A cerebral malaria epidemic in Rajasthan has its source in the Indira Gandhi Canal
Mosquitoes storm the desert
JUST as farmers in the dry districts of western Rajasthan were looking forward to a good harvest following the heaviest Irains in 2 decades earlier this year, a deadly disease - cerebral malaria - ran riot through the villages. All hopes of prosperity were dashed as hundreds of people were killed. In several cases, fever-stricken villagers were unable to even harvest standing crops.
Ironically, the cause of the tragedy was what is traditionally regarded as a boon in the desert state - water. A good monsoon and waterlogging from the Indira Gandhi Canal combined to create an outbreak of malaria which quickly spread to epidemic proportions.
Cerebral malaria is caused by the parasite Plasmodium falciparum and is transmitted by the mosquito Anopheles stephensi. Says Sanjoy Ghose of Uttari Rajasthan Milk Union Limited (URMUL) Trust, a voluntary Organisation, "The epidemic broke out in western Rajasthan which has the canal districts of Jaisalmer and Bikaner, with adjoining Barmer and Jodhpur districts."
The outbreak has revived charges that the canal has created ideal conditions for breeding of mosquitoes, the malarial vector, and spread of the disease. According to Surjit Singh, fellow, Institute of Development Studies, Jaipur, faulty canal implementation policies have brought problems such as waterlogging and disease- carrying migrant labour into the state.
The Rs 4,000 crore Indira Gandhi Nahar Project (IGNP), one of the country's most ambitious development projects, has a 445 km long main canal running from Masitanwali in Ganganagar district through Bikaner to Ramgarh in Jaisalmer district. The canal brings the waters of the Sutlej and Beas to the Thar. Through thousands of km of distributaries, the canal on completion will serve a culturable command area of 15.37 lakh ha.
Role discounted Discounting the canal's role in the epidemic, officials such as A S Kapoor, chairperson', IGNP Board, say, "Heavy rains this year have added to the growth of vegetation and malarial outbreaks during the monsoons, a common feature in the state. But that the canal is responsible for spreading malaria is disproved by the fact that maximum waterlogging is in Ganganagar district, which has not reported any malarial deaths." And the severely affected districts of Barmer and Jodhpur do not receive canal water yet, he points out.
However, NGO activists like Ghose claim that the development project's "attendant problems like water-bornediseases have been swept under the carpet by authorities eager to portray only a land blooming with the e4ect of the canal.
Says Devendra Kothari of the Indian Institute of Health Management Research, Jaipur, and a member of a committee constituted by the state government to study the cause of the present outbreak, "The enormity of the socioeconomic and geographical changes brought about by the introduction of water into the desert was not extensively studied by the authorities."
The vast amount of water brought in by the canal has transformed agricultural practices. In some districts, including Ganganagar, water-intensive crops such as cotton and wheat are now grown instead of the traditional crops such as jowar and bajra. Says Ghose, "These water-intensive crops are also sensitive to pests. As mosquitoes in the region get small doses Of DDT with pesticides sprayed on these crops, they gradually build up resistance against known insecticides."
Flood irrigation is now followed and stagnant water in the fields breeds mosquitoes. Parts of the canal itself have stagnant water as construction is not yet complete. And seepage from the canal has caused massive waterlogging. Says Ghose, "Whereas the IGNP has provided water for irrigation, drainage was not planned for."
The malarial epidemic may have spared Ganganagar, says Ghose, because repeated malarial outbreaks when the canal water first came to the district 2 decades ago may have enabled immunity to develop among its population.
However, even V P Sharma, director, Malaria Research Centre, Delhi, points out that malarial outbreaks are anticipated during the construction of any large development project and planners have standing guidelines that malaria control must be integrated into the project. This was ignored by canal authorities.
In corroboration, B S Rao, an epidemiologist at the National Malaria Eradication Programme (NMEP), part of a team dispatched from Delhi that toured the area from October 7-14, says, "In the disease's dormant period, there must have been persistent low-level transmission of the parasite which was triggered off by the heavy and prolonged monsoon rains."
Experts claim that the ecological circumstances for the present epidemic have been building up for many years in the face of a poor health infrastructure and a callous administration. Doctors in Jaipur point out that Rajasthan is outstripped only by states like Madhya Pradesh, Maharashtra, Assam and Tamil Nadu in malaria incidence. The sparsely populated, remote villages in western Rajasthan are in a backward region and lack adequate health facilities (each medical institution serms an area of 396 sq kin in Jaisalmer and 126 sq km in Bikaner).
