TOWARDS A TEN POINT STRATEGY FOR MALARIA / DENGUE CONTROL IN MANGALORE
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- Title
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TOWARDS A TEN POINT STRATEGY FOR
MALARIA / DENGUE CONTROL IN MANGALORE - extracted text
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TOWARDS A TEN POINT STRATEGY FOR
MALARIA / DENGUE CONTROL IN MANGALORE
(Some points for Discussion)*
1. NOTIFICATION AWARENESS
On 13th March, 1988, the Government of Karnataka notified Malaria / JE / Dengue fever
as notified infectious diseases under the Karnataka Public Health Act.
(a) Are doctors and health care providers aware of this notification?
(b) If so, how effective has the post-notification response been? Are we more aware of
the magnitude of the problem?
(c) If not, how do we make more health care providers aware of this notification and their
responsibilities?
(d) Are there other groups in society who should be made aware of this notification? If
so, how?
2. MANGALORE CITY CORPORATION BYE-LAWS
Bye-laws have been prepared by the City Corporation and forwarded to the government
for action
i) What has been the follow up action
ii) In everyone aware of the contents of the bye-laws
iii) The Mangalore bye-laws are different from the Bangalore bye-laws in some section.
Is every one aware of the differences?
iv) Has the Corporation Health authorities geared up to enforce the bye laws? Can
anything further be done in preparation?
3. STUDY OF VECTOR DYNAMICS
NMEP and MRC have constantly stressed the need for local assessment of specific vector
dynamics so that local action can be focussed around specific local realities
i)
Do we know enough about the local vector species to initiate action?
ii) Do we need further studies to understand the vector dynamics of all potential
mosquito vectors in Mangalore?
* A Workshop Discussion paper
prepared by Community Health Cell, Bangalore, April 1999.
For the Workshop "Towards an appropriate Malaria/Dengue Action Plan for Mangalore
City involving 'Civic Society"'
Organised by Malaria Jaivika Niyantrana Samithi
At KMC, Attavar on 6 - 7th April, 1999
D:\OFFlCEVctters of April 1999 doc
'1
iii) Have the MRC visiting teams studies helped to identify special situations / features?
iv) What further studies are needed on an ongoing basis to enhance local / focal
integrated vector control?
4. GUIDELINES FOR INTEGRATED VECTOR CONTROL
Different types of mosquito breeding sites have been identified in Mangalore city and its
environs. What guidelines can we evolve for vector control in each specific situation?
Overhead tanks?
Cemented tanks?
Curing tanks?
Fountains?
Wells (used)?
Wells (unused)?
Any other collections of water?
5. RATIONAL TREATMENT AND CARE
Rational Malaria Care and management are an important component of, effective Malaria
control. Rational, low-cost, effective and prompt treatment should be undertaken by all
alert heath care providers.
i)
What has been done so for to educate local health practitioners and providers in
Rational Malaria treatment and management?
ii) What more can be done?
iii) How significant is the problem of’resistance'?
iv)
Can the IMA-NMEP Guideline be widely circulated? If so how?
v) Who all could be actively involved with CME's on Malaria in Mangalore? How and
what could they do?
vi) What arrangements can be made to strengthen
Laboratory Diagnosis of Malaria / Dengue
Treatment of complicated cases?
6. INVOLVEMENT OF CIVIC SOCIETY
Community participation has been identified as a key component of successful control
strategy.
i)
Who are all the components of civil society in Mangalore, who could be made aware
and involved in action against Malaria and Dengue?
NGOs and voluntary agencies
DAOFFICEMcttcrs of April 1999 doc
Environmental groups
Trade unions
Women's groups
Peoples organisations
Religious / social /cultural organisation
Others?
ii) How can they be made aware of the problem? How can they be involved in
action? In what way, can they participate in control efforts?
7. INVOLVEMENT OF EDUCATIONAL SYSTEM & HEALTH
EDUCATION
Children and all those who are involved in the educational system should be made aware
of the problem of Malaria and Dengue, In addition, community Health education is
urgent.
i)
How could schools and colleges be involved in the programme?
ii) What activities could they do? Who would facilitate this and how?
iii) Are there any educational modules available for malaria training in school / college
curriculum
iv) How can the media be involved in health education?
v) What are the other modes of health awareness building that can be used in
Mangalore? Who / How would facilitate this?
8. FORMATION OF WARD COMMITTEES AND ENHANCING
LOCAL LEVEL COMMUNITY PARTICIPATION
i)
What has been the experience of ward committees in the past? In the present?
11)
What could be the composition of such committees?
ni)
What could be the functions of such committee?
iv)
Are there other methods of involving the community at local level?
9. PROTECTION AND MANAGEMENT OF CONTRACT
LABOUR AGGREGATIONS
Recently, the Goa Public Health Act has notified that contract labour must be under
surveillance and given treatment when required. The onus is on the contracter.
i)
Are we aware of the provisions of this Act?
D AOFFICEXlcuers of April 1999 doc
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A
11)
How can it be applied / evolved in Mangalore city?
ni)
What would be the key components of such an initiative?
iv)
How could it be introduced? Enforced?
10. INTER-SECTORAL ACTION
There is urgent need to tackle the problem of resurgence of Malaria /Dengue and other
vector borne diseases through coordinated inter-sectoral action
i)
What are all the sectors that contribute to the problem and hence should be involved
with contribution to control / action
(a) Agriculture Department?
(b) City Corporation?
(c) Urban Development?
(d) Construction sector?
(e) Fisheries department?
(f) Local industries?
(g) Any other?
ii) How can these be involved in control / action
iii) What specific contribution could each make to the programme?
11.ANY OTHER POINTS?
Finally, the participants can suggest other areas of action initiative that have not been
covered by the areas / questions listed above?
Are there other issues of concern?
Are there other strategies for action?
D:\OFFlCE\lcncrsorApril 1999 doc
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MALARIA / DENGUE IN MANGALORE
Follow-up action
What
Who
How
1. Notification
Awareness
2. Mangalore City
Corporation
Bye-Laws
3. Study of Vector
Dynamics
4. Guidelines for
Integrated
Vector Control
5. Rational
Treatment and
Care
6. Involvement of
Civic Society
i^pjU
''fa -^-
What
Who
7. Involvement of
Educational
System &
Health
Education
8. Formation of
Ward
Committees
and Enhancing
Local level
community
participation
9. Protection &
Management of
Contract labou^
aggregrations
I
10. Inter-Sectoral
Action
11. Any other
points
JaT
'L'w W
VO
How
LET US CONTROL MALARIA
Introduction
Malaria is an infectious disease, which is ailing mankind since ancient time. It can
definitely controlled by taking preventive measures, thereby operationalizing the wellknown process “Prevention is better than cure”. Keepring up with rising environmental
awareness, the thrus weak be on control of malaria through bio-environmental methods
for Mangalore city.
Educational Objectives
1) To impress on the fact that Malaria is a man-made problem and demonstrate that it is
more of an environmental problem than an medical problem
2) To illustrate the ecological balance in the triad of man, mosquito and environment
3) To suggest societal responsibility of every individual to control mosquitoes through
community participation.
4) To communicate orally and in written format to the people in community the role of
the Guppy fish can play in preventing malaria by reducing breeding of mosquitoes.
5) To reason out the preference for bio-environmental management over chemical use
in controlling mosquitoes.
6) Understand the importance of prompt treatment of malaria cases.
7) To imbibe the essentials of scientific investigations.
8) To help boost self-confidence of a student
Scientific Concepts
1) Life cycle of Malaria parasite.
2) Life cycle of mosquito
3) Bio-environmental control strategy
4) Physical characteristics of mosquito.
Previous knowledge assumed
1) That malaria is carried by mosquito
2) Mosquito breed in stagnant water.
Students Guide
Scenario: Mangalore city is specific and South Canara district of Karnataka in general is
one of the most highly literate, well informed and resource for regions of our
country. One of the reasons for the prosperity of the region was attributed to
the good health enjoyed by the people of the region. Over period of last 7-8
years, malaria has made major inroads in the region. Numerous reasons are
attributed i.e., construction, migration labourers, etc. The city will face
serious problem if malaria is not brought under control immediately. School
children have significant role in the process.
Your tasks:
1) Brainstorming of ideas over the issues.
2) With the help of zzoology teacher/ local malaria worker, get acquainted to
identifying mosquito larva.
3) Go around in your area in group of two and try to identify various types of collection
of water that could serve as potential breeding sources.
4) Look closely in water collection for the presence of larvae.
5) Mark ‘+ve’ for the presence of larvae;
6) Mark ‘-ve’ for absence of larvae.
7) Analyse the data with the teacher’s guidance.
8) Devise an action strategy for each variety of breeding source, to control/prevent
mosquito breeding.
Learning teaching materials
1)
2)
3)
4)
5)
6)
Bowl with handle
Rope
Bucket
Tray (white)
Guppy fishes
Work sheet.
{Worksheet for student is given next page in tabular form}
\
MOB
SI. Na
Small breeding sources
Big breeding sources
Wells______________
Overhead tanks________
Garden cemented tanks
Ditches and puddles on
roadsides and gardens
Drains______________
Water collection
in
construction sites like for
curing purpose________
Water collection in base
plate of indoor plants
Coolers____________
Window shades_______
Discarded tyres
Discarded/broken pots,
tins, bottles__________
Coconut shells_______
Tree holes
+ve
-ve
_________ Action Strategy_________
Release Guppy fishes______________
Change the water in the tank once a
week or can also introduce fishes
Fill in tihe ditch/puddle with mud, with
stone and mud___________________
Introduce fishes__________________
Change the water once a week
Empty the base plates after watering
Change the water once a week______
Drain out the water. Keep it dry.______
Remove the water by puncturing them
or with cloth____________________
Destroy and dispose
Destroy and dispose
Fill it up with mud
TEACHER’S GUIDE
Suggested teaching strategy:
1) Brainstorm before sending children to the field on following aspects of malaria:
a. Malaria - signs and symptoms
b. Life cycle of-----------► Malaria parasite
Life cycle of---------- ► Mosquito.
c. Different control strategies that could be adpoted to control mosquitoes/
d. Why bio-environmental control with guppy fish.
2) How malaria is man made problem, disease, what kind of activities lead to water
stagnation. Thus impressing on the children the relation between environmental
sanitation and health. And thus malaria control is possible with basic health
education and community participation.
3) Show that how each of the action strategy is based on the scientific concept, in other
words, application of the conceptual science into action that can be related to societal
problem.
The science behind it
v Closing the ditch/puddle
being that mosquitoes
* Emptying the water out of base plate of flower pot >
need water to lay the
v Drying the window shades
eggs
* Drying the inside of tyres.
4) Changing the water once a week would lead to interruption of life-cycle of mosquito
as they need to be in water for atleast once a week for their maturation.
5) Pros and cons of all other ways of mosquito control strategy should be discussed on
the base of feasibility, economic and environmental hazards.
Eg:
Environmental hazards
a. Pouring kerosene oil over water
b. Spraying DDT
> economic reasons
c. EPS beads
Students Handouts
Students can carry with them simple diagrammatic, pictorial representation of life
cycle of mosquitoes in the form of flip charts; while going out in the field to
convince the residents of the reason for avoiding the potential breeding of
mosquitoes in and around the houses.
2) Data table.
1)
Assessment of objectives achieved
1)
2)
3)
4)
5)
Comprehension
Feed-back from residents
Written test
Enthusiasm
Perseverance
6) Demonstration skills
Communication skills
7) Co-relation of scientific concepts
and activity
8) Decision making
9) Pre and post activity response of a
child.
TRAINING OF DOCTORS IN GENERAL PRACTICE AND NGOs ON
“EARLY DETECTION, TREATMENT AND MANAGEMENT OF
COMPLICATION OF MALARIA.
PROBLEM IDENTIFIED.
The government of India has recognised that the central India and North East
India are at high risk for Malarial fever and more and more resistant cases are
reported from Orissa , M.P and North East India. Further more than 90% cases
of fever are treated by the practioners of medicine in the general practice and
NGOs. Very few NGOs have ever attempted to get involved in the control of
Malaria in these high risk areas. No training programme or update educational
programmes are available for medical practioners in Bihar, Orissa , M.P and
North East India. Hence the CMAI having its network in these areas, being
requested by the NMEP to help in control of Malaria , has taken up the
responsibility of training medical practioners in private practice and NGOs areas
mentioned above.
OVER ALL PURPOSE.
To decrease the morbidity and mortality among people due to Malaria in Orissa
M.P, Bihar & NEI.
Objective:
To train 100 doctors in states of Orissa , M.P, Bihar & NEI on <early diagnosis
’*
of
Malaria, its treatment and Management of complications in 4 update workshop.
Activities:
1. Developing working relationship with NMEP at the central government level,
state and district levels in above mentioned regions by ,
* organising formal and informal meetings. Several formal meetings were held
with the NMEP at Delhi in 1998 and at the state level with officers in charge of
Malaria control programme at Berhampur (Orissa), Hazaribagh (Bihar), Dumka
(Bihar), and Guwahati (Assam).
* informal meetings were held with teachers of medical colleges at Ranchi,
Guwahati, Berhampur and school of tropical medicine Calcutta to mobilise
resource people for the update workshop.
* informal meetings were held with members , hospitals, at Ranchi, Hazaribagh,
Mohulpahari, Guwahati and Berhampur with the hosting institutions.
* informal and formal correspondence were done with CMAFs resource people at
Bishamcuttack and Bhubaneswar.
2. Orientation of progiamme officers at Ranchi and Guwahati was done to assist
at these workshops.
Achievements:
Kindly refer to the comprehensive report.
2
TOPICS
1. MALARIA OVERVIEW
2. EPIDEMIOLOGY & LIFE CYCLE
3. CLINICAL FEATURES & DIAGNOSIS
4. LABORATORY DIAGNOSIS
5. DIFFERENTIAL DIAGNOSIS OF COMPLICATED MALARIA
6. ANTI MALARIAL DRUGS
7. MANAGEMENT OF COMPLICATIONS
8. REFERRAL CENTRE & LINILAGAGERS
9. CASE STUDIES
10. OVERVIEW OF VECTORS
11. HUMAN BEHAVIOUR & MALARIA
12. CONTROL OF TRANSMISSION
- Impregnated Mosquito net
12. ROLE OF NGOs/GPs
TRAINING OF DOCTORS ON MALARIA
S/
No
1
2
3
4
Place &
Date
Berhamepur
Orissa
23rd to 25th
January
Dumka
Bihar
6th to Sth
March_____
Hazaribagh
Bihar
13 th to 15th
March_____
Guwahati
Assam
27th to 29th
March
3
Pre test
COVERAGE OF TOPICS
i
2
3
4
5
6
Ft
8
9
10
11
12
Poor
performance
GOOD
GOOD
GOOD
FAIR
GOOD
GOOD
FAIR
FAIR
GOOD
GOOD
NOT
DONE
GOOD
Poor
Performance
GOOD
GOOD
GOOD
GOOD
GOOD
GOOD
FAIR
GOOD
GOOD
GOOD
NOT
DONE
GOOD
NOT
DONE
Poor
Performance
GOOD
GOOD
GOOD
FAIR
GOOD
GOOD
GOOD
GOOD
GOOD
GOOD
NOT
DONE
GOOD
NOT
DONE
Poor
FAIR
GOOD
GOOD
GOOD
GOOD
GOOD
GOOD
FAIR
GOOD
FAIR
NOT
DONE
FAIR
NOT
DONE
Performance
Post
test
NOT
DONE
Comprehensive report on “Training of Doctors on Malaria (1998- 99)
SLNo:
1
2
3
4
State,place,
& dates
venue
Orissa,
Berhamepur
Radha Hotel,
23rd to 25th
Januray 1999
Bihar, Dumka
Bandarjodi Mission
6th to Sth March’99
Rem arks/feedb ack
Resource people
No
partici
pated
42
27
Bihar, Hazaribagh
27
St. Columba’s
Hospital, 13th to
15th March 1999
Assam, Guwahati
CBCNEI conference 27
centre, 27th to 29th
March 1999
CMAI__________
Dr.Sukant Singh
Dr. John Ooman
Dr.Ravi D’Souza
GOVT_______________
Dr.S.N.Das
Incharge Malaria
Dr.Satyanand Das
Asst.Medical Officer
Malaria
OTHERS________________________
From Berhamepur Medical College
Dr. Bijayalaxmi Parija, Physician
Dr.Sitaram
Mohapatra
Pathologist
Dr. Manoj K. Mohapatra-Physician
Dr.H.N. Sahu - Principal
Dr. N.M.Panigrahi - Rtd.Prof.G& O
Dr.Sukant Singh
Dr.Ravi D’Souza
Dr.Ujwal Hembrom
Dr.S.N.Jha, Physician
Sadar Hospital,
Dr.Manjhi
Civil Surgeon Dumka
Dr.Amitabh
School of
Calctutta
Dr.Sukant Singh
Dr.Ravi D’Souza
Dr.Pushpa Dass
Dr.R.N. Sahay
Civil Surgeon
H azarib a gh
Dr.Sukant Singh
Dr. C.Hera
Jt.Diretor (Malaria)
Dr.Vasudev
M.RC.Sonapur
Refresher
Dr.Sushil Kachyap, Physician
3.
update
Ranchi Medical College
Dr.Anugraha Paul,Physician
programmes may
be regularly held.
Ranchi Medical College
Dr.U. Sharma, Prof. S.P.M. CMC
Dr.Bhattacharya, Physician
Guwahati Medical College
Dr.A.Baishya Asso.Prof. S.P.M,
GMC
________ L
Nandi
Tropical
1. Participants are
not
asking
for
DA,TA but would
like if their stay &
food
can
. be
adequately covered
by CMAI *
Director, 2. More sessions on
studies,
Medicine, case
diagnosis
and
treatment will be
helpful.
ROLL BACK MALARIA
BRIEFING DOCUMENT
INTRODUCTION
1.
Governments and civil society in malaria affected countries will take the lead in
rolling back malaria as a means to reduce poverty and mortality, and promote human
development. Partners, in considering health sector issues, will agree to work together, at
country level, towards common goals using agreed strategies and procedures. The national
authorities of countries will direct the partnership.
2.
WHO has established a Cabinet Project to help country Roll Back Malaria
partnerships become fully effective. The project is implemented with the support of WHO's
Clusters and Offices at Headquarters, Regions and Country, and other partners. It is
spearheaded in Africa. It promotes effective investment in new medicines and other tools to
reduce the burden of malaria through WHO/TDR, MJM and the public-private MMV
(Medicines for Malaria Venture).
The project helps increase the level of international financial investment in the efforts
3.
of countries to Roll Back Malaria through international advocacy emphasising the current
and potential investment outcomes and ensuring updated information on the global malaria
situation.
To provide countries with the specialised technical support required to address the
4.
challenges of malaria, the project will establish a number of Resource Support Networks,
comprising experts in appropriate fields, particularly from relevant regions; thus making
implementation plans to reflect an evidence-based response to local needs and realities.
MISSION
5.
The Roll Back Malaria Cabinet Project will address a priority health issue through
contributions to strengthen national systems, provide effective and strategic interventions
through partnerships with groups within and outside WHO, and act as a pathfinder in offering
a new approach to the sustainable control of infectious diseases.
GOAL
6.
The Roll Back Malaria project will significantly reduce the global burden of disease
associated with malaria through interventions adapted to local needs and reinforcement of the
health sector.
MAIN AREAS OF WORK
1.
2.
3.
4.
5.
6.
Strategy Development, Communication & Advocacy
Activating Progress at Country Level
Building and Sustaining the Global Partnership
Promoting Consistent Technical Guidance
Strategy Support for Research and Development
Monitoring Progress & Outcomes
RBM/page 2
OBJECTIVES
7.
The objective of the Roll Back Malaria project during the preparatory phase, ending
7.
December 1999, is to maximise effectiveness of the Global Roll Back Malaria partnerships.
Specifically, it will lead to:
The establishment and operation of national Roll Back Malaria partnerships
7.1
in at least 20 countries in Africa
7.2
The establishment and acceptance of WHO-wide strategy to Roll Back
Malaria, which results in coherent WHO operations to implement Roll Back Malaria
in the context of health sector development
7.3
The establishment of up to 9 Technical Support Networks, utilising
indigenous expertise, where possible, to ensure that the best quality, science-based
technical support is available to help participating countries Roll Back Malaria in the
context of health sector development
7.4
The establishment and sustenance of a global information system to track
the progress of the Roll Back Malaria Initiative at country, regional and global levels
7.5
The development and deployment of new tools for effective malaria control
through partnership with the research community and private sector
7.6
Advocacy and resource mobilisation among members of the global
partnership for Roll Back Malaria and other country action in the context of health
sector development
STRATEGY DEVELOPMENT, COMMUNICATION & ADVOCACY
8.
Roll Back Malaria will build on the current Global Malaria Control Strategy and
current efforts, adapting them to achieve the highest levels of implementation. Technical and
implementation strategies, through a consultative process and a continuous dialogue with
countries, will be developed, based on epidemiological, regional, health systems needs and
economic circumstances. Further, these strategies will focus strongly on the community level
and will seek to strengthen existing implementation efforts and build on them.
ACTIVATING PROGRESS AT COUNTRY LEVEL
9
A country that commits itself to the Roll Back Malaria Initiative ( RBM country)
undertakes a needs assessment to develop national strategies for intensified action.against
malaria. Interventions for each country will be endorsed after reviewing information on
treatment and prevention practices of malaria at the household and community levels,
availability and quality of health care in public and private sectors and potential local
partners. An “RBM” country will have the technical content of strategies being pursued by
partners endorsed, technical and financial assistance for implementation brokered and
progress with Rolling Back Malaria within the context of health sector development
monitored.
A country which is not committed to Roll Back Malaria will continue to enjoy
10.
WTJO's ongoing technical support for malaria control activities.
RBM/page 3
BUILDING & SUSTAINING GLOBAL PARTNERSHIP
11.
A partnership representing Member States, organisations of the United Nations
system, development banks, bilateral development agencies, the private sector, the media and
civil society will be established at the global level to support country level action. Partners
will agree on the terms of their participation, approaches to international advocacy, means for
mobilisation and flow of resources, the basis for monitoring progress, and an appropriate
institutional framework to sustain the partnership; thus contributing to more effective action
on their part at country level.
PROMOTING CONSISTENT TECHNICAL GUIDANCE
Technical support networks will be established to provide expertise that is required
12.
for the implementation of RBM by countries. These networks will:
•
•
•
•
•
•
•
•
•
comprise experts (and institutions) in various disciplines with practical
experience available in countries within the region
provide direct support to control operations
address specific technical issues that are critical for control policy
address specific issues that can be more effectively dealt with in an inter-country
and/or regional setting
function in a “demand-responsive ” manner with respect to the RBM needs of
countries
encourage collaboration between countries
be the link with international expertise between research and academic
institutions, and disease control operations in endemic countries
be financed by various partners
be a potent mechanism through which to build country and regional capacity
STRATEGIC SUPPORT FOR RESEARCH & DEVELOPMENT
13.
International Research and Product Development activities that address key
constraints to rolling back malaria will be incorporated into the global Roll Back Malaria
partnership. This will result in intensified collaboration with the private sector to develop
new and more cost effective tools for malaria control. The major institution for this
component is the cosponsored Tropical Diseases Research Programme, managed by WHO.
Another is the Medicines for Malaria Venture (MMV) which will operate as a commercial
enterprise, using public funds to accelerate the development of effective new anti-malarial
treatments and vaccines. A third is the Multilateral Initiative on Malaria, an independent
consortium of research groups seeking scientific responses to the challenge of malaria in
Africa. Roll Back Malaria will help these vital initiatives to agreed priorities to accelerate
global efforts to reduce the malaria burden.
MONITORING PROGRESS & OUTCOMES
14.
Support to monitoring and evaluation will be provided by RBM, and standardised
methods and criteria for monitoring and evaluation of interventions at the district level will be
developed. Further, a monitoring and evaluation system will be established within WHO to
track the global progress of Roll Back Malaria implementation and its impact on the health
sector.
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Dear
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In 1998, the Mangalore Nagara Parisarasaktha Okkoota and Nagarika Seva
Trust have decided to take active interest in the problem of the resurgence of
bortsbacb
Malaria in Mangalore fitid its environs. With the active cooperation of the
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corporation Medical Officer’s team, the KMC staff, local professional
bodies and NGOs and the enthusiastic support of Malaria Research CentreBangalore and Community Health Cell-Bangalore, it organised a series of
meetings at different levels, visits by MRC team to study the problem; a
training programme for representatives of NGOs on bio-environmental
control; a dialogue with the corporaters; and the distribution of handouts and
some background materials. This led to the formation of the Malaria Jayvika
Niyantrana Samithi (Biological Control of Malaria Committee). In the last
few weeks, the same group of people have also explored the problem of
Dengue, which re-emerged in Mulki and other areas and may spread to
Mangalore as well.
u
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We now feel that it would be a good idea to bring together all our resource
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persons and enthusiastic collaborators in a 114 days workshop at Mangalore
on 6-7* April, 1999 to
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1. to present/share findings/experience of various visits and meetings held
in connection with malaria initiatives both in Mangalore as well as in
other parts of state and action taken;
2. chalk out a Malaria/Dengue Action Plan which identifies the challenges,
the specific peculiarities of the situation in Mangalore and the
responsibilities and roles of all the collaborating groups and especially
the active contribution and participation of ‘Civil Society’ in the control
programme in the months ahead.
0
7
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--------- —y
The meeting will be chaired by Dr. Murugendrappa, Joint Director, Malaria
and Filaria of the Directorate of Health Services, Karnataka, who is very
"VOG^
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keen to enhance the collaboration between government, NGOs and others in
the control programmes. Dr. K. P. Ganesan, Retired Principal, K.M.C,
Mangalore has consented to be the facilitator for the entire workshop.
cdjBDJJ6'
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You have been an active . participant/supporter of Malaria Action in
Mangalore city and we invite you to join this dialogue and share your ideas
and perceptions about the problem and help us to evolve a relevant action
plan.
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The view of the workshop will be K.M.C, Attavar Time : 10 a.m. to 5 p.m.
on 6th of April 1999, and 10 a.m. to 1 p.m. on 7th of April 1999. A tentative
plan of the workshop is enclosed.
We look forward to your active participation in the initiative.
With best wishes.
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Yours sincerely.
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TENTATIVE PROGRAMME
Workshop : Towards an appropriate Malaria/Dengue Action Plan for
Mangalore City involving ‘Civic Society’.
[The workshop will be an interactive, participatory workshop organised around group
dynamic principles to enhance the active involvement of all participants].
f 1
6th April, 1999
Tuesday
10 a.m.
Inauguration by Mr. E. V. Ramana Reddy, IAS
Deputy Commissioner, Dakshina Kannada.
10.15- 11 a.m.
Introduction to Workshop
Self introduction by participants
(especially interest/involvement in Malaria action)
li_ii i^
Ter
11.15-1p.m.
Understanding the situation in Mangalore
-
short presentation by. Dr. Parashiva Murthy, Dr. Ravi Kumar,
Dr. Venugopalan, Dr. Praveen Kumar, Dr. S. K. Ghosh, CHC
team and others;
-
Inputs by all participants in the discussion
(Session will identify the salient features of the problem of
Malaria/Dengue in Mangalore which need to be considered while
evolving an Action Plan)
1 - 2 p.m.
Lunch
2-4 p.m.
Ideas for Action - Evolving a checklist
- what has been done ?
- what can be done ?
(This session will take stock of all that has been done, all that is
being planned and all other ideas for action that participants any
suggest)
4-4.15 p.m.
Tea / Coffee
4.15-5.15 p.m.
Group Discussion
l.
Vector Control
n. Rational Malaria Care
m. Community participation
IV.
Intersectoral coordination
Wednesday
7th April, 1999
9.30 a.m.
Plenary : Towards an Appropriate Strategy for an Action Plan
Reports of Group I, II, III and IV.
Discussion
11.30 a.m.
Final session
-
Roles and Responsibilities of participating groups
-
A resources inventory - next steps
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.t
PROC^DIi.GS- OF. -Kix. Idi^Tli.G OF HIGH POW^R COFiMlil'e-o• Ou- •:
Il'lPixor^utgiTIOH 'OF BlO-L.iiVlRQuM^nfaJj b^'i'HODS OF HaLARlA
OOi.l’KOli
Un 261’11 00'i'UBr.R 1'99G .VI!’ 12.00 uOOn I..I ROOM
hOi ala, (JOwMl'l'iU--'RUOH, VIDH.'ii’.A SuUDH;i, B.H.GaLOiU U„lk.R ■ ■■
•fiU CHAIRriJi'.oiilP/OF CHUI? SXhUl’W ;i’O GOV^RhlWl’.
. IWiBeRS PR-SiLf:-
. '
1. - Sri B.K.Bhattaohary a
. }
Chief Secretary to Go vt... .Chairman
'•.•••
2. Sri
bri •B.aiswarappa.
p. sw r t.p
Secretary
to Govt.
