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.
