Pandemic proportions

-- In late 2005, an unidentified disease was noticed with rapidly increasing regularity in the southern and western parts of the country. It appeared to be severely debilitating, inducing high fever and excruciating pain in the joints, which would persist much after the fever subsided. The first batch of cases was reported in the country in October that year. But it was only in December that samples in Maharashtra tested positive for the chikungunya virus, a relatively unknown quantity outside research circles, especially because it had surfaced on a major scale 33 years ago.

Almost a year on, the disease has been detected in Karnataka, Andhra Pradesh, Tamil Nadu, Kerala, Maharashtra, Gujarat and Madhya Pradesh (see table State of the disease). There are reports that it has surfaced in Goa, Delhi and Rajasthan as well. As of August 22, 2006, over 1.1 million people were suspected of having contracted the disease.This figure is obscured in some ambiguity -- it could be an underestimate or an overestimate. On the one hand, only those coming to government centres are enumerated, on the other, fever cases are being labelled chikungunya across the board in affected areas.

On July 30, the health ministers of the four worst-affected states -- Karnataka, Andhra Pradesh, Tamil Nadu and Maharashtra -- held a meeting to draw up measures to tackle the problem. The minister from Karnataka took the initiative. The memorandum they submitted to the Union ministry of health and family welfare mentioned that poor people were suffering because they were not able to earn a living. Unfortunately, the states did not have much information to substantiate their claims. The Union minister, Anbumani Ramadoss, did not appear impressed, asking people to stop panicking since the disease was not fatal.

This might not be completely true for there have been reports of older people and people with existing health problems succumbing to the disease. The authorities are just not taking note. And now they are saying that the disease is under control. This is despite the fact that the system of data collection is flawed -- addresses are noted down only if samples are drawn. A door-to-door survey is carried out in areas from which patients have come and the number of people affected is identified. Samples are not being collected because the National Institute of Virology (niv) is overburdened and there is no account of new areas being affected or even whether the disease is under control or not. "We have sent 91 samples to niv. They requested us not to send any more as the burden was too much," says S D Awaradi, district health and family welfare officer, Dharwar.

Moreover, the kind of records that are maintained does not make it possible to establish conclusively whether individuals fell prey to chikungunya.

Clueless in Karnataka
Dharwar district, with 60 per cent of the population affected by the disease, is a good case study of the impact of the disease and the measures taken by the government to control the epidemic. Chikungunya had been confirmed as long back as on May 19, 2006, but Karnataka chief minister H D Kumaraswamy met district officials only on July 5 to ensure that adequate control measures were being put in place. M S Srikar, the district magistrate of Dharwar, says the administration is adopting a two-pronged approach to control the epidemic -- treatment and prevention. The authorities say the disease started declining by July 15.

According to figures released by the Dharwar district authorities, they have so far procured medicines worth Rs 5.72 lakh. The list of medicines does not include an antacid, necessary when huge amounts of painkillers like diclofenac are administered.

Some stories from Karnataka

Government records show that Belgaum district has had very few cases. But a visit to the Bidi taluka shows a lot a people have suffered. Rajesaab Kittur of Nayanagar village contracted chikungunya two months ago and has not been able to run his poultry business. He is a small trader and earns just about enough to meet his monthly expenditure of Rs 2,500. During the last two months, he has spent Rs 4,000 on treatment and borrowed Rs 8,000. He is now looking for more loans to buy chickens to revive his business

In the last week of June, Gadigeppa was the first person in Gangapur village to get chikungunya. When the symptoms appeared, he was scared; the media was full of stories of the debilitating disease. Finding the Ranebennur PHC too crowded, he decided to go to a private nursing home, where he was admitted for four days. It cost him Rs 5,000. He has 2 hectares of land but still had to borrow. Medication is continuing but he still gets weak if he works for two hours at a stretch. His brothers-in-law help out

"Maximum focus is on the painkiller diclofenac sodium (on which almost Rs 3 lakh has been spent). This could be the industry's way of making up the losses since the veterinary use of the drug has been banned," says Gopal Dabade, Drug Action Forum, Karnataka.

The use of this painkiller has created other health problems for people who end up using it for months. In Ranebennur taluka, where huge amounts of the drug have been administered, Nagaraj S Doddamani, surgeon at the government hospital, admits that a few patients with holes in stomach walls have been coming to the hospital. They need to be operated upon.

There are other irregularities. For instance, cases of doctors in government hospitals charging for medicines in rural Bangalore. Doctors say the reason for this is that people demand medicines that are not supplied by the government. To cater to the patients' needs, doctors buy medicines and charge for them. There are also cases of hospitals providing better treatment to influential people. When Yashwant K Sahukar of Maidur village in Ranebennur fell sick, he was given preferential treatment because he knew the doctor. This was the same hospital where the poor could not even get a place to sit during the peak epidemic time.