. • nb3ith
& Pami
iy Welfare Dept.,
; {Deputy Secretary to Govt., .• •
Health & Family Welfare Dept.,
. ,
:Direct'»rr Health & Family .
Welfare Services,
••• '.Mender
3< Sri C,Mohan
4. Dr.M.T,HetF.Are-ldy.
• bt- ncralore
n.
hi't r. b • mii
i n i*. ii'-'is i ■',,i 1
<in»j
•••’
,'1 ,'tj"1
••• .,Stot-$etary •
’I|"1 1
Rb^ioml Office of He3Ith ■
f<c Fntnily ,!'clf •Hre
nixilore.
7. Br^.T.C ..Chidambar Murthy
8. nr.M.V.Muru^eniranna
t'
r’i
11. Dr.Shyamal Biswas
12. ; Dr.S.K.Ghosh
•
j/>. Dr . i.S. Satya oar ay an .
.r 1
Dr .S. Ii.Tiwari •
15« Sri A.Prakash
•.
I
■ •
J .
•
■. ■
: To tat Director of Fisheries.^.; z ' .
:Intertnl Fiaonciol Advispr,.Heolth & Family Welfare Dept,'
/
:Officer I uohargc , h|ICDfGOI , B ,.l'®?e,
{Officer I ncharge ,M.R.C* Ba o^oiore . ...
. :A.R.S,:,M.R.C . ,Ba rgalcre.
• :M.R,«0. iBoBgolore. •
.
‘ l'
:S.r,entomologist, Health & Family
Self ore Services, Bnngolpre. .
) 9. Sri P.F:. Wul
m664
10. Sri C .S.S.SharmA .
<1 •
i
•
.
At the outset■Secretary He’1th and Family Welfare Depart
ment whUe'd is cuss i'tag the role of mosquitoes in the transmission of
. the diseases like Malaria, Japanese encephalitis and Dengue stressed
•the nced'"for implementation of Biological method of co ntrol. by the
use of. Larvivorus fish as it is one of the cost effective,' long-
lasting and nermauent measures. Further, he nointed out the urgent
necessity feasibility of its implementation in the Malaria problem
areas of Mangalore and Bellary cities
Dp.Shoipe, Senior Regional Director, viewed biological
2.
• pietho4 as
ne of, the interventions and not the only method for
ralarta n^ntral, it has to be snnplementSd/intocrated with other ‘v
metMis an4 cannat be oonliea .un’-formiy in all the places..
2, ..
!
i
zDirfcct^r,Deporteeot of Forest,
jicolnfry s n<. jintlvonnie nti
•Dc'mitv. Sucr^tory l/o.Irri^otion
Dent.
.
• Inint Direct or (WF),H«nIth <%
^a-oily .Welfsre Services , B1 lo.ru -
i
6. T?r.M.|K.BalAkrishnaiah
’
2
V
J.
Dr.Ghosh, Malaria Research Centre, highlighted the use of
Larvivor.us f ish. i n. P.H.C .' Kamas.amudr.a.4f or control of Malaria by
releasi ng, f ishesA?l,a all, the^ irrigation' w.e.lls; and tanks .which are
the? main breeding so.urces for Vectp.r mosquitoes i n, that. area.
x
4w Health Secretary enquired.whether the research findings .have
been independently evaluated by any other .organisation/ research c
• ’’centreY •'.*/ *• ’
• ' •
. •'. -1
.
.
5.
. DrlBalakrishnaiah, Director, Department of Forest, ecology
‘
•
’ •
■
t
it .
.
.
!
;
a nd; e nviro nmc nt brie fed. •■'regardi ng the mapping of water bodies
*’ through remote sensing through IRS which help in studying water
bodies resources • for deye.lopment in the field of fisheries, '.gricul-x-.<t
•
e^ture.’and Forest.
-> I
.. •• •
•’ Hen 1.th'.Secret’'Tryt>i the’ nriblem of moannito niiisonce in
6.
the •Ban'* a Tore liX-n^rt' ^re^, n Qi whether stickin'? nf Tnrvi.Vor^ns
fishes in the neorby Be"’ i oni-ir tqnk w.ouli br • n*T down the mosiQuito
me nape i n the area* •,
. ;f ■
«
•
F* ••
Dr,3horrib state'! that water sources of Bellaudur t'^nk is
. highly' polluted and only nuisance moaquitoes are found to be breeding
7.
Sri /ibdul H^mecl, Joiu(t Director of fisheries stated that due to
hi’gh Organic and low oxygen content, growth of wat^r hyacinth plants
.
are seen coxoriug the tank where control of mosquito breeding by
' ^.iah cannot be, achieved effectively.
•
8.
* “ ’'Df.M.y .Murugc ndrappa, Joint Director (M&F)’stated that all
major tanks including Virport area have been surveyed, and action plan
was suggested, by.'the Director, V.C.R.C.Pondicherry way bpek in 1988
itself which has to be implemented by the Corporation authorities
i uv j I vi. ng dll L nru ill Uu p rr line uL/Sun t irs with mu L lipin aijpf.* iches amt
integrated Vector Control Methods which is very much needed in this
. regard.
.9.
Health Secretary i nfarmed ..the Committee that recently
Government has issnei civic bve-laws for control'of mosquito breeding
and eradication ^f Falaria and other mosqui to- bop ne. diseases which
.. has ta be strictlv imole.m.enfed by the Ba nr;more.-'aha na^ara Bolike.
!
^r^-hash M
i^htei the ni^t stuiies carried o^t bv the
1 np -in besenrch Centre in ^HC ^nakltte
ani Banavara in uassan
r
i..utr
ji
’
icti
n
of
Larvivoraqs
fishes,
a n^ imnren-nated bei
district, bv
nets ta the Chief Secretiry. n se of biociie was iiscassei Pr.M.V.
Muru^e niraooa apirjei thit use of Biaciies requires further studies as
different studies had ftiven different results.
10.
i
I
I .
- 3 -
Health oecteta’-y stated that i utroduction of Larvivourous
fishe| to be taken.up in all high .'risk areas in the State on a war
footing basis.. Malaria Research Centre was requested to t’ke up field
studies to control Malaria in Mangalore and Bellary cities.
12. Cr.L.V.Murugendrippa> Joint Director stated along with introduc-' ■
tiori of L-irvivorous fish, other iuterveution measures are also Dto be
implemented oud already District level staff havfc been trained in
Raichur recently im this regard. I"
Hsnlth Department has Already takenup the introduction of LarvivourousJ fishes in the high risk areas in
17 districts so f^r. equipments have been provided for transporta-
tion and release of these fishes.
Use of i\eeni Oil for Larvicidal
sprny was also discussed. Dr.14.V.Murugeudrapoa further s.t'ated that
Malaria in nroject areas is spread by labourers who are brought by
the contractors. Government has constituted a Committee stating
th^t any project before inception has to obtoin clearance by the
Committee. Legislative act on the lines of Goa for screening of
migrant labour population has to be implemented. Health Secretary
asked Joint Director (Malaria) to obtain a cony of the legislation
said to have been enacted by Go^ Government and the Rules thereunder
and submit a self-contained comnrehe'psive r report for taking, similar
action bv the State Covernm^n t.
• ■y
1
1
15TJrJi.T.Hetn'iredd.y, Dirbctir, Heil.th V Family Welfare Svrvicsa . •'
Stressed regardi
the incartance af imaedi \te scree ui og of all labou
rers to be done as and when they arrive,
14.
Chief Secretary instructed to chalkout a detail agenda to be
t.-ikeu up for discussion in th« next meeti'Dg ind the meeting vps co nluded with thanks to the ch^ir.
Oj
Sd/CillajF G^CiUx'.mY.
•Ji » (
^o.HFW 103 81*11*1 98
(
C \'\ ;
”)
\(SIDDALIhG4\lAii)
) ?\ j.
lA
Under Secretary to Govt
Dtpnrtment of Henith & Family
Ll We If ore,
(Heolth)
?A »1
To :
I
*11 Co ncer ne'l.
I
li
i;
I
!■
MALARIA RESEARCH CENTRE
OTHER PUBLICATIONS
(1)
Proceedings of the ICMR/WHO Workshop on Com
munity Participation for Disease Vector Control
(1986) pp. 256
Edited by V.P. Sharma
(2)
Seroepidemiology of Human Malaria — A
multicentric study (1989), pp. 206
Edited by VJ*. Sharma
(3)
Indigenous Larvivorous Fishes of India (1991), pp.
66
A.G.K. Menon
(4)
Proceedings of an Informal Consultative meeting
WHO/MRC on Forest Malaria in Southeast Asia
(1991), pp. 206
Editors V.P. Sharma andA.V. Kondrashin
(5)
Malaria Patrika quaterly (Hindi) 1993 onwards.
(6)
Community Participation in Malaria Control
(1993), pp. 295
Edited by KF. Sharma
(7)
Larvivorous Fishes of Inland Ecosystem: Proceed
ings of the MRC-CICFRI Workshop (1994),
pp. 224
Editors VJ*. Sharma and Apurba Ghosh
Printed by Akhasdeep Printers New Delhi-2
URBAN MALARIA CONTROL
(Example Madras)
7-POINT ACTION PLAN FOR MALARIA CONTROL
Madras city is endemic for malaria and cases of drug resistant
Plasmodium falciparum malaria have been recorded. Focal
malaria outbreaks are often encountered and the problem of
urban malaria in Tamil Nadu is of long standing. It may be
pointed out that Madras city alone contributes 50-70% new ma
laria cases annually to the malaria problem of the state (Fig. 1).
The vector Anopheles stephensi responsible for malaria transmis-
100
90
80
70
60
50
40
30
72
68 67 68
63^
74
a,.
50
49
38 39
4i
46 4T48
4^
35
20
10
0 -
77 7 8 79 80 81
82 83 84 85 86 87 88 89 90 91
92 93 94. 95
Fig. 1: Percentage of malaria cases indigenous to Madras city in the state of
Tamil Nadu
1
sion in Madras city breeds in clean stored water such as in the
overhead tanks, cisterns and wells. Tables 1 and 2 give epide
miological picture of malaria in Tamil Nadu and Madras.
Table 2. Epidemiological data of Madras city
Year
For more than a decade Urban Malaria Scheme (UMS) is under
operation in Madras. The present system of malaria control as
practiced under the UMS is unlikely to eliminate this focus.
Based on the MRC’s experience of field work in six divisions of
the Corporation a 7-point action plan has been prepared to
eradicate malaria from Madras city. The region is also endemic
for dengue transmitted by Aedes aegypti. It is a container breeder
and a day biter. The action plan would also eradicate dengue as
a collateral benefit.
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
Table 1. Incidence of malaria In Tamil Nadu
Tamil Nadu_____
Year
No. of
cases
P. falciparum
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
79537
76227
95009
73381
71517
65797
67192
71320
71347
52741
55523
74303
90478
120029
146997
151633
147663
104266
2094
1512
3312
2802
2531
3048
4481
4724
4303
2848
3588
5214
4244
7039
1.2293
12244
8932
4974
______Urban malaria (No. of cases)
Urban
Madras
Madras Riverine
centres
city
city
area*
42661
50742
47840
47796
51839
54795
44852
40400
44734
64584
71551
86915
99335
104777
65024
28437
29953
33450
36193
44951
44981
44817
48523
51376
39197
31126
34400
45622
51272
67013
72314
76749
48352
Coastal
area**
+ ve
617
2560
36207
40623
28437
29953
33450
36193
44951
44981
44817
48523
51376
39197
31126
34400
45622
51272
67013
72314
76749
48352
136
482
388
297
242
124
189
830
1673
2971
3358
3185
2608
2218
1982
2542
3921
8024
7966
5894
2057
% Pf
API
ABER
SPR
5.31
1.33
0.96
1.04
0.81
0.37
0.52
1.85
3.72
6.63
6.90
6.00
6.65
7.12
5.76
5.57
7.60
11.97
11.01
7.60
4.25
0.27
0.96
13.28
14.54
9.93
10.42
11.58
11.65
13.73
13.41
12.98
14.72
15.68
10.59
8.28
8.46
11.40
13.50
17.40
18.66
19.21
12.72
2.30
9.30
8.70
9.40
9.70
8.80
6.70
8.90
9.20
10.40
9.40
12.60
13.10
16.00
13.90
15.10
15.00
13.50
13.47
11.00
9.77
1.26
12.99
14.68
9.34
9.67
12.86
16.16
13.83
12.06
10.58
12.36
10.47
7.03
5.20
6.05
7.50
8.51
11.20
11.83
17.12
13.01
Source: Madras Corporation
1835
1426
883
678
725
1811
3407
5095
10539
8621
7268
8164
6726
3988
4661
16322
11651
19489
38373
26296
19069
17986
*Dharmapuri, North and South Arcot District; **Ramanathapuram, Padukkottai
Districts.
Source : Directorate of Public Health and Preventive Medicine, Government of
Tamil Nadu.
2
Pf
No.of
cases
*
The strategy suggested in the 7-point action plan is simple,
indigenous, free from pollution, cost-effective and provides long
term control of the vector-borne diseases.
ACTION PLAN
Action by the Government: An appropriately worded
Government Order (G.O.) may be issued to the following agen
cies responsible for construction and maintenance of all build
ings including Defence and Railways, State Government build
ings, autonomous organizations, educational institutions, all in
dustrial houses, public buildings and other institutions etc.
The above agencies must observe the following responsibilities
with immediate effect.
3
Mosquito-proof all water storage overhead tanks (OHTs), cis
terns and wells. Water should not be allowed to leak from pipe
lines, taps etc. and proper drainage must be maintained. Water
coolers and air conditioners etc. should be cleaned atleast
once a week to eliminate standing water.
CAST IRON COVER (45Cm.Dia.)
.STURDY CROSS BAR
LOCKING
\
ARRANGEMENT
No further installation of OHTs/cisterns and wells should be
permitted unless they are mosquito-proofed ( Figs. 2-4).
One officer in each building/institution should be designated for
vector control work and given full responsibility to ensure that
there is no mosquito breeding in his building. His name should
be communicated to the Corporation as a contact person for
interaction and inspection. He should be allowed adequate
budget for vector control work and made fully accountable. Ex
penditure towards this activity should preferably be met from the
budget of the respective organisation/institution.
M.S. PLAT
/ 50mm.x 5mm.
HINGE
lCOLLAR
— RING
Fig. 2: Standard design of a cover to be used for mosquito proofing of OHT, well
or cistern
The Government should also ensure the following :
(i)
CHECK NUT.
45c.m. Did- COVER (Slightly Convex)
■LOCK
.HINGE
-HARD
GRIP
CHECK NUT
OVERFLOW PIPE
PROTECTED WITH
METALLIC PLATE
PERFORATIONS NOT
EXCEEDING 1-5 mm.
‘—M.S. OR R.C.C.
JT EXCEEDING
1*5 mm-
Technology for mosquito proofing of the wells, OHTs/cis
terns should be made available easily through various me
dia. It would also be advisable to ensure the availability of
readymade mosquito-proof OHTs/cisterns etc. in the open
market for installation.
(ii) Provision of loans (preferably interest free) should be made
through banks or Corporation to avoid hardships in the mos
quito-proofing of water storage facilities. Recovery of loans
should be made in easy installments.
(iii) A source for the supply of larvivorous fish and expanded
polystyrene (EPS) beads should be identified and given due
publicity.
(iv) Larvicidal oil should be available in the open market in tins
for use by the contractors (at present it is a government
supply). The label on the tin should provide full instructions
on its method of application.
Fig. 3: Standard design of over head tank
4
5
HAND
-PUMPOR MOTOR
MANHOLE COVER
1
—
f
I
»
r.
— LINING
Ji
•J
-—
-1
OPEN JOINTED BRICK
OR STONE MASONRY
Fig. 4: Standard method of mosquito proofing a well
A similar action of mosquito-proofing of OHTs/cisterns and wells
should be adopted in all colonies/divisions of the Madras city.
In order to implement the strategy Health Department/Corporation should elicit people’s participation, involve health education
bureau, prepare educational material and make full use of me
dia. The Health Department should also involve voluntary agen
cies, non-governmental organizations (NGOs), students, Mahila
mandals and other action groups in whatever manner possible
in dissemination of activities of the action plan for mosquito
control and solicit positive support through individuals and joint
action (e.g., shramdan) for the preventive and corrective aspects
bf;mosquito breeding.
It may be noted that main mosquito breeding sites of malaria
vector An. stephensi are OHTs and wells followed by cisterns.
Mostly Ae. aegypti (a day biter mosquito) breeds in cisterns,
and is responsible for dengue outbreaks and during 1989 there
were cases of dengue haemorrhagic fever in Madras.
A major activity of Health Department should be to identify all
mosquito breeding sites (geographical reconnaissance) and pre
pare action plan for the control of mosquito breeding for each
habitat. In this activity Health Department would be required to
solicit help from other departments/agencies. Follow-up action,
6
persuasion, providing technical guidance and monitoring would
be an important function of the Health Department which must
be planned and executed meticulously.
Early case detection through passive agencies, activated mass
blood surveys, rapid blood smear examination and administra
tion of presumptive and radical treatment must be ensured. In
certain high transmission areas malaria clinics may be opened
and given full publicity.
2. Inter- and Intra-Departmental Coordination: Health
department of corporation/municipalities in consultation with the
state health department should be responsible for coordination
of vector control work in the city. In that capacity they would be
required to solicit from their own and other departments/agen
cies their active participation in preventive and corrective as
pects of mosquito control. Some government departments must
participate in malaria control programme directly. For example
water supply department must ensure that water pipes/lines are
well protected and not damaged and there are no leaking water
taps or pipelines. All leakages/damages should be repaired on
priority basis within 24-48 hours and stagnant water drained.
Sewage and storm water pipes should be well maintained and
cleaned as and when due. All manhole covers should be re
paired and properly installed to prevent mosquito emergence.
Similarly, ventilating shafts should be mosquito-proofed. Horti
culture department must ensure that no mosquito breeding
occurs in stagnant water in gardens, parks, and ornamental
fountains etc. The fisheries department must ensure clear
shore line of the ponds and other water bodies and survival of
larvivorous fishes in all water bodies. All government engineering
departments must ensure prevention of water stagnation, ad
equate drainage and if stagnant water is required for some act
ivity it should be suitably treated to prevent mosquito breeding.
Health department should elicit people’s participation and in
volvement in mosquito control through educational programmes
and they should make full use of media in achieving this. School/
College students and voluntary agencies should be mobilised in
preventing mosquito breeding.
7
It may be pointed out that in certain parts of Madras city there is
acute shortage of water and people belonging to low socio
economic status are the worst hit. In such localities water lines
are damaged or public water facilities are misused. Government
must ensure proper water supply in such areas before initiating
action to repair the damage or stopping water supply to such
localities.
3. Legislative Measures: Municipal bye-laws must be
implemented rigidly and defaulters should be punished. Bye
laws in Madras have been amended recently for this purpose.
For the effective enforcement of provisions' under the Public
Health Act and Madras City Municipal Corporation Act, the Assis
tant Entomologists may be empowered to issue notices and
institute prosecution proceedings with the prior approval of the
concerned Senior Entomologist. The fine to be imposed to the
defaulters should double up every time with non-compliance.
The Government of Tamil Nadu may be requested to bring suit
able amendment to the Act.
4. Clearance from Health Department: New construc
tions should be permitted only after obtaining permission/clearance from the health department/corporation of Madras and it
should be made compulsory for the owners to deposit the ex
penditure to be incurred for undertaking anti-mosquito measures
in their premises. The Health Department/Corporation of Ma
dras should decide on the amount to be deposited, for undertak
ing preventive/remedial measures, depending upon the poten
tial breeding sources and duration of water storage. No building
plan should be cleared if it does not fulfill the conditions speci
fied in the Public Health Act. In the ongoing constructions mos
quito proofing of OHTs, cisterns and wells must be ensured, and
help of bye-laws should be taken for compliance. It may be
pointed out that this procedure is currently followed by the Bombay
Municipal Corporation and there are no protests or complaints in
the implementation of this system.
1
lishment of foci resulting in outbreaks of malaria. It is therefore,
absolutely essential that (i) incoming labour is screened for
malaria infection and given radical treatment, and (ii) all con
struction sites are made free of mosquito breeding. In order to
achieve this objective construction companies/contractors must
take help of health department and ensure that water is not
allowed to stagnate. All standing water whether for curing or
construction work must be treated with chemical larvicides like
Baytex or Abate or MLO. In certain situations like big water
reservoirs Gambusia (Gambusia affinis) fishes should be intro
duced. In polluted waters Guppy (Poecilia reticulata) fishes may
be introduced. There should be regular inspection of all sites
and preventive measures of mosquito breeding applied rigidly as
soon as any standing water is found.
It would be advisable to include the preventive aspects of mos
quito control in the contract itself. Government may therefore
issue appropriate instructions to all departments for such ac
tion. Failure to maintain the site free of mosquito breeding should
attract prompt action under the bye-laws. It is noteworthy to
mention that this is a fairly easy and inexpensive method of
malaria prevention, and if implemented properly it works wonder
fully.
In areas of large populations of migrant labour one time screen
ing of labour and radical treatment of those found with malaria
parasite may be undertaken by the health department.
6. Implementation Mechanism: The work should be
started in phases as indicated below :
Phase-1 (Six months)
(i)
Map all mosquito breeding sites. This information is already
available and may require minor changes/updating.
(ii) Implementation of bye-laws.
5. Tropical Aggregation of Labour: A large number of
agencies are constantly engaged in construction work all over
the township. It has been observed that tropical aggregation of
labour for construction is often the primary cause of the estab-
(iii) Government order should be issued to all Government, and
non-government agencies and other organizations as indi
cated under item 1.
8
9
(iv) Six divisions at present under the MRC should be taken up
(Divisions 30, 48, 49, 79, 80, 81) (Fig. 5).
(v) Fish multiplication ponds (for Gambusia and Guppy) should
be established in as many water bodies as possible.
Experimental
areas
(vi) Ensure the availability of EPS-beads and availability of mos
quito-proofing devices.
Phase-11 (Six months)
30, 48, 49
79, 80, 81
Bay of Bengal
API
>20
All high incidence divisions ( 20 API) should be taken up Fig. 5
(i) Stratification of Madras city according to API, and (ii) Areas
currently under the bioenvironmental control strategy i.e., divi
sions 30, 48, 49, 79, 80 and 81.
Phase-111 (Six months)
The entire Madras city may be included. (Figs. 6, 7 and 8).
Major mosquito breeding sites of An. stephensi (vector of ma
laria), Ae. aegypti (vector of dengue) and Cx. quinquefasciatus
(vector of filariasis and a nuisance mosquito).
11-19
Adoption of above methods will result in almost complete inter
ruption of malaria transmission and also cases of dengue fever
(Tamil Nadu is endemic for dengue) would come down drasti
cally. Mosquito nuisance will also be curtailed to a very large
extent. Control of Cx. quinquefasciatus, a nuisance tropical house
mosquito and the vector of filariasis (Wuchereha bancrofti) would
require major environmental modification works which could be
taken up at a later stage.
Fig. 5: Madras: The city is divided into 155 divisions. Figure showing the stratifi
cation of divisions according to 1993 API. Also shown are 6 divisions
under bioenvironmental control strategy implemented by the Malaria
Reserach Centre
10
7. Constitution of Committees: The 7-point action plan
may be monitored through a steering committee responsible for
ensuring continued government and political support and a project
committee to oversee the implementation and monitor its
progress. The membership to the committees may be finalised
by the Government of Tamil Nadu. The following compositions
are suggested;
11
°(
ano
’r
Experimental
areas
30, 48, 49
) /
y*
79, 80, 81
Bay of Bengal
<
O
API
z
Ul
m
u.
o
>
<
m
>20
2-10
> 1 Aedes
breeding cistern
per 10 houses
f
•t
Fig. 6: Madras: The city is divided into 155 divisions. Figure showing the stratifi
cation to 1994 API. Also shown are 6 divisions under bioehvironmental
control strategy implemented by the Malaria Research Centre
12
< 1 Aedes
breeding cistern
per 10 houses
Fig. 7: Madras: Aedes breeding potential in the city
(Source: Madras Corporation)
13
(i)
Mm
L
■■■rai
■■■■■■»'-««■> jiii Kkii
<■■■>■•:vi>
<
zO
UJ
m
u.
o
>
<
m
g High Culex
' j production
areas
A steering committee which would be an apex body may be
constituted to steer the project at the government, political
and community level. The committee could be chaired by an
eminent scientist of international repute. The committee
should have nominees of the Chief Minister, NGO, a social
worker, Director MRC, Chairman of the project committee
and any other member co-opted by the Chairman. This com
mittee would be responsible for obtaining whole hearted
support of the politicians and the government and mobilise
community’s involvement and participation. The committee
will also help in removing bottlenecks and ensure adequate
funds. This committee would meet atleast once in six months.
(ii) A project committee may be constituted with the Chief Sec
retary as Chairman to evaluate overall performance of the
project and to remove bottlenecks. The committee may com
prise of the Secretaries of the Department of Health and
Family Welfare, Urban Development, Chief Engineer Public
Works Department (PWD), Central Public Works Department
(CPWD), Local Self Government, the Director, Additional Di
rector (Malaria), Chief Entomologist, Directorate of Public
Health and Preventive Medicine, Special Officer, Commis
sioner (Health) and Health Officer, Madras Corporation, nomi
nee of the Director, MRC, representative of Railways, De
fence and two nominated members from social organiza
tions and any other member co-opted by the Chairman. The
committee should meet every quarter.
Low Culex
production
areas
*
Fig. 8: Madras: Culex breeding potential in the city
(Source: Madras Corporation)
14
15
I
■
J g!
■
)■
■ ’
’’
xg
m
r
■MAf-'
I .
'/■
-W
-
.-■
1
II
DIRECTORATE OF
NATIONAL MALARIA ERADICATION PROGRAMME
(GOVT. OF INDIA)
IN COLLABORATION WITH
IMA COLLEGE OF GENERAL PRACTITIONERS (HQ)
NEW DELHI
Government of India
DR. S P. AGARWAL
M.S. (Sufg.i M.Ch. (Xeurei.
WWW
DIRECTOR GEXERAl.
pRfuj
feccfl-l 10 01 1
DIRECTORATE GENERAL OF HEALTH SERVICES
NIRMANBHAVAN
NEW DELHI-110 Oil
National Malaria Eradication Programme
Dr. SHIV LAL
Director
(Directorate General of Health Services)
HFf, f^ccft-110 054
22, Shamnath Marg, Delhi-110 054
Dated 25th Feb., 1997
FOREWORD
PREFACE
Malaria was a major problem in India contributing
75 million cases with 0.8 million deaths every year
prior to the launching of National Malaria Control
Programme in 1953. Though the infection has been
contained substantially, it still continues to pose a
major challenge with 2 to 2.5 million cases annually.
During the last two decades an increasing trend has
been noticed in the proportion of malignant malaria
cases, with fulminating epidemics claiming many
precious lives.
Malaria continues to be major scourage in India Including
metropolitan cities. In the past the capital territory of Delhi
experienced malaria epidemics and the medical fraternity
was caught unawares with the sudden upsurge of cases in
epidemic proportions. The recent experience with dengue
epidemic is an apt example in this direction.
Private Practitioners play an important role in
the containment of malaria as a sizeable proportion
of patients seek medical aid from them. The concise
booklet being brought out by the Directorate of
National Malaria Eradication Programme and Indian
Medical Association would help and provide proper
guidance to the family physicians and health units
in private sector on the National Drug Policy on
Malaria.
In the light, of Revised National Drug Policy of Malaria
framed by the Govt, of India, the Directorate of National
Malaria Eradication Programme in collaboration with the
Indian Medical Association has brought out the present
guidelines in the form of booklet for the benefit of family
physicians to treat malaria patients in line with the
National Drug Policy. A substantial proportion of population
in the urban areas consult the family physicians or private
Nursing Homes for their medical needs. Many a time the
private practitioners treat malaria patients with different
antimalarials following variable or indiscriminate dose
schedules.
The Intensification of intra and inrersectoral
coordination and greater participation in the
containment measures auger well for early
achievement of our goal of effective control over
malaria.
It is envisaged that the salient guidelines given in this
booklet will meet the minimum requirements on relevant
aspects of diagnosis and treatment of malaria cases.
Critical comments and suggestions from the private
practitioners are most welcome which will enable us in
improving the future publications, whenever warranted.
(Dr. S. P. Agarwal)
(Dr. SHIV LAL)
1
INTRODUCTION
COMPLICATIONS J
Malaria one of the common diseases, is caused by Plasmodium parasite,
transmitted by the bite infective female Anopheles mosquito, during
Hyperpyrexia
Severe anaemia resulting in hypoxia
transmission season. There are four plasmodium species. In India, P. vivax is
Cerebral involvement (cerebral malaria)
commonest (60-70%) followed by P falciparum (30-45%), P malariae
Pulmonary oedema
species is rarely found and P ovale is not found in India.
Renal dysfunction
P falciparum is a malignant variety of malaria as 0.5% to 2% may develop
Hypoglycaemia
complicated malaria, of which up to 50% may lead to mortality if timely
Haemoglobinuria
treatment is not commenced. All malaria mortality is due to P falciparum
Jaundice
only. A single dose of chloroquine may save the life by averting complications.
