Two Indias: Medical tourism destination and malaria hotbed

Four Lisu tribal settlements are trapped in a tiny pocket of land between Namdapha Tiger Reserve and the international boundary with Myanmar. The level of basic public service facilities here evokes images of the Dark Ages. Besides the acute shortage of school teachers, the absence of health care is keenly felt. Children are not vaccinated, women do not have modern medical care during childbirth, and malaria and tuberculosis kill many, sometimes whole families. Should the Lisu wish to seek medical help, it’s a grueling four day walk through the Park if the weather is good. During the monsoons, when malaria cases peak, it takes twice as long. [caption id=“attachment_86369” align=“alignleft” width=“380” caption=“Archive picture of patients affected by malaria in West Bengal. Reuters”]  [/caption] While this may seem like an extreme example, we were constantly assured by villagers in other accessible parts of the state, that there were settlements in the mountains all the way north to the international border with China. There are no roads to drive up to these parts. If you must go there, you have to hike several days. These villagers may be citizens of India, but they have largely been forgotten by the state and its agencies. Malaria ranks among the top 10 causes of death in the Northeast. According to the World Health Organization, 311 million people are at high risk of contracting the disease in India, and since 2007, 1.5 million confirmed cases have been reported annually in this country. In the Northeast, more than 5 in 1000 people get malaria compared to the national average of less than 2 per thousand. Researcher Nandini Velho of the National Centre for Biological Sciences, Bangalore, and her team discovered, not only is malaria a public health menace in these parts but it also impedes conservation. In Pakke Tiger Reserve, Arunachal Pradesh, 24 anti-poaching camps, each with 3-4 guards, operate throughout the year. Each camp safeguards a 20 sq km area from poachers. The guards’ jobs are dangerous with a high possibility of an armed confrontation with illegal hunters. But a bigger threat to their lives is the risk of contracting malaria when the rains begin in earnest. Over a period of four years, 70% of the 144 staff fell ill with the dreaded disease at a time when the Forest Department could least afford to lose them. The resulting shortfall of 44,160 man-hours occurred when poachers are most active. The wet leaf litter muffles their footfalls so they can creep up to their quarry silently. The only primary health centre in this area is in Seijosa which is handicapped by a shortage of doctors, a limited supply of drugs and unreliable electricity to power the microscope for diagnostic testing. Four doctors are stationed here, but have no facilities for staying overnight. Therefore only one is on duty at any given time. When available, the primary anti-malarial drugs such as chloroquinine and primaquinine phosphate tablets are provided free. With the microscopes out of commission most of the time, Rapid Diagnostic Kits (RDK) are a quick and easy way of diagnosing malaria. However, the government-run centre does not stock either the RDKs or additional drugs which have to be purchased from a nearby clinic run by a private entrepreneur. The RDKs sell for Rs. 28 in Guwahati, Assam (the nearest big city), but the private clinic marks up the price to Rs. 150, four times their market price. Whenever possible, the District Forest Officer distributes RDKs and drugs to his staff and local villagers who cannot afford it. Despite the extortionist prices, most of the Park staff prefer to be treated at the private clinic. The state Forest Department reimburses the medical expenses but this is often delayed, or worse, remains unpaid when funds run dry. Should a patient with a severe bout of malaria be referred to a larger hospital, the cost of the ambulance is not covered by the state. Even when the bulk of the costs are defrayed, a delirious forest guard may have to spend one and half times his monthly salary getting cured of this debilitating disease. If the treatment is substandard, then he will suffer relapses. There is also a strong possibility that he may get infected again the next year. The Forest Department has no budget line item for malaria treatment although it eats up almost 3% of its annual budget. Besides compromising the protection of the park, malaria places a huge financial burden on the department. What then is the solution? Visitors to such areas can reduce their chances of contracting the disease to a great degree by taking prophylactic pills. But what can local people do? They cannot pop these powerful drugs all their lives. In the plains, the standard prevention campaign is to prevent the stagnation of water and spray insecticides in houses and settlements. However, the prevalent malaria-carrying mosquito of the region, Anopheles dirus species complex, is a forest creature, breeding along the edges of flowing streams and rivers. In March 2010, 120 insecticide-treated nets donated by Sumitomo Chemicals were distributed to the guards by Velho and her team. The insecticide impregnated in the net kills the insects before they can alight on it, making it twice as effective as an ordinary net. Last monsoon, there were only three malaria cases, a sharp eight- to ten-fold decline compared to previous years. Cutting down on the bulk of the malarial cases is as simple as that. Velho says, “Not only is the distribution of insecticide-treated mosquito nets cheaper and often easier to implement, it also means that fewer families will suffer from disease or death.” The mandate of the National Rural Health Mission, under the Government of India’s Ministry of Health, is to provide improved access and quality of health care to rural people. However, this lofty intention is compromised by the difficult terrain, remoteness, and institutional apathy. The National Vector-borne Disease Control Program is meant to distribute insecticide-treated mosquito nets in high malaria areas. Between 2001 and 2009, almost 25 million treated nets were distributed free in India. But preventive measures cover less than 30% of the population in high-risk areas of the country, according to a WHO report. Another member of the research team, N.S. Prashanth of the Institute of Public Health, Bangalore, says malaria has to be tackled at three levels. First, insecticide-nets are an effective, preventative public health strategy. The next level is early detection of the disease. The Rapid Detection Kits are easy to use even by villagers; it requires a mere four-hour training session. It is cheap enough for all Primary Health Centres to stock, instead of relying on the electricity-powered microscopic examination of blood smears. All the RDK requires is a drop of blood and the dip stick test provides a diagnosis within 15-20 minutes. Early detection is the key to survival. The third level is early and effective treatment. If the necessary drugs are stocked, and the doctors needed to administer them are provided housing facilities, the toll malaria takes in human lives and health, and conservation can be drastically reduced. For now, an NGO, Nature Conservation Foundation runs rudimentary health services for the remote Lisu settlements near Namdapha but clearly it is an unsustainable arrangement. At a time when India is an emerging destination for medical tourism, the National Rural Health Mission has to do more to bring the benefits of India’s progress to its citizens in the hinterland. For the health of its staff and forests, the Forest Departments of states across the malaria belt such as the Northeast, the Brahmaputra floodplains, the Shivalik-Gangetic plains, Central India and the Eastern Ghats should have a budget to purchase insecticide treated nets, provide treatment to staff should they fall ill, and offer life insurance.