckers, and blood .infusion-depe dants. The disease was also transm ted from mother to child during pre nancy and tlrrough breast-feeding.

Current medical/financial status

WHO estimates more than 2.5 m lion HIV-infected cases in Indi Full-blown AIDS victims numb 3,161. According to the Unn Ministry of Health and Fami Welfare, 3.298 million people we screened for HIV till March 1996. ( these, whom 74,960 were seropo:

tive (22.73 per 1,000 samples). 5,204 AIDS cases have been logged.

The annual economic loss so far has been assessed at US$ 15.2 billion.

Grim future

The National Aids Control Organisation (NACO) prognosticates that by AD 2000 India will have up to 7 million HIV infections, and 2 million with full-blown AIDS. Almost 90 per cent of AIDS patients in India are econoproductive and between 15 and _49 years old.

Response

Projects were first implemented in Maharashtra, Tamil Nadu, West Bengal, Manipur, and Delhi. They gained momentum only in 1992 after mounting pressure from multilateral agencies and the UN.

Spread control

mv infection control mandates an alteration in sexual behaviour. This can be achieved through information, education, and communication. While the behavioural abuse of contaminated needles is difficult to combat, the use of 'bad blood' can be challenged.

The 'glocalisation' of epidemics

Central and state government budgets .rouUnely de-prioritise public health, indicating difference ~ public sector institutions to vel oping and maintaining quality care and rvice. Political interference, mismanage-

nt and rampant corruption today ,pervert orities.

By 1996, there were 627 licensed blood banks Warped politico-

in the government sector, 234 private blood- economic policies . banks and 283 commercial blood-banks. A will ultimately

Supreme Court Judgement on 4 January 1996 directed the government to form national and state blood transfusion councils by 15 July 1996; make licensing mandatory for blood banks by 31 December 1996 (later extended to 17 May 1997); and discourage professional blood donation.

In India, where blood has always been in short supply (the annual demand of 6 million units receives only half the supply), professional donors fill in a massive deficit. WHO experts have suggested a 'no wastage' regime of blood use. But in a country which lacks basic storage machinery, the supply of only platelets and red blood cells and the use of plasma expanders is difficult.

diminish PHS resistance' to epidemics. That would be a disaster

Finances

The main contribution to the National AIDS Control Project is the World Bank's assistance of US$ 84 million.

Human rights issues

Ethical and human rights issues dominate the global mv / AIDS debate: confidentiality, gender problems, special situations such as prisons, sanatoriums, domestic-abuse shelters, and professional, tourist, and college dormitories. In India, they defer to medical research.

OTHER DISASTERS INDIA DISASTERS REPO~

A single strand of Policy changes

development can progressively link epidemics to disasters to retrogression. If the developed nations still refuse to codify epidemics as disasters, we are already at the last post

Public Health System

India's Public Health System customarily bears the brunt of budget cuts, the most substantial following the 1991 economic liberalisation policy. The funds meant for Primary Health Centres (PHCs) are just enough to cover infrastructure costs.

A more pragmatic system than today's vertically aligned disease control programmes, dictated from the Centre and dependent on huge international funds, would be strong PHCs at district, zonal, state, and national levels.

Disease control programmes often fail due to lack of people participation, an absence of the social dimension in disease control strategies."

Surveillance, co-ordination, and response

There is a high differential between unreported and reported cases. An up-to-date database on diseases, incorporating surveillance measures, and an autonomous co-ordinated organisation is of utmost importance.

Every death must be codified by age, perceived causes, and other parameters. The PHC should monitor the biological vectors of infectious agents in every region, infections in vertebrates, including rodents, which may cause zoonotic diseases, check microbial drug resistance, and drinking water and food quality.

Budget allocation

We recommend that it should be a statutory obligation on Governments to spend a minimum of 15 per cent of their revenues on health activities.