DIKHOSIS
CLINICAL PRESENTATION
TYPICAL :
CLINICAL NOH COMPLICATED
Sudden onset of high fever with rigors and sensation of
extreme cold followed by feeling of burning heat, leading to profuse
sweating and remission of fever by crisis thereafter. The febrile
paroxysms occur every alternate day. Headache, bodyache, nausea,
etc. may be associated features.
Atypical : In atypical cases, classical presentation as mentioned above may
not manifest.
Hence, any fever case until unless proved
otherwise, may be considered as malaria.
IN CHILDREN : Depending on the degree of temperature, complications
such as convulsions, dehydration and disorientation may be present.
P. FALCIPARUM [MALIGNANT1 j
Most of the case may present similar to P vivax or other malaria cases but in some
cases it is continuous and often reaches a high temperature, leading to hyperthermia
and other complications as given below.
3
Fever cases without the following associated symptoms may be considered as
malaria. Blood smear may be collected and treatment may be commenced.
•
Cough- Acute respiratory infections
•
Cold with running nose
•
Skin rash suggestive of eruptive illness
•
•
Burning micturition
Skin infections e.g., boils, abscess, infected wounds
•
Painful swelling of joints
•
Ear discharge
SERIOUSLY SICK MALARIA CASES NEEDIHG
HOSPITALISATION
•
Cerebral malaria - Cases of fever with unarousable coma not
attributable to any other cause
•
Hyperpyrexia, convulsion, severe anaemia,
•
Pregnancy with fever
•
Pulmonary oedema
•
Haemoglobinuria
4
PREPARATION OF THICK 0 THIN BLOOD
SMEARS FOR MALARIA MICROSCOPY
Blood smears should be made from all the patients reporting with fever or
with history of fever, if suspected for malaria. Slide may be taken even though
fever is not present at the time of reporting of patient.
TREATMENT
PRESUMPTIVE TREATMENT before the result of the slide is known.
The presumptive treatment is given to all fever cases or cases with history of
METHOD
1. •
CONFIRMED DIAGNOSIS :
MALARIA PARASITE DETECTED IN THE BLOOD SMEAR
Third finger of the left hand of the patient should be held with left
hand between thumb and finger by blood slide collector at the first
phalangeal joint
fever during the proceeding 1 5 days immediately after the blood smear is
collected. It is to be given to all person whatever be the age or sex. Even
pregnant women in any month of pregnancy or during postpartum period
should receive presumptive treatment. The presumptive treatment is also to
•
Wipe finger tip with swab dipped in spirit or Savlon solution
be administered to fever cases where the blood smears are not collected.
•
Allow the finger tip to dry
a) Presumptive treatment comprises of a single dose of Chloroquine
2. •
•
3. •
•
Hold the pricking needle in the right hand and prick the finger
Allow blood drop to ooze out
Take a clean slide
Take 3 drops of the blood (sufficient blood) 1 cm from the edge
of the glass slide
•
4. •
•
•
5. •
Take another drop of blood one cm from the first drop of blood
phosphate @10 mg/kg. body weight
ADULT DOSE
A Single Dose of Chloroquine Phosphate-600mg (4 Tablets)
- THIS IS TO BE ADMINISTERED BY ALL AGENCIES
The age-wise dosage of Chloroquine for presumptive treatment @10 mg/
kg body weight
Age in years
Allow it to dry
Put the slide identification No./Name on thin smear with lead pencil
No. of Tablets
___
Take another slide with smooth edge and use it as spreader
Make thick and thin smears
Tablet Chloroquine Phosphate
mg base
1/2
1-4
5-8
9-14
150
1
300
2
450
1 5 & Above
600
3
4
As per revised drug policy of NMEP presumptive treatment of all suspected/
clinical malaria cases in High risk areas is as follows :
(600mg adult)
Day 1
1 Omg/kg
Primaquine
Day 1
O.75mg/kg
Chloroquine base
Day 2
1 Omg/kg
(600mg adult)
Chloroquine base
Day 3
5mg/kg
(300mg adult)
Chloroquine base
f'9-
6
(45mg adult)
££iBICAL TBfMMEWT
b) Radical Treatment for microscopically confirmed Pfalcipaium infections:
The adult dose/drug schedule is as follows :
All microscopically positive cases of malaria are to be given i
radical treatment
with Primaquine for its gametocytocidal and antirelapse properties. This
A single dose of 600 mg Chloroquine (10 mg/kg body weight) and 4 5 mg
Primaquine (0.75 mg/kg body weight) is to given stat.
ensures a complete cure from malaria in the positive case: and makes him
non-infective to mosquitoes.
THE AGE-WISE OGSAGE OF RADICAE TREATMENT
a) Radical Treatment for microscopically confirmed P.vivax malaria
Age in years
infections :
Tablet Chloroquine
The adult dose / drug schedule is as follows :
Single dose
A single dose of 600 mg Chloroquine (10 mg/kg body weight) and 1 5 mg
mg base
Primaquine
Single dose
No. of
mg base
Tablets
Primaquine (0.25 mg/kg body weight) on the first day followed by 1 5 mg
(1 5 mg each)
Primaquine (0.25 mg/kg body weight) daily for the next four days.
THE AGE-WISE DOSAGE Of RADICAL TREATMENT
Age in years
Tablet Chloroquine
Tablet Primaquine
1 50 mg base
Single dose
mg base
No. of
2.5 mg base
Daily dose for 5 days
mg base
Tablets
No.of
1/2
nil
nil
1-4
1
2.5
1
5-8
300
2
5.0
9-14
450
3
15>
600
4
<1
75
1/2
nil
rm
1-4
150
1
7.5
1/2
5-8
300
2
15.0
1
9-14
450
3
30.0
2
15>
600
___ 4
45.0
3.
..
c) The radical treatment of cases in Chloroquine resistant strain areas for
P falciparum as suggested under the revised Dr
Tablets
75
150
Policy .r. as follows
ADULT DOSE
Sulphalene/Sulphadoxine
+
1 500 mg
Single dose
2
Pyrimethamine
75 mg
10.0
4
(3 tablets)
15.0
6
CAUTION : INFANTS AND PREGNANT WOMEN ARE
NOT TO BE GIVEN PRIMAQUINE
No.of
Tablets
Thereafter
Primaquine
45 mg
Single dose
is should be given cautiously and not on the: same day as both are
known to precipitate haemolytic crisis in sensitive ■
cases with G-6-PD
deficiency. The drug administrator should ensure that the patient swallows
Sulpha combination tablets in his presence and gi’
ives clear instructions to the
patient to consume Primaquine tables on the following day without fail.
8
THE AGEWISE DOSAGE IS AS EDILDWS
Age
Sulphalene / Sulphadoxine +
in
Pyrimethamine
years
mg base
No', of
mg base
Primaquine
Tablets
Tablets
2
1 25 mg
________ 3________
1/4
4
5
nil
nil
Persistence of fever after 48 hours
•
•
of initial treatment
Continuous vomiting & inability to
Severe anaemia
•
retain oral drugs
Headache which is continuously
•
•
Anaemia-pregnant women
•
Jaundice
•
•
increasing
Severe dehydration
General condition is too weak
•
•
Hyperthermia
Bleeding, clotting disorders
Changes in sensorium e.g.
confusion, drowsiness, blurring of
•
Pulmonary oedema
•
Haemoglobinuria
+
6.25 mg
1-4
500 mg
1
7.5 mg
1/2
+
•
25 mg
5-8
7 50 mg
l/1/2
15.0 mg
1
+
1 000 mg
2
30.0 mg
2
3
45.0 mg
3
of Chloroquine to the conscious patient,
1 500 mg
+
I.V. Quinine
(1 0 mg/kg) in suspected cerebral/complicated malaria cases
and send case sheet, details of treatment history and blood
50 mg
above
twitching
NOTE : Before referring patients, please take blood smear, give a dose
+
15 &
Convulsion or muscle
vision, photophobia,
37.5 mg
9-14
disorientation
•
(1 5 mg each)
(500mg + 25mg each)
1
REFtHBai Of MfiLftRlft CflStS
No.of
slide with patient.
SOME OORT'S IN MBtARia CASE MaHBEtMtHT
75 mg
NOTE .Sulphalene / Sulphadoxine & Pyrimethamine continuation does
•
Do not give anti malarials on
• Do not use heparin as
•
empty stomach
Do not use corticosteriods
anticoagulant
• Do not administer adrenaline
•
Do not give I.V. mannitol
• Do not over-hydrate
not take care of P. vivax cases.
In cases resistant to above drugs, and in severe & complicated malaria with
P falciparum\n\zc^\QX\ (microscopically confirmed) I.V. Quinine is to be used
PRtvtHTioH of wataRia
in doses given below :Quinine 10 mg/per kg b.w. thrice daily as intravenous infusion in 5%
•
dextrose /glucose solution over 4 hours.
When the patient regains consciousness the same dose schedule is given
orally to complete 7 days treatment.
Monitor Blood Sugar Quinine I.V. may precipitate Hypoglycemic crisis.
9
Screening of windows / doors
•
Proper clothing
9
Use mosquito repellent
•
Use mosquito net
• Do not allow water to stagnate in
the house or surrounding the
of house
house for more than 7 days
• Dry your cooler every Sunday
(complete change of water)
10
I
Date : 5-3-97
Malaria still continues to be a major scourage in
India and needs to be dealt with firmly by all
concerned. As the family physicians play a prime
role in effective delivery of primary health care to
the population at large, this book entitled "Malaria
A glance at the diagnosis and treatment for family
physicians" shall serve as a ready reckoner for all
involved in fighting the malaria upsurge. I.M.A.
College of General Practitioners commends the
remarkable work done by the Directorate of National
Malaria Eradication Programme in publishing this
handbook.
Dr. Vinay Aggarwal
Hony. Secretary
I.M.A.C.G.P (HQS)
Reproduced By :
SENIOR REGIONAL DIRECTOR
REGIONAL OFFICE FOR HEALTH & F. W.
II Floor, ZF' wing, Kendriyo Sedan,
Koramangala, Bangalore • 560 034
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TOWARDS AN APPROPRIATE
MALARIA CONTROL STRATEGY
Issues of Concerns and Alternatives for action
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The Expert Group and main contributors:
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1.
Dr. Ravi Narayan, MD, DTPH (London), DIH (UK), Coordinator/Secretary, Community
Health Cell, Society for Community Health Awareness, Research and Action, Bangalore.
2.
Dr. P.N. Sehgal, MBBS, DPH, FISCD, FAMS, Consultant, Voluntary Health Association
of India, New Delhi, ex Director National Institute of Communicable Diseases, Government
of India.
3.
Dr. Mira Shiva, MBBS, MD, Head, Public Policy Division, Voluntary Health Association
of India, New Delhi.
4.
Prof. Amitabha Nandy, MBBS, DCP, MD, Department of Parasitology, Calcutta School
of Tropical Medicine, Government of West Bengal, Calcutta.
5.
Dr. Rajaratnam Abel, MBBS, MPH, Head, RUHSA Department, Christian Medical
College & Hospital, Vellore.
6.
Dr. Sunil Kaul, MDBS, AVARD-NE, (Association of Voluntary Agencies for Rural
Development - North East) Jorhat, Assam.
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Voluntary Health Association of India
40, Institutional Area, South of IIT,
New Delhi-110016.
Society for Community Health Awareness, Research and Action,
Community Health Cell 367, ‘Srinivasa Nilaya’, Jakkasandra,
1st Main, 1st Block, Koramangala, Bangalorc-560 034
SECTION D : TOWARDS A RELEVANT MALARIA POLICY
21
22
23.
24
25
26.
27.
28.
29
30.
Malaria and National Health Policy
Health Humanpowcr Development and Training Issues.
Loss of Public Health Skill / competence
Malaria Research - Challenges
Forecasting / Monitoring Malaria Outbreaks / Epidemiology
Management Information System
Corruption / Political Interference in Policy Decision Making
International Public Health Cooperation
Centre - State responsibility
NMEP and Operational Management at various levels
81
85
89
90
93
94_
95
96
97
99
SECTION E : A COMPLEMENTARY STRATEGY AND ALTERNATIVES FOR ACTION
31
32.
33.
Towards a Complementary Strategy for Malaria Control
31a Supplementing Existing Strategy
31b. Complementary' Role of the Voluntary' Sector
Bibliography of References
Presentation and Review of the Report
105
105
110
112
127
APPENDICES
A.
B.
C.
D.
E.
F.
G
H
I.
J.
K.
L.
Regional Diversity of Malaria
Malaria Problem Areas
Adjuncts to Lab Diagnosis
Antimalarials - Production/Pricing/Availibility
A Catechism on Malaria
Voluntary Malaria Link Workers
Health Education challenges in Malaria
Messages in Health Education for Malaria
Activities for NGOs in Malaria Control
Potential Herbal Remedies for Malaria type fever
A Veterans Meeting - Lessons from the past
Malaria Surveillance - A suggestion
133
134
135
136
139
144
146
147
148
149
150
152
13. MALARIA AND PRIMARY HEALTH CARE
It is increasing!)' recognised that whereas in the past years, Malaria Control was organised as a
military operation with clear lines of control, guidelines for roles and responsibilities at every level
and the strategy was lop down, vertical and unipurposc; and that this approach also resulted in a
spectacular reduction in the problem; this approach is not easily sustainable especially when the
level of the problem becomes reduced and the problem becomes one of many community experienced
problems to be tackled by the public health system in the county'. The horizontal integration of
Malaria Control with the Primay Health Care centres and the primay health care approach is
therefore not just a necessity but becomes crucial to the sustainability of the programme and to
its continued efficacy in the long run
13.1 Malaria control has been integrated with PHC before India’s commitment to the Alma
Ata declaration but even more so after it. The multipurpose health worker, the lab
technician and the health supervisors under the leadership of the MO became the crucial
operational team of the programme within the PHC organisation and Malaria Control
has been for quite some time one of the many functions of the PHC. The Primary
Health Care approach however is not just 'public health’; and ‘preventive and curative
medicine' being provided by government and /or non-government centres in the
community, but is more. It is the active mobilization, involvement and participation
of the community in the planning, implementation and monitoring of the health programme.
That is the crucial challenge and malaria control becomes part of a Primary Health
Care strategy only when the principles of (i) Community participation (ii) Appropriate
technology (iii) Intersectoral coordination (iv) social equity - become central to the
strategy of the control programme.
13.2 In more recent years the Malaria control strategy in the county has become gradually
more Primary Health Care oriented and efforts are being made to ensure that the control
options and alternatives arc in the context of this approach. However, to ensure that
this linkage docs not become rhetorical but gets operationalised into a strategy, where
the involvement of the community in building up the first line of Health care in Malaria
control in the periphey becomes a reality, we make the following suggestions.
i.
The 'Community' in the urban slum, the rural or tribal area must first be, accepted
at all levels of the control strategy as ‘active participants’ of the programme and
not ‘passive beneficiaries’.
2.
The community and/or its representatives both formal and informal leaders, should
be involved in the planning and organisation of the activities at all stages of the
programme. A village health committee will operationalise this further.
3.
The focus of the activitics/stratcgies should not just be on providing the community,
a package of services but actively cnabling/cmpowcring them to participate in
decision making that helps them to make health their own responsibility
4
The large number of human resources that arc available in any community must
be identified and mobilised to participate in the programme - this means not only
just people - but traditional birth attendants and folk health practitioners; leaders
of the panchayat; mahila mandals; youth groups; farmers clubs, school teachers,
opinion leaders, general practitioners and practitioners of other systems, of medicine
and so on
61
5.
When required or whenever feasible, volunteers from the community should be
trained as village level health guides or link workers to ensure that grass-roots
level activity is made possible.
6.
The Primary Health Care approach is a comprehensive approach and therefore
Malaria control programes should not become unipurposc or selective in their
orientation and whether it is the village committee, the health guide, or the strategy,
there should be scope and openness to use the same structures and resources for
other disease and health problems in the country.
7.
A major thrust of such a primary health care oriented programme will be the
approach of demystifying the problem at the community level, to build confidence
and perspective to tackle it at that level itself so that the health team works in
close partnership with the people and the programme becomes identified by the
people as their programme.
8.
The Primary Health Care approach also calls for a certain humility in the
health team about not always wanting to 'teach’ or tell the people something
but also a willingness to learn from local experience^ wisdom and health culture.
The people, when provided the right forum and context will often share ideas,
options, alternatives that the health teams should consider and new approaches
or alternatives can emerge if this learning from the people and working 'with
them’ rather than for them’ becomes a team commitment.
Finally we believe that the Primary' Health Care approach gets translated into alternatives for action
in strategies such as involvement of voluntary agencies and GPs;. training of village guides and
link workers; health education and awareness building activity; involvement of village leadership
and panchayatraj institution; involvement of alternative systems of health and their practitioners,
and so on. All these have been further explored in subsequent chapters.
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14. COMMUNITY CAPACITY BUILDING
Empowerment of the community is essential if malaria is to be effectively controlled.
To facilitate empowerment the community should be encouraged to participate in making decisions
relating to malaria at the community level. They should be encouraged to decide on the needs for
diagnostic and treatment facilities, referral pattern for cerebral malaria and vector control
They could be asked to suggest innovative ideas in controlling malaria based on their local experiences
To achieve both the above they must have access to accurate information. These relate to the number
and type of malaria cases, deaths due to malaria, the drug availability, type of vector and'thc pattern
of insecticide spraying needed and schedule of spraying.
Such an empowered community must also help in enhancing the accountability for the resources
used and activities carried out
To facilitate community capacity building the following activities are necessary:
14.1 Providing complete knowledge on malaria, its cause, spread, treatment and prevention.
This forms the basis of community participation and action.
14.2 Stressing the importance of early diagnosis and treatment. The community needs to
be aware of the early signs and symptoms of malaria especially that of the early warning
signs and onset of cerebral malaria.
14.3 Providing easily accessible treatment centres including knowledge of proven locally
available herbal treatments.
14.4 The community should be made aware of the various development projects, their impact
on the environment and malaria and ways the impact on malaria can be reduced.
14.5 The community should be encouraged to identify and select a volunteer who can be
trained on behalf of the community in appropriate areas of malaria as identified as the
role of such volunteers. This person could be on a purely honorary or voluntary capacity
without any payments or paid a regular honorarium by the community/panchayat based
on its ability or may be paid on a fee for service basis as accepted by the community.
In general the 'no pay’ model is the best, the work being done with a service motive.
The community may recognise such a person in any non monetary way as acceptable.
14.6 Link workers
The possibility of developing a totally different category of a person may also be
considered in some settings. This person may be from the community being served or
from outside. This worker may have a larger area and may visit a village only periodically
on a regular basis. This person may be trained in collecting blood and in exceptional
circumstances where microscope is available may even read slides and provide treatment
cither based on presumptive diagnosis or confirmed diagnosis according to pre determined
guidelines. (Sec Appendix F for further details).
14.7 Community Audit
This concept is gaining acceptance in the Government. Ultimately the community should
be able to assess the state and extent of the malaria problem in its area, document the
work carried out by the Government or NGO and the improvements or changes resulting
from such an intervention To play this role, the community needs appropriate training.
63
Case Study : Action 2
Tackling Malaria in Rural Gujarat (Jhagadia, 1995)
[SEWA - Rural is a voluntary agency that has provided health and development services extending
from the nucleus of a small rural hospital in Jhagadia. This case study highlights the key
features of the experience with malaria control ]
■
As an NGO we had taken over a PHC and done mainly surveillance and presumptive/radical
treatment of fever just as any other PHC is supposed to do.
■
After four years we realised we were getting nowhere and malaria prevalence was changing
inspite of our efforts; so we decided to look at feasibility and efficacy of introducing simple
vector control measures.
■
We took a study and control population and monitored fever cases (smears) round the year
and vector density (standard procedures) fortnightly.
■
Interventions included simple engineering measures, fish, kerosene and very rarely insecticide
(for one-time use to curb exceptionally heavy breeding sites).
■
Interventions and Monitoring were done by Male Multipurpose workers and supervisor after
due training and alongside routine ’PHC work’. The female health workers took on some
extra load (of other work) from the male workers.
■
We also took the community’s help, especially school children, informally.
■ Ongoing informal health education was given to people about mosquitoes and malaria.
Result:
■
Vector density never rose above critical in study area but almost always remained far above
critical in control area.
■ General confidence of health workers in other vector control measures rose.
■
People became more aware.
■ No adverse effects on excellent performance in other health fields (MCH-FP activities)
Next Step
Encouraged by vector control feasibility/efficacy, we are now introducing on condition of
community/panchayat participation, a mosquito control campaign in the area!
SEWA -Rural, Gujarat.
64
15. HEALTH EDUCATION IN MALARIA CONTROL
Creating awareness and building up a knowledge base amongst communities arc the commonly accepted
forerunners to the involvement of communities and building up their capabilities to act collectively
and individually towards a common goal. Although the need for the same clearly comes out of all
the NMEP documents and manuals, the commitment to this activity is not adequately visible in
terms of the time, manpower, efforts or budgets earmarked for the same.
Since more than eighty percent of the malaria budget accounts for the salaries of personnel involved,
and most of the rest gets spent on drugs and insecticides, no more than lip service is being paid to
the role of malaria specific health education.
15.1 It is suggested that:
—
------- ■
There must a quantum jump on the manpower, effort, time, resources
and budgets allocation for this purpose. The methods of IEC to be used
for target groups for various issues of malaria a^'areness can be seen
in Appendix G .
■
The most vulnerable and high risk groups for the present P.falciparum
epidemic are usually illiterate and have no access to radio or television.
In view of this, socially relevant and low cost alternatives addressing
these particular target groups should be used. Folk artists, itinerant
performers and street theatre artists can be used to pass correct and
specific messages to entertainment - starved rural communities. These
artists can be employed under various employment guarantee schemes
or tribal development plans.
■
Campaign mode of door to door and village to village malaria education
in the pre-malaria season - (instead of observing such a week for the
entire country in May, North East could have it in February, and some
in May, depending on the onset of rains in the area) - by the health
providers working closely in that particular community, stressing the
symptoms of malaria, of its complications and that the treatment for
the same exists with them should be done.
■
Posters and videos do have their role but cannot be allowed to overshadow
the forms of communication mentioned above because of the irrelevance
to the most vulnerable and deserving section of the community.
■
Teachers and school children need to be specifically targetedfor malaria
specific health education as the long term effects on their action potential
are the most beneficial and effective.
■
Paucity offunds cannot be cited as reason for a lack of emphasis on
the above and innovative methods .
65
■
NMEP and MRC have in recent years produced many useful booklets/
pamphlets, videos and other useful health education materials. These
are however used only within the NMEP system. There is urgent need
to make them available freely on a much more open basis to all groups
outside the government system who wish to be involved in awareness
building.
■
Communication centres within the Voluntary agencies may be encouraged
to use these materials, adapt them to local/regional needs, translate them
into the local vernacular and work on alternative approaches to
communicate the key messages and facts in other interactive, low cost
ways. Their own expertise in alternate forms of communication could
be tapped by NMEP/MRC as well.
66
Case Study - Action 3
Health Education for Malaria
(An experience in Rural Gujarat)
[The Trust for Reaching the Unreached (TRU) is a voluntary agency involved with health
and development services for marginalised rural communities in the Panchamahal areas and
the bastis of Gotri area in Vadodara City.]
When TRU started its work in the Shivrajpur area of Panchmahals, 70% of our OPDs in July to
October were cases of Malaria. Patients would pour in from interior villages walking, on bicycles,
or being carried on shoulders or in a doly. For the first two years, we responded to this by a
clinic based approach.
In 1992 we decided to train our health workers for intensive health education work in malaria.
The training covered all aspects of clinical diagnosis, treatment and prevention. By 1993, their
clinical skill to treat and diagnose Malaria was adequate.
Since July 1993, our programme consisted of intensive door to door education on how to recognise
the early symptoms’ and how to treat it effectively. The emphasis was on taking 10 tabs of chloroqum,
continued intake of food and not going to private practitioners for injection or for IV fluids. A
few leaflets were given out as aids to health workers for person to person health education. Public
programmes including role plays on malaria and a folk dance on malaria were added during the
period.
School children between 8-15 years were taught elaborately about malaria including rational
therapeutics. The children were our real messengers. They had a weekly class in health and
produced posters during the health camps. The school programme went on in 10 schools in the
area.
Results
1.
While it is too early to claim a reduction in the OPD cases, people in general are more
aware, report fever earlier, and do not accept the private practitioners’ arguments for injections.
2.
During the Malaria season, all the surrounding areas showed increased incidence of malaria
but the villages around Shivrajpur were happy with full chloroquin course.
- Trust for Reaching the Unreached, Baroda, Gujarat.
67
16, ROLE OF THE VOLUNTARY AGENCIES IN
MALARIA CONTROL
The role of NGOs especially the voluntary agencies (not for profit NGO’s) is being increasingly
recognised in planning and policy circles as an effective complementary / supplementary strategy.
In the past, they have played this role without much governmental support. In more recent years a
greater degree of collaborative effort is emerging as a policy alternative.
16.1 The Voluntary agencies (Volags) have their Strengths
a)
They are closer to the people and usually more aware of grass root realities
b)
They often work in more interior and inaccessible areas or in accessible areas
with more marginalised groups and the underprivileged.
c)
They tend to be idealistic and committed to certain values and principles.
d)
They are more flexible in their organisational structure and their professional
approaches.
e)
They often have a stronger development orientation and awareness building
commitment and skill.
16 2 The Voluntary agencies (Volags) have their Weaknesses as well
a)
They are very dispersed and individualistic and not woven into any integrated
network.
b)
They are often aloof from governmental programmes having their own programmes
and agenda.
c)
They arc very diverse in their size, type, ideology, focus, distribution, linkages
and professional competence.
d)
They are inadequately informed about governmental programmes and initiatives
and often lack adequate professional expertise being stronger in spirit rather than
in skills.
e)
They often follow fund driven/donor driven agendas
0
They arc also not often present in areas where they are needed most.
Notwithstanding these shortcomings, it is a very important development that the
opportunities of government - non governmental collaboration arc being increasingly
promoted in recent years though involvement in malaria care is still not significant.
16.3 Concerns
a)
As a group, we were concerned that inspite of well organised network of voluntary
agencies and an increasing commitment of this constantly enlarging sector, to
alternative service provisions, alternative training strategies and alternative research
approaches and health communications and awareness building strategies, the actual
collaborative possibilities between the two sector has been so inadequately
68
mobilised
b)
Inspitc of competent coordinating agencies at National and now at state and regional
levels this involvement and collaboration has been a policy thrust but not a policy
reality.
c)
The government or the programme authorities still try to look at the Voluntary
agencies as primarily alternative service providers and often disregard their skills
in research, training, communication and mobilization.
d)
The large, rich network of Voluntary sector health communication efforts including
journals, bulletin, newsletters have not been adequately harnessed to spread the
key messages and strategies of Malaria Control and thereby enhance the involvement
of this sector.
16.4 The Voluntary agencies can play the following roles in Malaria Control:
a)
Diagnosis
Volags with health programme and having a laboratory facility can contribute to
lab diagnosis. When reliable centres are identified the reports of such centres
may be used for treatment and surveillance.
Volags who do not have a laboratory technician may have one or two trained as
smear technician on collecting blood samples correctly and where personnel
with capability and microscope is available some may be trained as microscopists
to identify malaria parasites.
b)
Treatment of Cases
Volags with or without a health programme can facilitate treatment both in
presumptive and confirmed cases and in radical treatment. However, clear guidelines
must be given to Volags and appropriate training must be provided to atleast two
or three personnel from each Volag.
c)
IEC
It is probably better to change this terminology from IEC to Education for Health.
IEC appears more to be passive transfer of information. Education for Health
requires certain additional steps to bring about individual and community action
- going beyond information transfer. If clearly acceptable and accurate messages
arc made available to Volags many of them can motivate the community to accept
or adopt changes in lifestyles or behaviour that is more health oriented.
d)
Vector Control
While volag personnel and volunteers cannot carry out vector control measures
according to present policies volag can participate in the following measures.
Volags can take up anti-larval measures including keeping surroundings clean
(without long term accumulation of water) and use of larvicides.
Volags can promote bio environmental measures such as use of larvicidal
fishes.
Educating farmers on methods that present growth of mosquito larvae
69
Motivate people to accept anti-vector spraying when done by trained personnel
and to allow proper spraying of indoors with adequate precautions
Work in coordination with the NMEP spraying teams in facilitating effective
spraying as it differs from place to place and habits of the vector.
[It may be appropriate to simplify technology and provide entomological information so that in
areas where there arc limited Government personnel, Volags can do the spraying after adequate
training]
16.5 Suggestions
To operationalise a healthy collaboration between NMEP and Volags the following steps
should be initiated as soon as possible.
■
The Central and State governments should involve the Volags in the
planning, implementation and evaluation of the Malaria Control
Programme. They should not be treated as mere adhoc agencies to be
used during epidemics, when government set up has failed to achieve
the desired results.
