Letters

Letters to the Editor — June 23, 2020

Vulnerable group

It is shocking to know 74% of COVID-19 deaths in Bhopal were survivors of the Bhopal gas tragedy in 1984. It was imperative to have kept the gas survivors insulated from the COVID-19 infection as soon as the deadly virus began to surface in India. Besides, it is puzzling why the Bhopal Memorial Hospital and Research Centre (BMHRC) — the dedicated super-speciality hospital for the survivors — was not admitting those survivors with COVID-19 symptoms, causing a delay in their treatment (Inside page, “74% Bhopal COVID-19 deaths were of gas tragedy survivors,” June 22). This tragic event only shows a lack of anticipation, planning, and, more importantly, compassion and empathy. It is the responsibility of the government to safeguard the well-being of vulnerable populations during the pandemic.

A. Venkatasubramanian,

Tiruchi, Tamil Nadu

 

Lessons of 1962

The country’s continuing conundrum (Editorial page, “India’s continuing two-front conundrum”, June 22) made me recollect those days of 1962 when I was a Class 10 student. India’s dismal state of unpreparedness to counter the Chinese aggression because of political miscalculations by the Prime Minister and the Defence Minister, and the subsequent damage to our national interest is a matter of history. Unfortunately, our policy makers do not appear to have drawn up a long-term plan to correct matters, if one is to go by the recent confrontations and conflicts with China. India has no choice as far as choosing its neighbours is concerned and we have to opt for a win-win relationship with them through diplomacy. War with full preparedness should be the last resort if our powerful neighbour fails to appreciate our gestures of peace. We cannot afford the luxury of a repetition of the 1962 debacle, which is still painful to recollect at my age.

M.V. Nagavender Rao,

Hyderabad

Enough’s enough

Women should be made aware of the fact that they need not suffer in silence when it comes to domestic and gender-based violence (Editorial page, “Fighting a double pandemic”, June 22). In many sections of our society, there exists the notion that for the well-being of the family it is best if the woman suffers silently under patriarchal norms. The first thing which should be done is to spread awareness among women, especially young girls, that it is not okay if men abuse them. As long as there are films and serials that perpetuate such ideas we cannot hope to put an end to gender-based violence.

Anjali Antony,

Edakochi, Kerala

Eliminating malaria while fighting the pandemic

I write this as Project Director, Malaria Elimination Demonstration Project, Mandla, M.P., Senior Adviser Global Health and Innovation, Sun Pharma, Board Member, Roll Back Malaria Partnership to End Malaria (RBM), Board Member, Asia Pacific Leaders’ Malaria Alliance (APLMA), and Board Member, Foundation for Disease Elimination and Control (FDEC) of India.

The global health community, policy makers, hospitals, physicians, law and enforcement officials, pharmaceutical industry, and government leaders have a collective challenge and responsibility today, which is to contain the spread of the novel coronavirus, SARS-CoV-2 and protect infected people from consequence of infection and the disease, COVID-19.

Since the first reported case of SARS-CoV-2 in Hubei province of China on November 17, 2019, this novel coronavirus has rapidly spread in 213 countries and territories. As of June 22, 2020, according to the COVID-19 Dashboard of the Center for Systems Science and Engineering (CSSE) at the Johns Hopkins University, Baltimore, U.S., there are 8,963,253 confirmed cases and 468,484 deaths globally. The United States has recorded the highest national tally with 2,280,969 cases and 119,977 deaths. Brazil has 1,083,341confirmed cases and 50,591 deaths. Russia has 591,465 confirmed cases and 8,196 deaths. The case load in India for the same period is 425,282 confirmed cases and 13,699 deaths. Today, India has the fourth largest number of cases globally and ranks ninth in deaths due to COVID-19. The first wave of pandemic is still evolving, and there is a broader consensus that a second and third wave is expected to follow.

