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Fighting the fever: the return of kala-azar in India

April 15, 2010

By Achintya Kumar Dutta

Kala-azar or black fever (visceral leishmaniasis) frequently figures in the news in India. Although the disease had nearly disappeared in the country by the mid-1960s, ostensibly owing to organised public health measures, this success was short-lived.

An epidemic resurgence of kala-azar in North Bihar in 1976–77 spread into West Bengal; the outbreak affected hundreds of thousands of people and caused the deaths of almost five thousand. Kala-azar transmission continued thereafter, resulting in more than 250 000 cases and numerous deaths. However, it is believed that the actual impact of the disease is far greater, as cases have gone unrecorded. The burden of disease was exacerbated by the acute shortage of drugs necessary for treatment at the beginning of 1977, which was mainly a result of local firms deciding to limit their production in India.

A house in India showing its last DDT spray dates. Wellcome Library

A house in India showing its last DDT spray dates. Wellcome Library

The World Health Organization played an important role during the 1977 crisis, providing emergency supplies of medicine to the region. It was also involved, along with the government of India, in convincing pharmaceutical companies to restart the manufacture of anti-kala-azar drugs, which allowed dispensaries and hospitals to provide treatment to the infected (these services were provided free to the economically disadvantaged). Organised vector control programmes, based on DDT spraying campaigns, started during the pandemic of 1977 and were continued in the following years. In this context, the WHO provided technical assistance in the form of technical advisers and field personnel. The National Institute of Communicable Disease was also involved in these disease control efforts: its officials surveyed affected districts in Bihar for data about epidemiological and social trends.

However, these anti-kala-azar measures were not introduced in an organised or uniform way across Indian states, which caused the disease to remain widely prevalent in Bihar and West Bengal (sporadic cases were also reported from the states of Uttar Pradesh, Gujarat, Punjab and Tamil Nadu). The National Planning Commission considered the problem to be serious enough in 1990 to approve significant financial assistance to an expanded scheme for kala-azar control; these funds were intended to provide for the assembling of teams of workers, chemicals for anti-vector spraying and drugs for treating people struck by the disease. UNICEF provided additional assistance for publicity and educational campaigns. These developments contributed to a decline in the incidence of kala-azar in the following years, even though these successes appeared transitory; insecticide spraying and active case detection work was not, for example, carried out in Bihar from mid-1994, even though 30 districts in Bihar and nine districts in West Bengal were found to be severely affected by kala-azar at the very time.

Disease surveillance activities, widely accepted as essential to any eradication programme, continue to be poorly organised in affected areas of India. The bulk of cases are concentrated in tribal villages, which have limited access to health facilities. Kala-azar has, for instance, been spreading rapidly in and around the tribal hamlet of Sarbamangal in South Dinajpur district in West Bengal; my investigations there reveal that its inhabitants have minimal access to healthcare facilities capable of treating the disease. The Public Health Centre is not even equipped with the pathological facilities to identify the kala-azar parasite; moreover, the health workers rarely invest time in case detection work or the spraying of insecticide. Acute shortages of effective drug treatments do not help either – indeed, sodium antimony gluconate, which is in use for the treatment of this disease, is not currently manufactured in India. Pentamidine isethionate, a product manufactured outside India, is frequently considered too costly to import by hard-pressed state governments. The widespread circulation of spurious drugs has created further problems for patients and health officials. Indian bureaucrats and administrators are also culpable, by refusing give priority to tackling the kala-azar problem. The available evidence shows that the disease generally affects the most disadvantaged sections of society. This ought to stoke more – rather than less – concerted action.

A man with post-kala-azar dermal leishmaniasis. Wellcome Images

The persistent neglect of health matters in public policy is evident from the relatively low levels of expenditure on health. Investment has fallen away gradually after the second five-year plan period; federal support for disease control programmes, which stood at 41 per cent in 1984/85, was reduced to 29 per cent in 1988/89 and scaled back further to 18.5 per cent in 1992/93. Health centre efficiency in several states continues to be adversely affected by insufficient facilities, medicines and staff. There is, thus, an urgent need for radical reform. The political visibility of health issues needs to be raised, and shortcomings in health delivery need to analysed, debated and countered both before and after parliamentary and local authority elections. Diseases such as kala-azar can only be eradicated through well-knit integrated campaigns. It is essential to mobilise community participation in health programmes, and special attention needs to be paid to ensuring the participation of women, since they are often the primary carers of children and the elderly. The Ministry of Health and Family Welfare recently constituted an expert committee on kala-azar elimination from India, with the declared aim of eradicating the disease by 2012 – this important goal can only be achieved through the committed determination of all stakeholders.

Professor Achintya Kumar Dutta is attached to the Department of History, Burdwan University, India.

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