■
Malaria Advisory Boards/Committees should be constituted at the
National/State and District levels with adequate representation of Volags.
The entire Malaria Policy and Strategies for control need to be looked
into and implementation reviewed at regular periodical intervals.
■
Health Education should be an important component for effective delivery
of Malaria Control Programme. The conventional manner of conducting
health education would not be suitable particularly in the tribal areas.
Health education should be based on socio-economic and behavioural
attitudes of the local community.
■
Volags have close liaison with the local people. Essentially, malaria
is a disease of human behaviour. The human behaviour has to be changed
against malaria transmission. This ranges from source reduction, timely
seeking of medical advice and undertaking self protection measures.
Health education with appropriate messages would be of considerable
value and Volags effort would be particularly suitable in this area.
■
The groups working in the field of health and development should be
given training in (i) Surveillance offever cases and reporting of unusual
occurrence of fever cases to the local health authority for prevention
and management of outbreaks, (ii) diagnostic skills - clinical and
microscopic diagnosis of malaria (Hi) rational treatment-presumptive
as well as radical (iv) health education and public awareness (v)
integrated mosquito vector control.
70
■
Volags should be actively involved in public awareness campaigns before
the start of malaria transmission periods.
■
The pattern of involvement of Volags in the NMEP should be on the
pattern of National AIDS Control Programme where certain percentage
of the budget is earmarkedfor implementation of the programme through
Hplags and private sector. The technical capabilities of these new partner
groups should be developed through suitable trainings so that they can
play an effective role.
■
All these efforts could be coordinated at National and State and even
regional levels by utilising and promoting the involvement of the
coordinating/networking agencies of the Voluntary agencies like VHAI
(Voluntary Health Association of India), CMAI (Christian Medical
Association of India), CHAI (The Catholic Health Association of India),
MFC (Medico Friend Circle) and their state and regional units rather
than dealing with specific individual Volags in an adhoc fashion. These
networking agencies can enhance collective action which is crucialfor
the programme.
■
In the context of Malaria Programme ’ since there is such a diversity of
complementary activities that could become part of Volag initiatives it is
necessary to ensure that the contact/ coordination/involvement is not confined
only to the Health oriented' projects/organisations of this sector but also
the larger components ofdevelopmental organisations, environmental groups,
womens organisations, trade unions and communication/media groups. Flach
component of this sector could identify its special supportive/ complementary
role. (See Appendix Ifor further details).
71
17. CAPACITY BUILDING OF VOLUNTARY AGENCIES
Flexibility availability and facilitating community participation have been some of the acknowledged
strengths of Volags, that have made them useful partners in intervention and development programmes
If the capacity of Volags are developed in the area of malaria control then they can be effective
partners in keeping this disease under control. The following are some of the areas of capacity
building:
1.
Developing Volag Resource Centres
Since many Volags operate in isolated areas selected Volags with commitment to the
malaria control programme may be identified and developed as resource centres. Roughly
it may be one Volags Resource Centre for each district. These centres will have trained
human resources, (malariologist, smear technician, microscopists, health educator,
diagnostic equipment, treatment facilities and training infrastructure to train other
personnel primarily of Volags and where necessary and feasible of Government personnel
also. Existing laboratories in Volag Centres may also be strengthened. Diagnostic
materials and drugs may be provided by the Government to such Volag Resource Centres.
2.
Capacity Building for Enhancing Community Awareness, Action and Involvement
Volags may be provided with correct messages on malaria to be passed on to the
community. In addition they may be provided educational and IEC materials for
community education. They arc usually adept at enhancing community participation
and action. Where these skills/orientation are required the large network of community
health trainers who are experts in this may be tapped to facilitate these skills among
field based Volags.
a)
Personal Protection Measures
Volags may be provided with complete information relating to personal protection
so that they can incorporate these as part of the intervention strategics in the
community.
b)
Vector Control
While spraying is primarily a task of the NMEP personnel in selected regions,
for some areas it may be useful to build the capacity of Volags to cany' out spraying
insecticides according to guidelines and criteria procedures laid down by the
Government. In addition they may be trained fully on biological methods of vector
control including anti larval measures.
However, in most situations Volags should be trained that they have access to
the Government spray team according to defined needs.
c)
Volag Cell at NMEP
Since according to the present malaria control policy there arc definite roles defined
for Government personnel and Volag personnel it would be useful if there is a
Volag Cell at NMEP both in Delhi and at the State Headquarters Having such
a cell would facilitate better interaction with Volags and give them a forum or
channel within the Government through which they can work better in malaria
control. Tins NGO cell should work in close coordinator with National networking
72
agencies of the voluntary health sector like VHAI, CHAI, CMAI and their regional
and or State level units. (See 16.5)
d)
Funding for Volag Capacity Building
At the grassroot and the community based intervention level training costs may
be incorporated into the regular NMEP budget and even state health budgets for
training. Select Volag personnel from Resource Centres may have funds provided
through bilateral and international funding available to the Government. This
could be for both select short term training programmes as well as for participating
in workshops, meetings and other opportunities for south-south and south-north
dialogue.
Case Study : Action 4
Preventing Malaria in a Rajasthan Taluka - Lunkaransar, 1995
[The Uttari Rajasthan Milk Union Limited (URMUL) Trust is a farmers cooperative that
organises an integrated rural development programme with health care being an important
component of the diverse development package. They were actively involved during the malaria
epidemics in their area of operation in recent years and tried to evolve strategies to keep
their villages free of malaria deaths.]
Aim to keep our villages free of deaths from Malaria .
Our limitations
1.
One lab technician for our 30000 population scattered over 2500 kms. and also doubling
as Health Coordinator.
2.
3 PHCs and 1 CHC as referral support and numerous RMPs and quacks - none of them
under our control.
3.
No data for 1994 but government data put API below 2 everywhere so no spraying could
be done.
4.
Literacy levels of women <5% and males below 20%.
Our Strategy
a)
Drug Distribution Centres with teachers who were trained for the purpose.
b)
Chloroquin taken from government and replacement made every month.
c)
Modified Fever Treatment Depots with our own workers.
d)
Presenting our findings on fortnightly basis to CHC, CM & HO, Dy. CM & HO- Malaria,
District Collector and Divisional Commissioner to galvanise action on behalf of district
authorities.
e)
Posters procured from government and pasted all over.
f)
Pamphlets in Hindi for all educated people and RMPs and quacks.
g)
Street theatre and puppet shows by our communication team in each village.
h)
Placing slides with RMPs etc., to help in monitor patients.
i)
Introduced larvivorous fishes in own campus to help staff gain confidence in method
and effect.
J)
Holding and referral facilities for the serious at our headquarters centre.
Results: Succeeded in our pledge to prevent malaria deaths.
- URMUL TRUST, Rajasthan.
73
18. ROLE OF PRIVATE PRACTITIONERS IN
MALARIA CONTROL
The National estimates of the percentage of health care provided by private practitioners in rural
and urban areas vary greatly from different source but overall estimates conclude that nearly
2/3rds of the health care provided to the people are by this sector. Private practitioners include
those trained in medical colleges in the allopathic tradition ( MDBS), those registered as medical
practitioners (the RMPs) from different backgrounds, and those trained formally and informally in
other systems of medicine which include seven alternatives in the Indian context - Ayurveda, Siddha,
Unani, Naturopathy, Homeopathy, Yoga, Tibetan Medicine. They are most often the providers of
first contact care especially when home remedies and folk health practices have not been effective.
The total guestimates range between 4-5 lakh practitioners who would fall into this category atleast
(probably an under estimate!). In the context of Malaria - they are the first group to be consulted
at the onset of the febrile episodes and their involvement in Malaria control becomes crucial. It is
surprising however that NMEP has not had adequate clarity and policy focus on the involvement
of this sector in an active way.
18.1 Issues of concerns
It is a matter of great concern that in the absence of a planned dissemination of relevant
information and update on rational malaria diagnosis and treatment including rational
regimes utilising the generics/specifics available in the Indian market, the role of the
Private practitioner community in malaria control is rather dubious and marked by
increasing commercialization and unethical prescribing trends.
Some aspects of this trend are:
1.
a use of a wider diversity of irrational regimes and combinations often at high
cost to the patient and totally at variance with the NMEP guidelines
2.
a tendency to exploit the illness episodes by the use of injectable preparations
and other adjuncts not in consonance with the principles of rational malaria care.
3.
a tendency to see the ’outbreak’ or ’epidemic’ as an opportunity for gain rather
than as an opportunity to be actively involved in a national health programme
and national efforts to tackle a major public health programme.
4.
These trends arc further complicated by an increasing fall in clinical diagnostic
standards and inadequate recourse to lab diagnostic facilities. The clinical
laboratories also have been showing a lack of quality and standardization even
when they arc available and utilized.
5.
Further some degree of medical misinformation by medical representatives pushing
their company’s remedy against the other to enhance profit margins even when
low-cost generics arc available is a growing problem.
6.
The obvious result of such continued, irrational medical practice is reflected in
the increasing problem of drug resistance, as well as the continuation of unnecessary
and avoidable suffering.
74
I
18.2 SUGGESTIONS FOR ACTION
■
The GPs, RMP, other unregistered practitioners are to be considered
part of the Malaria Control Programmes and therefore to be educated
about the aims, objectives andfunctioning of the NMEP and to be oriented
accordingly.
■
They should be made to feel their responsibility towards country's malaria
control and the people.
■
CME programmes should be organised involving IMAs, medical Colleges
and other professional organisations using uniform “Module " with minor
regional variations wherever needed.
■
Malaria treatment guidelines and other aspects of malaria may be
communicated through publications in professional journals, bulletins
newsletters, and/or distributed through small booklets, pamphlets and
handouts.
75
>
19. DISTRICT PLANNING / DECENTRALIZATION
There is a growing realization that the regional disparities/difiercnces are so wide and the
development process including health service development so diverse that planning at regional
level and at district level particularly is not only necessary but also relevant.
The understanding of Malaria as a focal disease with its own peculiar socio-epidcmiological
characteristics adds a new urgency to more decentralised district level planning.
The whole renewed development and emphasis of the Panchayatiraj concept and structure
also emphasises the urgent need and opportunity for this.
Finally the concept of involving the grassroots community in the planning process now considered
to be more relevant, favours this shift as well.
To support this shift of emphasis, we suggest the following action:
■
The urgent development of capacities and capabilities to undertake district
planning.
■
The urgent training/orientation of Health Centre staff particularly MOs
in the ability to make local plans based on local data and to involve
the panchayat/community in the planning process.
■
The urgent training/orientation of emerging panchayat leadership to
participate meaningfully in the health planning process.
■
Community level Malaria plans could be a short term goal to support
the long term goal of district plans.
76
r
Malaria
A Socio - Epidemiologial
Perspective
. Ra’
arayan. Community Health Cell
Alternative malaria
control strategy
REPORT
■ Towards an
Appropriate
Malaria Control
Strategy
WHAT
■ Reflections /
Recommendations
WHO
■ An Expert Group
(6) and a
Reference Group
(44) from the
Voluntary / NGO
sector.
■ WHEN
. Ra
arayan. Community Health Cell
■ Apr. ‘96 - Jan.’97.
Appropriate Malaria
Control Strategy (contd.)
■ WHY
■ To provide an :
/ Alternative,
z Community
oriented
/ Socially relevant
perspective.
HOW
■ Interactive &
Participatory
Individual
contributions
. Ra
arayan. Community Health Cell
Group reflections
Identification of
Key issues and
ideas through
meetings
HEALTH FOR ALL
Indian Council Of Social Sciences Research &
Indian Council Of Medical Research. (1981)
j
. Ra'
L
■ Reduce:
j poverty,
z inequality and
z spread education
■ Organise poor and
underprivileged to:
j fight for their basic rights
■ Move away from :
■/ Counter-productive and
z Consumerist
Western Model of Health
Care
■ Replace with
/ Alternative based in the
arayan, Community I IcG©GQITIU 0 Ity.
LESSONS FORM
HISTORY
■ Sustained Public Health
Action
■ Diversity of Approaches
■Political and ‘health’
leadership synergy
■ Local solutions for local
realities
■ Economic advantage of
programmes
Rav Narayan, Community Health Cell
THE NEED FOR
SOCIO-EPIDEMIOLOGY
■ Studying the COMMUNITY at
risk & SOCIETAL CONTEXT
- not only the Agent / Vector /
Environment.
From - TECHNO- MANAGERIAL
problem analysis and assessment
■ To - SOCIO-CULTURALPOLITICAL BEHAVIOURAL
issues.
. Ra
arayan, Community Health Cell
REDISCOVERING THE
‘COMMUNITY’ IN
MALARIA CONTROL
■ Enhancing Community Participation,
Capacity and Health Education
Z by involving :
w Panchayat
mr Local Community Organisations
i-r Voluntary Sector Projects
i-r Private practitioners
nr ISM’s and Folk Healing traditions
nr Folk & local media
»-r School based programmes
nr Creative , interactive - culture sensitive
approaches
. Ra1
arayan, Community Health Cell
EXPLORING NEW
CHALLENGES IN
RESEARCH AND ACTION
■ Improvement of M.LS to tackle
=> Under reporting
=> Underestimation
■ Re-establishing Bioenvironmental control
■ Study / Assessment of ISM’s
for Malaria Care
■ Enhancing Decentralised
Planning & Action Capacity
. Ra
arayan. Community Health Cell
COMPLEMENTARY ROLE
OF THE
DIALOGUE BETWEEN
NMEPIMRCWCRMD
&VOLUNTARYSECTOR
AT RATIONAUSTATBREGIONAL LEVELS
irt
I
5
f^‘ii^-if-r;}
Disseminate of Guidelines / experiences VOLUNTARYSECTOR-nEIW itelf
ofNMEPWCRCICD
partial ii
protasWcfefttt.
t
o
VOLUNTARYSECTOR
if
tairtHFMIHOJIaodotewfali®.
<
:
■■'
I/
.
Y.
<
,
■
■
■
<
■
Wi11WrfWrt3 \ iCwh“MHkn
. Ra'
arayan, Community Health Cell
COMPLEMENTARY ROLE
FOR THE
■ INVOLVEMENT IN MALARIA
CONTROL(FOCUSSING ON VOLUNTARY SECTOR
strengths')
Creative Health Communication
o Mobilise / involve human resources
at community level
Comunity health orientation - at all
levels
< Orientation and involvement of
Panchayat leadership
o Dialogue with ISM and Folk healers
< Invlovement / cme of GP’s at all
levels
. Ra
arayan, Community Health Cell
COMPLEMENTARY ROLE
OF THE
VOLUNTARY SECTOR-III
■ FACILITATING AND
WATCHDOG ROLE
o Enhance Social-political-culturaleconomic context analysis in
Malaria policy.
o Rational therapeutics / Rational drug
policy in Malaria
o Monitoring “Market Economy”
distortions at various levels evolving counter strategies.
o lobbying for a more decentralised
community health policy
. Ra'
arayan. Community Health Cell
REURCENCE OF MALARIA IN INDIA
- Issues of Concern and Alternatives for Action*
The resurgence of Malaria, especially in the last decade has become a matter of serious
concern for health professionals, policy makers and planners. The epidemics in Andhra
Pradesh, Manipur, Nagaland, Rajasthan and West Bengal in 1994 and in Assam, Maharashtra
and West Bengal in 1995 and again in West Bengal and North East in 1996/97 has been
characterised by high morbidity and mortality and increasing evidence of the spread of
plasmodium falciparum infection around the country.
As chairperson of an Expert group on Malaria, convened by the Voluntary Health Association
of India, New Delhi, I had the unique experience of working with 5 other experts and 44
reference group participants in participatory interactive process, that made an independent
assessment of the Malaria situation in the country and identified issues of concern and
alternatives for action. The review was conducted from April 1996 till January 1997 and
after a dialogue on the draft report with National Malaria Eradication Programme, Malaria
Research Centre and Vector Control Research Centre experts and representatives of
VHAI/CHAI/CMAI/WHO/ and others was published in May 1997 (1).
The group went beyond the classical Public health approach, that is dominated by a
biomedical perspective and studied causes for the resurgence that go beyond the usual drug
resitance and parasite resistance paradigms. While these are major problems, a broader socioepidemiological analysis highlighted a larger number of crucial issues which taken together
represent a breakdown of the public health system in the country and an increasing resistance
in the health care system to rational and sustained programmes of malaria control.
A few of the important issues of increasing concern are highlighted here.
i.
The first concern is the near absence of a reliable surveillance system, plagued by
shortage of laboratory technicians at the primary health centre level and male
multipurpose health workers at the field level - who between them constitute the
surveillance team at the grassroots. Not surprisingly, the NMEP / MRCs estimates
through indirect evidence has shown that the actual numbers of malaria cases is closer to
30 million, rather than the 2 million cases presently reported through the existing MIS.
Such a gross underestimate has crucial policy implications.
ii. The second concern is the continuing irrational management of suspected malaria cases
by general practitioners and specialists in the country. A combination of ignorance,
misinformation and textbook guidelines that have emanated in very different
epidemiological situations ensures that suspected malaria cases gets a plethore of
irrational injections, antibiotics and antipyretias to begin with and the NMEP’s guidelines
on Drug Policy on Antimalarials is totally disregarded . There is a tendency to exaggerate
*
Dr. Ravi Narayan,
Coordinator / Secretary,
Community Health Cell,
Society for Community Health Awareness Research and Action,
Bangalore - 560 034, Karnataka.
*
the prevelance of chloroquin resistance and mefloquin is promoted as the new wonder
drug and used often as the first line of treatment. Studies have recently been presented at
a National Seminar on communicable diseases organised in February 1997 at Bangalore,
highlighting the role of chloroquin in inhibiting hoem dependence protein synthesis in the
parasite, the implication of which is that increasing the dosage of chloroquin ( a cheap,
effective and adequately available remedy) would probably overcome the resistance
problem in most cases rather than taking recourse to a costly alternative. The dangers of
misuse and overuse of mefloquin need to be critically assessed. Apart from the severe
toxic effects including neurotoxicity, it does not act on gametocytes and hypocotes; action
on parasite is slower; has to be imported; cross resistance with quinine is known; is
contraindicated in mothers who are breastfeeding their children. In the Indian situation, it
is also not easy to comply with the condition that compulsory laboratory report by
qualified parasitologists are required before it can be prescribed.
iii. The third concern is that while personal protection measures are important in the short
term, the most sustainable long term approaches are integrated bio environmental
methods. More recently, however, there is a concerted and well orchestictical efforts by
international public health organisations and consultants to socially market insecticide
treated mosquito nets (ITMNs) as the magic bullet and this will divert funds and attention
to a top down vertical, distribution and marketing programmes which will not be
sustainable. An IDRC/WHO publication has already cautioned that ITMNs may not be
easy to implement and sustain on a large scale in routine health interventions and this
advise needs to be heeded.
iv. The fourth concern was ‘malariogenic’ development strategies that result from inadequate
environmental impact assessment. The most recent example of this has been the
epidemics in Rajasthan. The review of causative factors have included the swepages and
other effects of the Indira Gandhi canal that was built and not subjected to any form of
health impact assessment. ‘Agricultural development’ and ‘migrant labourers’ are other
components of development strategies that need to be closely reviewed.
V.
The fifth concern was a hast of interrelated issues that are not specific only to malaria but
are symbolic of a disintegrating public health system - a phenomena that is reaching crisis
proportions.
These include
=> a loss of public health skill and competence at all levels of the health care system
=> theacute and increasing shortage of health human power especially at the peripheral
health centres;
=> the inadequate involvement of voluntary agencies, general practitioners and
practitioners of all the sytems of medicine in the country in control strategies;
=> the increasing corruption and political interference in health care decision making
affecting all aspects of health care and all levels of national programmes;
=> the decrease in health budgets and health care expenditure and investments;
=> the confused dialectics of centre-state responsibility in health care;
=> the inadequate development and or use of forecasting and monitoring systems to
strengthen responses to epidemic and increase epidemic preparedness;
=> the increasing subservience of nationally derived strategies and programmes to the
priorities and imposed guidelines set by international funding agencies and
international consultants with little knowledge of the region and agendas and
perspectives that do not support local expertise.
The ‘Public Health crises’ symbolised by the above is probably the most significant
contributer to the re-emergence of the disease.
The Expert Group’s review included areas such as socio-epidemiology of malaria; rational
malaria control; malaria and primary health care; and policy issues in malaria control. It also
attempted to evolve a complementary strategy in malaria control that would involve general
practitioners and practitioners of all systems of medicine and all the voluntary sector projects
in a more comprehensive and interactive strategy. This would involve:
1. Promote an active dialogue between the Voluntary agencies and NMEP to identify a
special complementary role for the sector in the Malaria Control programme.
2. Promote an active dissemination of ideas and experiences and guidelines of NMEP /
MRC to the voluntary agencies through publication and CME updates.
3. Organise informal meetings of Volag network all over the country but perhaps to begin
with focussing on the North East, the States of Gujarat, Maharashtra, Rajasthan, Bihar,
Madhya Pradesh, Uttar Pradesh and Orissa and the 15 cities / towns which have been
designated as problem areas - to mobilise the voluntary agencies and involve them in
malaria control activities.
4. While the voluntary agencies members could be involved in all aspects of the programme,
initiatives should be focussed on those aspects on which the voluntary agencies has
something concrete to offer:
i. Creative health comunication strategies
ii. Mobilization / utilization of human resources and groups at community level
iii. Dialogue with ISMs and Alternative Systems of Medicines
iv. Rational therapeutics and Rational Drug Policy in Malaria
v. Community Health oriented training of health staff at all levels
vi. Orientation and reorientation of Panchayat leadership
vii. Orientation and involvement of Teachers and children through school based
programmes, child to child and other approaches.
5. Finally - while playing a complementary/supplementary role at the field level to enhance
the action response of the voluntary agencies, VHAI through its MEG and other resource
associates should play an active facilitating and watchdog role to
i.
Enhance socio-political-economic-cultural context analysis in Malaria Policy
ii. Monitor the Market economy distortions at various levels and evolve counter
strategies
iii. Enhance the role of the voluntary agencies as issue raisers, awareness builders and
lobby for a more community oriented empowering malaria strategy integrated with a
decentralised, community oriented health policy.
If the Voluntary Agencies through its efforts can bring back the
people/community back to the core of the Malaria strategy as full active
participants and not as passive beneficiariest we would have made a significant
contribution toi the programme.
Bringing back the community into the Malaria Programme let that be our strategy - let that be
our slogan.
References:
1.
VHAI/SOCHARA Towards an appropriate malaria control strategy : Issues of concern and alternatives for
action, New Delhi, Voluntary Health Association of India, 1997.
2.
National drug policy on antimalarials (Chairman : Director General of Health Services), New Delhi:
National Malaria Eradication Programme, Directorate General of Health Services, May 1993.
3.
Padmanabhan G. Newer drug targets in the malarial parasite. ImAbstracts of the third national seminar on
malaria and other tropical diseases. University Grants Commission/Bangalore University/Society of
Applied Genetics, 1997.
4.
Lengeler C. Cattani J. Savigny Don de.
IDRC/World Health Organization, 1996.
5.
Bradley D, Narayan R. Epidemiological patterns associated with agricultural activities in the tropics with
special reference to vector borne diseases. Effects/Agricultural Development on Vector Borne Diseases.
Food and Agricultural Organization Monograph, AGL.MISC/12/87.
6.
Pai M. Zachariah A. Rose W. Satyajit S. Verghese S. Joseph A. Malaria and migrant labourers - Socioepidemiological inquiry. Economic and Political Weekly 1997; XXXII (16), 19 Apr.
7.
Narayan, R. Resurgence of Malaria, Editorial, The National Medical Journal of India, Vol. 10, No.4 1997, p
157-158.
Net gain:A new method for preventing malaria deaths,
7 o r>
COMMUNITY HEALTH CEIL
367. "Srinivasa Nilaya"
Jakkaaandra I Main.
I 81 Oik, Koramanqala,
BANGALORE 034
Report of informal meeting of the Malaria SRAG (Study Reflection Action Group)
held at CHC on 27th October 1997
The meeting commenced with self-introduction, and Dr. Ravi Narayan (co-ordinator of
CHC) welcomed the group and appreciated the increasing involvement of more and more
members and organisations. A total of 13 participants from Govt, and NGOs participated
(Appendix A).
Dr. Ravi Narayan started the discussions by explaining the many activities and initiatives
that were conducted during 1997, especially during the Malaria month and their follow
up, and asked the individual members to present their informal reports.
1) Dr.S.K. Ghosh from MRC. briefly presented the report of MRC and certain
additional information was given by Dr. Sathyanarayana. During the Malaria month
in June 1997, messages about Malaria were propagated at all levels including District
and Panchayat level. Messages included information about other mosquito borne
diseases especially Dengue fever (outbreak in Delhi) and Japanese Encephalitis and
try ing of artificial collection of water.
He also mentioned about organising Health Camps (inaugurated by Dr.
Murugendrappa, Jt. Dir - Malaria and Filaria, Govt, of Karnataka) where stress was
laid on Bio-environmental methods to control malaria. He re-emphasised that use of
insecticides were very costly and invariably resistance developed within 10 years. He
also reiterated that if Govt, of Karnataka had stuck to their initial plan of bioenvironmental control throughout (rather than introduce DDT), malaria would not be
at the present situation. He briefed in detail about the success of larvivorous fish and
explained that they were small (11/2” - 2” size), viviparous, prolific breeders, breed
3-4 times in a year, hardy and thrive in dirty, polluted waters also. Their studies in
Kolar and Hassan districts were very’ successful and have been reported in the press
also. Their studies were presented at the National Conference on Malaria at
Bangalore as well as International Malaria Conference (Ronald Ross Centenary) at
Hyderabad.
He also explained that when ponds which had dried up were again filled with water,
simply transferring a few fish from another nearby pond was enough to reseed the
pond. He also elaborated on the success of EPS beads. (Polystyrene beads or
thermocol balls) in unused wells (more than 10,000 in Bangalore itself). These
functioned as larvae asphyxiants and whenever the wells are required to be used, the
beads just require to be removed.
Dr. Ghosh also spoke about the limited success of IBN (Impregnated Bed Nets) in
Hassan District trials and preferred larval control.
chc/msword/c:/malar/cmainmep.doc
. . x . .
Several workshops on Malaria were conducted. 3 health camps in 3 villages were
conducted in which more than 100 health workers attended and evinced keen interest
in the camps. Two health camps were also organised in different schools including
Air Force School and Kendriya Vidyalaya. A special camp was organised at KIMS
(Kempegowda Institute of Medical Sciences) in which about 40 undergraduate
medical students participated.
Health camps organised at Panchayats and in a city slum were well attended and the
participants actively involved themselves in the camps.
Dr. Ghosh also spoke of the encouragement received in use of Neem plants
(Repellant and larvicide) and stated that they had collected them form the Forestry
Department and distributed almost 40,000 plants to people in rural areas. (Detailed
report by MRC attached).
2) Dr. Sukhant Singh from CMAI briefly touched on the CMAI activities which
function through their network of institutions and members. He stated that a special
desk for Infectious Diseases has been set up with major emphasis on Malaria and TB.
He briefly spoke of the proposed involvement of CMAI with NMEP in a World Bank
aided Project for three years, starting in April 1996 in the States of Orissa, Bihar,
Madhya Pradesh and North-East. Since private practitioners (Pps) are handling more
than 90% of fever cases, the aim is to hold training workshops (3 days for NGO
doctors and 1 day for Pps) on rational treatment of malaria, early diagnosis and
treatment of complications. A pilot project is planned in Ranchi to train PPs/NGOs.
3) Ms. Neerajakshi from VHAK stated that they also functioned through a network of
institutions and members. A special Newsletter on Malaria was issued during
Malaria month. She also stated that a special section on Malaria has been included in
all the Training programmes, organised by VHAK. VHAK is also planning training
programmes on Malaria for NGOs/private practitioners at the request of VHAI, New
Delhi. She handed over two pamphlets in Kannada on Malaria which had already
been widely distributed.
4) Dr. Ravi Kumar, Chief Medical Officer, Regional Office for Health and Family
Welfare then reviewed some of the activities during the Malaria month. He was
happy that Zilla and Gram Panchayats took a lot of interest in the Malaria education
campaigns. A booklet on Malaria for school children was brought out and proved
very popular. The same was now being used by health workers as a flip chart.
Another booklet by NMEP - “Malaria Control - An Attempt” translated into Kannada
was also distributed (copies of the booklets will be sent to CHC for distribution). He
spoke about the poor response from IMA, Bangalore regarding a CME on Rational
Drug Policy for Private practitioners, but however said that another attempt would be
made to contact IMA, especially for a CME on Malaria treatment. He expressed
chc/msword/c:/malar/cmainmep.doc
. ♦
3 . .
happiness about the overall fall in incidence of Malaria in Karnataka but expressed
concern about the recent outbreaks in Bellary city (where > 12,000 cases were
reported recently).
