LEPROSY
Item
- Title
- LEPROSY
- extracted text
-
RF_DIS_8_PART_1_SUDHA
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Social Medicine
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L
PLANTAR ULCERS IN LE9R0SY
The ulcers on the under surface of the feet in patients
who suffer from leprosy are peculiar in their formation.
These ulcers can occur even in patients whose leprosy is
completely cured. So it is not directly related to leprosy.
It is the result of the damage to the nerves. In early stages
nerve damage can be corrected but afterwards even with good
treatment the nerve damage can be corrected only partially.
Normally when a person walks9 concertrated pressure, is
applied on the underlying tissues over the bony promini^^.is
The small muscles inside the foot will contract and maintain
the bones in their position and so unusual pressure does
not fall on bony premininces.
If the skin is sensitive, damage to the tissues produces
pain over that area. This is the warning signal of the body
telling the patient that damage has occured and that part of
the body needs rest or attention.
Because of the nerve damage that occurs in some patients
who have lenrosy, the skin of the foot become insensitive and
the patient can not feel pain, The muscles also become weak
and cannot keep the foot bones in their proper position, The
bones which are deformed hit the skin and the tissues under
them whenever patient walks, runs or jumps. This will damage
the tissues and the tissues are destroyed and ous form. Once
the ous reaches the skin, the skin will break with any slight
injury, and the ulcer bcs^^avisible. So the ulcer is already
formed within the skin much before it is seen outside, Once
the ulcer has formed other germs from the soil etc. $ill get
inside and the ulcer become septic, If not treated correctly
the natient will get swelling of the feet and sometimes fever.
During this stage the patient usually walk since there is no
uain. This will allow the germs to enter deeper parts of the
foot and the whole foot becomes septic.
With good treatment and comolete rest the ulcer will heal
but with a tough scar. This scar is not good to protect
the tissues since it behaves like a pebble under the skin.
This will oroduce tissue damage again as before. But this time
the patient will get ulcer faster unless he takes adequate
precautions. The important precautions and facts to remember
are: 1. Even if the patient*s leprosy is cured he can get
ulcers if the nerves of the foot are damaged.
cont1d
2
. .2
2. Treatment of leprosy alone will not prevent ulcers or cure
them once it has already formed.
3. It is much better and easier to prevent a palntar ulcer
than curing it.
4. More damage^ to the foot, more care to be taken to prevent
new ulcers.
5. The ulcers are due to walking and running oressure with
feet which have damaged nerves. In most, damage cannot
be corrected fuUyz So other measures are to be taken.
Most important of these are:
ao
To walk as "itfe as necessary
b. To walk as slow as possible
c. Not to walk for long distances at a stretch
da To take short steps while walking.
e. Never run or jump
f. If Possible to use a cycle and out pressure overthe
heal or other undamaged area.
g^ Every .day in the evening cress the different areas pf
the so’e and check for deep pain. If deep pain is
present over any points it is certain that an ulcer is
being formed under the skin there. At this staoe if
the patient takes rest the ulcer will not form at all.
FOOT WE^R
I ENTS WTTH FA4A ED NERVEf STTOU1:D WE*R FOOT WEAR,
The following points are important.
1. No nail or thread should be used while making the
footwear. Instead only adhesives should be used.
2 . The so1 e, if made of microce.U ular rubber will have a
better nrotective effect- of
of feet.
- the
-- tissues
------ the
3. The foot wear should be 'worn-in'. That means the
person should we r the chaonals for short periods till
the foot wear becomes soft and the feet adjusts to
the foot wear.
4. The footwear should be made according to the individual
oatients needs eg. an expert cobbler can make foot wear
which takes away pressure from ulcer orone areas.
5. The correct foot wear will only help to reduce the•chances
of ulcer formation. 3o all’ other measures should be
carried out meticulo isly even if the person uses correct
foot vzear.
D)-s> &«.■
surveillance including relapses on monotherapy and MDT; bacteriological enumeration;
hospitalization facilities; rehabilitation; training inputs; mo- 'ring and supervision.
Analysis of operational information provides inlormaliv on programme function.
r This information provides valuable clues to the estimation of the leprosy problem
through data routinely available in most countries and provides programme managers
with a rapid assessment. This has been demonstrated by experience gained in India, the
Philippines, Papua New Guinea, I'iji, Western Samoa, Tonga, the Cook Islands and also
Vanuatu.
