Meghala Easwaran is waiting for her daughter to be discharged from hospital. It’s been four days since her admission for fever at the Salem Medical College Hospital, and it’s getting increasingly difficult to manage financially. “She first developed fever about a week ago. We went to a private doctor and then to a government hospital near our village and they referred us here,” said the 31-year-old.
Both Meghala and her husband are daily wage labourers and haven’t been able to work for about 10 days due to hospital visits. Their other two children are at home with Meghala’s in-laws, but she says they will not go to school unless she is there. For four days, the couple have slept at the hospital while their daughter undergoes treatment. Treatment is free, but as the couple can’t work, they will have to borrow money for living expenses, she says.
Ward after ward at the Salem government hospital is filled with patients who have fever. There are eight wards for children alone — with 250 admitted earlier this week. More wards are allocated for men and women and there are close to 100 outpatients seen just on one day for fever.
In Kuruppa Naickan Palayam in Erode district, where weaving is the primary occupation, every few houses has someone admitted to hospital. Residents said they had pawned jewellery and gone into debt. In families where more than one person falls sick, the problem is acute.
Across several districts of Tamil Nadu, fever is filling up wards and outpatient departments, forcing hospitals to create more space and leaving residents anxious and panicky. As of Friday, there were about 8,000 people admitted with fever in the State, at both government and private hospitals — this is more than double the usual at any given point. For many, it is not just the fever — though there’s always the worry it could be dengue — but the repeated hospital visits, the staying over at the hospital for several days and the consequent drop in income that hurt.
Dengue may account for only a section of the patients admitted in the hospitals. But the increase in its incidence this year has created fear, especially among parents of children, and many of these fever cases that can be treated at home end up at hospitals. Therefore, the key to controlling fever cases at hospitals lies in bringing down dengue occurrence, which can be achieved through government intervention and greater awareness on sanitation and garbage clearance, public health officials say.
All-season disease
The cause of the fever is only known in about 50-60% of the cases, says State Director of Public Health, K. Kolandaisamy. “During outbreaks we are able to determine the exact disease — typhoid or leptospirosis, for instance — in over 90% of cases. Otherwise, for a number of reasons including not being able to get samples at the correct time, the exact cause is not always determined. While the majority of fevers will recede without any complications and with proper fluid intake, people tend to seek admission for fever when it is going around, he said.
One of the reasons admissions are high, said Dr. Kolandaisamy, is that the government is encouraging doctors to admit patients at the earliest — to check for diseases and to ensure they receive protocol-based treatment. It is asking private hospitals to refer patients whose platelet counts go below the 1 lakh mark or when danger signs are noticed. It is asking hospitals to keep patients on for two to three days after they are treated — as with dengue, complications can begin after the fever goes down.
Dengue lies at the roots of the public health crisis the State is seeing. The last time cases of dengue rose over 5,000 was in 2013. This year, as of August 13, it’s already 6,500 and counting. Tamil Nadu and Kerala, together with Karnataka, account for over 80% of all dengue cases in the country, as per the National Vector Borne Disease Control Programme.
The pattern of dengue, Dr. Kolandaisamy said, has changed over the years. What was once common during the rainy season towards the end of the year is now seen throughout the year. During the dry season, it breeds indoors in improperly covered water containers. Despite the copious rains the State has received this monsoon, the State is still reeling under a drought. Many residents, especially in parts of Salem and Erode have taken to storing water in their homes, and if not covered properly, these can become breeding sources for the mosquitoes, he said.
Mosquito-borne diseases are the outcome of the failure of personal hygiene, house hygiene and the town’s hygiene, said P. Kuganantham, former Chennai city health officer. He pointed to rapid urbanisation without scientific planning as a contributor, and recommended a vector-control fee be charged to eradicate mosquitoes from large construction sites.
Effect of drought
In Tiruvallur district’s Bandikavanoor village, water is in short supply. The village recently saw 11 hospitalisations for fever in the space of a week and a medical camp was ongoing. At nearby Jothi Nagar, another village, public health officials were fogging the lane outside the house of a woman who tested positive for dengue, distributing NilavembuKudineer (a herbal drink thought to boost immunity), sprinkling bleaching powder and checking water sources for mosquito breeding. Garbage fills the road margins, in spite of warnings about problems, a health official says. The area is covered with stagnant pools of water after a recent shower.
