The long term damage to Kerala’s health

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Fever patients waiting to see the doctor at the Chittar Primary Health Centre, Pathanamthitta, on July 17.
Fever patients waiting to see the doctor at the Chittar Primary Health Centre, Pathanamthitta, on July 17.

Vinod Thomas

The State is struggling to cope with the spread of Chikungunya, dengue, and other viral fevers.

The outbreak and spread of chikungunya, dengue, and related viral fevers are a wake-up call for Kerala. They signal the dramatic deterioration of health and environmental conditions in the State, and the weak management to deal with crises — both of which need to be reversed swiftly.

Ironically, outside observers think that Kerala is best positioned to confront such health-related disasters, if not avert them. First, they think that the State’s favourable health indicators — it has taken the lead in reducing infant mortality, for instance — should position it against vector-borne diseases. Secondly, they believe that its superior social organisations should help deal with such problems.

Yet, both assumptions have not held up. The State struggles with worse conditions compared to eight others that also have a serious incidence of chikungunya — Gujarat, Karnataka, Maharashtra, Orissa, Goa, Tamil Nadu, Rajasthan, and Delhi. Moreover, the State has not been better prepared: it has allowed the problem to deteriorate and take an unacceptable human toll.

To be sure, specific factors have made Kerala vulnerable. These two diseases are transmitted by the aedes mosquito, which breeds in small water collections in and around the house. Furthermore, thanks to rubber plantations, parts of Kerala have become endemic for dengue, as rainwater collect in the containers used for harvesting rubber sap.

In dealing with these realities, it would be crucial to build on the two (perceived) assets of the State. For one thing, it is important to regain the strengths of the State’s health systems. For another, it is vital to get back to a reliance on civil society and the private sector, and not just the government, in finding solutions.

The government, of course, has a crucial role, which it has failed to play effectively.

Managing health is as much a concern of Health Ministries as Finance Ministries, Education Ministries, Environment Ministries, and even Tourism Ministries.

These actions must be part of a strategy to give high priority to health and tackle the interrelated issues of public health, education, hygiene, and the natural environment.

Needed are greater public awareness and coordinated actions by society and the government. In the case of chikungunya, the only effective remedy is to avoid mosquito bites and to eliminate mosquito breeding sites through a swift campaign of control and prevention by the authorities and the communities, and with external support if needed.

Effective control

For effective control of the aedes mosquito, every household should eliminate the domestic and peri-domestic breeding places, in addition to the government looking for such breeding places. In the case of rubber plantations, simple measure such as turning the containers upside down or covering them with a fibreglass sheet can avoid the breeding of mosquitoes. This requires partnership with rubber estate owners, the Rubber Board, and the Department of Health.

There also needs to be a systemic approach. There have been good efforts to collect data, but the ability to analyse the data and initiate action by district surveillance officers needs strengthening. Furthermore, there needs to be the involvement of the private sector in disease reporting. These need to be addressed through hands-on training in field epidemiology, engagement of the medical community, and provision of rapid diagnostic kits.

There is a pressing need for dedicated district epidemiologists and entomologists. Kerala also requires an epidemiologist to manage disease surveillance at the State level. Like Tamil Nadu, Maharashtra, and Gujarat, Kerala could create a public health cadre and benefit from the field epidemiology training programmes.

Such inputs will help not only in the prevention and control of communicable diseases, but also in the promotion of healthy lifestyles to address the rising burden of non-communicable diseases.

It is disturbing that the State with such a favourable health status is seeing an increase in diseases linked to poor hygiene, environmental degradation, and lack of awareness.

The health and productivity losses from neglecting these illnesses are grave. There is also a less direct, but economically ominous, effect: tourism — an increasingly important engine of growth — is a likely casualty of poor health conditions, costing crores of rupees.

The immediate epidemic needs to be stamped out. But equally, the underlying causes need to be addressed collectively and systematically for the long term health of the State.

(The writer is Senior Vice President, Independent Evaluation Group, The World Bank. Email:



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