Epidemic fever in Kerala: fact, fiction or phobia?

By T. Jacob John

Since the 1980s, Kerala has had a series of outbreaks of new diseases — leptospirosis, dengue, Japanese encephalitis (JE) and chikungunya. Each time the government was caught unawares and the health system was unprepared.

Support TwoCircles

These diseases are caused by rodents (leptospirosis) and mosquitoes (dengue, JE, chikungunya) and are tell-tale signs of environmental degradation and neglect in the state.

Only new diseases catch media attention. But every year Kerala faces outbreaks of diseases like typhoid, dysentery, cholera, viral hepatitis and malaria.

Except malaria, all other diseases are caused by microbes transmitted by contamination of water or food. Most local outbreaks go unnoticed but the media plays a crucial role in reporting large outbreaks in many places.

Two myths surrounding Kerala have been shattered. The environment in the state is no longer clean and healthy, and the health system is no longer a model for other states.

Outbreaks are either contagious or non-contagious. This distinction is very important.

Contagious diseases spread directly by close social contact. Infected people spread microbes by coughing and sneezing, and others get infected because they breath the air carrying the germs.

Influenza is a classical and dreaded example. Common cold is another. There are many others that cause fever outbreaks and mostly go undiagnosed in Kerala. They cannot be controlled easily.

However, non-contagious diseases spread through environment-related factors, many of them man-made. Systematic and scientific interventions are well known but unless applied, outbreaks cannot be prevented.

For example, the health system must always keep a close watch on diseases. Early signals of clustering should be picked up immediately, diagnosed, investigated and intercepted before they spread widely. This is the core function of any public health system.

Obviously in Kerala, like the environment, the health system has also deteriorated. All political parties and successive governments have neglected public health.

People suffer the punishment, namely recurrent outbreaks, while the government keeps defending itself in the legislative assembly and outside. Strangely, it doesn't matter which party is in power, the same drama keeps getting repeated.

In politically conscious and highly literate Kerala, suffering and death of people — new-born babies, school children, young adults and senior citizens — do not evoke compassion from the administration.

This is a peculiar "Kerala disease" — pride in past reputation causing intellectual paralysis. People loudly deny outbreaks and deaths, defend actions and inactions saying there is no problem, our health system is great, one day every one has to die.

Everyone participates in this death dance – the media criticises, the government denies. Medical colleges do not study the problem and private hospitals have vowed silence. The attitude seems to be that if you don't know how to solve the problem, then deny it – let us not scare tourists away.

In 2007, the media reported statewide fever outbreak with high mortality. The government denied it. Nobody bothered to ask if was contagious or not. Government statistics cover only attendance at Public Health Clinics (PHC) and hospitals.

Every summer, which in Kerala coincides with monsoon rains, there is an upsurge of illness and fever. This is so common that it is taken as inevitable.

It is not scientifically investigated but given the name "viral fever", which is a nice euphemism for an unknown cause. In 2006 the state witnessed an undeniable chikungunya outbreak.

Technically, there was no outbreak as the number of fever cases was not more in 2006 than in earlier years. So, statistics can and do lie. Data from private hospitals is not collected.

This year the health minister insisted that numbers are within normal limits while the opposition and media asserted a huge outbreak. It may sound funny, but was there an outbreak at all? If you believe it, there was one; but if you don't, then there was none. Apparently, the tourists got wind of it, cancelled travel plans and Kerala seems to have lost about Rs.150 crore (Rs.1.5 billion).

Why does Kerala have to invite outside experts to diagnose the cause of outbreaks and prescribe preventive measures for every outbreak – from Andaman for Leptospirosis, Pune for hepatitis, Kolkata for cholera, Madurai for JE and Delhi for dengue and chikungunya?

This year, the army and navy were brought in – sending out two signals simultaneously. One, that there was an outbreak. Two, that the health system was incompetent to handle it.

The central government has removed the chief of vector-borne disease control for not taking pre-emptive action. Yet Kerala had no outbreak?

Did people die in large numbers in 2006 due to chikungunya? Health officials said "no" but the chief minister said "yes". Who decides the cause of death and how? Is the death of people a political ball game?

If chikungunya caused many deaths in Kerala, which it did not in most other places, the state had the unique opportunity to investigate the biology of the disease and reasons for death to contribute to medical science. Obviously, medical science in Kerala is not prepared to investigate anything new. Was the current upsurge of fever the unusual clustering of several diseases? Or was there a single cause for the outbreak?

Chikungunya was present, but only in small numbers. Dengue was present but infrequently. Leptospirosis, typhoid, dysentery, viral hepatitis and malaria were diagnosed but not as the cause of outbreak. Have we missed the very cause of the fever cases that occurred in large numbers in most districts?

Can a state with nearly 100 percent literacy afford to be ill prepared for outbreaks of ever-present infectious diseases? Why should every ruling party go into a defensive mode when it is the collective problem of all political parties? Why can't all parties discuss this and make diseases the common enemy?

It is the "state of health" of the health system that needs urgent diagnosis and treatment if we are to face future outbreaks systematically and scientifically. If literacy does not introduce intolerance of infectious diseases, the basic tenet of public health, even education has fooled Kerala.

(T. Jacob John is a public health expert. He headed the Indian Association of Medical Microbiologists in 1994 and has been a recipient of the prestigious B.C. Roy Award. He can be reached at [email protected])