The second coming
WHILE the World Health Organization (WHO) indulges in endless prolatives of achieving "Health for All" by 2000 AD, the global disease burden is on the boil, especially in developing countries. According to the Organization's World Health Report, 1996, infectious and parasitic diseases killed about 17 million people in 1995 - almost one-third of all deaths due to illnesses reported in that year; over 99 per cent of these deaths were from developing countries. Tuberculosis (TEI), which claims over three million lives a year globally topped the list, while malaria, with a toll of'2.7 million, stood a close second - mainly due to the emergence of virulent, multiple- drug-resistant forms and the lack of effective new drugs or vaccines to combat them. Moreover, TB being the most common opportunistic infection in AIDS patients, the advent Of HIV has contributed further to its expansion.
India has its unenviable share of global incidences Of TB and malaria. Every year, of the over 10 million cases Of TB, 2.5 million turn out to be infectious. With about five lakh deaths per year, India contributes almost 17 per cent of the global deaths due to TB. The case of malaria is no better. Almost 2.5 million cases are reported every year, of which the fatal falciparum or cerebral malaria claims over 1 000 lives. India contributes about 40 per cent of all malaria cases in the world outside Africa.
These figures do not reveal the entire picture, though; the virtual collapse of health surveillance and information systems in India has led to gross manipulation and under-reporting of data by concerned authorities. Lack 6f surveillance has also affected the management of disease-control. This is especially true for malaria and TB, which require prolonged multi-drug therapy for complete cure and prevention of relapse. For example, lack of epidemiological information regarding the type of malarial parasite, vector species and the level of drug resistance in a particular area leads to the choice of wrong drugs/insecticides and doses.
Surveillance, however, is only one of the many problems. The dismal condition of our primary health care centres, total neglect of preventive measures, shrinking health budgets, liberalisation of drug policy, irrational drug use, excessive privatisation of health care delivery, increasing poverty and malnutrition have all contributed to the present situation.
An important aspect that is often missed while discussing the growth of these diseases is their correlation with our unsustainable and inequitable development patterns. It is now widely recognised that the growth of malaria is directly related to the creation of malariogenic conditions through neglected inland water bodies, irrigation and construction projects etc. On its part, TB is a common occupational health problem along with silicosis and other respiratory disorders among workers of industries such as mining, iron and steel, glass, cement and asbestos.
Our disease control programmes - 'vertical' approach ones like the national malaria eradication programme, which runs parallel to the general health services (GHs), as well as 'horizontal' approach types like the national tuberculosis control programme, which is totally integrated within the GHS - have failed to achieve their goals. One reason for this is their dependence at the peripheral level on rural primary health care centres and multipurpose health workers. This is unlike in the '60s (the golden era of the Indian public health system) when there were separate malaria and T13 workers. Another major problem is the fund sharing between the Central and state governments, beset by non-compliance on both sides. A general decline in health budgets has further compounded the problem.
Tackling the two maladies is as much a scientific challenge as one of public health. The age of triumphant chemical warfare against them is pass6. Drug resistance is on the rise and new vaccines are still non-existent. In the case Of TB, the BCG vaccine is already proving ineffective for adults.
Obviously, there are no short-cuts. A strong public health network, better infrastructure, a reliable and prompt health surveillance system, better living and working conditions, stress on prevention, health education, community participation, higher health budgets, focussed research, and above all, strong social commitment and political will for the proper implementation of the stated programmes are all equally important if results are to be achieved and sustained.
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