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The epidemiology of disability in leprosy
including risk factors
W C S SMITH
Introduction
It is disability which sets leprosy apart from other diseases,1 and a control programme
cannot be successful if it fails to control disability. Disability is a very relevant
measurement of progress in leprosy control.2 To the lay person leprosy means deformity3
and leprosy without disability is often not recognized as leprosy by the general public,
even in the untreated lepromalous stage. Il is quite clear that disability is an important
measure in the evaluation of control however, to be able to use this fact, it is necessary to
be able to define disability, and correctly measure it, and to understand its determinants
and distribution. In particular, it is important to understand the evolutionary process of
disability in individuals and populations in order to estimate the impact of various
interventions on disability in leprosy.
Definition and measurement of disability
It is rare to find in the leprosy literature a definition of disability other than the alteration
of function as opposed to deformity which is defined as the alteration of shape. Most of
lhe disability literature in leprosy lists items rather than considers definitions and these
lists include deformity as well as disability, and changes in anatomy and physiological
function.
An International Classifications of Impairment, Disability and Handicap (IC1DH)
has been developed’4 in parallel to lhe development of lhe use of lhe term disability in lhe
leprosy world. This classification introduces concepts of disability related to rehabili
tation in contrast to lhe strictly descriptive definition used in leprosy. The International
Classification uses the following definitions:
a. Impairment
b. Disability
c. Handicap
‘Any loss or abnormality of psychological, physiological, or anatomical
structure or funclion’—WHO, 1980;
‘Any restriction or lack (resulting from an impairment) of ability to
perform an activity in lhe manner as within lhe range considered normal
fora human being' WHO, 1980;
‘A disadvantage for a given individual resulting from an impairment or
disability, that limits or prevents fulfilment of a role that is normal,
depending on age, sex, and social and cultural factors for the
individual' WHO, 1980.
0305-7518/93 063023s+ 08 $01.00
('/ Lepra
23s
24s
W C S Smith
It can be seen from these definitions that what leprologists call disabilities are j
probably regarded by the ICIDH definition as impairments.
;
Thus the whole system of approach to disability terminology in leprosy differs from I
that now recommended by the World Health Organization. The approach used in leprosy 1
is suitable for measurement and description of disabilities, and for epidemiological |
purposes, however, it fails to incorporate the concepts of rehabilitation, which is a major J
deficiency. Thus a weakness in a muscle group may be seen as a disability to be corrected J
surgically rather than developing an understanding of what this functional loss means to
that individual patient, if anything at all.
?
A number of scales of disability assessment have been developed5 7 and it is clear that 1
none arc considered adequate by all as new modifications arc developed.8 It may be j
considered that no system is ideal when so many have been developed or, perhaps, that 'J?
different scales are developed for different purposes. There are two major purposes for j
measurement of disability and each require different tools. The first is the simple grading J
of the level of disability—this can be carried out quickly in the field and gives a rough jj
assessment of disability. The second is a measurement tool which is sensitive enough to ^1
measure change in disability. The first tool cannot do this but if the first purpose is the one M
required then the more detailed assessment is unnecessary. The exact measurement tool
used for the assessment of change depends on what changes the observer wants to 1
examine. However, there is still the need for a standard measure which can be used to I
compare disabilities between places and over time. The use of a variety of measurement 1
tools makes it difficult to compare the experience in different programmes.
A very different approach to surveying disability is taken by the ICIDH system from
that generally used in the field of leprosy. The survey begins with questions to the ]
individual about function ability to see if that person has a disability. When a disability is ?
identified in this way then further investigation is carried out to identify which impairment 1
gives rise to the disability and whether the disability constitutes a handicap. This is an j
interesting approach which would identify the disabilities that are important to the
patient rather than those which are important to the health worker. This approach |
certainly merits consideration by leprologists.
