WITH only 80 confirmed cases of infection by the influenza A(H1N1) virus and just one death reported until August 20, the mood in Kerala was, for a brief while, one of relief even as the State waited with the rest of India to see what the virus had in store for its victims. But the realisation soon sank in: the numbers of those affected by the swine flu virus were far lower than the toll from the sporadic outbursts of resurgent and emerging infectious diseases that have been reported regularly from all parts of the State since the early 1990s.
In fact, just before the news of the first A(H1N1) victim in the State broke, the media were full of reports about how several villages in the northern district of Kozhikode were in the grip of a debilitating type of viral fever, with chikungunya-like symptoms, triggering a panic. Entire families fell victim to the fever, stretching resources in local hospitals, puzzling doctors, and even leading the fever-affected to call a protest meeting in one village, though allegedly with a political motive. In the first week alone, according to one estimate, nearly 4,000 people in a small geographical area were affected by the viral disease. A lot more fell ill in the days that followed.
Doctors and researchers had continuously cautioned Kerala against being smug about its health care and demographic achievements and advised it to be concerned about its embarrassing failures in public health. They now say that the State can continue to ignore the warnings only at its peril.
In the 1970s and 1980s, Kerala recorded outstanding progress in many of the demographic health indicators, such as low birth rates, low infant and maternal mortality rates and improved life expectancy at birth, which set it apart from the rest of the country and seemingly on a par with the developed world. It was then believed that these achievements would naturally lead to better health of Kerala society as had happened in developed countries.
This belief also led to claims being made about a Kerala model of health development, implying that it was the path for less developed societies to follow in order to achieve health for all, even with meagre incomes and resources. Predictably, by the late 1980s, Kerala saw a rise in the proportion of adults and the elderly in its population, a result of the decline in fertility, and an increase in the diseases of the rich, the so-called lifestyle or chronic diseases such as diabetes, heart diseases and high blood pressure, just as in the developed world.
But the similarity ended there. The developed world had achieved such a transition only after first undergoing another one, an epidemiological transition. The shift to longer life expectancy and high rates of lifestyle diseases happened only after those countries had first ensured drastic improvements in hygiene, sanitation, and socio-economic and living standards and had eliminated (or reduced) almost all the common infectious diseases such as cholera, malaria, dysentery and typhoid fever. This, however, did not happen in Kerala, even though few realise it even now.
While the disease pattern shifted from communicable to chronic in developed countries, Keralas demographic transition was a result of targeted interventions that skipped improvements in social hygiene, public sanitation and the environment. Therefore, while successive governments began to bask in the glory of the Kerala health model, the State began to face the double burden of both communicable as well as chronic diseases, Dr T. Jacob John, former head of the clinical virology and clinical microbiology services at the Christian Medical College, Vellore, and an expert on infectious diseases in India, told Frontline.
Many confused the demographic transition and growth in health care facilities in the State with a dramatic improvement in Keralas public health status. From the mid-1980s, studies conducted by the Centre for Development Studies (CDS), with sponsorship from the World Health Organisation (WHO), had warned about the low mortality, high morbidity syndrome in Kerala, as the frequency of such communicable disease outbreaks began to increase.
Governments and experts were often in denial mode about the high levels of morbidity in the State for fear of upsetting the unreal comfort offered by the Kerala health care model, said Dr Jacob John, who has led several inquiries into infectious disease outbreaks in the State.
By the early 1990s, one by one, many infectious diseases, including malaria, which was virtually eradicated from the State by 1965, cholera, typhoid fever and tuberculosis, began to re-emerge. In one study led by Dr Jacob John in Kottayam district in 1999-2001, long-submerged evidence of the prevalence of leptospirosis in all districts of the State since the mid-1980s was brought to light. With the State government no longer able to deny its existence, it was soon known that over 500 people had been dying every year in the medical college hospitals because of the disease.
In early 1996, there was an outbreak of Japanese encephalitis in Kottayam and Alappuzha districts, for the first time in Keralas history, followed by two other outbreaks of malaria (in Kasargod district) and cholera (in Alappuzha district) in quick succession.
Though they were controlled quickly, the realisation that the State lacked even a laboratory to diagnose such diseases properly led to the State government appointing an advisory committee headed by Dr Jacob John.
Among other things, the committee recommended the establishment of a State-level reference laboratory, the strengthening of laboratory services in district as well as medical college hospitals, and the establishment of a disease surveillance system in each district for early detection and remedial action on such outbreaks.
These recommendations were implemented half-heartedly by a government towards the fag end of its term and were soon overturned one by one by the government that followed, often for unspecified reasons. But, at least for a short time, a State Institute of Virology and Infectious Diseases came into being in Alappuzha, and district-level disease surveillance was launched in at least six of the 14 districts of Kerala.
The disease surveillance projects conducted during 1999-2001 in several districts showed that though people appeared extremely conscious about cleanliness, the most frequently reported diseases (in addition to leptospirosis) were acute dysentery, typhoid fever and acute hepatitis, which indicated faecal contamination of drinking water sources and lack of proper sewage systems and safe drinking water.
