19 November 2016

Malkangiri Sojourn: Some Concerns on Japanese Encephalitis

On 14th of November 2016, the day celebrated as children's day in India, I had been to Malkangiri. One of the reasons was to understand the issues related to the recent child deaths (more than a hundred since September 2016), which has been largely thought to be on account of Japanese Encephalitis. During my visit, I interacted with some volunteers helping the district administration to address this and also met the District Magistrate. Some of my observation are as follows.

The causal or, rather, associational factors from a public health perspective could be discerned into three broad categories - proximate, intermediate and base. Of course, at times, it would be a thin line separating the categories, but the analytical separation could help in our understanding.

The proximate factors are as follows: Japanese Encephalitis is a mosquito-borne virus with pig as host. It has a high case-fatality rate among children.

The intermediate factors are as follows: some communities (particularly, Koya's) live in close proximity to pigs, which they breed for livelihood purposes; post-monsoon increase in breeding of mosquitoes; and unhygienic living conditions.

The base factors are as follows: absence of adequate curative care through health care systems preparedness in terms of human resources and infrastructure, lack of appropriate preventive care to reduce unavoidable deaths (including addressing malnourishment).

I must applaud the efforts of the district administration and volunteers who have been pushing themselves to work against all odds - inhospitable terrain, cash crunch, and falling temperatures. The defogging exercises to decimate mosquitoes has been largely effective. With winter setting in, the breeding of mosquitoes is also on the wane. This largely addresses the proximate factors.

They have also been able to separate the living space between pig sty's and human settlements. The efforts here would address the intermediate factors in a temporary sense. Temporary, because it involves lifestyle changes and will incur other transaction costs to the community. It will require sustained efforts from the administration to understand and address this.

The administration has responded to the health care emergency in sending more health care professionals. While appreciating this quick measure, there is a case for addressing the preparedness of the health care system in terms of permanent solution to have an impact on one of the base factors. 

Addressing preventive aspects will also be important. In this context, convergence with the Swach Bharat Mission, which is already being implemented in the district (as one saw in some of the houses of the villages one visited) will help. The recent initiatives by the state government to revive millets and facilitate integrated farming will also help in addressing these concerns - these need to be rolled out soon.

Having said that, one needs to point out that vaccination of all children from 9 months to 15 years of age (as one heard) is not an appropriate way forward. One argues against this for the following reasons. All the deaths are not on account of Japanese Encephalitis. In fact, a particular report points out that from 96 deaths that were examined only 32 were on account of Japanese Encephalitis. Majority of reported deaths are among children less than five years of age (only a handful are older than that). Again, most of the deaths (particularly, those related to Japanese Encephalitis) are largely restricted to some communities - in particular, Koya's who live in close proximity to pigs; it has not been observed among Hill Bondas who also live in close proximity to pigs. Further, mosquitoes, the carrier for Japanese Encephalitis are in any case on the wane due to defogging and because winter has set-in.

In summary, I would say that large number of child deaths on account of Japanese Encephalitis and other reasons is a matter of concern, but this does not articulate a case in favour of a Japanese Encephalitis vaccination. The response from the administration and volunteers need to be applauded. However, their efforts largely address the proximate factors, the intermediate factors in a temporary sense and a part of the base factors as an emergency measure. Greater effort and convergence is required to address the intermediate and base factors.

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