Epidemiology of disability (impairment) in leprosy
Epit,
8
'Ology of disability in leprosy including risk factors
25s
Table 1. Risk factors for dis
ability in leprosy
1 Age
2 Sex
3 Classification
4 Duration of disease
5 Site of skin lesions
6 Reversal reactions
7
X
9
10
11
Ircatment
Socioeconomic lactois
Educational attainment
Geographical factors
Ethnic group
12 Occupation
13 Method of case detection
■
Percentage
70-1-----------------
Menn
60-
504030-
Women
20-
100-H0-4
5-14
1
15-24
25-34
35-44
45-54
55-64
65*
Age in Years
N=931
Men
Women
The well-recognized risk factors for disability in leprosy arc listed in Table 1. In common
with most disease processes, disability in leprosy increases with age. (See Figure 1, based
Figure I. Percentage with impairment.
on a data set from India.2) This observation is well known and well documented,910 as is
the fact that disability rates are higher in men than in women.
|
Classification of leprosy is also related to the frequency of disability, being highest .
towards the lepromatous end of the spectrum (Figure 2). This is not a surprising
observation given the pathogenesis of the disease. The age effect, however, is independent f proposed during the monotherapy era and there is evidence that nerve damage occurs
of the type of leprosy. Duration of disease is also noted to be a risk factor.10
! during NDT.1- but whether this is more Frequent than during monotherapy or when
intreated is not known (Figure 3).
The treatment of leprosy is related to disability in many studies, which show that those
who are receiving treatment are more likely to be disabled than those who are not
Poor socioeconomic status and low educational attainment have both been identified
receiving treatment.10 " Two explanations have been proposed, first that those disabled
is disability risk factors,10 " but whether this is cause or effect is unclear, and may in
are more easily detected and more likely to be motivated to take treatment; and secondly ' individual patients be either or both. Occupation has also been identified as a risk factor,
that treatment may cause disability. This later controversial -explanation has been
and this is not unexpected where those with heavy manual jobs or with occupations which
w
26s
W C S Smith
/7’
%
% Impaired
80 -i----------------
60 r
I
50
III
60
40
20
0 J
%
I
27s
tliMihiltty in hino\\ m< hiding ri\k feu tors
BT
IT
BL
LL
40 •
30 r
20
10
0
Household
ALL
Voluntary
School
Contact
Method of Detection
Classification
I
l_
Series 1
Series 1
Figure 4. Impairment rates
Figure 2. Impairment by classification.
Trends in impairment rates
PB Cases on MDT
MB Cases on MDT
-
No NarvB Damage
314
j
No Nervo Damage
1700
R New Nerve Damagt
■
26
Now Nor vo Damago
62
2161 patients
J
The trends in impairment irates arc important in evaluation of leprosy control
programmes and a number of important points need to be emphasized. Firstly, as control
develop me
the impairment rates in newly-detected patients (Figure
decline. n
programmes ocvciop
(Figure 5) decline.
This would happen even if the treatment programme had no efTcct on disability and it is a
mistake to attribute the effect to the programme without using a control group. This is
because disabled patients arc more easily detected and as programmes develop most new
patients added arc diagnosed earlier.
A second important point to note is that those with impairment naturally tend to
deteriorate (f igure 6). I he rate of deterioration varies byJ classification
_...ion.
TU---------------------------- The current practice of deleting from treatment registers and releasing
from control
patients with impairment disguises
the .problem of disability
--j in leprosy
j ini a community,
and this is especially true with the use of MDT. Figure 7. again based on data from India,
shows the rapid decline in registered cases after the introduction of MDT but no similar
decline in the prevalence of patients with impairment. 13. 14
Figure 3. New nerve damage during MDT.
Prevention of disability
involve walking for long distances are more susceptible to secondary disabilities. Ethnic
This is an important element of control programmes which has recently been studied.15
group and geography have both been noted as important in disability rates within
where attention was focused on the leprologists' approach to disability. The 1CIDH
individual countries, but lack of standardization of methods is often a problem in
classification would suggest a broader approach to disability prevention at three levels: (1)
interpreting studies between countries. Factors such as different distribution of prevention of impairmentby early detectlion and treatment of disease and of acute nerve
classification may confound geographical differences in disability.
> ; damage; (2) limitation or reversal of disability due to impairment using aids, appliances,
Different disability rates are noted by method of case detection (Figure 4) where surgery and patient education; (3)prevention of the transition from disability to handicap
voluntary reporting shows the highest rates.2
T j by public education, social and cultural adaptation and vocational training.