In villages, malpractice is rampant. rmps prescribe antibiotics and vitamins indiscriminately to treat this disease. In Kotur village, 40-year-old Kallava Garagad fell sick in August. As per government guidelines, she should be prescribed the mildest of painkillers and an antipyretic. Strangely, the doctor gave antibiotics and vitamins along with paracetamol. He also gave her two injections. For this he charged Rs 100, money borrowed from a neighbour. Luckily, he did not put her on intravenous fluids, a practice being followed by a lot of other doctors. This would have meant more money for the doctor but would have led to more swelling in her joints. A similar case could be seen in the Gudagur village in Ranebennur taluka. Thirty-two-year-old Devaka was sick for two months and fell prey to quackery. For a total expenditure of Rs 2,000, she has been treated with diuretics, painkillers, antibiotics and vitamins. She has been sick for so long that even the people in her village have started giving her medicines they found useful in their treatment.

The government put up special camps in villages. But these camps were few in number and there was no effort to upgrade existing treatment facilities. Though there is a phc in Garag, Dharwar district, for instance, Angadi had to get treatment from a private doctor because he could go to the doctor only in the evening. The phc does not have the doctor all the time -- he attends the clinic two to three times a week but can be called in case of emergency. For the three Angadis who fell sick, the family had to spend around Rs 2,000.

There are some initiatives, however. Dharwar district has carried out a small trial for homoeopathic treatment. District officials approached a private practitioner, Mohan Kumar from Hubli, on July 10, 2006, to get this experiment rolling. A total of 220 people suffering from chikungunya in three villages were treated. Around 30 per cent of the people got better within one hour of being medicated. The results have been communicated to the state authorities.

Prevention
The second approach has been to create awareness about the disease and take precautionary measures. The Dharwar health department has bought six new fogging machines and these, along with the four existing ones, have been deployed in rural areas. Five mobile teams had also been created to monitor the incidence in the five talukas of the district. A total of 40 litres of pyrethrum has been sprayed so far. The responsibility of fogging lies with the village panchayats. This may not have helped much, as senior officials in the health department accept that the fogging is not done inside houses where mosquitoes are likely to be. In fact, the officials went on to say that fogging was only a placebo effect and was not effective in controlling the disease.

Nevertheless, the Centre is buying 400 fogging machines for four states. State authorities say this is not enough. Observers say that the chemical industry lobby is pressuring the government to buy fogging machines. The problem is the simpler solutions are not pursued. Karnataka, for example, does not have a public health law to ensure that people do not allow stagnant clear water pools, in which the Aedes aegypti mosquito breeds, says Ravi Narayan, advisor, Community Health Cell, Bangalore.

The state health machinery is not equipped to handle the burden of creating awareness. In rural Bangalore, of the sanctioned 670 posts of field workers, 180 are vacant. In Kanakapura taluka, of the 72 posts of female health workers, only 28 are occupied, and of the 43 posts for male workers, only 18 posts have been filled. Even these people do not have the time to go to villages to create awareness or collect data because they have to be in the hospitals to deal with the increased work load caused by the disease, says K P Paramesha, Kanakapura health officer.

Federal face-off
The responsibility of controlling this kind of vector-borne disease lies with the directorate of National Vector Borne Disease Control Programme (nvbdcp) in Delhi. The directorate reveals that logistics and technical guidelines have been provided to the different states. States have been authorised to incur expenditure on information, education and communities out of the funds made available by the Centre under nvbdcp. Temephos, for killing larvae in water, and pyrethrum, for fogging, have been provided to four states. Teams from the National Institute of Communicable Diseases (nicd) and nvbdcp have made field visits to review the situation and provide technical guidance and logistic support to states.

At the interstate meeting in July, the state health ministers claimed that all possible steps have been taken to contain the disease. These include active surveillance by the health workers and early detection of cases, supply of drugs, establishment of fever treatment depots with the assistance of anganwadi workers, ngos and teachers, vector control by cleaning all water storage units once a week, fogging and putting larvicides in open water sources, and community sensitisation.

The health ministers decided to implement a joint action plan to prevent and control chikungunya. For this they wanted central assistance for control of the vector (insecticides and fogging machines), diagnosis of the virus, treatment and research. The four states demanded around Rs 92 crore. Basavaraju, Karnataka commissioner, health and family welfare services, says Rs 13.77 crore has been spent in his state on chikungunya control.

The responses of the states and Centre are expected. There are the usual tall claims and jockeying for funds. What is absent is a coordinated approach and efforts to prioritise the areas -- research and control -- on which the focus should be.