5) Mr. Murali from CHAI-KA stated that he had recently joined the organisation and
was now involved in the modalities of de-centralisation of activities from CHAI
headquarters. He volunteered his organisation’s help through Bellaiy diocese, to
help in the recent outbreak of Malaria in Bellary.
6) Dr. Krishnan, from Institute of Aerospace Medicine, Indian Air Force,
Bangalore remarked about the alarming epidemic of falciparum Malaria in Calcutta
city and emphasised the importance of controlling Malaria in Bangalore city. He
elaborated a little on the observance of dry day being followed in the Armed Forces.
He also volunteered his services to the different NGOs (as he was free in the
afternoons), especially in view of liis experience in tackling Malaria in the North-
East.
7) Dr. Ravi Narayan of CHC then summarised the various activities of CHC regarding
Malaria. He displayed the Report of the MEG group titled “Towards an appropriate
Malaria Control Strategy” and also the final report of ‘Reflections of Malaria in
India’ which would be brought out shortly. He also spoke about the new joint venture
by CMAI, VHAI and CHAI for training of NGOs and General Practitioners with Dr.
Sukhant Singh, Dr. Sehgal and Dr. Mani as potential nodal trainers.
He spoke about a number of journals bringing out special issues on Malaria (some
with extracts from the MEG report) and also circulated an editorial in the National
Medical Journal of India.
He expressed his satisfaction that even in the Ross Centenary meetings at Hyderabad^
the emphasis on bio-environmental control over chemical control was significant.
The meeting ended with the decision that the next meeting would be held at CMAI (HVS
Court, III Floor, 21, Cunningham Road, Bangalore - 560 052) on 13th November, 1997
(11 am to 1 pm) to review the Training modules on Malaria (by NMEP) and evolve the
content of the 3-day training for NGOs and 1-day training for GPs for the CMAI-NMEP
training programme (see 2). It was also decided to assist VHAK in the planning of the
Karnataka training plan requested by VHAL
chc/msword/c:/malar/cmainmep.doc
, . 4* •
APPENDIX - A
List of participants who attended SRAG meeting on 27th October 1997
1. Mr. Murali,
CHAI - KA,
St.Martha’s Hospital,
Nrupathunga Road,
Bangalore ■ 560 009.
7. Mr. David,
CHAI - KA,
St.Martha’s Hospital,
Nrupathunga Road,
__ Bangalore - 560 009.
2. Dr. S.K. Ghosh,
Malaria Research Centre,
Field Station,
Epidemic Disease Hospital Campus,
Old Madras Road,
Bangalore - 560 036.____________
8. Dr. T.S. Sathyanarayan,
Malaria Research Centre,
Field Station,
Epidemic Disease Hospital Campus,
Old Madras Road,
__ Bangalore ■ 560 036._____________
3. Mr. N. Ananda,
Voluntary Health Association of
Karnataka,
Rajini Nilaya, No. 18,
Mutt Road Cross, Ulsoor,
Bangalore - 560 008.
9. Ms. T. Neerajakshi,
Voluntary Health Association of
Karnataka,
Rajini Nilaya, No. 18,
Mutt Road Cross, Ulsoor,
Bangalore - 560 008.
4. Wg.Cdr.Dr. S.K. Krishnan,
Institute of Aerospace Medicine,
Airport Road,
Bangalore - 560 017.
10. Dr. Ravi Kumar,
Chief Medical Officer,
Regional Office for Health & Family
Welfare,
II Floor ‘F’ Wing,
Kendriya Sadan, Koramangala,
Bangalore - 560 034.
5. Dr. C.M. Francis,
Community Health Cell
Bangalore.
11. Dr. Ravi Narayan,
Community Health Cell,
Bangalore.
6. Dr. Rajan,
Community Health Cell,
Bangalore.
12. A participant from
APD- Bangalore
13. Dr. Sukant Singh,
__ CMAI, Bangalore.
chc/msword/c:/malar/cmainmep.doc
»
EVOLVING A COURSE CONTENTS FOR
THE TRAINING OF G.Ps AND NGOs ON MALARIA.
■
■
1
.
■ I
AGENDA
V'l
Modorator
Dr. C.M. Francis
1.
Welcome and in troduction of invitees and the subject matter
2.
Course contents for 1 day programme for G.P.s on “Early diagnosis, treatment
of Malaria and management of its complications.11
3.
Course contents for 2 day programme for G.Ps and NGOs on “Prevention and
control of Malaria”..
4.
Specific suggestions from the participants on the training of Gps & NGOs.
■
■'(
zr
5.
Any other business.
J
«i
A
il
Malaria in India
Reflections, responses and the quest for
alternatives
Editors
Madhukar Pai
Ravi Narayan
C M Francis
Society for Community Health Awareness, Research and
Action, Bangalore
J
1
CONTENTS
SI.
No.
Title
Author
1.
Foreword
Madhukar Pai, Ravi
Narayan & C.M. Francis
2.
Resurgence of Malaria In India
Ravi Narayan
3.
History of malaria and malaria control in India
P.N. Sehgal
4.
Exposed and vulnerable: tribals and malaria in Bihar
P.A. Chacko SJ & Prabir
Chatterjee
5.
Malaria, an emerging problem in Igalpuri
Dhruv Mankad & the
Vachan Team
6.
Getting through the defences: resurgence of malaria among
the armed forces troops
S.K. Krishnan
7.
What makes a place malaria prone? Jalpaiguri as a case
study
8.
Malaria and migrant labourers: lessons from a South Indian
experience
Madhukar Pai, Anand
Zachariah, Winslcy Rose,
Samuel Satyajit, Santosh
Verghese & Abraham
Joseph
7.
Rational treatment of malaria: a critique of the NMEP
strategy
Anant Phadke
8.
Hand over responsibility to the States
N.S. Deodhar
9.
Why has the National Malaria Eradication Programme
failed?
Prabir Chatterjee
10.
Malaria control in tribal areas: issues and problems
Ravi D’Souza
11.
Managing malaria epidemics: Notes from the field
R. Antony, E. Gajraj, M.S.
Jacob, T. Mathew, Sr.
Anita, S.P. Joseph, J.S.
12.
Towards a sensible use of a scarce resource
Sunil Kaul
13.
Partners in Action: the role of NGOs in malaria control
A.S. Nair, Rajaratnam
Abel, P.N. Sehgal
14.
Can we work together for malaria control?
Study Reflection Action
Group on Malaria,
Community Health Cell.
15.
Our struggle to prevent malaria deaths
Sunil Kaul & the URMUL
Team
16.
Personal Protection Measures: the good, the bad & the
impractical
Sunil Kaul
17.
Ilealth Education: a potent weapon against malaria
Rajaratnam Abel &, Sunil
Kaul
18.
Health Education messages for malaria control
Rajaratnam Abel
19.
Beyond the clinic base approach
Lokswasthya Mandal
(Trust For Reaching The
Unrcachcd)
20.
Towards A People’s Movement Against Malaria
Johnny Oommcn
21.
Involving People in their own health care
N.H. Antia
22.
Integrated Vector Management For Malaria Control
Sanjoy Scngupta
23.
Vector Control against Malaria: the SEWA-Rural
experience
SEWA-Rural Research
Team
24.
Back to Basics !
Madhukar Pai
25.
Malaria & Alternative Health Systems
Rakhal Gaitondc
26.
Community Dynamies In Malaria Control; The Kolar
Experience
Parcsh cl al.
27.
Afterword
Madhukar Pai, Ravi
Narayan, C.M. Francis
-
I
"I
THIRD NATIONAL SEMINAR ON
MALARIA
OTHER TROPICAL DISEASES
I
j1
February 18-20, 1997
■
1^
Sponsored b\j
■■
University Grants Commission
&
Bangalore University
Souvenir
Abstracts
1
I
Organised by :
Society for Applied Genetics
Centre for Applied Genetics
Bangalore University
Bangalore 560 056
■
E ■
Venue :
'Yavanika' Auditorium
State Youth Centre
Nrupathunga Road
Bangalore 560 001
L
100
106
Towards an Appropriate Malaria Control Strategy:
and Alternatives for Action
Issues of Concerns
Ravi Narayan
Community Health Cell, Bangalore 560 034
s
....... ..
Dr Rajaratnam Abel and Dr. Sunil Kaul)
paper
—yof
“eo^oXrnX be inidated to supplement the work of the Na
1
tional Malaria Eradication Programme so that the rcs"rSe"“ ° X’iden»
Xh'^rtaken b^a
bl I
different sectors, primarily the voluntary sector.
treatm
,
&
d t rediscover the community dynamics
hethh education, role of voluntary sector, general P'actrttoners and
u
t i riorchin and the urgency of decentralised planning and the
assessment of the role of the ISMs. Policy issues such as health human power
development, research, monitoring and forecasting, corruption and pohhcal
interference, Centre-State responsibility and International public health co-
operation are also included.
I
I
I
The Malaria Study Ref 1ection Action Group faci1itated by CHC, met
9th February, 1998 at CHC at 2,30 pm.
Members present
1 . Dr. Ghosh, MRC
on
Invitees
1 . Dr.Raghunath Rao ~ ex ICMR-MRC,
New Delhi.
2. Dr. Chandra Thomasj, SMH
3. Dr. Raj an Rati 1 j, CHC
4. Dr. Denis Xavier, CMC
2. Mr. Satyanarayana, MRC
3. Ms. Neerajakshi „ VHAK
4. Mr. Anand, VHAK
5. Dr. C.M. Francis, CHC
6. Dr. Ravi Narayan, CHC
7. Dr. V. Benjamin, CHC
8. Mr. Murali
Murali, CHAI-Ka
9. Wg. Cdr. S.K. Krishnan
Krishnan,,I.A.M.
10. Dr. Pankaj Mehta, Manipal Hospital
11. Mr. As Mohammed, SJMC
Minutes
1 ) The meeting started with a welcome, followed by a self-introduction
by all participants and then a brief introduction to the Malaria -■
SRAG and its evolution.
2) CMAI-NMEP-MOU;
(who was
(who
Dr.
Ravi Narayan, on behalf of Dr. Sukhant Singh - CMAI
unable to attend the meeting), gave an overview of the process that
between
has
led to the evolution of a Memorandum of Understanding
CMAI and NMEP for training doctors in the voluntary sector and GPs
He informed the group about
in Orissa, MP, Bihar and North East.
four pilot workshops that are being organised at Raipur and
the
Jagdalpur (MP), Rayagada (Orissa) and Ranchi (Bihar), and circulatthe final
ed all the papers sent by Dr. Sukhant Singh, including
Prac
titioners
of
the
“
Update
on
Malaria
Worskhop
for
Medical
plan
in Private Voluntary Sector".
The members reviewed the programme and the following comments
noted:
(i) Since there was a pretest
were
there should he a post-test as well.
in
( ii ) There are many good MRC-ICMR videos on various topics shown
the programme.
These should be reviewed for their suitability
programme.
to the course and utilised to improve the audio—visual dimension
of the training.
(iii) While Dr.Gille's (WHO) publications on routine drug management
and management of severe and complicated malaria is very compre
hensive,
there are differences between its recommendations and
those of NMEP/MRC.
This should be kept in mind and preferably
guidelines evolved by local experts should be highlighted.
(iv) The cycle of topics in the course should be evolved carefully,
ensuring that key sessions are at times of day when
retention
and application are the best (’).
Post-prandial sessions should be more interactive and practical.
(v) NMEP,
MRC and VHAI materials and pamphlets should be used by
trainers for the pilot workshop and then, new handouts/publications can be evolved if some of these are not found suitable.
(vi ) Bio-environmental approaches should be included and impregnated
bednets should not be over-emphasised.
Adequate time for demon
stration and some hands-on experience should be provided.
adaptations
by
(vii ) For personal
protection - various local
should
appropriate technology
community
and simple,
stressed.
the
be
(viii > Case stimulations will need, we 11 trained subjects. ■for them to
be effective.
3) VHAK ~ Training for Karnataka (Sponsored by VHAI)
being
The group then discussed some ideas for the Malaria Training
contemplated by VHAK for N(30s, Microscopists and Private Medica 1
practitioners in Karnataka.
Ms. Neerajakshi informed the group
that Mr. Ananda of VHAK was attending a training workshop organised
by VHAI in Delhi later this week and would evolve an action
plan
during this workshop.
plan
Some general guidelines were discussed to help evolution of a
for Karnataka, which would provide opportunity of training to al 1
groups and members of VHAK, CHAIKA, CMAI and to all the GP's and
even RMPs in the State.
These included:
the 20(26)
(i) The data on Malaria situation and trends for
from
the
of
Karnataka
could
be
collated
districts
could
be
State/Central Health offices so that districts
rearranged according to magnitude of the problem.
(ii) A district-wise potential
NGO participant
list could be
evolved - consolidating membership lists of VHAK, CHAIKA and
partici—
CMAI, keeping in mind that there could be potential
these
pants who are not necessarily members of any of
coordinating groups.
L
( iii ) The training programme evolved in earlier metings should be
reviewed - emphasising needs/options for Karnataka State,
e.g. bednets would be less emphasised than bio-environmental
methods:
neem oil and its various uses thorugh appropriate
technology could be emphasised.
A suitable handout collating
these experiences is urgently required.
avaialble health education/training materials known to the
(iv> All
group should be reviewed for suitability and comprehensiveness
and
'translations'
of some newer handouts should be started.
VHAK informed that they were awaiting the green signal from VHAI
for translating VHAI pubilcation on Building NGO capability, into
Kannada.
Mr. Ananda and his colleague would be initiating
this
shortly.
(v>
11 was also suggested that some of the ICMR-MRC videos could be
pro
in Kannada - if they were suitable for the training
dubbed
grammes.
t hose
should
emphasise
only
(vi) Training
programmes
to
the
materiaIs/methods/options that are easily accessible
of the project of the voluntary sector.
community or iclientile
-
4) CHAI-Training 3
Dr.
Ghosh emphasised that at a recent NMEP, meeting the role of
rural dispensaries was highlighted and
smal 1
Sister/nurses in small
and at the instance of CMAI and in col laboration wi th
recognised
fever treatment
CHAI,
NMEP was considering the organisation of
workshops for Sisters/nurses running small rural dispensaries.
important
Murali of CHAIKA emphasised that in Bellary diocese, an
concern was the problem of malaria and hence, a one day workshop
about the Malaria situation and dialogue on options with CHAIKA
that
It was suggested
members in that diocese was an urgent need,
a
one-day
consultation
could
he follow this up with the diocese and
MRC (Dr. Ghosh),
VHAK
(Ms.
be organised
in the next few weeks.
Chandra
Thomas
(St.
Martha's
Hospital)
evinced
Neerajakshi) and Dr.
this meeting and offered to support it as resource
interest in
persons.
It was felt that CHAIKA could follow up the Bellary initiative as a
pilot for a future training programme for Sister/Nurses which could
be organised
by CHAI all over the country in collaboration with
NMEP.
5) Other initiatives;:
(i) Dr. Ghosh informed the group that the Karnataka Government had
now decided to extend bio-environmental control to the whole
State in the coming years.
3
I
II
<ii) Dr. Ravi Narayan informed the group of:
(a) Dr. Minay Kamat's study report on some socia1/anthropolog
aspects of Malaria in urban Mumbai which he had
ical
received from him
(b) the process towards the evolution of an urban malaria
research network
that would be supported by
IDRC and
facilitated by MRC and would
focus on social-science
aspects of research in malaria and malaria control.
(iii) It was decided that a more focussed meeting on the "Karnataka
Training plan” will be held after Mr. Anand returns from the
VHAI-Malaria orientation programme.
Tentatively,, it was felt
that this would be held in the second half of April
after
elections and examinations are over.
mum ********
4
ORE
( 3/i
7
1
'7^ {/C.
BANGALORE
Masterplan swept under carpet 10 years ago being revived
Sriranjan Chaudhuri
BANGALORE: It was a master plan pre
pared almost a decade ago on the invita
tion of the Karnataka government to deal
with Bangalore's mosquito menace.
Compiled by the Vector Control Research
Centre (VCRC). Pondicherry, it has been
collecting dust, even as the city's mosqui
to problem got out of hand. With the
monsoon on its way. it can only get
worse.
Efforts are now on to revive the plan
with the help of environmental and citi
zens' groups and by involving the BCC. A
seminar, scheduled for later this month,
will attempt to rework parts of the plan
Says Dr Ravi Narayan of Community
Health Cell, which will be organising the
seminar. The VCRC solution was an
environment-oriented solution, which is
long-term, as the mosquitoes have devel
oped resistance to fogging ”
The plan divides Bangalore into 24 dis
tinct ranges and suggests ways ;ir>d means
of tackling mosquitoes, given the unique
conditions prevailing in each area.
Controlling the mosquito menace in
the city was first discussed during the
Southern Regional Health Minister s Con
ference held at Pondicherry in 1983. With
Pondicherry having successfully quelled
its mosquito problem, based on sugges
tions forwarded by the VCRC. the Kar
nataka government, at the initiative of
then health secretary N.P. Singh, invited
the research centre to study the situation
in Bangalore and prepare a master plan.
After meetings with then Chief Minister
MOSQUITO MENACE
Ramakrishna Hegde. the VCRC estab
lished a field unit in Bangalore. An inter
im report was submitted in January 1983
“This was circulated to all the high pow
ered committee members chaired by the
chief secretary, for implementation.”
wrote the Director of VCRC, Dr P K.
Rajagopalan. who has now retired.
Problems plagued the team from the
initial stages itself. The time schedule for
the preparation of the master plan could
not be adhered to as the facilities for car
rying out such a survey, which were
promised through a government order,
were not provided by the Directorate of
Health Services,” Dr Rajagopalan wrote
in the preface to the final report
Despite this, the VCRC carried out a
detailed survey pressing its own man
power and accomplished the task of
micro-level planning for the control of
mosquitoes in Bangalore.
According to Dr Rajagopalan, “The
master plan is obviously the first of its
kind in the country which is so designed
as to incorporate ail the essential mosquitogenic characteristics of a metropoli
tan city-, the optimum use of the existing
staff and finances for mosquito control
and the measures to maintain a clean
environment with better men and mater
ial management."
Initially, when the VCRC established
the Bangalore Mosquito Control 1 nit. it
was planned that it would function for a
‘De-weeding, desilting drains,
multi-pronged attack will help*
Sriranjan Chaudhuri
BANGALORE: The decade-old
masterplan of the Vector Control
Research
Centre
(VCRC).
Pondicherry, to control Banga
lore- mosquito menace had divid
ed Ithe
<41
IIV kit*
city 11
into
114 J —
2-t laut^vs
ranges .UIU
and suggested solutions for each, taking
into consideration the conditions
prevalent in each
VCRC divided Bangalore into
mam
citv
areas
such
as
Mallesw ar.im. Rajajinagar, Gandhinagar. Chickpet. Binnypet. Chamarajpet. Basavanagudi and Jayanag.ir to outlying ones like Sarraki.
N.tgarabhavi.
1 losekerahalli.
Peenya. Byrasandra and Agaram.
Commenting on the use of insec
ticides by thc°BangaIore City Corporation (BCC) to control the mos
quito menace, the plan said. "The
(_____ of
______________________
quantity
insecticides used clearly
indicates mosquito control is not
hampered for want of insecticides."
It added the total quantum of insecticidcs used was more than adequate when compared with the
quantity of insecticides recom
mended by the National Malaria
Eradication Programme (NMEP).
"Generally sewage lines run paral
lel to storm water canals and are
blocked. Instead of cleaning these
-ewcrage lines and making diem
MOSQUITO MENACE-II
functional the BWSSB has allowed
the sewage to flow through
stonnw-ater canals. This has convert
ed all the stormwater canals
into
.
P'tential breeding ground tor mos
quitoes.
The water blocked in st. rmwatcr
canals with mounds of garbage
i '
dumped “
into
in -the
‘iw them aided
— ■■■
breeding of adex quinquefascuitu
~a dominant species of mosquitoes.
r
VCRC also examined tanks, box
drams, cultivation, kutcha drains,
wells, overhead tanks, cess pits,
[
vacant plots and found that all of
these were perfect breeding
ground tor mosquitoes.
The masterplan suggested envi------------ to ........
--------- .1 ------ronmental
improvements
combat the mosquito
menace,
"Deweeding, desilting and cleaning of drains can ensure free flow
of water thereby reducing mosquito 'breeding.
If *this
no
t"
"
"J ,c
u “ is" done
A
spraying would be required1 in the
drains and will result in considerable savings in the cost of insecti
cides." the plan claimed.
To achieve this more inputs
should be provided for garbage
and solid waste disposal, it added,
In fact the plan suggested that the
silt and debris removed from
drains, if utilised for filling quarry
pits and other low lying areas, sub
stantial reduction in breeding
habitats could be achieved.
VCRC also spoke of the need for
multisectoral collaboration and
called for cooperation betwien
the BCC. BVVSSB and BDA. "It ha-.
been universally recognised that
mosquitogenic conditions in and
around the city are mainly due to
bad engineering practices and lack
of interdepartmental coordina- i
tion. ’ the VCRC emphasised. It '
also points a finger at the community w hich it says by dumping solid
waste into drains was creating a
serious problem.
Tlie VCRC plan was also critical
of the procurement of substandard
insecticides. “It was noticed the
mosquito control activities are car
ried out in a casual manner and fol
low crisis management technique
real breeding habitats in several
areas remain unattended." it said
It then went on to suggest a
time-bound action plan for each oi
the 24 ranges and recommended
means of controlling each breed
ing ground such as drains, tank
industrial complexes, wells and
cesspits. VCRC. also suggested a
monitoring and feedback system
period of five years, it became appar.
before long that the cooperation rv
derect by the concerned department- v.
not commensurate with the promi-c
made and therefore it was felt this gt
would not be achieved easily,” the pre.
ace says.
As a result of bottlenecks faced at cm r
stage, the VCRC plunged into action
its own and prepared the master pi..
within the shonest possible time :
placed it before the government to imr
ment in 1987-88.
Even that did not happen, with
result that mosquito-borne disease
dengue began rearing its head in the
Tomorrow: Details of the ma-i
plan
March-April 1997 Vol.23 No.2
J&y'lraKM"
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C&1&&CC
'T’/ve greatest killers are on prowl, medical break1 throughs notwithstanding. The price being paid for
glossing oner the global emergencies of Tuberculosis
and Malaria is very heavy. The challenges ahead are
tough, resolute steps are called for. The fight needs to
start at home and then spread globally. Braver actions,
than seen hitherto, is the need of the hour.
Makeshift shelters, clustered together, with plastic or
cardboard roofing, exposed to the scorching sun, icy
winters and drenching rains, are grim realities of the
urban and semi-urban India. These subhuman
surroundings, with no privacy, space or fresh air, are
the ideal most grounds for the spread of communicable
diseases. The TB and Malaria time bombs tick, not just
for some forgotten hill tribes, or for the neglected people
in the rural hinterland, or for the refugees living below
the poverty line, but even for the well-heeled and wellnourished. These diseases are fast covering up the
entire map of the country.
To add fuel to fire, the dual epidemic of TB-A1DS has
become the most serious threat to public health in
recent times. This partnership, besides being the biggest
killer of adults, also orphan more children than any
other health problem. TB killed some 3 million people
last year, the largest ever in history, more than tropical
diseases, malaria and AIDS deaths put together. TB is
spreading faster each day. 50 million people are
estimated to be already infected with the drug resistant
TB bacteria, a man-made disaster which has virtually
no treatment.
Government is, of course, seized of the matter. New
policies and programmes are being formulated and
envisaged. But are these properly researched and
thought-out? Do they offer the best alternatives Io suit
the specific needs of the population? How rational and
sustainable are they? These are some of the basic
questions, health activists seek answers to.
Despite the existence of the National Malaria
Eradication Programme since 1953, Malaria continues
to haunt millions in different parts of the country. If past
events are any indication, this year holds no promise
either. Last year, two million people were affected,
including a large number with the deadly cerebral
malaria, caused by the Plasmodium falciparum parasite.
The introduction of the Revised National TB Control
Programme, based on the DOTS strategy and the new
approaches in Malaria control have wide ramifications
on the health status of the people. It is, therefore,
imperative that these matters are analyzed critically
before advocating them for implementation.
Concerned seriously with the emerging threat from
01141 eattZCtld/LOWt ...
these diseases and alarmed by the lack of information
on the ongoing planning process, VI!Al decided to look
into these issues systematically by setting up an Expert
Committees each on TB and Malaria, in collaboration
with other scientific agencies. Summaries of the
findings of these Committees are presented in this
issue. VHA! hopes that these initiatives would strengthen
its drive for a sustainable, need-based and accountable
medical services system in the country.
Greater orientation and commitment, on the part of
medical personnel and political establishments, towards
the eradication of Malaria, may be a fitting tribute to
mark the centenary of Ronald Ross’ discovery of the
/ ? lalaria parasite.
The problems of communicable diseases are
aggravated by many factors which include close
proximity of people living and working together, half
hearted control efforts by concerned authorities, failure
of diagnosis and follow up, poor data collection and
premature termination of treatment by patients. The
combined effect of these factors have made the
situation almost getting out of hand.
Besides the issue of the basic needs, the availability
of quality goods and services in sufficient quantities is
a major concern of the people. Law, or even judicial
activism’ alone cannot ensure a just society capable of
disciplining market forces. Product knowledge, based
on scientific analysis is essential for raising people’s
conscience. Some light is thrown on this aspect in this
issue.
At this critical juncture, close to the turn of the
century, the portents are ominous. It is no longer safe
to expect from the state and political decision
makers, to handle all the responsibilities of health
management. A people’s movement cutting across
divisive lines, spread across the country, is yet to play
its decisive role. In these times of political turmoil,
people's voices are likely to be lost in the melee.
Determined campaigns combined with innovate social
interventions are absolutely necessary, at the
government and voluntary sectors. The trend is likely
to be reversed as the political haze has started
evaporating. Unfortunately, the people cannot wait
infinitely. They are getting impatient.
/t frontal assault on these resilient pestilences
perpetuated by poverty, is an utmost urgency. High level
policy negotiations and plethora of committees including
the suggested National Disease Surveillance and
Response System apart, the people of India expect
deeds that prevent and cure diseases, and not pious
resolutions and empty words. ■
I
Malaria and Tuberculosis:
Our Concerns
Dr. Mira Shiva is Ihe
Head of the Public
Policy Division in VHAL
Dr. Mira Shiva
F
Ii
Il.
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•1
I
I was in 1978, that 116 countries
signed the Alma Ata Charter which
gave priority to the concept of
primary health care, besides
highlighting the socio-economic and
political dimensions of health, on
which depended the health status of
the people. It is almost two decades
since that historic declaration was
made.
The negative health impacts of
the structural adjustment pro
grammes in Africa and South America
were clear warnings and glaring
examples for nations which dras
tically altered their economic policies
with cuts in expenditure on health,
education and social sector. As
‘profits before people’ was legiti
mized by the market-driven growth
approach, it was natural that human
lives and human values were to be
paid as the price.
The resurgence of communicable
diseases is not at all surprising.
Unless the above phenomenon
and trend is reversed, no amount of
anti-TB drugs and anti-malaria
drugs can control these diseases.
The 1995 World Health Report
by WHO spoke about the increasing
disparities between the rich and
poor nations, and between the
rich and poor within the nations a phenomenon which has resulted
in the worsening of extreme
poverty and also Ihe diseases of
poverty. So much so that a new
category was added to the
international classification of
diseases, called Z 59.5 which stands
for extreme poverty.
India witnessed malaria epidemics
in Rajasthan in 1994, where
over 1000 people died (soon after
the plague epidemic in the country),
in Assam in 1995 and in Mewat
region of Haryana and many other
areas in 1996, with hundreds of
deaths and thousands afflicted.
During the same time, Delhi recorded
over 300 deaths from haemorrhagic
dengue fever.
SHP
mW f•I
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3
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Health for the Millions • March-April 1997 *2
■...." T..
These epidemics have
clearly shown that malaria
deaths occur when
malariogenic conditions are
created and health care
services, both in the public
and the private sector, fail to
prevent, diagnose early and
effectively treat the disease
from the beginning. Most of
the victims are from the
poorest sections of the
society.
Malariogenic and tuberculous
conditions continue to be created by
distorted development patterns and
commercialization of medical care.
Public health and community health
are being rapidly replaced by the
profit-oriented and irrational curative
care, 80 per cent of which is in
private hands with little or no
accountability. Unprecedented
increase in the medical-industrial
complexes, with hardly any regu
lation or social control, lend to
market medical care as a business
commodity and not as a public
health service.
The egalitarian principle in health
care has been defined as ‘receiving
treatment according to the needs
and paying for them according to the
55^^
ability to pay’ (Wapstap and Doorslair
1993). The phenomenon of increa
sing unemployment and social
marginalisation of a large number of
s people, has put greater demands on
i
health care. Resurgence of epidemics
Q
S' of communicable diseases is being
o
seen worldwide, especially in the
£
WiP
Third World countries. This is
precisely the time when the
privatisation of medical care is
leading to spiralling of medical care
costs and rural indebtedness. At the
same time national governments are
expected to provide cost-effective
health care, with ‘fee for service’.
