The incidence of dengue cases has come down with the retreat of monsoon; and with it the public sound and fury over the outbreak of dengue has abated. The apathy and neglect of the essential preventive measures are back in place. And anchors like Arnab Goswami no longer find the need to scream at panelists demanding to know “why anti-malarial treatment cannot be started for these patients”. The issue has fallen off the radar of media front pages and the health authorities can now go back to their disgracefully negligent ways.
At the height of the recent outbreak in the capital, the government embarked on three usual standard measures in their efforts to pacify the public at large and present a façade of hectic efforts at containment. In order of priority, these were, first a fogging campaign; the second was to make extra beds available to cope with the sudden spurt of cases and thirdly the launching a public campaign for preventive measures to keep households free from mosquito breeding sites. Most experts agree that the preventive measures should have been accorded top priority, and the outbreak should have been anticipated given the intermittent nature of the rainfall accompanied by high temperatures; ideal conditions for water stagnating and perfect conditions for mosquitoes to breed.
The campaign for preventive measures that was initiated was misguided and at times amusing. The public was advised to cover up by wearing long sleeved shirts and full length trousers bearing in mind that the dengue carrying mosquito was a daytime indoor biter. The most notorious breeding grounds are the construction sites with their cement curing processes and stagnant water. It is difficult to imagine a daily wage laborer working in a full sleeved shirt and long trousers. The dengue mosquito has a range of 100 meters, and it becomes imperative that every household be primed to institute measures to prevent breeding of the carrier by simple steps to avoid water collecting in puddles around the house. Repellant creams would certainly provide added advantage. The problem is that such educational campaigns require budgets; and maintaining levels of health care expenditure that keep company with countries like Myanmar, Haiti, South Sudan, Timor-Leste and Pakistan will do nothing for preventive measures. India spends 1.3% of GDP on health and thus stands 12th from the bottom in health care budgets. The result is halfhearted attempts to contain such outbreaks.
Meagre resources such as are available for healthcare are squandered on ineffective and economically inefficient efforts like fogging. Introduced in 1996 as a measure to contain the mosquito, fogging uses a mixture of 19 parts diesel, and one part Malathion, a chemical insecticide with pyrethrum a natural insecticide. 95 liters of this mixture are used per hour to create a “fog” which does kill the adult mosquito. The problem is that the “fog” remains in the air for only five minutes with no lasting effect, and does not affect the larvae. Fogging is carried out outdoors, whereas the dengue carrying mosquito is more an indoor pest.
The Malathion enters the human body by inhalation or skin contact and is converted in the liver into Malaoxon, a highly poisonous substance. WHO in fact classifies Malathion as a “slightly hazardous” or Class III substance harmful to children, asthmatics and pregnant women. The cost of fogging has been worked out at approximately Rs. 6000.00 per hour; and the recommended usage is for two hours each, twice daily per colony. If used as recommended it therefore costs Rs. 24000.00 per colony per day. And at the end of this exercise, the unaffected larvae continue to thrive oblivious of this exercise. The oily residue also seeps into the ground and contaminates everything it comes into contact with including ground water. All experts, including Dr. Seth, director of MCD headquarters and Dr. Reddy, president of Public Health Foundation agree that fogging only serves to provide a false sense of security to the unsuspecting public and political mileage to the our so called leaders. It is at best a weak attempt at containment and does nothing for eradication, and a colossal waste of public funds that is best abandoned.
The authorities also decreed that no hospital, including private ones could refuse to admit patients suspected to have dengue. Not all patients require admission; there are well laid down clinical parameters which divide patients into three groups, group A, B, and C. The first group can be managed at home with general measures like control of fever and adequate hydration. Groups B and C need admission. There is no specific treatment for dengue; general measures are implemented like maintenance of fluid levels, monitoring the platelet count with supplementary transfusions if indicated. The problem is that whilst the health authorities dictated that “no hospital could refuse admission” nobody specified who would meet the expensed incurred in such treatment. After all private hospitals even when functioning as charitable institutions need to recover costs. With the authorities failing to make contingency arrangements they in fact abdicate their responsibilities and dump the patient onto the private sector, leading to unpleasant situations.
At the end of the day, the WHO guidelines for containing the dengue menace still stand. They consist of making sure there are no dengue mosquitoes breeding in discarded tyres, drums, plant pots and water containers. Protective clothing does help but may be impractical; repellant creams are certainly useful. Mosquito nets around infected patients are also important. It is only with these common sense basic measures can we honestly say to all those who lost their loved ones to dengue “gone but not forgotten”
(Dr Gladstone D’Costa is the Chairman, Accreditation Committee and member, Executive Committee, GMC)
