Virtual viruses corrupt the system. Real ones have exposed it. The mystery fever that attacked Siliguri, a small town in West Bengal, this year is yet to be identified, but it definitely unmasked the rot in India's medical system. What began as sporadic incidences of strange fevers gradually gripped the entire town. Schools were closed. People refused to leave their homes and when they left, they used handkerchiefs as protection -- even the bride and bridegroom covered their faces. The panic was unprecedented. Medical practitioners fled the town fearing the fever was contagious. The fear of the unknown had struck. But there was little respite. Over 37 people lost their lives. "What do we do? We don't even know the cause," rued a helpless Bikash Ghosh, the mayor of Siliguri.
Meanwhile, the soothsayers of the medical fraternity were having a field day. All sorts of causes made it to the front pages of newspapers. From Japanese encephalitis, cerebral malaria and plague to mutating measles and what not! The panic also triggered a political turmoil in the state. The opposition Trinamool Congress in the state demanded the resignation of the state health minister even as the death count continued to rise. Inside parliament, the country's medical system virtually crumbled as a hesitant health minister admitted the government's inability to identify the fever. Even after eight months, the government claims to be close to identifying the fever. But nagging questions on the credibility of the identification process and the system are just coming to the fore.
The Centres for Disease Control (cdc), Atlanta, usa, was called in. It analysed samples and a detailed report was sent in early September. However, the Union government has not made the report public. Down To Earth has learned that W J Bellani of cdc, in a letter to Robert Kim-Farley of the World Health Organisation (who), New Delhi, has narrowed the causal pathogen to be either Nipah or Hendra-like virus. D Neogi, head of the virology department, Calcutta School of Tropical Medicine corroborates this fact. The Nipah virus epidemic took place in Malaysia in 1999, where pigs were reservoirs. The Hendra occurs in Australia in horses and people. Siliguri and its neighbouring areas have a large population of pigs. But how the virus surfaced here is not known.
The lack of coordination among the various government departments is apparent. Neogi, who was a member of state fact-finding team visiting Siliguri during the crisis, claims that he had suspected the pathogen to be Nipah right from the onset. He apparently had told the director of the National Institute of Communicable Diseases (nicd), New Delhi . But nicd experts negated his view, instead propagating the theory of mutating measles.
The turn of events from early February in Siliguri clearly reveal the level of under preparedness and the lack of expertise and coordination within all the stakeholders -- be it the government or scientific fraternity.
The Siliguri incident is just the tip of the iceberg in more ways than one. It got widespread media attention and the virus close to being identified. But there are many more cases across India that go unreported and in some cases wrongly diagnosed. Down To Earth reporters travelled to a few hotspots that reported strange diseases. But they only ended up with similar tales and symptoms: lack of a healthcare network, infrastructure and expertise, thus very little information. The mystery continues. Rae Bareli
Rae Bareli in Uttar Pradesh has a tryst with strange monsoon fevers. Doctors say every year there is a sudden rise in the number of fever cases. This year it claimed 18 children. Though the district administration put the body count at two, the district hospital's records show seven children died of 'suspected brain fever' between mid-August and first week of September. In this period, more than 60 fever cases were registered in the Rana Beni Madhav Singh hospital, the district hospital of Rae Bareli.
But hospital officials claim the issue has been blown out of proportion. "Only a few cases went undiagnosed, the rest were natural deaths," says R N Bharadwaj, chief medical superintendent of the hospital. Officials say that the patients complaining of fevers died within half-an-hour to one hour of admission. To ascertain the cause is, therefore, impossible. "Twenty-six blood serum samples were sent to Sanjay Gandhi Post-Graduate Institute of Medical Sciences (SGPGI), Lucknow, and four were sent to nicd," says R S Pandey, deputy chief medical officer (Epidemics), Rae Bareli. The results are intriguing.
SGPGI says that 14 out of 26 cases tested positive for Japanese encephalitis. "Interestingly, all 14 persons who tested positive are alive, though a 30-40 per cent death ratio is generally recorded in such cases," says Pandey. Then what was the cause? "It is difficult to say. We tried to repeat the tests, but could not coordinate with the patients," adds Pandey. Another way could have been to analyse post-mortem results. But they were not carried out. So till the time a detailed study is carried out, Rae Bareli's cup of woes will keep overflowing.
Situated in the rural backyard of the industrial city of Meerut, Khiwai witnessed a major outbreak of a mysterious fever with 'Japani viral' (possibly a local name for Japanese encephalitis) in 1997. According to Rohshanlal, chief medical office of Meerut, a large number of children, between the ages of 2-8 years, mostly boys, suffered from continuous fever and coughing, vomiting and shivering. This viral infection is suspected to be waterborne. "There is no protocol, except for the use of blood slide to diagnose malaria. Hence, mysterious fevers remain undiagnosed. NICD too has not submitted its report on the incident," says Rohshanlal. Shabbir Ali's four-year-old son had vomiting, behavioural changes and loss of appetite and sight. He succumbed to the fever 14 days later. Fourteen children died in all. S K Singh, medical officer-in-charge for Khiwai village says the village is densely populated and there is little awareness about health and hygiene, and their only source of water is a stagnant pond that is poorly managed. However, the cause of the 1997 outbreak is not understood according to local medical officers and the NICD.