Just as the Consumer Protection Act
attempts to protect only the consu
mer, so also, these health policies
address only those with purchasing
power.
There is conflicts between
different policy objectives; costefficiency or cost-effectiveness vs.
equity; between different reform
instruments; negotiated contracts vs.
patient choice etc. They have con
fused the implementation process,
according to Meri Koivusala and
Ollila in their extremely analytical
book on “International Organisations
and Health Policies”.
The excellent article in the British
Medical Journal (BMJ) “Tuberculosis:
old reasons for new increase Socioeconomic deprivation threatens
TB control” reminds us, yet again,
that TB notification in UK had started
falling steadily long before the
specific chemotherapy for TB was
made available. The most powerful
factors in providing TB, observed
over a century ago (in 1899) were:
* Air contaminated by the so called
Tubercular bacillus
« Food inadequate in purity, quality
and quantity
♦
Confined
dwelling
and
overcrowded
* A low state of general health and
low body resistance.
A century later, the factors remain
very much the same. According to
official figures, there are about 14
million people with TB in India of
which 2.5 million are infectious and
500,000 dying annually. Poverty,
unemployment and homelessness
and poor nutritional status are
inextricably linked together to
increase the vulnerability to TB.
The failure to reduce TB in most
developing countries, in spite of the
availability of effective chemotherapy,
5^
7F-X 7—-------
d1
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d
has been attributed to the failure to
improve socioeconomic conditions,
as per evidence from Britain,
provided by Janet H Desbyshire of
University College, London Medical
School.
Since 1988, there has been an
increase in TB in England from 172
in 1991 to 305 in 1993, so also an
increase in unemployment. Half the
number of TB cases are migrants
and refugees. In Britain, the greatest
increase in TB between 1980 and
1992 occurred in the poorest 10 per
cent of the population, indeed an
increase occurred only in the poorest
30 per cent of the population.
This year WHO has attempted to
highlight the global emergence of
infectious diseases as their annual
theme, as we celebrate the centenary
of Sir Ronald Ross for his tremendous
contribution to understanding of
malaria by sharing the presence of
the malarial parasites in infected
mosquito.
As the country prepares for the
summer and monsoon, the
mosquitogenic/malariogenic months,
as loans for the revised TB, malaria
strategy are being made available
from the World Bank, it is important
to look three to five years hence.
Identification of the greatest burden
of diseases based on an assessment
by use of Disability Adjusted Life Year
(DALY), which is incidentally an
economic tool, has been made.
When most malaria deaths are not
even reported but are recorded as
fever, as blood tests for malaria
parasite is not done or not reported,
how accurate would the DALY’s for
malaria be?
The National Health Policy was
never revised since 1983. As changes
are made, which affect lives of the
millions, we in VHAI reiterate our
priority to those in the Z 59.5 category,
who do not have the purchasing
power. They will be the most afflicted
and will continue to make great
sacrifices with their lives.
The most important question
remains whether there can be a
rational health care in a patently
unequitable world, when creation of
inequality is the accepted global
trend. Resurgence of infections is a
symptom of this deep pathology.
While this economic tool gels
increasingly used by policy-makers,
it further mystifies the process and
the victims continue to die in greater.
numbers. Increase in population,
corruption, inadequate health
budgets and other such factors
contribute towards worsening the
situation. ■
i
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Ah important factor that
has direct effect on health
care iis corruption. Nobody
takes serious note of it.
.....- .........
I Narayan
Dr Thelma
*• *•
L>
UJJ L- C- I
V/ fl
/iv-llllff
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Health for the Millions • March-April 1997 • 3
Towards An Appropriate Malaria
Control Strategy:
Issues of Concern and
Alternatives for Action
rT’his Expert Group was a collective
1 initiative of the Voluntary Health
Association of India (VHAI), New
Delhi and the Society for Community
Health Awareness, Research and
Action, Bangalore. The preparation
of the preliminary report involved
interactions and consultations with a
large number of organisations and
specialists in India.
The Malaria Expert Group (MEG),
which functioned from April December 1996, consisted of six
members. It was set up to seek
wider opinions on the malaria
situation and suggestions on how to
tackle the problem as a follow up of
VHAI’s active involvement in
epidemiological studies and malaria
control measures in Rajasthan in
1994 and in Assam in 1995. The
Expert Group aimed at bringing
together all the complementary
initiatives and processes that have
been going on in the voluntary
sector, over the last few years, with
regard to malaria care to strengthen
the emerging control efforts.
This Group tried to do a realistic,
action-oriented exercise with an
alternative perspective and new
direction. Key issues of concern,
This write-up is based on
lhe Executive Summary of
the Report of the Malaria
Expert Group, containing its
reflections and
recommendations, prepared
by Dr. P. N. Seghal.
some of which have not been
adequately considered in the recent
planning process, have been duly
considered.
I
■
Resurgence of the Malaria
Epidemic
In 1952, there were 75 million malaria
cases with 0.8 million deaths per
year in India. The National Malaria
Control Programme (NMCP) was
launched in 1953 and National
Malaria Eradication Programme
(NMEP) in 1958. The programme
achieved remarkable success in 1964
when about 100,000 cases were
MEMBERS OF THE MALARIA EXPERT GROUP (MEG)
i
I
Dr. Ravi Narayan, MD, DTPH
(London), DIH (UK), (Convenor),
is the Coordinalor/Secrelary
Community Heallh Cell, Society
for Community Health Awareness,
Research and Action, a policy
research and training resource
centre in Bangalore, Karnataka.
Dr. Narayan was formerly Associate
Professor of Community Medicine
at St. John’s Medical College. He is
currently involved in developing a
community health orientation in
malaria control with special
reference to lhe health of
agricultural workers and control of
vector borne diseases.
Dr. P.N. Sehgal, MBBS, DPH,
FISCD, FAMS, (Consultant) is
former Director of lhe National
Institute of Communicable
Diseases. Dr. Sehgal has worked
on the issue of malaria for many
decades and is currently a
Consultant to Voluntary Heallh
Association
of India.
His
specializations are Public Health,
Epidemiology and Control of
Communicable Diseases. He has
served in several malaria technical
and evaluation committees at the
national and international levels. He
was awarded Fellow of National
Academy of Medical Sciences, India
(1983).
Dr. Mira Shiva, MDBS, MD
(Member-Secretary) is the Head,
Public Policy Division, in VHAI and
Coordinator All Indian Drug Action
Network. She has been involved in
policy, advocacy and public
awareness programmes on issues
related to Low Cost Drugs and
Rational Therapeutics for lhe past 18
years. She was also involved in
Malaria epidemics in Rajasthan,
Assam and Mewat (Haryana).
Prof. Amitabha Nandy, MBBS,
DCP, MD, is with the Department of
Parasitology, Calcutta School of
Tropical Medicine, Government of
West Bengal, Calcutta. He is In-charge
of lhe Malaria Clinic and Central Kalaazar Laboratory. Prof. Nandy has been
working as Advisor to WHO and
the Government of India.
Dr. Rajaratnam Abel, MBBS,
MPH is the Head, RUHSA
Department, Christian Medical
College and Hospital, Vellore, Tamil
Nadu. He runs an integrated
Primary Health Care Programme
in North Arcol. He is a working
group member of lhe Tamil Nadu
State Planning Commission. He
has worked extensively in
Community
Health
related
programmes in Nepal, Himachal
Pradesh,
Bihar,
Punjab,
Maharashtra and Andhra Pradesh.
Dr. Sunil Kaul, MBBS is with
the Association of Voluntary
Agencies for Rural Development North East (AVARD-NE), Jorhat,
Assam. He worked in lhe Army
Medical Corps from 1983-1994. He
was one of the key persons in
providing relief to lhe victims during
lhe malaria epidemic in Rajasthan,
in 1994, besides training and
coordinating medical work.
i
Heallh (or lhe Millions • March-April 1997 • 4
I
I
I
reported withi no deaths. The
resurgence of
c. Malaria after 1964
reached its peak in 1976, when
about 6.7 million cases were
recorded. In spite of the best efforts
by NMEP, the situation has plateaued
to around 2 to 3 million cases with
gradual increase of cerebral malaria
due to P.falciparum.
The resurgence of malaria as a
major Public Health problem has
become a matter of serious concern,
especially in the last decade, due to
occurrence of epidemics in
Rajasthan (452 deaths), Nagaland
(253 deaths), Andhra Pradesh (173
deaths), Manipur (48 deaths) and
West Bengal (3 deaths) in 1994. In
1995, Assam, West Bengal and
Maharashtra experienced malaria
epidemics with high morbidity and
reports of deaths.
surveillance
system
which
disregards the non-governmental
sector is bound to produce a
gross underestimation of the
reality.
In states, the availability of
laboratory technicians at PHC level
are diminishing with vacancies of
50-75% not being filled. In such a
situation, underreporting of cases
will become the norm.
THE EXPERT GROUP’S
SUGGESTIONS FOR ACTION
Epidemiological Aspects of Malaria
Control
Urban Malaria Scheme
One of the major problems in the
Urban Malaria Scheme (UMS) is that |
the responsibility of implementing
them lies with the local bodies like
municipalities and corporations. In I
most urban areas, local bodies give
excuses of lack of resources and
human power for their poor .
performances in malaria control. A I
large number of UMS posts remain
vacant; blood smears remain
unexamined for months to end; |
fogging and space spray operations
are done only when there are
outbreaks; larviciding operations are I
conducted without any evaluation or
monitoring.
Malaria being an exclusively focal
phenomena, governed by presence
Development Projects
|
of parasite, vector, susceptible hosts
and suitable environmental condi
The mosquitogenic potential of large
tions in the community, it is important
development projects such as dams,
that national and/or state level
irrigation/canal systems, bridges, |
programme norms or guidelines
laying of roads and railway lines etc.
Gross Underestimation
need to be flexible and should allow
or establishment of large industries
Deaths due to malaria, reported
diversity of response to the diverse
has been well documented. It is I
annually by NMEP, are between 200focal situation.
therefore recommended that this
500 from 1984 to 1993 with an
There is urgent need to effectively
continuing
neglect or near total
increase to 1000 + in 1994 and 1995.
monitor the spread of P. falciparum
absence of environmental impact .
If crude death rate in the country is
(which causes cerebral malaria) all
assessment (E1A) of development |
10.8/1000 and of the 7.4% fever
over the country. Resistance to
projects must be reversed and EIA
deaths, 0.8% are malaria fevers (GO1
chloroquine inRfalciparum was first
must become mandatory for all
information), then malaria deaths
reported in the North-East/Assam
projects.
j
would be 73795. Vital statistics of
(1973) but now it has slowly spread
The problem areas such as hard
India collected separately also
to many other parts as well. NMEP
core
areas - tribal areas mostly;
reported malaria deaths as 137,846
has been gradually mapping the
epidemic
prone areas; project areas; i
in 1985 and 75,285 in 1987 (NMEP
resistance problem but this data is
Triple Insecticide Resistance Areas I
figures were 213 and 188
not yet adequately shared or
and urban areas should get greater
respectively).
communicated to health care
attention and very different
The National Malaria Eradication
practitioners to help them modify
responses. NMEP will have to |
Programme (NMEP) estimates on
their treatment schedules and treat
become
more flexible and local in its
malaria morbidity have been cross
resistant forms actively with
programme
planning.
checked by the Expert Group, on the
alternative regimens. This sharing
Malaria which was predominantly I
basis of consumption of antiand distribution of information is
a rural disease in India has now '
malarials especially chloroquine
crucial for malaria control.
diversified into 5 ecotypes namel]
phosphate.
While vector dynamics are
Tribal, Rural, Urban, Industrial ano
important components of malaria
Border. These ecotypes and sub
It appears that a more
control, the inadequate or near
ecotypes have their own specia
absence
of
field
oriented
realistic and safer
features and these must be
entomologists mean that a major
adequately understood, analyzed and
assumption would be that 20
adjunct to policy analysis and solution
monitored while malaria contrc
to 30 million episodes of
is being neglected. The acute
programmes are planned. Th<
shortage of entomologists and their
malaria occur every year as
malaria control strategies will have
improper deployment and support
to be based on these epidemiologicc’
against 2 to 3 million cases
to those who are in the public health
characteristics.
reported by NIVIEP.
system and NMEP is reaching a crisis
The understanding of epidemic
situation which needs urgent policy
dynamics calls for strict surveillance,
In the absence of malaria being
redressal.
maintenance of an adequate suppl
a notifiable diseases, any
________________ _
Health for the Millions • March-April 1997 • 5
of drugs and an increasing epidemic
preparedness in years of good rainfall.
Social Dimension of Malaria
Control
The overall emphasis on techno
managerial issues has completely
over-shadowed what has been
suggested as socio-cultural, economic
and politico-behavioural issues
relevant to the community at risk. The
malaria control programme has
seldom involved a sociologist or
anthropologist, to complement/
supplement research efforts or to
actively participate in a truly inter
disciplinary way with problem
analysis and problem solution.
Behaviour science approaches and
socio-anthropological and socioeconomic/health economic research
competence must be urgently built
into the ‘problem analysis’ and
‘problem solving’ structures at all
levels.
i
Rational Malaria Control
Diagnostic Support
One of the biggest deficiencies in the
entire malaria control programme is
lack of scientifically functional
diagnostic facilities at almost all
levels of health care delivery. The
important fallacies in the diagnostic
machinery are:
♦ Time lag between blood
collection and examination
♦ Absence of functionally viable
microscopes and lack of their
maintenance.
♦ Lack of training on malaria
microscopy of the lab. technicians
as well as doctors attached to
health centres.
♦ Shortage of lab. technicians to
the extent of 50 to 75% of
sanctioned posts.
Malaria is a relatively
simple disease provided it is
diagnosed early and
treatment started promptly.
Most of the malaria deaths
are due to delayed diagnosis
and treatment.
Health for the Millions • March-April 1997 • 6
Areas needing urgent attention are:
♦ Logistics for laboratory supplies
should be streamlined.
♦ In-depth rigorous training for
lab. technicians in malaria
diagnosis.
♦ NGOs should be trained and
supported to open peripheral
laboratories, particularly in remote
areas and brought under the
network.
♦ Training supervisors for laboratory
work and cross checking of the
findings
♦ Setting up of graded laboratory
facilities appropriate to different
levels of health care delivery
system for early diagnosis,
treatment and monitoring of
complicated malaria cases.
Issues in Clinical Diagnosis
Health personnel of various levels
i.e. doctors, para-medics and health
workers need to be well trained in
clinical skills to diagnose malaria
early, exclude other causes of fever
and identify complications of malaria.
Il is, therefore, suggested that a
key component of malaria control
strategy should be to upgrade the
skills of Medical Officers and General
Practitioners in the government and
voluntary sector in clinical diagnosis
through distribution of simple
booklets on standardized modes of
diagnosis and continuing medical
education (CME) programmes in
collaboration with medical/nursing
colleges, IMAs and NGOs.
Rational Drug Policy
It has been observed through a
prescription survey that more than
90 per cent of the anti-malaria
prescriptions are irrational. This has
been mainly due to lack of awareness
among medical professionals about
therapeutic aspects of the disease.
This situation is leading to untimely
exposure of the parasites to newer
drugs leading to drug resistance.
Chemoprophylaxis in the endemic
area and presumptive treatment to
any fever cases are to be looked into
seriously with regard to their role in
I
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Courtesy: VHAI
the emergence of chloroquine
resistance.
By and large, the Expert Group
endorses most of the aspects of the
Treatment Policy on Malaria,
recommended in the Malaria Action
Plan Operational Manual (1995) of
the NMER Clear policy statements
are required on which anti-malarial
drugs should be allowed in the
market. This applies also to drugs
that are no longer recommended
e.g. Amodiaquine and new drugs
e.g. Mefioquine and and Artemenine.
The results of the drug resistance
monitoring must be made available
to district health authorities and also
to the medical profession in
respective areas. Adverse drug
reaction and monitoring of old/new
anti-malarials should be undertaken
besides ensuring post marketing
surveillance by manufacturers of
newer anti-malarials.
In endemic areas,
anti-malarials should be
available free (as mentioned
in Malaria Action Plan 1995)
or they should be very
reasonably priced.
G6PD deficiency and sickle cell
anemia mapping should be done
and made available to doctors in the
affected region with warnings about
avoidable anti-materials and other
drugs.
Proper prescription audits,
i
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medical audits and drug audits must
be
undertaken
periodically.
Specialized centres for treatment of
complicated malaria should be
established in teaching hospitals of
medical colleges.
Prevailing Confusions
There is need for NMEP to initiate
dialogue with professional and
academic bodies and medical
colleges to popularize their guidelines
and reduce the existing confusion,
vis-a-vis treatment schedules,
controversies and debates related to
new anti-malarial drugs such as
Mefloquine and the use of SulfaPyramethamine combination drugs
for chloroquine resistance strains. A
major effort is required to incorporate
these guidelines into medical
(undergraduate and postgraduate)
training as well as in the courses for
nursing
and
allied
health
professionals.
NMEP’s stand on Ayush-64
(Ayurvedic preparation) should be
made clear, which has been
recommended by the Central Council
of Research in Ayurveda and
Siddha.
NMEP should publish its guidelines
(at least once a year) on drugs,
dosages, precautions, indications
and
contraindications
in
scientific publications which are
routine reference materials for
practitioners.
Personal Protection Measures
Personal protection measures must
be known to all the affected
population to reduce the chance of
mosquito bites and hence of
contracting
malaria.
Simple
measures like wearing of adequate
clothing after dusk to avoid mosquito
bites, smoke fumigation, especially
burning of neem or tulasi leaves in
houses before sleeping hour may be
mentioned for the choice of the poor
sections of the population. The
efficacy of bed-nets in malaria
prevention should be made known
to people. Encouragement of Neem,
Lemon-Grass
and
Citronella
plantation
as
environmental
intervention measures for the family
and community
highlighted.
need
to
be
Malaria and Primary Health Care
Malaria control has been integrated
with Primary Health Centres (PHC).
The multipurpose health worker, the
lab. technician and health supervisors
are the crucial operational team of
the programme within the PHC
organization. However, the crucial
challenge is that malaria control
becomes part of a Primary Health
Care strategy only when the following
principles are adopted:♦ Community Participation
♦ Appropriate Technology
♦ Inter-sectoral coordination
♦ Social Equity.
The community needs to be
actively involved in planning and
implementing the strategy. They
should be accepted as participants
rather than beneficiaries of the
programme. The strategy should be
directed towards enabling and
empowering the community rather
than just providing a service.
Community Capacity Building
To facilitate community capacity
building the following activities are
necessary:-
♦ Providing complete knowledge on
malaria, its causes, spread,
treatment and prevention.
♦ Stressing the importance of early
diagnosis and treatment. The
community needs to be aware of
the early signs and symptoms of
malaria specially that of the onset
of cerebral malaria.
♦ Providing accessible
treatment
THE ‘MEFLOQUINE’ ISSUE
The Malaria Expert Group (MEG)
is deeply concerned with the
introduction of Mefloquine, at this
stage, in the National Drug Policy
on anti-malarials, without its
rational use being ensured,
because :♦ Cross resistance with quinine
develops rapidly, so loss of
effeclivity of quinine due to
Mefloquine misuse especially
when P.f infections are
increasing in the country, could
lead to a major public health
catastrophe.
♦ Technically Mefloquine has no
advantage over other available
anti-malarials effective for
P. falciparum.
♦ As the gametocytes are not
killed by Mefloquine, so a patient
treated with Mefloquine will
remain a reservoir of infection
and a public health danger,
spreading the infection in the
community.
♦ In practice, in the Indian
situation, it will not be possible
to comply with the condition of
‘compulsory laboratory report’
by qualified parasitologists
indicating that there are R
falciparum rings.
♦ Mefloquine is not recommended
by the CDC (USA) for standby
treatment in any situation.
Breast-feeding mothers taking
Mefloquine is contraindicated.
Terotogenicity in animals has
been noted and, therefore, .it
should be avoided in the first
trimester. It is contraindicated
for those with history of
convulsions,
psychiatric
disorders, severe renal, hepatic
dysfunction
and
cardiac
conductive disorders.
♦ Taking all those factors into
consideration, the permission
to import Mefloquine will only
facilitate unethical medical
practice and promote misuse/
overuse of a drug that should be
kept severely restricted as the
only second line against
chloroquine resistance. Il is
therefore suggested that the use
of Mefloquine should be
seriously reviewed in the light of
known factors in order to restrict
its use.
Il.-.illh lot Hi.- Milli..ns • \I.ik li- \|.nl I9')7 • 7
centres including knowledge of
proven’ locally available herbal
precautions and treatment.
♦ Identification and involvement of
all human resources in the
community including panchayat
leaders, informal leaders, mahila
mandals, youth clubs, teachers
and school children, Traditional
Birth Attendants, General
Practitioners including those of ’
Indian Systems of Medicine.
IMPREGNATED BED-NETS : SOME LOOPHOLES
Bed-nets impregnated with
synthetic parathyroid insecti
cides @ 25 mg/sq. m have
been found useful depending
on the biting behaviour of the
local vectors and also the
cultural habits of the
population.
Impregnated bed-nets
(IBNs) should be promoted as
part of a multi-alternative
programme and a multi
pronged strategy but not as the
only option in all initiatives,
government or non-government.
Studies should be done on
their acceptability, feasibility and
sustainability, focusing particularly
on the poorer sections of the
community. They should be
community-based
communitycontrolled and^subsidized or
distributed free through the
programme.
A large majority of the population
do not even have proper beds. They
are too poor to invest in nets.
Overcrowding is a common problem.
I this country, with a long hot summer
and no facilities for cooling
systems, nets cannot become
too popular. While family bednets and impregnated curtains
etc., may be appropriate
alternatives, too much focub
on ‘impregnation’ may divert
5 attention from other methods
> and----------strategies.
Il is important to distinguish
between the promotion of
impregnated bed-nets/curtains
through public education and their
application as an intervention for
malaria control, aimed al a certain
section of the population. It is
essential that their efficacy under
local conditions has to be
documented
and
their
sustainability ensured.
1
I. _
THE VECTOR CONTROL SCENARIO
1
I
The principal objective of vector
control has been reduction
of malaria incidence by decreasing
transmissions. Reliance in vector
control is now being shifted from
total dependence on insecticides
to an integrated vector control
strategy suitable to local situations.
Issues of concern are:
♦ Development of insecticide
resistance among vectors of
malaria.
♦ Environmental pollution due to
use of insecticides.
♦ Lack of adequate infrastructure
and studies about the relevant
environmental, ecological,
social, economic and health
service facilities for selective
vector control in different areas.
♦ Lack of effective inter-sectoral
coordination between different
departments and development
projects (irrigation, agriculture,
flood control, public works, water
supply and drainage system in
urban areas) for reduction in
vector breeding.
♦ Lack of adequate entomological
expertise on whether or not to use
spraying in a particular area, which
insecticide and when to do the
spraying operation.
There is lack of adequately
trained staff for sound
technical management. Till
now plans for spraying have
been based on a single
uniform criterion viz., a certain
annual parasite incidence (API)
without taking into account
other epidemio-logical and
social factors.
treatment
of
♦Irregular
the breeding places and lack
of inspection at frequent
intervals.
♦ Lack of management infor
mation systems and dece
ntralization of decision
making.
These areas of concern call
for appropriate strategies which
include strengthening vector
control measures primarily by
enhancing capacity for selective,
local / focal spraying with
insecticide and bio-environmental
control at all levels. Enhancing
the state and local self
administration’s capacity to ensure
proper water and waste disposal
and enacting model bye-laws
to implement the measures
under the urban malaria
scheme are essential in vector
control.
T
Health for the Millions • March-April 1997 • 8
I
!
Health Education
A vigorous, effective and massive
Health Education effort need to be
undertaken, using not only mass
media but more significantly other
strategies especially for those who
are illiterate and have no access to
radio or television.
Certain measures should be
emphasized.
♦ increasing the budget for health
education.
♦ promoting folk media and
community-based interactive
culture sensitive approaches.
♦ involvement
of
media/
communication centres in the
government, voluntary and private
sectors.
♦ inclusion of malaria and other
diseases in the school curriculum
at various levels.
♦ making available health education
materials, existing and new
production, in local languages.
♦ door to door and village to village
malaria education in the pre
monsoon season, depending upon
the onset of rains in the area.
Voluntary Agencies in Malaria
Control
The role of voluntary agencies in
malaria control is being increasingly
recognized in planning and policy
circles as effective complementary
and supportive agencies. A relevant
and operational linkage between
government and non-government
initiatives in malaria control should
be evolved to involve them not only
as alternative service providers but
also as health communicators,
community mobilizers, alternative
community health oriented trainers,
action and operational researchers
and issue raisers and awareness
builders.
These voluntary agencies can play
significant role also in diagnosis and
treatment of cases, health education
and vector control with proper
training in surveillance and
management of malaria outbreaks.
Voluntary agencies with commit
ment to the malaria control
programme may be identified
and developed as Resource
Centres. They should have trained
human resources (malariologist,
smear technician, microscopists,
health educator, diagnostic
equipment, treatment facilities and
training infrastructure to train other
personnel both in voluntary and
private sectors.
At the grassroots, the costs of
training community level people and
personnel of Volags Resource Centres
should be incorporated into the
regular NMEP budget. A separate
cell to deal with Voluntary Agencies
and private sector may be established
at NMEP, both in Delhi and at the
State Headquarters.
Private Practitioners in Malaria
Control
It is estimated that nearly two-thirds
of the health care providers in rural
and urban areas in India are private
practitioners. These include
practitioners of allopathic and other
systems of medicines. It is surprising,
however, that NMEP has not
adequately clarified the policy on
the involvement of this sector in any
active way. It is a matter of great
concern that there is no planned
dissemination of relevant information
and update on rational malaria
diagnosis and treatment regimens
utilizing the generics/specifics
available in India. The role of private
practitioners in malaria control is
rather dubious and marked by
increasing commercialization and
unethical prescribing trends.
It is suggested that General i
Practitioners, Registered and I
un-registered medical practitioners
should be educated and oriented
through Continuing Medical
Education (CME) programmes
with the help of professional
organisations and communication
materials.
Decentralized Planning
Planning should be decentralized to
district/PHC level by developing
planning skills at that level. The
Panchayat leaders should be trained/
oriented to participate meaningfully
in health planning.
Indian Systems of Medicines
(ISM) in Malaria Control
There is urgent need for consultation
and dialogue with experts of ISM on
the potentialities of ISM to malaria,
study and strengthen local health
traditions and practices relevant to
malaria control, regular assessment
and research of herbal and other
alternatives.
Health Humanpower Development
and Training
A humanpower development
strategy for malaria control should
promote the following:
♦ Provision and/or development of
adequate trained staff at all levels
of the programme.
♦ Re-introduce “Malariology” as a
separate course as well as a
<T
27
a;
1
O
Health for the Millions • March-April 1997 *9
module in medical/nursing and
public health engineering
education.
and
♦ Constant
monitoring
supportive supervision as well as
accreditation of institutions
associated with training of the
programme team.
♦ Bringing in a policy of filling up
vacancies.
Loss of Public Health Competence
The National Malaria Eradication
Programme, as well as all
other health programmes in India,
is being greatly affected by the
increasing disregard of public
health competence’ and public
health perspectives in health policy
and health care decision-making. At
the Central and state levels, there is
increasing marginalization of
technical leadership with public
health competence, by their clinical
counterparts and also of both these
groups
by
lay
generalist
administrators. Decisions that need
sound epidemiological and technical
background are now being
increasingly taken by those who are
not adequately qualified to do so.
Therefore serious efforts be made to
strengthen public health training and
services in the country.
Malaria Research Challenges
There is an urgent need for
promoting operation and field
research in malaria control,
particularly focusing on socio
epidemiology; informal
research process guiding
network; appropriate
technology; and an efficient
lab to field programme
transfer.
Epidemic Forecasting
The NMEP guideline for Mobile
Epidemic Control Units (MECUs) al
district level should be opera
tionalized urgently. Concerted action
to promote epidemic monitoring and
or control/prevenlion at the field
level and enhancing the epidemic
preparedness at the district level is
needed.
A Relevant Malaria Policy
Programme and policy planners in
malaria control must actively study
and contextualize the wider socio
economic-cultural-political setting in
which their strategies must be
located. A broader context of public
policy must therefore inform their
deliberations, understanding and
strategies for action, research,
training and evaluation.
Management Information System
The existing MIS in Malaria should
be reviewed to ensure that the
whole system is simple, integrated
and responsive rather than
complicated, compartmentalized
and bureaucratic.
Regular feedback, based on the
analysis of all data collected, must
be passed downwards to the field
staff which shall help the collating
agency to analyze the data and to
make the process relevant, promptly
and regularly. It will enthuse the field
staff in providing their relevant inputs
because they may identify their
contribution to the management
system.
International Public Health
Collaboration
While promoting International Public
Health cooperation, it is necessary to
have a watchdog committee of the
government and members from
voluntary agencies to evaluate every
bilateral project to ensure that it is
geared to:
♦ Enhancing national capacity to
deal with the problem.