In India like in many other countries, the pandemic is still evolving, and the infection and case load is predicted to peak in the next several of months. There are few epidemiologic and structural reasons for predicting rise in the number of cases and deaths. First, the large number of asymptomatic cases may continuously seed new infections leading to outbreaks and community transmission. Second, opening up of economy will enhance person-to-person contact, which in the absence of effective community-based infection control, can increase person-to-person transmission. Third, the mass movement of citizens (I will not call them migrants) that have travelled long-distance from their place of work to their native places could also lead to outbreaks and sustained community-based transmission in semi-urban and rural areas. Fourth, lack of appropriate and adequate hospital facilities equipped to handle complicated COVID-19 cases in rural and semi-urban areas could pose significant problems.

While the fight to contain, control and eliminate SARS-CoV-2 virus is being undertaken at State and national levels, I argue there is a need to simultaneously focus on implementing other important public health services and programs, such as childhood immuniszation services, and programmes for elimination of malaria, TB, Kala-azar, and polio. Many countries, including India, and various global health organisations and stakeholders have made significant investments for control and elimination of infectious disease and diverting focus away from these key programmes will come at a significant cost, in terms of potential of disease outbreaks and lives lost.

The World Health Organization (WHO) has also recently warned that the slowing down of immunisation programs during COVID-19 pandemic poses a clear and present threat of resurgence of diseases that are prevented by safe and effective vaccines. WHO has reported that more than 177 million children in 37 countries are at risk of missing out on measles vaccines as COVID-19 pandemic surges globally, and that immunization campaigns in 24 countries have been already delayed.

The impact of COVID-19 on malaria elimination also needs to be fully understood and appreciated at policy levels. The findings of a new modelling analysis done by the World Health Organization’s Global Malaria Program envisions a worst-case scenario, where bed net distribution campaigns could be suspended and there could be a 75% reduction in access to effective antimalarial medicines. The model indicated 769, 000 people could die in sub-Saharan Africa this year alone. This amounts to a doubling in the number of malaria deaths compared to 2018 and a return to mortality levels last seen 20 years ago.

Malaria remains one of the most ancient and deadly diseases, still putting nearly half of the world’s population at risk, including over 1.2 billion people in India. However, progress against the disease over the last 20 years has been substantial, with global interventions preventing more than one billion cases and saving more than seven million lives. In India, the fight against malaria has progressed rapidly in the last 10 years, with dramatic reductions in both malaria cases (67%) and deaths (68%), putting the target of a malaria free India within our reach.1

There is a need to continue mobiliszation of political support for malaria elimination. At the 9th East Asia Summit (EAS) in 2013, Heads of State/Governments of ASEAN Member States as well as India, the United States, China, Russia, Australia and Japan, agreed to the goal of an Asia Pacific region free of malaria by 2030. Progress in India, which still accounts for 58% of the region’s malaria burden, will be crucial to realising this goal. A malaria-free Asia-Pacific will further support the global ambition, expressed in the Lancet Commission on Malaria Eradication to eradicate malaria within a generation.

Historically, India has a long history of successes and struggles with malaria control. Prior to the launch of the National Malaria Control Program (NMCP) in 1953, 75 million cases of malaria and about 0.8 million deaths were reported annually. The widespread use of DDT Indoor Residual Spray (IRS) resulted in a sharp decline in malaria cases, and in 1958, the NMCP was converted to the National Malaria Eradication Program (NMEP).

The NMEP was initially a great success with the malaria incidence dropping to a 0.1 million cases and no deaths due to malaria reported in 1965. In 1971, the Urban Malaria Scheme (UMS) was also launched to cover 131 cities and towns. These gains were short-lived, and in 1976, 6.4 million cases of malaria were reported. The resurgence was attributed to complacency and various operational, administrative, and technical challenges. After the 1970s, malaria rates decreased again in India in the 1980s, but still existed at substantially higher rates than the 1960s. In the 1990s, new resurgences occurred.

However, as part of the global efforts to scale up the core malaria prevention, diagnosis, and treatment efforts, there is once again good news to report in India. In 2016, a total of 132 malaria-endemic districts were identified in the country. This number has been reduced to 63 in 2018. The recent World Malaria Report by the WHO has spotlighted India’s progress in malaria elimination. The report revealed that India recorded 2.6 million fewer malaria cases in 2018 compared to 2017.

This is a remarkable progress.

