CHICKUNGUNIA THE MEDIA AND A SICK HEALTH ADMINISTRATION

K Vijayachandran

Monsoon season in Kerala is the season of epidemics and deaths: Daily death rates shoots up much above its average level of five hundred. Nowadays, visitations of Cholera, Typhus and Dysentery are rare, because of piped water supply system, thanks to the Kerala Water Authority. Better hygiene habits have checkmated bacteria, and malaria and philariasis eradicated by appropriate vector control programs. However, virus fevers like influenza and and common common colds occasionally develop into epidemic proportions, but people are not scared of these ordinary air-born infections.

Even influenza was looked upon as a deadly villain once, more like chickungunya or dengue, spread by some new breeds of mosquito, that has recently migrated into selected districts of Kerala coast. I may recall here my own influenza days, way back in 1957: I contracted it on my journey to state capital, for the admission interview for engineering studies and remember even today, the big media stories on how influenza was finding its way into Kerala villages from far off Thiruvananthapuram, Chennai and Singapore. Newspapers carried details about its symptoms and the damage it could cause to human body. Preventive medicines and procedures were prescribed in plenty, and isolation was the best of recommended procedure. My fever lasted only two or three days, but I had turned a VVIP within that short period. Being the first or only victim of a fancy decease in the locality, I had numerous visitors: They were allowed to look at and communicate with me only through windows, and from safe distances. Everybody learn from experience, and not from media: Today, no body is scared of influenza, and I recall my VVIP days, whenever my NRI friends refer to it as some stupid country fever.

Media response to the recent fever epidemic was an altogether different experience, in content as well as in style. Focus of reporting was on the number of deaths, the dilapidated condition of Government hospitals and the human misery waiting in queue for hours and hours to get medical attention, that had to be rationed under conditions of acute scarcity and panic. It conveyed a simple message very effectively: Chickungunya means near certain death, rush to the safety of nearest hospital! Testimony by doctors and medical experts that, there was hardly any chickengunya death was heavily discounted by the media, and statements by ministers vehemently challenged on political grounds. There was no serious attempt by the media and the medical community, to educate the people on the specifics of the decease. People were not counseled to get treated as outpatients and not to overload Government hospitals. Initially all fever cases were reported as chickungunya and then they were referred to as contagious fever or pakarchappani.

Pakarcha pani epidemic was mostly due to the familiar country fever, and had nothing to do with the exotic chickungunya, if we go by absolute numbers and its incidence was not uniform across the districts. Most fever cases were reported from Pathanamthitta or Kottayam district: Number reported till mid June from Kottayam was 7213, of which only 463 were suspected as chickungunya. For Pathanamthitta, the corresponding figures were 2846 and 81. Last year's outbreak of chickengunya was concentrated in Alapuzha district which accounted for about 85 percent of the 70200 suspected cases in the state and over 90 percent of the 81 deaths. However, this year Alapuzha seems to be lagging far behind its neighboring districts. In 2005 there was the dengue fever; 4 out of the 8 deaths reported were from Ernakulam district. Thiruvananthapuram district accounted for nearly half of the 1046 cases reported cases but, there was no death causality. These statistics are confusing, and there is no explanation, why the mosquito induced chickungunya and dengue are confined to certain specific localities. Rain harvesting projects are fairly widespread in most of these localities. During pre-monsoon showers these projects, if poorly implemented, could provide fresh-water breeding grounds needed for chickungunya vector. These and other factors supportive of the new-breed mosquito need urgent investigations. Attacking mosquitoes in general will be unproductive.

These southern districts are under attack by chickungunya and dengue for the third monsoon in succession. But the Public Health Administration in the state is hardly sure about what needs to be done: It has not come out of the shock of the fever epidemic of last season and the scandalous exposures in SAT hospital. Public health administration network in the state is quite large and a leviathan, with an annual budget of around Rs.1400 Crore: that works out to more than Rs. 400 per head. According to the Economic Review, there were a total of 2808 hospitals and dispensaries under state government (including the cooperative sector) in 2005 for Alopathic, Ayurvedic and Homeopathic treatment, and they had 55962 beds. In the private sector these numbers are 10805 and 73230 respectively for the year 1995; latest figures on private sector are not available in government statistics and are likely to be much higher. Public Health Administration in the state has absolutely no control over the large health care resources in private sector, which plays an altogether unhealthy and exploitative role. Private sector was totally indifferent to the tragic scenes enacted around them during the recent crisis, remained a passive observer, and behaved as if they had no role to play in managing it. Maybe, the Government had no mechanism to rope in their services and cooperation. However, the media which politicizes all sort of issues, were totally insensitive and silent to the fact that, more than two thirds of the health-care resources in the state could not be called upon to play its legitimate role, when tens of thousands of poor people were desperately seeking urgent medical attention.