♦ Building national infrastructure
especially trained and skilled
multi-disciplinary manpower.
♦ Is rooted in approaches of
strategies responding to local
needs and socio-economiccultural-polilical realities.
♦ Ensuring that projecl/linkage are
transparent and subject to
collective interaction among all
those who are seriously involved
and interested in ‘malaria’ as a
public health problem.
Centre-State Responsibilities
Stales have failed to sanction and
establish PHCs/sub-centres as per
prescribed norms and also to match
central allocation on 50:50 basis due
to low priority to malaria problem
and lack of resources.
We believe that a lime has come •
for a new policy alternative to
seriously establish the primary
responsibility of the slates in the
programme and devolving funds to
that level. This will also mean re
orienting the central NMEP organi
zation to provide training and other
supportive facilities. Increased inputs
into the health infrastructure and
health programme costs by states
will greatly stabilize the programmes
leading to greater responsibility and
involvement simultaneously.
NMEP and
Management
the
1
i
Operational
There is a need to review all the
operational aspects of the pro
gramme al all levels and making
suitable mid-course corrections and
managemen t/organizational
modifications responsive to the local
field realities based on the
suggestions given by expert groups
from lime to lime. Stale level
organization need to be strengthened
in the field of epidemiology and
entomology. Behavioural scientists
should carry out periodic ad hoc
surveys in different areas for
formulating effective control
strategies in those areas.
Finally, we need to ensure that
malaria becomes part of an
integrated, people-oriented, decen
tralized, empowering programme in
which the people/community be
come central to the whole policy
framework.
For a more detailed report of the Malaria
Expert Group kindly write to:
Dr. Mira Shiva
Member-Secretary
Malaria Expert Group
VHAI
New Delhi 110 016
Health for the Millions • March-April 1997 • 10
r,
MEWAT CALLING
library’
f
A brief report of the Malaria outbreak in Mewa \
by DR. MIRA SHIVA
%
T^he malaria deaths in Haryana in
1 1996 were unprecedented.
Following reports of the outbreak, in
the Mewat region of Gurgaon
(Haryana), a VHAI team consisting
of Dr. Mira Shiva, Dr. Deepak
Meshram and Dr. J.P Jain visited the
affected areas in November 1996, to
assess the situation from the people’s
perspective.
The team covered three blocks of
Gurgaon, namely Nuh, Ferozepur
Jhilka and Nagina, coming under
the eastern forest region of Mewat
which is the poorest region in
Haryana, predominantly inhabited
by muslims. Moreover it suffered
badly from floods during the 1996
monsoon.
While the national dailies
were full with news of haemorr
hagic dengue fever deaths in Delhi,
great
number deaths, especially
from falciparum malaria, in the
Mewat region, went largely
unreported.
There were 1300 deaths of
fever from 36 villages, in a
population of 6 lakh. 10 per
cent of the total population
seemed to have been
affected.
In some villages, there was
not even a single home wheTe
someone was not lost. Deaths
were maximum in children underfive and among people above 30
years. Gender based data were not
available. Of the 564 deaths reported
in Punhana, 378 were fever related.
Of the 667 deaths in Ferozepur
Jhilka, 348 were fever related, and of
the 384 deaths in Nuh, 137 were
fever related, mostly in rural areas.
Almost 50% of the cases were
falciparum malaria.
Observations and
Recommendations
The following reasons were observed
by the team for the malaria epidemic
in the Mewat region.
♦ Environmentally compromised
area. Very high rainfall - 1500 mm
in 1996 (normal being 200 mm)
and floods from Rajasthan.
♦ Poor drainage of water due to
blockage of the natural drainage
into the Jamuna by roads, rail
tracks and houses. Low lying
areas led to water stagnation.
♦ Relief agencies pulled out after
the floods. Water-borne diseases
like diarrhoea, hepatitis and
typhoid increased due to water
sources getting polluted. With
increased
mosquitogenic
conditions, malaria and dengue
were to be expected.
♦ The mosquito vector species
found was ‘Anopheles stephensi
& culcifaecies’.
♦ DDT
was
ineffective
as
insecticides, therefore malathion
was being used. It was also stated
I
by the authorities that there was
100% sensitivity to chloroquine.
But there were reports death in
spite of treatment with drugs.
♦ Socioeconomic and develop
mental factors. The region is
economically backward with large
scale unemployment and female
illiteracy, compounded by floods
in recent years making agricultural
work impossible.
♦ Social factors. A large percentage
of affected people belonged to
poor minority communities.
Average family size was 4 - 7 with
little or no spacing or fertility
control due to religious reasons.
♦ Transport and Communication.
Due to earlier floods, there was a
breakdown of transport and
»
ANO
DOC'JMeNTATlON
' f)
,jNH
..... <.
a •'A
^7
communication services which
caused delay in relief operations.
There were no ambulances and
jeeps to carry patients. Relatives
brought patients on cycles, wading
through water. The inability of
health services to reach patients
during the epidemic and delay in
patients reaching
medical
services increased the gravity of
the problem.
♦ Surveillance and monitoring
mechanism. This was poor. The
State government was alerted only
after newspaper reports. WHO,
NMEP, NICD got involved even
much later and NGOs were not
involved in provision of services at
all, despite the PHC doctors
approaching them for help with
trained health personnel and
transport.
♦ Underestimation of the fatal
potential of fever. Early deaths of
the malaria epidemic were
reported as mysterious deaths
since many patients died within a
day of getting fever, headache
and vomiting.
The malaria fever was viciously
malignant (falciparum malaria)
unlike the familiar version with chills,
rigorous and headache which cured
within few days of treatment.
Warnings to health personnel and
the villagers came too late. Many
patients delayed seeking help from
private practitioners being too poor
to pay the high fees. The Govt,
centres usually did not have enough
medicines. Therefore, many patients
did not even bother to go there.
♦ Preparedness. Health services
were not geared to face the
epidemic. Large number of
patients who died of fever were
undiagnosed in the absence of
blood tests. It reflects lack of
adequate mobile health services
with lab back up. 95% of the
deaths were in the villages.
Health for the Millions • March-Apnl 1997 • 1 1
Photo by Mira Shiva
-
-
F
’ \
♦ Health Status of people. Deaths
were also due to severe
malnutrition, anaemia and
infections like TB. Acute malaria
infection in the nutritionally
compromised population made
the situation worse and life
threatening.
♦ Flood prevention measures.
Pumping of water from inundated
area had to be done so that winter
crops could be planted. Road
repairs and vehicles were needed.
Improvement in health services
was essential by involving private
sector and improving surveillance
and monitoring mechanisms.
- Involve medical colleges (SPM
Depts.) during epidemics for
public health training.
- Provide adequate lab back-up.
- Give therapeutic guidelines for
doctors and health personnel.
- Ensure adequate quantity of
anti malarials.
- Strengthen MCH related work
as large number of patients
were children and women.
- Pump of water from
inundated areas so as
to reduce mosquitogenic conditions.
♦ Vector control :
Do
selective
spraying,
guppy Tish and cultivate
neem, lemon grass etc.
Encourage self prote
ction with mosquito nets
and neem oil. Ento
mological study about
vector intensity and
J
vector resistance needs
to be undertaken.
♦ Poverty alleviation pro
grammes: New initia
tives with improved
expenditure on health
are required. Income
generation programme
specially for women who
are home-based needs
to be promoted.
♦ Involvement of other
agencies. NGOs, panchayats, schools etc.
should be involved in a
greater degree in fighting the
problem al all levels.
♦ Development of the Mewat
region. This should be taken up
on a priority basis, involving
the minority communities
themselves, with due emphasis
on economic factors as well us
education.
♦ Drug quality. Since many patients
had died, despite taking
medicines, questions were raised
about the quality of chloroquine
prescribed.
According to the Health
Department, additional personnel
were posted in the villages,
34 posts of doctors have been
sanctioned, 26 labs have been set up
and 15 fogging machines were put
into operation to spray malathion. A
50 bedded hospital has been set up
in Jhilka. Nutritional programme have
started in 20 highly sensitive areas,
besides providing assistance by way
of drugs, blood donations and food
articles. However, villagers complai
ned that many of the posts in the
health centres had not been filled
up. ■
!
|
I
■
I
OTHER INDIA PRESS
NEW TITLES
The Organic Farming Source Book Edited by Claude Alvares. The
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efforts to revert to sustainable agriculture. Pp. 344 (LF) Rs 250.
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Pp. 213, Rs 90
Available from: The. Other India Bookstore
Above Mapusa Clinic
Mapusa 403 507, Goa. India
Fax: 91-832-263305
Tel: 91-832-263306
Health for the Millions • March-April 1997 • 12
j
ISSN:0970-8685
‘Net Gain’: A new method for
preventing malaria deaths
Priya Varadan is a
free lance uniter
based in Delhi.
Priya Varadan
dited by Christian Lengeler,
Jacqueline Callani and Don de
Savigny. Published jointly by the
International
Development
Research Centre, P.O. Box 8500,
Ottawa, ON. Canada KI 1G 3H9 and
lheWorld Health Organization, 1211
Geneva 27, Switzerland, 1996,pp. 189.
Aptly titled ‘Net Gain’, the book
speaks at length about the efficacy
of the Insecticide Treated Nel
technique
(ITN) in malaria
prevention and control. In particular,
it discusses the operational research
and sustainability aspects of ITN
technique at regional levels.
At a time when malaria vaccine is
yet to see the light of the day, and
early diagnosis and treatment with
anti-malarial drugs not proving to be
as successful as expected, ITN
technique offers a new insight into
the control and prevention of malaria.
‘Net Gain’ reviews and discuses,
in its five chapters, the ITN technique
in totality, development, implemen
tation or usage, safety, everything is
there. For all those who want to see
the killer malaria out of this world
one day, this book serves as a guide.
The book is the outcome of an
initiative namely the comprehensive
reviews of operational aspects of
ITNs, from an international workshop
organized by the International
Development Research (IDRC) and
the Training in Tropical Diseases
(TDR) (of WHO, UNDP and World
Bank), to look at the specific research
issues and support of research
proposals.
The implementation experiences
and the promotion in Sub-Saharan
Africa, where ITN interventions have
drastically brought down malaria
deaths. The third chapter titled
‘Experiences of implementation’
Ih-.ilili for Hi-' Millions • M.m li \|>iil l'»‘i; • 40
reviews the
Net Gain
operational *
experiences of
ITN. It discu
sses
input
(includes the of
supply of bednets, staffing
and training F',
etc.) process
and activities to
achieve the
desired results; macro level strategy
(including source of finance and
responsibility for distributing nets and
offering treatment services); micro
level strategies (including information
as to who uses, requirements,
preference, beds-nets, cost effective
ness etc.) monitoring; evaluation etc.
Bed-nets and chemical sprays are
two well known tools in the control
of mosquitoes but are of little effect.
But, the ITN technique has proved
that if these two tools work in
tandem, they can become powerful
weapons to fight malaria.
Countries like Gambia, Kenya are
proofs to ITNs success where malaria
is highly endemic. ITN intervention
has resulted in reduction of mortality
rate of children below five by 63 per
cent.
How does ITN technique work
and how effective is it in fighting
malaria?
The presence of pyrethroids on a
net greatly reduces a mosquito’s
ability to feed through the fabric or
penetrate small gaps in it. An ITN
with large holes protects as well as
an intact untreated bed-net, reducing
biting by 95 per cent. A treated net,
besides preventing mosquito bites,
also kills them.
ITN
changes
mosquitoes’
behaviour to a very large extent,
I n*« 'ntinod
iw«
aiaun*
depending on the exposure
and interaction to insecticide. Trials
show that only few mosquitoes feed,
many especially the female
mosquitoes were killed before or
after their blood meal and the rest
were compelled to leave due to
repellence.
Regarding the resistance to
pyrethroids, the book says such cases
are rare. Incidence of resistance to
impregnated nets should be reported
as it helps in monitoring and
improving the technique.
Explaining the safety and side
effects of pyrethroids, the book says
pyrethroids have no tendency for
bio-accumulation, unlike DDT for |
instance. It break downs rapidly
both in mammalian tissue and soil.
Pyrethroids exposure to skin, I
especially the mucus membrane, ‘
can cause transient tingling
sensation. The first few days of
exposure to the net leads to problems |
like sneezing, nasal irritation etc., but
there are no long-term effects.
The treatment procedure of the I
net is well described. Highlighted in
the form of a box item. It clearly
explains procedure, precautions,
measurement etc. The need for
improvement in the technical aspects,
in terms of standardization, moni
toring etc., are also recommended, j
The success of the promotion of
ITN technique will largely depend on
communication. Again methods of
communication will depend on the
socio-economic and cultural environs
of the region.
After the Sub-Saharan experience,
many countries are considering
incorporating ITN into their malaria
|
control programmes. If rightly
i
implemented the net gain will be
ours too. ■
J
ISSN:0970-8685
RNI:28527/75
...
'J
O'co^
r’<O'*’<on
' ■ 'J c
■
■
■
"*r
z-
Available from
Voluntary Health Assocication of India (VHAI)
Tong Swasthya Bhawan, 40, Institutional Area, New Delhi - 110016
I
TWO-DAY WORKSHOP ON MALARIA CONTROL - INTERSECTORAL
COORDINATION BETWEEN GOVERNMENT AND VOLUNTARY
ORGANISATIONS
VENUE: KING EDWARD HALL, BANGARPET, DISTRICT KOLAR
28 AND 29 JANUARY 1997
REPORT OF THE WORKSHOP:
A two-day workshop on malaria control was held on 28th and 29th
January 1997 at King Edward Hall, Bangarpet.
This workshop was a
collaborative effort of Regional Office for Health and Family Welfare, Malaria
Research Centre, Voluntary Health Association of Karnataka, Catholic Health
Association of India- Karnataka region, Christian Medical Association of India,
Community Health Cell - Bangalore and SIBS and CRUES at Bangarpet.
Representatives of 10 government and 16 voluntary organisations engaged in
community health and development programme of Bangalore and Kolar
districts participated in this workshop.
The programme began with an introduction by Ms. T. Neerajakshi,
Promotional Secretary, VHAK.
The General Secretary of
CRUES,
Mr.
Premanand Thambi welcomed the dignitaries and participants. Each participant
gave a self introduction and then shared briefly about their role in improving the
health status of the community.
To enable greater understanding and active
involvement, the workshop was conducted in regional languages (Kannada and
Telugu).
Dr. K. Ravi Kumar, C.M.O, Regional office of H & F.W during his inaugural
speech traced the history of malaria and emphasised that the malaria problem
cannot be solved without the active participation and involvement of community
and voluntary organisations. Underlining the main objective of this workshop
which is intersectoral coordination he called upon the community and the
voluntary organisations to complement and supplement the efforts of
Government organisations in the control of malaria. Ms. T. Neerajakshi
reiterating the objectives of the workshop, requested the voluntary organisations
and government to work hand in hand to combat the malaria problem. She said
the workshop sessions would explore the malaria problem in Kolar district, its
transmission, what measures have been undertaken, problems faced by the
government, alternate strategies of malaria control, Bio environmental control,
role of community and voluntary organisations in strengthening the control
programme. She also stressed the need for goal oriented action plan involving all
the functionaries.
1
Later Dr. Ravikumar briefly shared his experiences regarding malaria and
it’s control and encouraged the participants to similarly express their views and
experiences. The participants shared about the people’s perception of malaria,
what they do at the village level, medical aid seeking pattern, superstitions and
beliefs etc. They also opined the need for creating awareness and emphasized
the collaborative efforts of voluntary organisations and Government agencies in
reducing the mortality & morbidity due to malaria. Productive Human resources
can be conserved by controlling malaria menace. It should be a joint effort of
Government and Voluntary Organisations.
Mr. Nagaraj representing the District Malaria Control Officer, described
the malaria problem during pre and post-independence periods and emphasised
that malaria control programme was one of the National Health Programmes
which has resulted in bringing down the incidence of illness among vulnerable
groups such as children, young adults and socio-economically backward groups.
Further he lamented that since enough health education was not imparted
regarding D.D.T spraying and the community participation was poor, there was
sudden rise in malaria cases in 18 PHCs of Kolar district. He concluded by
proposing the following areas which voluntary Organisations can share the
responsibilities •
•
•
•
To co-operate in the collections of smears,
Blood testing
Treatment of disease
Implementing the Bio-environmental control methods
Dr. Khazi, Medical Officer of Kyasamballi PHC briefed about the systems
adopted by government to control malaria and three phases
1. Malaria Eradication Programme of 1958.
2. The objectives of Modified Plan of Operation 1975
a) . Encompassed decreasing the death rate due to malaria.
b) . Bring down the incidence of P. falciparum malaria.
c) . Decreasing the morbidity rate.
3. The objectives of Malaria Action Programme of 1995 are
a) . Identifying the problematic areas.
b) . Establishing ( starting) malaria clinics.
c) . To consider health workers of voluntary organisations as voluntary
link workers.
Dr. Ethirajulu felt sorry that though we are nearing the 21st century,
malaria problem which had been described early in the 7th century was still
around.
Only 25% of the population are aware of the problem and
consequences. He also explained the stages (Hot, Cold, Sweating) and the
types (Mixed infections of malaria, severe malaria and Cerebral malaria).
2
Dr. Krishna Kumari, LM.O of Robertsonpet narrated the consequences of
malaria problem on mother and child.
Dr. K. Ravikumar, C.M.O, Regional Office for Health and Family Welfare ,
clarified certain doubts and misunderstandings of the participants. He also
satisfactorily answered the questions raised by the participants.
During the post-lunch session Dr. Sathyanarayan and Mr. Reddy of
Malaria Research Centre explained the work undertaken since last five years in
Kolar district regarding the malaria control using bio-environmental control
methods.
The Participants were then divided into 4 groups and each group in turn
was appraised on the following areas.
1. Microscopic examination and identification of vector mosquitoes and its
life stages, mode of transmission of malaria.
2. Life cycle of malaria parasite.
3. Bio-environment control methods emphasizing on release of larvivorous
fishes for malaria control.
4. Poster session on malaria control.
The group discussion facilitated the participants to know the details of
mode of transmission of malaria, signs and symptoms, control methods, the
treatment component and all other aspects of malaria problem. This
knowledge was further strengthened through projection of slide shows.
(ANNEXURE-3)
The day’s programme
highlighted the following -
came to an end with the video show which
What is malaria ?
Malaria signs and symptoms
Mode of transmission
Life cycle of malaria parasite
Control measures
Bio-environmental measures
Preventive measures
Treatment
Resistance level
Environmental sanitation in rural and urban areas.
3
On the second day, programme started with a quiz on the exhibition and
demonstrations by the MRC team. This was conducted by Ms. Neerajakshi and
Mr. Anand to assess the participants comprehension of previous day’s afternoon
session and clarify the doubts that still persisted among the participants. There
was good response to the same.
Dr. Koradhanyamath from Bangalore Medical college and Mr. Reddy from
MRC cleared the questions and doubts put forth by participants.
Government perception of malaria control was then shared by Dr. Khazi
and Mr. Nagaraj. Continuing, Dr. Khazi detailed that for every 5000 population
there is a male and female health worker who will visit the village once in a
week. He also stressed the importance of information dissemination, education,
and communication strategies imparted into health education and the need to
sensitize people that the malaria problem is not an individual problem alone but
a community problem and thus the community plays a very important role in
controlling malaria. Dr. Khazi also emphasised the significance of taking blood
smears, correct address of the patient for prompt treatment (presumptive and
radical) of the migrants and labourers, Microscopic examination of blood smear
and follow-up of malaria patient. It is essential to take atleast 10 random blood
smears out of everyWO population. Regular mass blood surveys and identifying
problematic areas can make the workers to concentrate more in that area. Use
of bio-environmental control measures should be emphasised. Establishment of
drug distribution centres in all the problematic areas. He reiterated that there is
an urgent need in running malaria clinics i.e. taking blood smears on the spot, on
the spot blood examination and on the spot medical treatment. This would go
long way in gaining the confidence of the public and at the same time reducing
malaria.
Mr. P. Nagaraj, representing district medical officer, Kolar briefed about
preventive measures, immediate treatment and reiterated the importance of IEC
component and the role of voluntary organisations.
Thereafter the following questions were asked by the participants.
•
•
•
•
Will the government supply the mosquito nets ?
Will the government supply the material for collecting blood smears ?
Is there a honorarium for interested voluntary health workers?
What is the role of education, revenue and health departments?
The above questions were satisfactorily answered by Dr. Khazi and Mr.
Nagaraj. After a break of 10 minutes the participants were divided into 5 groups
to work on an action plan. To facilitate the action plan the following guidelines
were given
•
To enumerate their operational area & specify the villages/clusters if the
villages are too many .
4
•
•
•
Staff strength of the institution and how many would be available for
malaria control programme ?
What are the existing sanghas and associations in their operational area
& which are the ones facilitated by your organization ?
What are the various malaria control programmes that would be
envisaged by your organization in the ensuing next 6 months ?
There was active participation in each group. The Action Plan that emerged in
the 5 groups is enclosed.
The plenary session was presided over by Dr. Koradhanyamath and
plans were then shared with all the participants.
action
Appreciating the active participation and presentation by the groups, Dr.
Koradhanyamath consolidated the group discussions and highlighted
the
following points.
1. Urgent efforts are needed to Complement & supplement the efforts of
Government by Voluntary organisations in malaria control programme.
2. Need to understand the importance of MRC’s studies and promoting
strategies evolved by them.
3. Need to build effective Referral services.
4. Need for Intra-sectoral co-ordination of various departments.
Immediately after the plenary session Dr. Ravi Narayan shared his views with
the participants which are as follows :
•
•
•
•
•
•
•
This programme is a result of collective effort & follow-up of the
meeting held during January, 1996. at Bangalore.
Though after a lapse of one year the programme under reference has
been materialised by the co-operation of many institutions and active
participation of voluntary organisations.
The attempts made by the Kamasamudram PHC and MRC are very
much useful.
Importance of short term planning ( six month programme planning)
He made them realize that such programmes are the responsibility of
individual voluntary organizations and network organization such as
VHAK, CHC, CHAI-K, CMAI and MRC etc. would facilitate the work.
The points that have come out of the group discussion are in black &
white. To realise the same, heads of voluntary organisations should
consider & implement the programme accordingly and undertake the
follow-up action.
Malaria control programme should be on the agenda of KOVAN
meeting.
5
•
•
•
•
•
•
•
•
•
•
•
Under the malaria control programme, the following should be
planned, organised and implemented.
-IEC
- Identification of cases
Treatment
- Bioenvironmental control
- Intra-sectoral coordination
Strengthening the existing street theatre group of MYRADA, CRUES,
Sunanda organisation by training in effective communication so that
they can actively participate in Jathas.
If the action plans envisaged are successfully accomplished, the same
may be replicated elsewhere.
June has been declared as a malaria month.
Follow-up programme would be held during July 1997.
Ms. Neerajakshi clearly stated that network organisation would only
act as catalyst & would give the technical support. She welcomed the
suggestions.
Dr. Khazi was confident that the voluntary organisations in Kolar
district are active & with their help malaria clinics could be established.
Mr. Premanand Thambi was of the opinion that voluntary organisation
working at the border areas of
Kolar district may undertake
bioenvironmental control methods as well.
Mr. Reddy outlined the implications of above suggestions & said such
activity involved the permission of DHO of respective district.
Mr. Ramamurthy suggested that official letters should be sent to all
the PHC s which come under malaria problematic area.
Mr. Nagaraj offered to extend all possible help from district malaria
office.
Mr. Premanand Thambi then requested Mr. 'Lion' Nanda, a well known
citizen of Bangarpet to address the participants. He said that programme
should be understood properly ,and we should share the information with others
& serve the rural people. He emphasised that we should practice what we
preach to others & called upon all to take up the programme immediately.
Vote of thanks was proposed by Mr. Premanand Thambi to one and all who
contributed directly & indirectly for the success of the programme.
* **
6
ACTION PLAN
CMAI
rPoccna
hVikas
MRC
CRUES
KOLAR ACTION PLAN
FVakruf
FOR MALARIA CONTROL
SURD J
/ I
\ V[SIBS
Group One:
Group discussion :
a) S.B.M Education Society : Working in 12 villages of Mavalu and Sulikunte
gram phanchyats. It has a staff of 6 persons. Two of them can be spared for
malaria control programme. As other sanghas and associations are not
existing in their area of operation, they have established mahila and youth
sanghas.
7
b) MYRADA : Working in 150 villages of Kamasamudram and Budikote hobli
of Bangarpet Taluk . It has a staff strength of 30 persons and it can spare 15
persons for malaria control programme. Mahatma Gandhi youth Sangha
was functioning. MYRADA is working through self help groups, women, men,
youth and children sanghas besides mixed sanghas.
c) Sunanda Maitri Sangha : Working in 20 villages of T.Gollahalli panchayat.
It has a staff of 7 persons and 2 can be spared for malaria control
programme. They are working through mahila, young and dry farming
farmers sanghas.
d) Poorna Vikas Samaj: Working in 30 villages around BEML nagara. 4 out of
8 staff can be spared for malaria control programme. They work through
mahila sanghas.
All the above institutions would undertake the following activities.
People’s awareness, health education regarding malaria through exhibitions, film
shows, and charts.
Organizing group discussions and mothers meeting.
Distribution of neem sapling and supply of malaria fish.
Propose to take up the activities mentioned below with the help and
cooperation of government. Their request from the government was:
1. Participation of government staff and officials in various meetings and
activities such as people’s awareness programmes and street theaters.
2. Supply of posters.
3. Related handouts.
4. Audio Visual cassettes.
5. Provision for TV and V.C.R
6. Supply of handouts on time before the transmission season to malaria health
worker.
7. Provide fish and financial help to set up hatcheries for fish.
8. Provide neem saplings.
9. Meetings/Workshops should be organised from time to time by government
officials and networking voluntary organisations.
10. Provide necessary information regarding malaria situation at village level,
drugs and slides and prompt examination of slides collected by voluntary
organisations.
Representatives :
1. S.B.M Education society : Mr. K.M. Ramaiah, Mr. S.G. Venkatesh
2. MYRADA
Shri. G.Subbarao, Smt. Anita Thomas
3. Sunanda Maitri Sangha : Smt. M. Kalyani
8
•
Encourage and motivate the villagers and other voluntary organisations to
actively participate in any Government Programme related to malaria.
Expectations :
•
•
•
•
•
•
•
MRC team to educate and give the necessary training to the villagers
during their sangha meetings.
Posters, charts, slides etc., that are available with the government.
Help the health workers in the distribution of medicines.
Training regarding blood smear examination for the health workers and
supply of necessary material (slides, needles, spirit, cotton, antimalarials
etc.).
Repair of borewells by gram panchayat.
Assistance in getting the fishes.
Extend help to health workers by personal meeting and correspondence.
Group Three
Institutions
1. Prayog - Huledenahalli
2. Prakruti - Mulbagal
3. SURD - K.G. F
4. CRUES - Bangarpet
Group members : Ramamurthy, R.K.Gowda,Veera,
Gurumurthy and James
Paramesh,
Farid Khan,
Prayog : 40 villages of Tekal and Mast! Hoblis. 6 staff members and all would
be spared for malaria control programme. They have mahila, Men, Youth, and
children sanghas.
Prakruti : They work in 25 villages of Duggasandra and Bairakur Hoblis. They
have 17 staff members of which 13 would work for malaria control programme.
They have Mahila and farmers sanghas.
SURD : They work in 150 villages around KGF in Bangarpet Taluk.They have a
total of 50 staff members of which they would spare 25 for malaria control
programme.
•
•
•
•
•
•
Collection of data (malaria cases)
Meet and arrange discussions with health department.
Create awareness through mahila sanghas in problematic villages.
Establish mahila sanghas in all the problematic villages.
Awareness regarding environmental sanitation and safe drinking water.
Motivate people to construct latrines.
9
•
•
•
Awareness regarding bioenvironmental control of malaria using fishes and
encourage villagers to do fisiculture.
Disseminate information regarding malaria through cultural programmes.
Create awareness among school children.
Expectations :
• Audio-Visual support to create awareness among the mass.
• Posters and charts.
• Training to health workers.
• Free drug distribution.
• Technical help.
• Results of blood smears should be declared immediately.
• Staff of Government health Department to be partners.
• Motivate the Gram Panchayat to involve in malaria control programme.
• Preventive measures to be undertaken in all the problematic areas.
Group Four
CRUES : They work in 30 villages and these are divided into 3 clusters, each
comprising of 10 villages ( Tattanahalli Ramalingapura, Kuppanahalli and
Hulibele) 3 staff members out of 15 would work for malaria control programme.
•
•
•
•
•
•
•
•
•
Mahila sanghas, youth, children, farmers and co-operative sanghas would
be involved in this work.
Awareness through street theater and cultural programmes.
Collection of blood smears of all fever cases and act as a link between
Govt. Health department and the public.
Identification of malaria cases through home units and give medical
treatment.
Referral services, preventive measures, school health programmes would
be conducted.
Identifying water collections ( wells, ponds , irrigation pits and tanks) in
and around problematic villages which are the major sources of malaria
mosquitoes and release of malaria fish in these water bodies.