28s
ir C S Smith
Er
I
3
%
iology of disability in leprosy including risk factors
29s
Prevalence Rate of Leprosy
8
20
Rste per 1,000
5
15
4
3
10
2
5
i
o —
1979
1983
1087
YEAR
0
1979
1983
1987
----- Series 1
YEAR
■
Prevalence Rate of Impairment
Series 1
Rsts per 1,000
100 |---------------------------------------- - ---------------------------------------------------------------- ,
Figure 5. Impairment in new patients.
80
80
% Deterioration in DI 2
16 |----------------------------------
40
14
12
10
8
6
4
2
0
20
lias
BT
BL
LL
0 —
1979
1983
1987
YEAR
----- Series 1
Figure 7. Prevalence changes leprosy and impairment.
ALL
Classification
Series 1
I
Important research questions are now being addressed as to the effectiveness of
different methods of disability prevention and in particular to their cost-effectiveness.
Studies arc currently under way to look at these issues but it is important that analysis of
these studies take account of the natural trends in disability and that proper controlled
studies are designed.
19 improved, 28 Deteriorated
Conclusions
Figure 6. Deterioration in impairment (IIS patients followed over 4 years).
Disability in leprosy is extremely important because to the patient and the public it is the
disability that sets the leprosy patient apart. Standardized methods of measurement of
ir C 5 Smith
3()s
1^'pr Rev (1992)
dL-ability
U111 ly oLIll
still llVvvl
need LO
to be
L'v kJ
developed
V C1 p/v kJ cl
and
11VI the
LllV clJJJ'l
approach
Udvl I cl
adopted
VI vJ Lv VI by the
LllV new
IIV/W International
1 11 Lvl lid LlV/llul /
». .
Classification of Impairments, Disability and Handicaps needs to be given consideration ||
by those in the leprosy field. Measures of disability are important for evaluation of |
programmes, evaluation of treatments, to identify needs for patient education and for j
rehabilitation. Approaches to disability prevention need to be evaluated in terms of costeffectiveness which take into account the natural progression of disability and must be |
based on controlled trials. Disability is the measure of progress in leprosy control which is
relevant to the general public.
Supplement, 31s 39s
x_l 1
Epidemiometric modelling in leprosy based on
Indian data
M FLECHAT
References
•- a
1 Brand PW. Deformity in leprosy. In: Leprosy in theory and practice, Cochrane RG, Davey TF (eds), BristolJohn Wright and Sons. 1964, 2nd Edition, pp. 447 96.
2 Smith WCS, Antin US. Patolc AR. Disability in leprosy: a relevant measurement of progress in leprosy. Lepr
R<r, 1980; 51: 155 66.
5 Srinivasan H. Dharmcndra SIL Deformities in leprosy. In: Leprosy Vol I. Dharmcndra SH (ed), Kothari
Medical Publishing House, Chapter 27, pp. 197.
^0
4 World Health Organization. International Classification of impairments, disabilities and handicaps. Geneva: &
WHO, 1980.
5 WHO Expert Committee on Leprosy. World Health Organisation. Technical Report Series No 189, 1960.
6 Bechelli LM, Martinez Dominguez V. Disability index for leprosy patients. Bull WHO, 1971; 44: 709-13.
77 .......
• • . -Report• -Series
• WHO Expert- Committee
on •Leprosy. World Health Organisation. Technical
No 768, •«««
1988.
8 Pohninghaus IM. Boerrigter G, Fine PEM, Ponninghaus JM, Russell J. Disabilities in leprosy patients .
ascertained in a total population survey in Karonga District, Northern Malawi. Lepr Rev, '990; 61:
61:366-74.
366-74. ®
9 Noordeen SK, Srinivasan H. Epidemiology of disability in leprosy, hit J Lepr, 1966; 34: 159-69.
Kushwah SS, Govila AK, Kushwah J. An epidemiological study of disabilities among leprosy patiente
attending leprosy clinic in Gwalior, hit J Lepr, 1981; 53: 240 7.
11 Noordeen SK, Srinivasan H. Epidemiology of disability in leprosy. Ini J l^'pr, 1966; 34: 170-4.
12 ParkheSM, Smith WCS, Samson PD. Solomon M. Sudden paralysis associated with Multi Drug Therapy—*
cautionary talc. Abstracts of the 13th International Leprosy Congress. 1988. p. 380.
13 Smith WCS. Parkhc SM. Solomon M. Samson PD. Leprosy disability in a control programme—trends over
10 years. Abstracts of the 13th International Leprosy Congress, 1988, p 603.