Garbage is a common problem. Plastic bags and containers, coconut shells, discarded tyres and other debris litter the side of roads and inside villages. In Kuruppa Naickan Palayam, garbage was piled by the temple tank bank. Residents alleged the local administration was not doing much to clear it. Outside several houses, water was stored in containers, uncovered.
At Erode’s government hospital where there were 159 people admitted with fever on Thursday and over 348 outpatients seen, the women’s ward is full. Nurses bustle back and forth, IV fluid drips hang from the side of beds, and there are more bottles everywhere.
V. Pavitra’s family has already spent upwards of ₹30,000 at a private hospital before they were referred to the Erode government hospital, where they arrived by bus from over an hour away. Her father is a carpenter, her mother a home-maker. “People in all the houses near our home have had fever,” said the 19-year-old. Many residents continue to first go to private hospitals or even go back and forth from government to private hospitals if they are not happy with the treatment provided, cannot afford the costs or are referred. Overcrowding, lack of information and delays are complaints made of government facilities, though most patients said they were receiving good treatment.
There is a direct link between improving sanitation and reduction in cases, Dr. Kolandaisamy said. “In Erode itself, when we reduced breeding sources, eradicated adult mosquitoes, ensured disposal of garbage and chlorinated the water — all sanitation measures — there has straight-away been a decrease in cases,” he said.
State steps up
For the State then, it’s a fight on several fronts. It’s not just fever and its treatment that is the problem, but the eradication of breeding sources. Any pool of fresh water can have eggs laid and, in about 10 days, there are adult mosquitoes to contend with.
The health department has launched a massive effort in coordination with other departments — a ₹13.95 crore initiative to eradicate mosquito-borne diseases in the State. For fever management, the State ensures private doctors are treated on fever protocols. Surveillance of fever cases is on throughout the year.
Quacks, estimated by the Tamil Nadu Medical Council to number about 30,000 in the State, are also a problem, say health authorities. “Quacks sometimes inject patients with steroids or analgesics, which can have serious health consequences, especially in dengue patients,” said K. Senthil, president, Tamil Nadu Government Doctors Association.
Many patients want an injection though the State’s fever protocol does not involve an injection at all. Self medication too, is an issue, say doctors. Big buildings and organisations, both public and private, pose another huge problem with breeding sources. In Salem, for instance, four private schools have had their sanitary certificates cancelled, 230 public health notices have been issued asking people to rectify problems and three people arrested for preventing public health officers from doing their work, said deputy director of health services K. Poonkodi. But it is an uphill task, she said.
Earlier this week, in an effort to tackle Aedes breeding sources at government buildings, a State-wide programme was begun for a 48-hour clean-up operation. Heads of institutions needed to certify that their premises were free of mosquitoes. “We realised that government building premises could also be sources of mosquito breeding and this needs to be tackled,” she said. The health department is releasing videos and pamphlets to spread awareness. The department is tying up with schools, colleges, self-help groups, resident associations and Anaganwadi workers to spread awareness about dengue and about the eradication of breeding sources.
The fever incidence is falling in some parts, including in Erode, and in certain belts of Salem, which were hotspots last month. Doctors report a decreasing trend in admissions and dengue positivity there. Overall too, Dr. Kolandaisamy said, there has been a decline.
But, he points out, without cooperation from the community and the public taking responsibility to dispose of and clear waste, dengue will be tough to eradicate.
Still work to be done
At the Gundakal village in Salem district, residents said that after the death of a 14-year-old girl, a health camp was set up for two weeks last month. A staff nurse continues to visit the school every day, they said. Many homes in the village have had hospitalisations and the mostly daily wage working residents are scared of fever spreading again. One young mother whose child was admitted with fever last month said health officials had told them all about the dangers of mosquito breeding — she repeated their instructions to ensure there were no unused containers lying around. Across the road, however, garbage lies by the side of the road, uncleared.