Cleaning of wells and ponds.
Preventing mosquito breeding by introducing EPS beads in all the unused
wells.
Health education and examination of floating population.
10
•
•
•
Staff of Government health Department to be partners.
Motivate the Gram Panchayat to involve in malaria control programme.
Preventive measures to be undertaken in all the problematic areas.
Group Four
CRUES : They work in 30 villages and these are divided into 3 clusters, each
comprising of 10 villages ( Tattanahalli Ramalingapura, Kuppanahalli and
Hulibele) 3 staff members out of 15 would work for malaria control programme.
•
•
•
•
•
•
•
•
•
Mahila sanghas, youth, children, farmers and co-operative sanghas would
be involved in this work.
Awareness through street theater and cultural programmes.
Collection of blood smears of all fever cases and act as a link between
Govt. Health department and the public.
Identification of malaria cases through home units and give medical
treatment.
Referral services, preventive measures, school health programmes would
be conducted.
Identifying water collections ( wells, ponds , irrigation pits and tanks) in
and around problematic villages which are the major sources of malaria
mosquitoes and release of malaria fish in these water bodies.
Cleaning of wells and ponds.
Preventing mosquito breeding by introducing EPS beads in all the unused
wells.
Health education and examination of floating population.
Expectations:
• More co-operation from PHC and Government Hospitals.
• Medicines, slides, needles, cotton, spirit, fish collection equipment ,
antimalarials and health education material should be supplied.
• Regular health checkup camps should be organised.
• Technical support - immediate (within 15 days) to know about fish
collection, blood smear collection .
Group members : D.Venkatesh, Nirmal, Malathi, Lalitha, Shiny and Rosy
Dr. T.S. Sathyanarayan -facilitator.
Group Five
11
Group - Government officials
Governments expectations form voluntary health organisations
1. Voluntary organisations should volunteer to actively participate in malaria
control programmes.
2. Impart health education to population and motivate fever cases to get their
blood examined.
3. Organise group discussion in every village and involve the Govt, staff in
disseminating information.
4. Distribution of posters and charts pertaining to malaria with the help of Govt,
staff.
5. Organise street theaters, Harikathas, Lavnis, songs (folk media) etc.
6. Establishment of fever treatment depot and procure required items
(infrastructure) from the government.
7. Establishment of more and more drug distribution centres in villages and
collect medicines from the state health department.
8. Educate the people to take 4 AO tables for all the fever cases ( according to
age) and encourage them to take 8 AO tables for all identified malaria cases.
9. Educate the population to destroy the breeding places by free flow of
stagnant water, construction of soakage pits and to keep the water tanks
closed.
10. Educate and motivate the people to use mosquito nets (bed nets), neem oil,
window mesh to prevent and control malaria problem.
11. Education regarding bioenvironmental control of malaria and disseminate the
information to people (a) To introduce fishes in irrigation pits, tanks, ponds
and monitor their survival, (b) to introduce EPS beads in unused/neglected
wells.
The group assured to extend all possible help if above programmes related to
malaria control programme are undertaken by voluntary organisations.
Since malaria control programme is one of the National Health Programme, it is
the responsibility of every individual and voluntary organisation to participate in
the programme which is immediate need of hour.
Hence, to effectively
implement the programme Government appeals to the voluntary organisations
for their co-operation and active involvement.
12
Annexure I
Participants of the Workshop
Government organisations :
1. Regional Office for Health and Family Welfare- Bangalore
2. Malaria Research Centre - Bangalore
3. PHC- Kamasamudram
4. PHC - Andersonpet
5. PHC - Budikote
6. PHC - Kyasamballi
7. D.M.Os office Kolar
8. General Hospital - Bangarpet
9. Taluk Medical Officer
10. Department of Preventive and Social Medicine; Bangalore Medical College
Voluntary Organisations :
1. RORES - Srinivasapur
2. Prakruti - Seegenahally ; Mulbagal Taluk
3. Poorna Vikas Samaja - BEML nagar; K.G.F
4. SURD-K.G.F
5. MYRADA - Kamasamudram; Bangarpet Taluk
6. Prayog - Huladenahally ; Malur Taluk
7. SIBS - Health and Rural Development Project: Bangarpet
8. CRUES - Bangarpet
9. TREES- K.G.F
W.Sunanda Maitri Sagar- Gollahally; Bangarpet
11. VHAK-Bangalore
12. CHAI-K - Bangalore
13. CHC - Bangalore
14.5. C.O.P - Bangarpet
15.5. B.M Education Society - Bangarpet
16,Sharada Vidya Niketan - Bangarpet
13
ANNEXURE -2
Demonstrations at the Workshop
Station 1.
Microscopic examination and identification of vector mosquitoes
and its life stages, mode of transmission of malaria. - Dr. T.S. Sathyanarayan
Various stages of life cycle of mosquito were shown to the participants.
The mode of transmission of malaria, breeding and resting habits of anopheline
and culicine mosquitoes were explained. Specific characters of identifying the
anophelines and culicines were shown under microscope. There were many
queries from the participants regarding malaria transmission.
Few
misconceptions such as all mosquitoes transmit malaria, and malaria vectors
breed in drain water etc., were cleared.
Preparation of thick and thin smears and staining procedure Station 2.
- A. Bapaiah
Equipment required:
2. Rectified spirit
4. Cotton
6. Register
8. Antimalarials (chlorquine)for
presumptive treatment.
1. Clean glass slides
3. Pricking needle
5. Slide box
7. Lead pencil
Method :
a) Preparation of blood smears
1. Take third finger of left hand of the patient and hold it in your left
2.
3.
4.
5.
6.
7.
8.
hand between thumb and finger at first phallangial joint.
Wipe finger tip with cotton swab dipped in spirit solution.
Allow the finger to dry.
Hold the pricking needle in right hand and prick the finger gently.
Allow the blood drop to ooze out.
Take clean slide and take three drops of blood one centimeter from
the edge of the glass slide, and take another drop of blood one
centimeter away from the first drop of blood.
Take another clean slide with smooth edge and use it as a
spreader.
Make thick smear by rotating the plain slide over three drops of
blood and thin smear by spreading the one drop of blood at 45°
angle.
14
9. Allow the blood to dry
10 Note the serial number of the patient over the thin smear by lead
pencil.
b) Staining of thick and thin smears
i)
Staining the thick smear:
1. After dehaemoglobinisation (by putting few drops of distilled
water over thick smear and remove the excess water after one
minute and allow the slide to dry)
2. Dip the thick smear in JSB II stain (two to three times).
3. Wash the thick smear to remove the extra stain in buffer water
by gently dipping it.
4. Keep the thick smear in JSB I stain for 45-60 secs.
5. Wash the thick film in buffer water.
6. Allow the slide to dry then examine the slide under oil
immersion under 100X compound microscope using blue filter.
ii) Staining the thin smear:
Thin film should be fixed in methyl alcohol ( by putting 2 drops of
methanol over the thin smear, but care should be taken not to allow the
methanol to pass over the thick smear). Then follow the steps 2-6 of
thick smear staining procedure.
Station 3. Bio-environmental control of malaria - Dr. A.K. Kulshrestha
Bioenvironmental control methods are those that utilise the
naturally occurring biological agents in controlling the disease without
endangering the natural balance.
In the control of malaria at
Kamasamudram PHC area, locally available larvivorous fishes (guppy
available at KGF) were released in all the breeding sites such as
irrigation wells, draw wells, irrigation pits and temporary ponds that were
specifically identified as the breeding sites for malaria vectors. Care
should be taken that no garbage or leaves should be thrown in these
water bodies as that would hamper the larval feeding by the fishes.
Station 4.
Poster session on malaria control. - C.B. S. Reddy
Various strategies used in malaria control and their limitations
were explained in detail to all the participants. All the participants were
highly enthusiastic and freely exchanged their views.
15
Duties and responsibilities of village Health Guides :
1. The village health guide will make the thick and thin smear on glass slide
2.
3.
4.
5.
6.
from all fever cases reporting to him for treatment.
Administration of a single dose of antimalaria drug to the patient
(recommended dosage) as a presumptive treatment.
Keeping a detailed record of individual cases in duplicate along with the case
history.
Report any death due to fever in the village to the PHC medical officer.
Assisting the spray teams during Insecticidal operations by motivating the
community to accept the Insecticidal spray.
Imparting health education to the community on malaria- the disease, its
symptoms and its control for minimising the mosquito breeding and for
observing the personal protection methods
16
J
In the quiz programme the participants answered well showing that they
understood most of what was taught to them.
Annexure - III
Quiz
Questions:
1. What do you mean by malaria ? What are the symptoms of the disease ?
2. What will you do when you are attacked by malaria ?
3. What is the root cause of malaria ?
4. If malaria is spread through mosquito is it culex or Anopheles mosquito that
transmits the disease ?
5. Whether both male and female mosquito spread malaria ?
6. Where do malaria mosquitoes breed ?
7. What do male and female mosquitoes eat and Why ?
8. What is the approximate life span of a mosquito ?
9. During its life cycle how many days does a mosquito spend in water ?
10. In what type of waters does the malaria mosquito prefers to breed ?
11. Which method do you suggest to control adult mosquito breeding ?
12. What method do you suggest to control mosquito larvae ?
13. What is the meaning of bioenvironmental control ?
14. Where do you find malaria fishes ?
15. When there is malaria problem if you are given malaria fishes, in where all do
you release them ?
16. What precautions would you take before and after release of malaria fishes in
mosquito breeding sites ?
17. Are the malaria fishes introduced in water are of edible type ?
18. Where can you put EPS beads (Expanded polystyrene beads) and how does
it control mosquito menace ?
17
Annexure IV
DISTRICT MALARIA CENTRE : KOLAR DISTRICT
* Malaria indices in Kolar District
Year
Pop.
B.S.Ex
Pos.
P.f.
ABER
SPR API
P.f.
R.T
Spray
97.2
97.3
96.8
96.3
94.5
48.7
45.8
33.7
21.7
%
1992
1993
1994
1995
1996
2081532
2211300
2211300
2234545
2290942
419308
395490
339139
387213
413903
29586
23830
19200
16563
18600
7269
3852
3736
4154
4775
20.4
17.8
17.4
17.3
18.0
14.4
10.7
8.6
7.4
8.1
7.0
6.0
4.9
4.2
4.4
Taluk - wise malaria problematic PHCs (18 PHCs)
1.
Bangarpet Taluk
Kamasamudram
Budikote
Adersonpet
Kyasamballi
4
2.
Malur Taluk
Malur
1
3.
Mulbagal Taluk
Devarayasamudra
1
4.
Srinivasapura
Kooregapally
1
5.
Chintamani
Kaiwara
Batlahally
2
Bassettyhalli
Sadali
2
Dibbur
Peresandra
2
6.
7.
Sidlaghatta
Chikkaballapura
8.
Gudibande
Gudibande
1
9.
Bagepally
Gulur
Bagepally
Pathapalya
Chelur
4
18
24.5
16.1
19.1
25.0
25.6
!■
I
Vacancy Positions in Kolar district:
8. No
Name of the Post
1
2
3
4
5
6
7
8
9
10
Junior Health Asst. (M)
Senior Health Asst. (M)
Senior Malaria Inspector
Health Supervisors
J. H. A (F)
S. H. A (F)__________
Jr. Lab Technician_____
Sr. Lab Technician
Jr. Pharmacist________
Sr. Pharmacist
12.1.97
Sanctioned
Working
vacant
282
72
4
4
552
90
77
10
126
18
199
30
1
1
515
66
14
2
57
12
83
42
3
3
37
24
63
8
69
6
to 19.1.97
PHC_________
Kamasamudram
Kyasambally
Adersonpet
Budikote
MF - 1 (Pos.)
11
20
17
2
***
19
P.v
10
18
12
2
P.f
1
2
5
To:
Malaria Expert Group, VHA1
Malaria Reference Group
Study, Reflection Action Group - Karnataka.
A MALARIA MONTH COMMUNICATION
June 1997
Dear Friends,
This newsletter comes to you in the 'Malaria month (June 1997) to keep in touch
with all of you and keep you informed about initiatives and developments since the
March 7th meeting at VHAI when the Malaria Expert Group (MEG) presented the key
findings and reconunendalions of the MEG Report to policy makers from NMEP, MRC,
VCRC.
mwAwns an ArTRnruiAir
MAI.ARIA COMWm. SIRAtrnY'
It**** «4 C***♦*■ w»4
1. MEG REPORT PUBLICATION
fw aHten
wnww •
I
The process of publication of this report, to
disseminate our findings and recommendations and to
lobby for change has been undertaken by VHAI. An
executive summary of the report and a report on the
7th March meeting have been incorporated into the
publication. This is expected to be out of the press
shortly. Write to Dr. Sehgal or Dr. Mira Shiva at
VHAI, New Delhi, for further details.
KARNATAKA
2. MEETING WITH VOLUNTARY AGENCIES IN
BANGALORE DISTRICT
CHC (along with VHAI, CMAI, CHA1-KA, MRC and
Regional Office for Health and Family Welfare)
' organised a days workshop on 22nd March 1997 for all
the voluntary agencies and institutions in Bangalore
district to explore ways and means to increase their
involvement in Malaria control. The chapter of the
MEG report on "The Role of Voluntary agencies in
Malaria control" was distributed as a background. Dr.
Murugendrappa, Joint Director - Malaria & Filaria, Dr.
S.K. Ghosh - Officer Incharge, Malaria Research
Centre, Bangalore, and Dr. Ravi Kumar of the Regional
1
rflwgj-
Office for Health and Family Welfare were resource
persons for the workshop. The participants explored
various ideas for the involvement of their institutions
in Malaria control (separate report available on request
from CHC, Bangalore.)
3. CME IN RATIONAL MALARIA TREA^FMENT
CHC organised a CME programme for postgraduates
from all tlie medical colleges in Bangalore on 26th May
1997 and one of the themes requested by them was
Rational Malaria Treatment.
Drs. Cecil Ross
(Department of Medicine, St. John's Medical College)
and Dr. Ravi Narayan (Coordinator, CHC) covered
this topic. The chapters of MEG - 'Towards a Rational
Drug Policy for Malaria' and 'The Mefloquin issue'
were distributed as background paper.
4. HEALTH COMMUNICATION WORKSHOP AT
BANGARPET
Dr. Uma, freelance health trainer who has evolved her
own creative method of training grass root health
workers through innovative communication methods,
games and group activity took a special 3 day session
with ANMs and health workers of government and
voluntary agencies at Bangarpet in April 1997, in
collaboration with VHA-Karnataka. While Malaria
was the focus of the training, Dr.Uma's methods can
be adapted to different problems and situations.
(For further details write to CHC or Thread - Orissa for
copies of her 6 volume training manual (Rs. 600-00)
which covers:
•
•
•
•
•
•
Community Organisation and
Volume 1
Participation
Volume 2 - Preschool Education
Volume 3 - Community Health & Immunisation
Volume 4 - Nutrition
Volume 5 - Women and Child
Volume 6 - Water and Diseases
2
,
5
to
6.
LAK TECHNICIANS ORIENTATION COURSE
As a follow up to the Bangalore district meeting (see 2)
and with special reference to improving the Malaria
diagnostic skills of Laboratory technicians in the
voluntary agencies / hospital network in the State, the
first of a series of orientation and skill development
training programme was organised for 10 lab
technicians from 8 institutions of the voluntary sector
at the Regional Office for Health and Family Welfare,
Bangalore, particularly at the initiative of Dr. Ravi
Kumar of the Regional Office and Dr. Sukant Singh of
CMAL This was a small but meaningful initiative in
government-voluntary agency collaboration and we
hope there will be many more of such events in the
months ahead.
(For a copy of the programme and or a small booklet
for lab technicians on Malaria diagnosis in Kannada,
write directly to Dr. Ravi Kumar, Chief Medical
Officer, Regional Office for Health & Family Welfare, Il
Floor, 'F' Wing, Kendriya Sadan, Koramangala,
Bangalore - 560 034).
MALARIA
MONTH
JUNE
1997
PREPARATIONS FOR CELEBRATION
r.- ' j
You must have all received a letter from Dr. P.N.
Sehgal of VHAI informing you in March 1997 about
the decisions of NMEP/Ministry of Health and Family
Welfare to designate June 1997 as Malaria Month and
also some suggestions for action initiatives. I am sure
many of you are involved in such initiatives during
this month and we look forward to getting news from
you to include in the next occasional newsletter.
In Karnataka, the Directorate of Health constituted a
special Committee to plan activities for the Malaria
month in which CHC and VHAK were included.
VHAK has also sent a letter to all its members to
observe the month through awareness building
activities.
Our focus has been particularly on
Bangarpet Taluk of Kolar District where two
workshops held for NGOs in May 1997(orientation)
and then June 1997 (planning local action plan) has led
to a generation of enthusiasm in this sector and the
3
c
potential of
collaboration.
increasing
government
NGO
(Copies of the proceedings of the Planning workshop
are available on request from CHC or VHAK
Bangalore).
7’
^3
cX
MEDICO
FRIEND
CIRCLE
PLANNING
SESSION
ON ANNUAL MEETING ON
RESURGENCE OF INFECTIOUS DISEASES.
A small group of southern members of medico friend
circle organized a day's brainstorming at CHC on 5th
April 1997 to explore the various factors that are
contributing to the resurgence of infectious diseases in
India including Malaria, Dengue, TB and a host of
others. The Annual Meeting which is proposed to be
organised at Sevagram, Wardha, in December 1997
will explore particularly the socio-epidemiological
aspects that are contributing to this resurgence.
(For further particulars and a copy of the perspective
document for the meeting, kindly contact Dr. Anand
Zachariah, Lecturer, Department of Medicine,
Christian Medical College, Vellore - 632 002).
WORKSHOP
8. THE_______ 1TMN
BHUBANESHWAR (MARCH 1997)
AT
A workshop was organised by ODA/CARE in
Bhubaneshwar in mid March to review the experience
of the ODA/CARE project trial of promoting the use of
Insecticide treated bed nets in Keonjhar District in
Orissa.
An independent evaluation had been
conducted by a CMAI team which was presented at
the Workshop. Experiences of MRC in Assam and
Maharashtra government of the Mitra programme
Bissamcuttach (Dr. John Oomen's initiative) was also
presented. The MEG report chapter on ITMN's was
circulated as a background paper (for a copy of the
proceedings of the workshop, please write to Ms.
Alison Dembo Rath, Health Officer, Project
Management Office, Orissa Health and Family
Welfare, 57 Forest Park, Bhubaneshwar - 751 009,
Orissa.)
4
?
(
J
J
ORISSA
PLANS FOR MALARIA CONTROL IN ORISSA
(RUHSA)
Dr. Abel of RUHSA has written to us about their
initiative of planning with NGO partners in Orissa.
Broad objectives have been developed and some long
term plans in which 'malaria control activities' will be
included are being drawn up. 12 NGOs were trained
in smear technology. During malaria month, they plan
to distribute messages relating to Malaria in Oriya and
disseminate them as much as possible through NGOs.
Plans to hold one day malaria workshop for NGO
personnel in most districts of Orissa are also evolving.
io. INTERNATIONAL MALARIA MEETING AT
SECUNDERABAD
AND
CENTENARY
CELEBRATIONS
OF
RONALD
ROSS
DISCOVERY (18-22 AUGUST 1997)
An International Conference on Malaria is being
organised from 18-22nd August 1997 at Secunderabad
to commemorate the centenary of Ronald Ross's
discovery of the Malaria parasite in the female
anopheline mosquito. The Conference is expected to
have papers on all aspects of malaria. On 20th
August, there will be a release of a commemoration
stamp, unveiling of a statue of Ross on the lakeside,
dedication of a memorial building (which is the
renovated laboratory in which the discovery was
made) that has been made possible by a partnership
between Osmania University, INTACH and British
Council. It will be an opportunity for some of us to
raise the key issues of concern and suggest alternatives
for malaria control from the MEG report and all the
evolving action thereafter.
4
• o'Az
(All those interested to participate or get more details
of the Conference should write to Dr. V.P. Sharma,
Director, Malaria Research Centre, 22 Sham Nath
Marg, Delhi - 110 )
published
a
If
any
of
you
have
book/booklet/newsletter/journal or article on Malaria
5
hi
that needs wider circulation, this may be a good
opportunity. Perhaps you should write to Dr. V.P.
Sharma and explore this possibility further.
11. THE NEXT PUBLICATION FROM THE MEG
PROCESS
With the assistance of Dr. Madhukar Pai, a
Community Health Physician, a malaria enthusiast,
who recently completed his M.D.
- Community
Medicine from Christian Medical College - Vellore
and is presently with Sundaram Medical Foundation
in Chennai, we are in the process of editing the next
publication arising out of the enthusiastic, original
responses received from so many of you to the Malaria
Expert Group process we facilitated last year. The
publication presently entitled "Malaria in India Reflections, responses and the quest for alternatives"
. consists of all the experiential and innovative action
oriented articles that have been further edited to
highlight a range of ideas and alternatives. The
editorial team consists of Madhukar Pai, Dr. C.M.
Francis and myself. We are all happily surprised at the
continuing enthusiasm and the prompt responses from
so many of you to our suggestions for modification of
the article or approval of the edited version of the
chapters. We have identified a potential source of
funds for this publication and we hope that the final
manuscript can reach the press by early July 1997.
12. HFM - SPECIAL ISSUE ON MALARIA AND
TUBERCULOSIS
The Health for the Millions special issue on Malaria
and Tuberculosis has just arrived (Vol. 23 No.2,
March-April 1997). It includes articles by Dr. Mira
Shiva (Policy concerns), Dr. P.N. Sehgal (Executive
summary of MEG report). A brief report on Malaria
outbreak in Mewat and a book review of 'Netgain' an
1DRC/WHO publication.
(If you have not already received a copy, please write
to the Editor, Health For the Millions, Voluntary
Health Association of India, 40 Institutional Area,
South of I1T, New Delhi -110 016.)
6
KiS
I
13. HEALTH ACTION, SPECIAL ISSUE ON
PEOPLE -VS- MALARIA (Volio, No.6 June 50)
a
has just been released. It consists of a cover story
Malaria Control : People -Vs- Malaria that outlines the
recommendations of the MEG, an interview that
emphasises that /Topdown solutions won't do", a
review of the bio environmental option, a case report
from the Mitra People's Programme for Malaria in
Bissamcuttack, Orissa and an overview of Herbal
remedies for Malaria.
(If you have not seen a copy, please write to the Editor
I Circulation Manager, Health Action, Post Box
No.2153, 157/6 Staff Road, Gunrock Enclave,
Secunderabad - 500 003).
14. CLEARING DOUSE FOR MALARIA RELATED
PUBLICATION
CI IC continues to receive Malaria related publications
from all over the country and the world. A list of
recent arrivals is enclosed [seeAppendix A). For
further details or copies write to the authors/publisher
directly, or to CHC for further information. Please also
post us any publication, papers, handouts, that you
produce during your continuing involvement in
Malaria control so that we can include them in future
communication
15. TOWARDS AN ALTERNATIVE NMEP
o
Prof. N.S. Deodhar, Retired Director of All India
Institute of Hygiene and Public Health, Calcutta, has
written to us in response to the receipt of the MEG
report with some provocative and valuable
suggestions based on years of experience in Public
Health in India . We circulate his comments (see
Appendix B)to stimulate a discussion on his
suggestions. Please send your response to him (Dr.
N.S. Deodhar, Consultant, Health Science Services,
Management and Research, 134/1/20, Banar Road,
Aundh, Pune - 411 007, Maharashtra) with a copy to
CHC.
7
We may use the opportunity of the medico friend
circle Annual Meeting to work on a more definitive
alternative based on his suggestions as the next step of
the collective process.
Finally, you must have read recently that World Bank has okayed a loan of around
163 million dollars for the Malaria programme in India. Being a Ioan, it is even more
important that the funds obtained are used for the most meaningful, relevant and
effective strategies for malaria control, in areas of greatest need. The NMEP project
report "Strengthening Malaria Control in India" already outlines the main
framework of this World Bank supported project. All of us need to be involved in
whatever way we can organise our involvement to make sure that the project is
effective - be it through collaboration as health activist, awareness builder, issue
raiser, alternative trainer, researcher, policy maker or grass roots health action
initiator. Through our efforts, we could help to evolve an alternative NMEP that
works. Every small effort will be a contribution to the grand strategy of Malaria
Control that is urgently required. We would like to be involved and informed about
all that you and your network of associates do. The MEG report and each of its
chapter can be freely used in all your actions. The published version from VHAI
will also be available soon to help in your efforts.
We hope that through this Newsletter we can do our little bit to keep you all in touch
with each other.
With best wishes from the CHC team and hoping our solidarity in health action
including malaria control will grow.
Yours sincerely.
Ravi Narayan,
Coordinator.
^£5EA^-
peek.
0
o
0
APIP’ENDKX
A
Publications on Malaria received by QIC in recent months
1. Souvenir and Abstracts of Third National Seminar on Malaria and other Tropical
Diseases (UGC/Bangalore University), February 1997
(for a copy, write to Prof. N.R. Shelly, Society for Applied Genetics, Centre for
Applied Genetics, Gnana Bharalhi, Bangalore University, Bangalore - 560 056)
2. Health Action Special issue People -Vs- Malaria, Vol.10, No.6, June 1997 (Rs. 15/-)
3.
Health for the Millions Special issue on Malaria and Tuberculosis, Vol.23, No.2,
March-April 1997.
4.
Public Health Technical Information Series No.12, by Bayer AG Germany. Mam
theme : Use of impregnated bednets for Malaria Control.
5.
An AHRTAG/PATH directory of Insecticide Treated Nets for Malaria Control for
Subsaharan Africa (suppliers of insecticide mosquito nets), AHRTAG, London, 1997.
6. Muraleedharan V.R. & Veeraraghavan D., (1992) - Anti Malaria Policy in the Madras
Presidency:An overview of the early decades of the Twentieth Century. Medica 1
History, 1992, 36, 290-305.
7.
Hamare Chilli Apke Naam (I ICAN) - A newsletter for Health workers - special
issue on Malaria, July-September 1996 (Hindi version). Write to VHAI for a copy.
Or to VHAK- Bangalore, for a copy of the Kannada version.
8- "Malaria' - an Anubhav series publication (experiences in Health and Community
Development) from VHAI, New Delhi. Write to VHAI for a copy.
Malaria Control - capacity building in community based NGOs / workers - a
booklet in English/Hindi from VHAI, New Delhi.
/
10. Malaria Control - An attempt - a booklet from NMEP/DGHS, Ministry of Health &
Family Welfare (Government of India), 1996.
9.
11. Videos from Malaria Research Centre, Delhi for Health Education.
(The topics include: (a) Fighting Malaria; (b) Insecticide Impregnated Bed Nets for
Malaria Control; (c) Man Made Malaria; (d) Community Participation in Malaria; (e)
Life Cycle of Malaria Parasite; (f) Global Malaria Control - An approach Plan; (g)
The Microscope; (h) Flow to make a blood smear & stain for Malaria Parasite, (i)
How to treat Uncomplicated Malaria; (j) Cerebral Malaria; (k) Malaria in Pregnancy;
(1) Laboratory Diagnosis of Malaria; (m) Malaria - Spread the Knowledge).
9
I
Appendix JB>
Towards ah Alternative NMEP
......... I feel that it is essential for some of us to meet and deliberate on important and
critical issues. Just one illustration. What is the role of "surveillance" in the current
situation? Always one desires to go back to old days surveillance. NMEP goal of
eradication is no more. The old surveillance was designed to delect each and every case
of malaria and treat it radically. The aim was to wipe out the parasite plasmodia - thing
that we did to smallpox virus. We wanted to reach a stage when we might have the
vector mosquitoes, but no parasite, and malaria is gone. Incidence figures, we got, but
as a bye-product. Coverage was near complete in mid-1965. Now nothing holds good.
MPW approach and integration cannot be taken back. In fact, it will be a great mistake,
a blunder, strategically and epidemiologically.
There are two things we have to attain. One is to treat cases, reduce morbidity and
eliminate malaria deaths. Secondly, prevent epidemic outbreaks, and control malaria
transmission so that the disease loses its public health importance. In other words, learn
to live with malaria at a very low ebb. If so, what do we do?
a) Separate out "curative" management from the "control" operations.
b) bully integrate the services/programme into general health services.
c) We can easily work out "curative" portion (with the above objectives), fully
involving the people, panchayats, LSGs, NGOs and decentralization of operations.
d) "Control" components need to be considered afresh. We have to give up once for
all, control of adult vectors with sole emphasis on insecticides. In fact, we have to
shift from malaria control to vector control programme. We have to largely depend
on the engineering interventions with cumulative impact, and the control of
breeding has to be the main thrust. We have the technology.
e) Strategy and preparedness for early detection and abatement of malaria outbreaks
and epidemics.
f) 1EC drive, integrated, to inform the people on prevention and minimizing manmosquito contact.
We have to be specific and on focus. Patch work will not do.
Prof. N. S. Deodhar.
D 0 II
10
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