Recent data from the State of Odisha and Madhya Pradesh provides information and lessons that could be replicated for elimination of malaria from rest of the country. Through public outreach and mass surveys, the Odisha model improved access to malaria control tools, treatments and reduced the reservoirs of malaria in the community. The Madhya Pradesh model was a Public-Private-Partnership between the Sun Pharma established Foundation for Disease Elimination and Control (FDEC), which is a non-for-profit organization under its CSR portfolio, the Government of Madhya Pradesh and the Indian Council of Medical Research. This model aimed to demonstrate that malaria elimination is possible in the 1,233 villages of the Mandla district. Mandla was chosen because it presented varying complexities of demographic (forest malaria, hard to reach places, tribal malaria, etc.) and epidemiology (both species of malaria, seasonal malaria, seasonality of transmission, and asymptomatic malaria).

Both models work with and within the existing health-care system and are very much replicable. Taken together, the Odisha and MP models have shown that malaria elimination can be accomplished using tested and proven strategies and tools. A collateral benefit of malaria elimination would be the strengthening of health systems, which on one hand would eliminate illnesses and deaths due to malaria and on the other hand may also reduce the burden of other vector-borne diseases, such as dengue and chikungunya.

It is in this context that I argue that a Malaria-Free India is feasible and desirable by 2030, despite the challenges and burden on health systems posed by SARS-CoV-2 pandemic. The common element of fight against malaria and COVID-19 is that these infectious agents will not: 1) recognise state borders; and 2) infect individuals based on their age, gender, religion, economic status, ethnicity, or political ideologies.

The top-level need is to institute effective management, administrative and technical controls that are built on and guided by the proven principles of public health knowledge and practices. The lessons learned from combating COVID-19 can be used for malaria elimination, the most critical being the role assigned to District Collectors for managing supply chain and direct supervision of diagnosis, treatment and infection control measures. On the other hand, community-based models of diagnosis and treatment at house-hold levels can be deployed for fight against COVID-19, including the use of tested Information, Education and Communication (IEC) campaigns that informs people in their languages and geographic contexts.

For malaria elimination, the country is spending substantial amounts of money through Central and State governments for malaria control and elimination. The results of a study by the Institute of Economic Health, New Delhi in 2014 indicated that the total economic burden from malaria in India may be as high as US$ 1.940 million. The major costs to households come from lost earnings due to the disease (75%), while 24% comes from treatment expenses.

We have effective tools of disease surveillance, diagnostics tests that have been used in malaria elimination programmes by countries that have eliminated malaria. All of these tools and commodities are made in India and are tested and proven to track, test and treat malaria. The elimination program, however, will not succeed with business as usual practice and attitudes. The programme will benefit from a private sector-like approach that has appropriate operational, technical, financial and management controls. When executed with proper controls, oversight and accountability framework, the total outcome will be more than the sum of individual efforts.

A Malaria-Free India would mean: 1) rural, tribal and urban areas will be malaria free; 2) no women will have to worry about the consequences of malaria during pregnancy; 3) no child under five years will be at risk of death and severe disease; 4) there will not be school and workplace absenteeism due to malaria-related sicknesses’; and 5) in the long run, there will be significant returns on investments. The malaria elimination efforts in the next 10 years would need an ‘all-hands on deck’ approach, with a strategic pathway to achieve zero malaria. Like with small pox and polio, strong leadership from the Government in needed.

The ‘Malaria Free India Starts with Me’ campaign, which will complement similar campaigns by many African countries, should start from the President of India to the Prime Minister to Heads of Opposition parties and Union Minister for Health and Family Welfare, the Chief Ministers and from the Principal Health Secretaries of the State to the District Collectors. With this combined commitment, it would be possible to engage private sector and civil society to meet or even beat the 2030 target for Zero Malaria in India, which is just 10 years away.

For this goal to be realised in a timely manner, Malaria Free India and a world free of malaria has to be everyone’s goal in the present and difficult times of COVID-19 pandemic.

 

Altaf Ahmed Lal,

Georgia, U.S.

 

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Printable version | May 11, 2021 10:58:17 AM | https://www.thehindu.com/opinion/letters/letters-to-the-editor-june-23-2020/article31893340.ece

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