14
Smith WCS, Parkhc SM. Disability assessment as a measure of progress in leprosy control. Lepr Rev, 1986;
57:251 9.
15 Watson JM. Disability control in a leprosy control programme. Lepr Rev, 1989; 60: 169 77.
10
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Introduction
Today. I suppose, any moderately bright child who has had a minimal exposure to
computers could programme an epidemiometric model on a rainy Sunday afternoon
using existing softwares and a technologically basic machine, but the situation was quite
different in the early 1970s when the leprosy epidemiometric model was first designed.
The problem addressed was clearly circumscribed. After 20 years of large scale, mass
control campaigns based on dapsonc monotherapy, leprosy had not been eradicated, and
even worse, it was not known whether the disease was or was not on the decrease
International funding agencies such as UNICEF, nongovernmental organizations as
well as governments, all were getting tired of emphatic promises and overdue delays.
There were talks of a vaccine which could revolutionize the control strategy.
The concerns at that time were: (I) wns it reasonable to expect a decline of the leprosy
problem in the next 20 years, using current control methods? How much of a decline?
How long would this take? (2) Could some improvements in the implementation of
control, such as earlier detection or better compliance, speed up the decline? (3) Could
some radical changes in the strategy, such as old-fashioned isolation or futuristic
vaccination, modify the prediction? In what direction, and by how much?
The model aimed at predicting the trends in incidence over 20 years by using the
control methods of that day. It also attempted to simulate the trends which resulted from
changes in the control parameters. The indicator used was incidence, i.c. the number of
new cases per year in the population.
Structure
Asa first step, the development of the model required the definition of a structure and the
identification of the various population subgroups (stages) as well as the permitted
transitions and their directions (Figure 1). The stages were:
healthy susceptible;
latent;
multibacillary patients, nontreated, treated for less than 1 year, treated for 1 year or more,
dropped from treatment, discharged;
paucibacillary patients, with the same categorization as the multibacillary patients.
0305-7518,92 06303Is+ 09 SOLDO
( Lepra
31s
Comprehensive Rehabilitation
in India
- a Community Based Approach for People
Disabied by Leprosy and Others
Report from a Preparatory Mission on Swedish s upport
to a Rehabilitation Programme.
F
Ia
1 F
fJ •
L.
$ ’W-
*
-f
COMPREHENSIVE REHABILITATION IN
INDIA
A COMMUNITY BASED APPROACH
FOR PEOPLE DISABLED BY LEPROSY AND OTHERS
Report from a preparatory mission on Swedish support to a
rehabilitation programme.
•iTi
Contents:
Page
Summary
Introduction
Background
Visits to three states
Orissa
Maharashtra
Tamil Nadu
Reasons for a comprehensive
rehabilitation in leprosy treatment
Reasons for an integrated rehabilitation
Conclusions and Recommendations
Budget
1
3
4
7
7
9
11
Terms of Reference
Programme
Persons encountered
Summary in hindi
Background papers
Annex 1.
Annex 2.
Annex 3.
Annex 4.
13
14
16
18
March 198.
Tomas Lagerwall
The Sw< lish Institute
for the Handicapped
Gdbor Tiroler
International Child
Health Unit
A
1
Sumin arv
For thousands of years people with leprosy have been considered as
outcasts by society. This is probably mainly because it is a disabling
and disfiguring disease. Thanks to scientific advances , first Dapsone
and then the Multi Drug Therapy, MDT, it is now possible to cure the
disease. It is also possible to rehabilitate those affected so that they can
live and work in their communities.
It is estimated that still at least 800,000 people are handicapped in
India because of leprosy and the prejudice surrounding it. The
situation for women and children in leprosy families is especially
difficult. There are few and only limited rehabilitation programmes foi
them.
In India a National Leprosy Eradication Programme was started in
1982 as a continuation of the earlier Leprosy Control Programme.
SID A has been supporting these programmes since 1978. The
emphasis has been on medical treatment and there have not been any
provisions for rehabilitation as part of the programmes. Parallelly, a
dialogue on the needs of disabled people has been going on between
India and Sweden since the International Year for Disabled Persons
i.e. 1981. Various alternatives for Swedish support have been
presented. In February 1988 the Government of India submitted a
request for rehabilitation of cured leprosy patients and other disabled
people. To meet this request, a delegation was set up by SEDA with the
task to make recommendations for a "pilot rehabilitation project where
leprosy patients vHll be given a priority".