The emergence of leptospirosis, a disease spread by rodents, recently in epidemic proportions in urban areas, and the rising number of adult deaths because of the disease, pointed to a complex set of ecological problems, including changes in agricultural practices and solid waste and waste water disposal, which Kerala was yet to unravel.
In fact, many of the re-emerging infectious diseases can be traced to poor community hygiene, poor sanitation, spreading garbage dumps and unsafe drinking water in villages and urban centres. Though several projects have been launched, solid waste collection and scientific disposal remain ineffective in urban areas. Stagnant rivers and streams clogged by solid waste offer breeding grounds for disease vectors.
With changes in land use, agriculture patterns, fertilizer and pest control measures, the rodent population is on the rise even in the rural areas. Many observers find the dangerous contrast between the penchant for personal cleanliness and the neglect of social hygiene among the people of Kerala as the main reason for the re-emergence of communicable diseases.
The dengue virus and the Aedes aegypti mosquito were unheard of in Kerala. But by 1997, they emerged as a significant problem. The State witnessed a virulent attack of dengue fever in 1997 and an epidemic in 2003, which, according to official figures, affected 4,128 people and killed 33. Dengue fever and its more severe manifestation, dengue haemorrhagic fever, have now become endemic in the State.
The latest in the series of infectious diseases in Kerala is chikungunya, which is transmitted by the Aedes mosquito. Until 2007, it had never been reported in Kerala. According to the State Health Department, it affected 24,052 people in 2007 and 24,795 the next year. The figures are likely to be much bigger. The pre-swine flu fever spread of 2009 that affected nearly 7 per cent of the population in Kozhikode district was mostly caused by the chikungunya virus in addition to other mystery fever pathogens.
The public health crisis in Kerala is much more serious than what we have realised so far. The State is fast losing the edge on the provision of primary health care, once a model for the country. The States demographic achievements have reached a plateau, and the near-universal immunisation coverage that it achieved is falling. Treatment costs are shooting up, along with the spread of chronic diseases. The spread of infectious diseases is a clear indication that Kerala has to start cleaning up and go into a mission mode for it, if reasonable results are to be obtained, say, five years down the line, said Dr C.R. Soman, a leading public health expert who (along with P.G.K. Panikkar) was among the first to point out the paradoxical situation of high morbidity and low mortality in Kerala as early as 1985.
Health care system focusses on individuals and deals with the curative aspects, while public health focusses on the community and the preventive aspects of health, Dr Jacob John said. This difference is not often realised by many, especially in the Kerala context, with the result that the State failed to develop the necessary infrastructure for monitoring outbreaks and controlling infectious diseases or the expertise in practical epidemiology or even have a real understanding of the concept of public health.
Thus, though it did not want to admit it, the State had never gained control over contagious diseases or learnt to do real-time disease surveillance, an essential step to improve public health, said Dr Jacob John. That is why it seems today that Kerala is being caught off guard by infectious ailments. The fact that environment and health are interrelated was lost in the confusing setting of emerging infectious diseases and the growing prevalence of long-term, chronic health conditions.
Surely, the virulent outbreaks of communicable diseases and the reasons for them have to be seen in the larger health care setting where they coexist with chronic lifestyle diseases, dilapidated government health care facilities (especially at the grassroots), the unbridled growth of private hospitals and laboratories that are run with a profit motive, and rising health care costs.
Kerala also has an ever-increasing number of the aged in its population, and according to one estimate, 20 per cent of Kerala society will be above 60 by 2010, a segment that will be particularly vulnerable to costly chronic diseases. Some observers say the large number of deaths caused by emerging viral diseases such as chikungunya is because the victims were already suffering from other chronic conditions that affected vital organs.
However, what is most alarming about the public health crisis in the State, which once boasted about its universal, free, equitable and efficient government health care system, is the marginalisation of the poor, who are increasingly unable to deal with the rising treatment and occupational costs of diseases.
Primary and secondary health care facilities have fallen into disuse and only 30 per cent of the poor depend on such government facilities. Sixty per cent of the doctors and hospital beds are in the private sector. A 2006 study by the non-governmental organisation Kerala Sashtra Sahitya Parishad (KSSP) found that treatment costs had gone up 20 times in the past two decades and the poor spent 39.63 per cent of their monthly family budgets on treatment.
The burden would be much more on the poor with the emergence of new infectious diseases whose after-effects are long lasting, with patients suffering even six months to a year after infection, Dr Soman said.
Consequently, the once-acclaimed low-cost and equitable health care model in Kerala with its welfare objective is fast being replaced by a costly and increasingly exclusive one that denies treatment to the weaker sections of society.
It has, therefore, become imperative for Keralas society and government to learn the simple lesson that prevention is better than cure.
Says Dr Jacob John: If we invest more in public health facilities, we can prevent at least 50 per cent of the communicable diseases. Health care can then concentrate more on chronic diseases that are more difficult to prevent or control.
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