Dr. Sunil Kaul, our Executive Director and Founder Trustee, in this series of writings, critically analyse various illness that plague the health of the nation and how as a state we have failed to address these important social issues. This is a narrative of a social worker in a rural corner of Assam, calling out for collective action.
A study published in The Lancet issue of 21st October 2010 that was led by teams of the Registrar General of India and from Centre for Global Health Research at St Michael’s Hospital and University of Toronto, Canada showed that malaria accounted for about 2 Lakh premature deaths between the ages of 1 month to 70 years. This was almost 10 times more than any other estimate earlier recorded where the Government was a party to the estimation. Based on deaths recorded between 2001 and 2003, more than fifty percent of these deaths were from Odisha, Chhattisgarh, Jharkhand, Assam and the northeast states. 90 percent of these malaria-attributable deaths were in rural areas and 86 percent of these happened at home. And all this, while the official mortality figures reported by the National Vector-Borne Diseases Control Programme ranged between 400 and 1700 a year, a 100 times lower!!
the ant, an NGO working in one of the Bodoland Territorially Administered Districts invested in semiliterate community health workers armed with a box of 30 medicines
and also in 11 community-selected microscopists, a few years before the National Rural Health Mission could roll out. Between them, these community volunteers ensured that no one died of malaria in their villages of nearly 50 thousand people! The National Institute of Malaria Research found that more than 95% of a sample of their slides reported the correct species of malarial parasite, and one of their senior officers along with a senior WHO consultant were so impressed that they flew down to see how this could be achieved in 2006-07! the ant always believed that malaria was and remains one of the easiest of diseases to control, and all that it needs is the most basic of systems of early diagnosis and prompt treatment. And if one can’t control malaria, it indicates that the health system is not even providing basic services!
But why do i mention this here? Because last year, India made a national framework for elimination of malaria by 2030. It can dream this because all or most of Assam’s districts have entered the pre-elimination stage of malaria. From the time when Assam contributed to thousands of deaths every year in the pre-NRHM era – the time period coincides with the study quoted in the first paragraph – we have reached a stage where one can barely identify a malaria case in the past few years. Maybe the ant may have contributed to this goal for a few years in one of the districts, but what about the rest? How did all the other districts succeed?
Dr Debabar Banerjee, Professor Emeritus at the Centre of Social Medicine and Community Health in JNU, who has been an inspiration to many of us public health practitioners, would deride every vertical disease-specific programme. “Let the fate of the disease sink or sail with the primary health care of the country,” he would always advise. I would attribute the success in malaria to the wonderful roll out of the National Rural Health Mission in Assam in the initial years, say from 2006 to 2011 whereby it used Central grants to build and make functional many primary level health centres. It appointed nurses practically everywhere. It didn’t wait for MBBS doctors to go to the rural areas, and instead depended on Ayurvedic doctors to take up the posts. Unlike the MBBS doctors who are unable to survive in the low-cash economies of rural Assam, many of these Ayurvedic doctors have been residing in deep pockets of Assam’s hinterland, and as they are not prone to violating Government treatment guidelines, they manage their workforce also to go by the public health book, and i think that is the primary reason that we see very little of malaria today. The rest of the success must be attributed to climate change, the rapid diagnostic kits that did away with the necessity of good laboratory skills and Artemesinin based drugs brought into the PHCs for countering drug-resistant malaria.
While Arunachal and Meghalaya could learn from Assam, it would be a tragedy if Malaria were to return to Assam, something clearly possible as the Centre is seen to be cutting down the finances for health. Just like the levels of TB can be seen to be an indicator of how many people go hungry in a nation, malaria serves as an indicator of how well a tropical nation invests in its primary health care – and maybe an indicator of how much it doesn’t spend on statues and armaments!
(photo credits: CDC)