All these exposes the hollowness of usual argument that, successive governments in Kerala were following a welfare state model, and spending lavishly on public health. It will be relevant to quote the State Planning Board on the health care needs of Kerala, from its latest Economic Review: Kerala faces three major problems in the health care sector in the beginning of the 21 century: (a) Difficult access to health care and impoverishment of a sizable segment of population owing to high out of pocket health expenditure. (b) Rapidly increasing prevalence of diseases associated with lifestyle and aging and (c) Prevalence of environment related diseases owing to problems of community hygiene and pollution. These are relevant observations and the facts brought out by the present fever epidemic and its management has simply endorsed them: Health Administration could not cope up with the relatively simple task of handling a few thousand cases of ordinary country fever in a couple of districts: It was thrown out of gear completely, could not win the confidence of the people or the media, leading to a near-panic situation. Suffering of the people was more of panic and less out of objective factors related to illness. Army doctors were called in and numerous central teams, political as well as professional, traveled the affected districts and visited the suffering people: State level authorities were hardly visible, other than the health minister herself.

As a matter of fact, the minister could do precious little in managing the crisis: Situation was beyond her and that was none of her fault. As already pointed out, health minister of the state has no control over the sizable health care infrastructure under private management. Secondly, public health organization, under the minister, is an extremely fragmented setup with numerous programs, objectives and targets. There are programs and directorates for Allopathy, Homeopathy, Ayurveda, Sidha etc,, and then for specific deceases like leprosy, malaria, filariasis, tuberculosis etc, and numerous centrally sponsored programs for family welfare, aids control, minimum needs program etc etc. Medicines and other hospital supplies are procured centrally from the Government secretariat which also manages a couple of public sector enterprises, for drug manufacture, ambulance services, pay wards etc. Medical education and related institutions, as well as laboratories and research organizations are also under the charge of health minister. Under the prevailing culture of governance, all these field institutions numbering around 3000, including the hospitals and dispensaries in remote locations, are under the live supervision of the minister's office and the health secretary. Funds and resources are allocated to hospitals and clinics under various heads and schemes, which seldom matches the real needs at the field level. Field units are thus under compulsion to falsify the accounts for which the administrative staff extend its cooperation and provides the necessary expertise.

Health administration in Kerala operate under this inefficient and unwieldy structure, evolved over the past few decades. It has turned insensitive to the health-care needs of the people and the benefits are totally incommensurate with the expenditure incurred. It is high time to restructure the health administration, decentralize its management, and bring health care delivery under the control of the Local Self Government Institutions and specialist institutions that are autonomous. Deferent disciplines like Allopathy, Homeopathy and Ayurveda, as well as family welfare, community health and other programs have to be integrated at the LSGI level and delivered in a wholesome manner for the benefit of the people.

Alternative system of medicine plays an important role in our health care system. People have faith in the efficacy of Ayurveda and Homeopathy in treating a variety of ailments. Official statistics indicate that, only half of the outpatients reporting to the primary health units operated by public health administration opts for Allopathy; the other half prefers Hmoeo or Ayurveda. The picture is likely to be the same in private sector as well, and likely to be even more skewed in favor of alternative medicine.

Health Minister has recently announced, the Government intentions to operate primary health units of diverse systems of medicine under a common umbrella. The proposal is not for mixing up the methods of treatment, as alleged by some ill-informed critics, but for sharing the clinical as well as administrative infrastructure. It will be a matter of great convenience for the people, who are sure to get far better and more wholesome service at far lower costs to the public exchequer. Integrated health care centers at the local level, operated by the LSGIs under a common roof, could be used also for regulating the private sector institutions in the locality. They could serve as the initial steps towards the consolidation of our health care system and liberating it from the present anarchic regime, in the best interests of the people.

24.07.2005