The Bhore Committee

At the dawn of Independence, the comprehensive Bhore Committee report was accepted by the government. The Committee had laid emphasis on preventive services, linking health to overall development. It had also worked out a healthcare budget requirement. However, all plans since then have been under-funded.

Worse, the health budget, which was 3.3 per cent of the total outlay of the First Year Plan, became 3 per cent in the second, 2.6 per cent in the third, 2.1 per cent in the fourth, stagnated at 1.9 per cent in the fifth, sixth, and seventh, and plummeted to 1.7 in the Eighth Plan." The public health outlay constituted a fraction of this.

298 INDIA DISASTERS REPORT OTHER DISASTERS

We have to act now to make sure you to be a Rockefeller to afford decent healtlt

this country.

Jay

Budget cuts were particularly bad ly after economic liberalisation. There per cent cut in the malaria programme, cent in TB, and the AIDS budget was a fourth. Even the World Bank professed and the government had to revise it in me lowing year's budget. However, the damase been done. The NMEP was particularly The states had no imprest account to malaria outbreaks."

Central and state government budgets ly de-prioritise public health, indicating lllU1UIj'I_ ence in public sector institutions to

Political interference, mismanagement, and ram. pant co~ption today pervert priorities.

Tackling epidemics Right to information Hamstrung by a government policy that has long illegalised direct interaction between civil servants and the people, civic authorities and official medical professionals are unwilling to release correct information. Perhaps an independent forum could take on the function of information dissemination and mobilisation.

Decentralised surveillance

A district-wise management information system is a vital necessity. Invaluable information, even investigatable rumours, may be obtained through epidemiological surveillance, reports from healthworkers, healthcare institutions, the media, and the community.

Preparedness

A contingency plan must be integrated into every natural disaster preparedness programme. No such plan exists today. It must take into consideration logistics, inventory of available and required resources, investigation and control plans for the most probable epidemics in any given region, the availability of drugs and equipment, adequate finance, both imprestand long-term, human resources, and inter-sectoral support.

Managing epidemics

Measures for the prevention, control, and eradication of communicable diseases require an understanding of the epidemiology of diseases, their optimum environment (physical, social, and political), and the combat resources available.

The measures include health education and popular interacti vity with the control programmes, immunisation and increase in resistance (better health and nutritional status),-reduction of the reservoir/source (human and animal), and the interruption of transmission.

Absolute eradication demands total extermi-

. nation of the biological agents. The only disease claimed as globally eradicated is smallpox. Poliomyelitis is a likely candidate for eradication, stymied mainly by a lack of transportation and storage hardware like non-electric freezers.

Action pointers

It is the responsibility of local healthworkers to he on an 'epidemic watch', tapping medical institutes and colleges, and PHCs. They should help ill updating and documenting epidemiological data, and streamlining the disease notification network.

Tackling the roots

III the final analysis, the re-emergence and continuation of epidemics represent both a breakdown of our PHS and the inadequacy of our developmental strategies. The time has come for health policy makers to move from narrow biomedical approaches seeking only technological fixes to a much broader social and communityoriented paradigm shift in research problem and action initiatives."

Endnotes

, Th« World Health Report, p. 126.

! See Sharma, V. P., ~996, 'Malaria: Cost to India IIlId lurure Trends', South-East Asian Journal of

.. 6'.

"h'/,im' Medicine and Public Health, vol. 27, no. 1,

pp.4--14.

, ( 'onjrrence of Central Council of Health and Fumily Welfare, 1996.

, li't' World Health Report, 1996-7, p. 231. '/1/1/1/11// Report, 1996-7, Ministry of Health and Fllillily Welfare, Government of India, p. 153 .

• I )US, P K. and P. Jambulingam, 1997, 'Vector con-

OTHER DISASTERS INDIA DISASTERS REPORT 299

trol, an attainable goal', Health and EnvironmentThe Hindu Survey of the Environment, pp. 77-81.

