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The National Vector Borne Disease C ontrol P rogramme is in the process of changing the country's drug policy. A meeting was held in March 2006 to discuss new directions but the final policy has not yet been determined. In October 2005, a workshop was held by nimr to discuss the drug policy and come to a consensus regarding treatment of both Pv and Pf. The group suggested that oral artemisinin derivatives should be used only in combinations to ensure that resistance against them is not developed.
But the process of change can be described as too little, too late. As of now, treatment is presumptive, which helps pathogens to become increasingly drug-resistant. Moreover, the government does not seem to be particularly interested in shifting to artemisinin-based therapies. A sample of the denial mode comes from P L Joshi, director, nvbdcp. "We have changed the policy wherever there is a resistance problem. All Pf is not resistant to chloroquine and sp. In Assam, response to chloroquine is very good. Implementation is a problem. There is a need to give the full dose. Only then, one should say that it is not working. Health is a state subject -- they have to ensure that they control it," was his comment on the situation.
Besides, the Centre's treatment protocol stipulates giving chloroquine as a first line treatment where resistance has not been proved. In case this drug doesn't work, sp is given as a second line of treatment. And in areas where chloroquine resistance has been proved sp is administered as a first line treatment and act is the second line treatment. " States have to persuade the Centre to change this protocol. As of now, the protocol has been changed and implemented only in areas where there is resistance. There is no logic in doing this in patches," says Nana Zarkua, medical coordinator, msf, Delhi. Vectors do not respect the government's boundaries.
" who has clearly established a protocol, based on scientific information, that all Pf cases should be treated with act. The Indian government cannot say that they will treat Pf cases with act only if resistance to chloroquine or sp is proved," says Leena Menghaney, project manager, India, Campaign for Access to Essential Medicines, msf. The problem, she says, is that there is a huge resistance to change and there is no public pressure on the government to change. act just costs around us $2 (Rs 90 approximately) to treat one patient. The price is likely to go down further if industry sees that the government is interested in act. "The fact that people in malaria-prone areas are dying is an indication that the current drug regimes are not working," she adds.
That's one of the big problems. Reporting on malaria is bad. While a 10 per cent annual blood examination rate is considered adequate to reflect the ground situation, data from 2004 shows that many states -- Arunachal Pradesh, Assam, Bihar, Jammu and Kashmir, Jharkhand, Kerala, Manipur, Meghalaya, Nagaland, Sikkim, Tripura, Uttaranchal, Uttar Pradesh and West Bengal -- do not adhere to specified testing procedures. While estimates prepared by who suggest that every year there are around 15 million cases and 20,000 deaths in the country, nvbdcp reports around 2 million cases and 1,000 deaths. Medical certification of cause of death data for 1998 shows that only around 15 per cent of certificates gave a reason for death. Of this, around 4,531 were certified as malaria deaths (data for j & k, Bihar, Assam, Mizoram, Uttar Pradesh, West Bengal and Chandigarh not included). If this statistic is extrapolated, approximately 49,746 people died of malaria in 1998.
nvbdcp is responsible for monitoring drug resistance in the Pf pathogen. It was given the responsibility in 1978. But, at present, there are only 13 monitoring teams in 11 regional offices countrywide. The northeast has only one. The data they collect is used to map areas with pathogens resistant to chloroquine and create a database for the national drug policy. Joshi says areas where doctors report treatment failure are assessed regularly. Given the fact that complete treatment is seldom provided in government facilities, this claim is far-fetched.
That reporting is in tatters is also reflected in basic infrastructure lacunae. To ensure that chloroquine is not used as a presumptive treatment, use of rapid diagnostic kits has been recommended to distinguish between Pv and Pf. nvbdcp started providing limited numbers in 2005 after procuring 965,000 kits. In 2006, it has procured 236,000 kits and will order 5,900,000 more in three months. This is not enough.
Bureaucratic sloth is a metaphor for the government's resistance to change, which mirrors the falciparum's resistance to drugs. Unfortunately, the government cannot mimic as easily the pathogen's plastic response to its environment.