A nondescript and remote block of Sarguja district, Wadrafnagar in Chattisgarh, made headlines in July this year for all the wrong reasons. A strange outbreak affected 66 villages and claimed more than 100 lives within a span of two months. Local people allege that this is a conservative estimate and the actual figure could be more than 300.
According to statistics of the district health officer, M H Parmar, a total of 14,333 cases were reported by the end of August, out of which 1,288 cases were due to gastroenteritis. Deaths were reported from 24 villages. Out of the total of 115 deaths that took place, 46 were due to gastroenteritis. "Most of the other cases were categorised as viral fevers of 'different nature'," says Parmar. He, however, admits that no one is quite sure of the type. NICD director K K Datta says that it was an attack of cholera and the local officials had been informed. Local officials, however, say that they have not heard anything from NICD.
Asked if there is any protocol for the sampling or identification of the virus, Parmar said: "We neither have the facilities nor am I aware of any such protocol. We are expected to take control measures to check the epidemic and to cure the cases. Given the extremely difficult conditions, our doctors are doing remarkable work." Delhi
"It is now a trend. There is nothing to be alarmed," says J N Pande, head of medicine, All India Institute of Medical Sciences, (AIIMS). "Every day our out patients department receives a sizeable number of patients who suffer from frequent fevers." Delhi is particularly notorious for viral fevers -- since 1986 three major peaks of viral fevers were seen during the change of season from winter to summer to monsoon and again to winter. These fevers have no distinct morbidity patterns but have a differing pattern of virulence. Children and adults, women and men suffer from varying intensity of the symptoms. According to most physicians at any given time, 8-12 per cent of Delhi's population is suffering from viral or unknown fevers, and peaks of viral fevers are spreading out evenly to become a regular feature of the city's woes.
So far, no one in the city of Delhi has succumbed to any of these widely prevalent viral fevers claim doctors. Doctors too admit an increased prevalence and incidence of the fevers and some also perceive that the fevers are gaining virulence. But no one knows what are the types of fevers and what causes them.
The city that never sleeps boasts of some of the oldest medical institutions in the country. The local people claim that they have the best infrastructure and municipal services. But all this confidence withers away each time an epidemic strikes. Every monsoon, people residing in the slums brace themselves for waterborne fevers and other mystery diseases. One such disease is Leptospirosis. Public health experts complain that patients register first in private hospitals that have no clue in diagnosing and treating patients. The disease is often confused with other diseases like jaundice and malaria. Hence the first few affected are the early victims of the disease. Municipal authorities and government hospitals remain secretive about the emergence and hope that the disease is actually a stray incident rather than an epidemic.
This year like any other year, Mumbai was greeted with the disease. Leptospirosis is a febrile illness caused by infection due to Leprospira interrogans -- which results from contact with the urine of infected animals, mainly rodents. The disease has struck earlier -- Patna (1985), Chennai (1988), Andamans (1993), Mysore (1997), Surat (1994), Mumbai (1999, 2000 and 2001), Kerala (since 1993) and all along the Malabar belt.
Between April and May 1998, the suburban town of Delhi experienced a "mystery illness" that claimed the lives of more than 15 children. Tests conducted by NICD failed to establish the cause. As in many cases in the past (see box: The X-files). Children below the age of four complained of vomiting, loose motions and fever to certain private physicians. Broad-spectrum antibiotics and anti-pyretic drugs were administered. But these led to complications: the children could not pass urine and later developed renal failure. They were then shifted to hospitals in Delhi, where they were put under peritoneal dialysis. A few days later they slipped into coma and died within the next few days.
A team from NICD collected samples, but their analysis has established very little. Doctors and medical experts are at loggerheads about the cause of this illness. Some say that it was due to indiscriminate and inappropriate use of drugs. But NICD has still a lot to answer.
NICD has admitted its inability to identify many mysterious fevers
Mystery forever. This is the impression that one gets while analysing past outbreaks of mystery fever in India. Whether it is the unusual fever in Gujarat’s Sabarkantha district that affected 20,000 people in 1980 or the recent 31 deaths in Thoram of Andhra Pradesh’s Vizianagaram district in 1996.
The National Institute of Communicable Diseases (NICD), which is supposed to identify such fevers, admits its inability to identify them in its annual reports. NICD director, K K Datta, attributes this to bad sampling and misreporting by local health centres.
||Sabarkantha district, Gujarat
||Around 20,000 people were affected by an unusual fever. Three people died.
||20 people got a fever, two died.
||15 people died of a fever that affected adolescents and adults.
||Shimla, Himachal Pradesh
||17 people died due to a fever.
||Five people died due to a fever.
||Vizianagaram district, Andhra Pradesh
||More than 30 people died in six tribal populated villages.
||Meerut, Uttar Pradesh
||19 people died of a mysterious disease.
|Source: Annual Reports, 1980, 1983, 1984, 1996, 1997, NICD, New Delhi