7 Ramalingaswamy, v., 1998, statement at the seminar on Health and Environment, organised by Centre for Science and Environment, New Delhi.

8 World Health Organisation, 1993, Implementation of the Global Malaria Control Strategy, Report of a WHO study group on the implementation of the Global Plan of Action for Malaria Control 1993-2000, WHO-TRS no. 839, Geneva, p. 57.

9 Towards an Appropriate Malaria Control Strategy, VHAIISOCHARA, 1997, pp. 51-2.

10 Kumar, Priti, et al., 1998, 'A Close Hard Look', Down to Earth, 15 July.

11 'Medicinal Plants and the Control of Parasites with Particular Reference to Malaria, Drugs and Pharmaceuticals'; Current Rand D Highlights, vol. 20, no. 2, 1997,pp. 83-8.

12 Kalra, N. L., 1998, statement at the seminar on Health and Environment, organised by Centre for Science and Environment, New Delhi.

!3 Ibid.

14 Chatterjee, Prabir, 1995, 'Kala-azar in Santa! Parganas', Medico Friends Circle Bulletin, April 1-3. 15 Annual Report, Ministry of Health and Family Welfare, Government of India, 1997-8, p. 145.

16 Qadeer, Imrana, K. R Nayar, and Rama V. Barn, 1994, 'Contextualising Plague: A Reconstruction and an Analysis', Economic and Political Weekly, 19 November, pp.2981-9.

17 Annual Report, Ministry of Health ~d Family Welfare, Government of India, 1997-8, p. 145.

18 Rao, Mohan, 1992, 'Of Cholera and Post-modem World, Economic and Political and Political Weekly, vol. 27, 22 August, pp. 1792-6.

19 John, Albert M., 1996, 'Epidemiology and Molecular Biology of Vibrio Cholera 0139 Bengal', Indian Journal of Medical Research, vol. 104, pp. 14-27.

20 Anand, Zachariah, Madhukar Pai, ana Prabir

,'.

300 INDIA DISASTERS REPORT OTHER DISASTERS

Chatterjee, 1997, 'Cholera 0139 Pandemic. LOl from a Micro Experience', MFC bullettin, September-October.

21 Singh, J. R., R S., Sharma, and T. Verghese, ,1 'Epidemiological Considerations on Age of ParalytIc Poliomyelitis', Journal of Tropical Paediatrics, vol. 42, pp. 237-40.

22 Tangermann, R. H., B. Aylward, and M. Birmingham, et al., 1997, 'Current Status of the Global Eradication of Poliomyelitis, Expanded Programme on Immunisation', WHO, World Health Statistical Quarterly, vol. 50, nos. 3-4, pp. 188-94.

23 The Times of India, Bangalore, 14 December 199'. 24 The Hindu, Madras Edition, 12 December 1997.

25 World Health Report, 1996, p. 231.

26 Annual Report, Ministry of Health, Government ot India, 1997-8, p. 150.

27 Banerjee, D., Serious Implication of the Proposed. Revised National Tuberculosis Control Programme for India, VHAI, 1997.

28 Narayan, T., 1998, A Study of Policy Process and - Implementation of the National Tuberculosis Control Programme in India, Unpublished doctoral thesis, University of London, March.

29 Das, P. K., 1991, 'Community Participation in Vector-Borne Disease Control: Facts and Fancies', Ann. Soc. Belg. Med. Trop., 71 (Supplement 1), pp. 233-42.

30 Health Information of India, CBHI, DGHS, Ministry of Health and Family Welfare, Government of India, New Delhi, 1994.

31 Banerjee, D., 1997, Landmarks in the Developments of Health Services in the Countries of South Asia, Keynote address to the South Asian regional seminar on the Impact of Structural Adjustment Programme on Health, New Delhi, p. 20. 32 Narayan, R, 1997, 'Resurgence of Malaria', Editorial, The National Medical Journal of India, vol. 10, no. 4, pp. 157-8.