The delegation visited a number of projects all over the country. It was
found that only a few of them succeeded in integrating people with
leprosy into the society. Other projects were catering for the needs of
specific groups of disabled people. There were, however, no
rehabilitation projects aiming at social integration for disabled people
in- general.
Social integration is very much the aim of, or even a part of,
Community Based Rehabilitation, CBR. That is the approach which
nowdays has the widest acceptance internationally. India has also
subscribed to it and it is being implemented in several projects run by
governmental and non-governmental agencies.
2
One experinjent with CBR in India is the District Rehabilitation Centre
(DRC) programme. Eleven centres have been started, and they could
be successful after some modifications to give them a real basis in tincommunity. They could reach a majority of disabled people all over
India, even in urban slums and rural areas. But as the programme
stands, it lacks provisions for people with leprosy. Another experiment
is going on in Kerala since eight years.
It is recommended that SIDA gives support to rehabilitation in MPTdistricts, as requested. Alterations are suggested to the original
proposal, so that a comprehensive rehabilitation can be provided
aiming at social integration not just isolated medical, surgical,
technical or other interventions. Further, it is recommended that the
services be integrated to serve not only those affected by leprosy but
other disabled people too.
In a first phase, a steering committee and a working group will be set
up; background material, publications and documents will be
produced and studied at seminars; districts and implementing
agencies selected and a co-ordination between the DRC programme
and this programme initiated. The estimated budget for this phase,
timed for 1989-90, amounts to Rupees 3,200,000 or (with additional costs
in Swedish currency) SEK 2,000,000,
The second phase, starting in July 1990, would be the creation of
rehabilitation services of two or three different models with regard to
the organisational set-up in the same number of districts. The first to
be served would be "burned out cases of leprosy" ensuring the
establishment of permanent services for d eferent disabilities with the
involvement of local people supported by those trained in the project.
March 1989
Tomas Lagerwall
■i*—1
Gdbor Tiroler
3
Introduction
This report is the result of a preparatory mission ori rehabilitation of
disabled peeople, with a special emphasis on those who are disabled
because of leprosy. The mission was set up by SIDA following a request
made by the Government of India. Terms of reference are found in
Annex 1.
The delegation consisted of six people (E|r Sharad Gokhale, Ms Ratna
Kapur, Mr Tomas Lagerwall, Dr Balu Sankaran, Mr Gabor Tiroler and
Ms Inese Zalitis) representing different aspects of rehabilitation and of
development cooperation. Mr Lagerwall and Mr Tiroler are SIDA's
consultants on rehabilitation. Ms Zalitis belongs to the SIDA office in
Delhi. Dr Gokhale is a specialist on the social aspects of rehabilition,
particularly leprosy. Ms Kapur is a lawyer specialized on women's
rights. Dr Sankaran is an orthopaedic surgeon who has held a post with
WHO Geneva.
The mission worked between January 11 and February ,3, 1989.
Discussions were held with representatives of the Government of India.
Ministries of Health and Welfare and international agencies in Delhi,
WHO and UNICEF. The delegation visited the following districts:
Ganjam and Cuttack in Orissa, Amaravati and Wardha in
Maharashtra and Chingelput and North Arcot in Tamil Nadu.
Apart from a continuous exchange of impressions and ideas during the
mission between the consultants and the SIDA office in Delhi, which
was largely facilitated by the presence of Ms Z ilitis, preliminary
conclusions were presented to her and to the head of that same office in
in
a preliminary draftat the end of the mission.
t
A
Background
Leprosy has a very long history . It is mentioned in Hindu scriptures
already 600 B.C. as well in the Bible. Considering this, it is remarkable
that so much prejudice and ignorance surround the condition and that
very little is understood about the cause of the disease, its transmission
and cure.
Leprosy is not fatal in itself, rather it is disabling. Fear of it causes
society to shun people who are affected or suspected to be affected, and
they become socially and physically handicapped, i.e. shut out from
normal, social life. A term often used in India is "dehabilitated", which
has a similar meaning but with a stronger emphasis on the loss of or
deprivation of abilities.