NMEP officials say that there has been no malaria surveillance in- the regioa and that doctors were obviously unable to recognise P falciparum - or were indifferent to it - else the disease would have been detected earlier. Thus, in the state this year, the disease spread unchecked in remote areas in the western region during July and August, till it reached epidemic proportions. Unlike P vivax, which subsides naturally even without treatment. P falciparum is not eliminated from the body without radical treatment - the intake of both chloroquine and primaquine. And it multiplies very fast in the human body, often proving fatal.
Reports of cerebral malaria deaths broke first in end. August from Bajju village in Kolayat tehsil of Bikaner district. NGO representatives claimed that over 40 deaths had occurred in Kolayat tehsil a1one from mid-August to September. From September onwards, voluntary organisations began reporting deaths from almost every village in Jaisalmer and Barmer districts and from Osian, Phalodi andShergarh tehsils of Jodhpur district. From October on-wards, cases were being reported from all over the state, with at least 10 more districts being affected by the disease.
However, there are conflicting reports from NGOs themselves on the extent of the epidemic. URMUL and VHAI claim that there were 90,000 cases of cerebral malaria in the 4 worst affected districts of western Rajasthan, and at least 1,000-2,000 deaths had taken place from the post-monsoon period upto October 22. Other NGOS Claimed that the death toll was as high as 4,000. State opposition Congress representatives claimed that between 6,000-10,000 deaths had taken place in the state. But state minister for health and family welfare Rajendra Singh Rathore stated that 257 deaths had occurred from January onwards.
Rajasthan chief secretary M L Mehta was, appraised of the situation by the NGOs in end-September. Says Ram Babu, campaign manager of the Jaipur based Rajasthan Voluntary Health Association, "Government doctors did not alert the authorities because they were not aware of the realities in rural areas, now that the state has allowed them private practice. They ignore the villages, and remain in towns." Only when newspaper headlines screamed of a plague-like situation with up to 4,000 dead in Rajasthan did the state administration move towards damage control.
Official toll suspect
Ram Babu says that the official death toll was low because it was based only on government hospital records. These are unreliable, he claims, because Primary Health Centres generally discharge patients when they take a turn for the worse, so that deaths are not recorded. Hamlets in Barmer and Jaisalmer are so remote that conditions there are unknown to the government; technicians are not trained to even recognise malaria in blood slides; and, more over, P fialciparurn often requires repeated testing before showing evidence. On the other hand, says Ghose, "Our figures are based on information gathered firsthand from extensive travelling in western Rajasthan."
The month-long crash programme of malaria control launched by the state government on October 2 set up control committees under the chairpersonship of the district collector in each affected district. In addition, 358 mobile hospitals with 910 paramedical staff and 359 doctors have been dispatched. Medical universities in the state have also deployed 28 teams. The state claims to have distributed free about 40 lakh tablets of chloroquine and 17 lakh of primaquine. Additional supplies Of DDT and BHC have been rushed in by the Centre.
However, Parasram Maderna, MLA from the opposition Congress, declares that "the control programme has been totally ineffective". A week after launching control operations, 2,100 new malaria cases were reported from the severely affected Pokhran tehsil in government records itself.
|Percentage increase in the incidence of malaria from 1985 to 1994
Ram Babu alleges that vacancies in government medical centres are as high as 80 per cent. "In the Pokhran Civil Hospital, for instance, there was only I doctor as against 7 vacancies. The state's laxity, however, is combined with the doctors' reluctance to accept appointments in these remote rural areas."
Medical experts claim that most of the measures being taken are short-lived. Any investigation into the epidemic for its control must study epidemiological factors such as mortality through time, seasonal variation and geographic distribution; entomological factors such as vector breeding fauna, distribution and density of vector; administrative infrastructure such as money and humanpower for surveillance and diagnostic and treatment facilities; and technical factors such as resistance of vectors to insecticides and drug resistance of the parasite, feel experts.
Therefore, although the epidemic is expected to subside naturally from November 15 with the onset of winter, experts fear a resurgence in February- March when climatic conditions become suitable once more. It remains to be seen whether the Rajasthan government disproves the adage Once bitten, twice shy.
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