Although most people with leprosy have no significant disability, they do
get handicapped by the barriers of ignorance, fear and prejudice in
society. The primary aim of rehabilitation must be to remove that fear
or to make social integration possible in the second. One of the things
that can be done for this purpose is intensive health education involving
the community as well as people cured of leprosy, the so called "burned
out cases". Once fear and stigma are eliminated, many more
opportunities for education, jobs and active roles in society will be
available for those already treated and those inder treatment.
Vocational assessmant, training, identification of job opportunities,
counselling, loans for self-employment, assistance to the setting up of
cooperatives contribute to economic self-sufficiency and give disabled
people an equal role in so ;ety. This demonstrates to the society at large
and to other disabled that cured leprotics are certainly not representing
any risk but on the contrary a resource, and that it is correct to give
them the opportunity to live and work with others.
As a matter of fact, leprosy is in large areas of India today the most
important cause of motor disability alongside with poliomyelitis, and one
international au hority even holds the view that
|
Our concern should be the occurrence of deformity rather than the occurrence of cases,
since leprosy is in a very real sense deformity. Since it is disability which sets leprosy
apart from other diseases, disability rates may be a more relevant measure /of a suc
cessful programme/ than the number of cases” (Antia, Lepr.Rev:51,1980:155-66 >.
5
The number of people suffering from leprosy in India is estimated to be
about 4.4 million. For many decades treatment was based on a single
drug, Dapsone. Though effective, it demanded a long period of medical
treatment and carried quite a few side effects. During the last decade,
the drug has become less effective in many cases -due to the increasing
occurrence of resistance- and as a consequence new lines of treatment
have been developed. The Multi Drug Therapy, MDT, combines three
drugs. They are more efficient and effective but also more expensive and
more complicated to administer.
A National Leprosy Eradication Programme was started in 1982
following an appraisal of the National Leprosy Control Programme and
its inclusion as an All India priority in the so called 20 points
programme.
Since 1978 SIDA support has been given to the National Leprosy Control
Programme and from 1983 to the MDT-programme under the National
Leprosy Eradication Programme. 18 districts all over the country now
receive SIDA support either through WHO (15 districts) or through
UNICEF (3 districts). Ganjam, Amaravati and North Arcot receive
SIDA's support through WHO. Chingelput and Pune receive similai
support through UNICEF. Cuttack is involved in the MDT-programme
through DANIDA. All the mentioned districts have or had until recently
a high prevalence rate in leprosy.
The MPT-orogramme has until now not contained measures directed
at ,the disability aspects of the disease. Various NGO's have been
entrusted to carry out such measures, some of which have been quite
successful but only for small numbers of people and in limited areas.
The WHO Expert Committee on Leprosy has stated that:
The aim of all leprosy-control activities is to control the spread of the disease by
progressively decreasing the amount of infection through the use of anti-leprosy drugs.
- The mere distribution of medicines has little effect if other measures of a social,
informative and administrative character are neglected. The expert committee goes
on to state, that 'In areas where an effective control has been set up no new cases of
deformities should occur."
6
The Indian authorities hold in fact a similar view and one of the major
recommendations in the Report from the working group on the eradi
cation of leprosy, Min. of Health and Welfare, 1982 is that
Tt is essential that rehabilitation becomes an integral part of leprosy control— for this
coordinated efforts of health, education, welfare and voluntary agencies are
necessary."
Multi Drug Therapy can stop the spread of the infection to others and
halt the progress of the disease in the individual affected- But in many
cases it cannot prevent progressive disability unless coupled with
rehabilitation. When detected, at least 20% of all the patients have
already suffered a loss of sensation (feeling), but not all of them will be
diagnosed. Others may get nerve injuries after the first visit at the
health facility. All run the risk of visual (sight) and locomotor (mobility)
disabilities apart from the sensorial loss. These people need advice and
training to prevent injuries to their feet, hands and eyes. They also
require the provision of shoes, adaptive devices and simple aids for daily
living, because, as the National Report points out, ’The stigma is 1 rgely
due to the physical deformity caused by the disease".
These measures should have been introduced when starting a course of
MDT, but since that has not been the case, the necessity of rehabilitation
is even greater.
A dialoque between Inu.a and Sweden regarding the needs for disabled
people has been going on since 1981, the International Year for Disabled
Persons. Different alternatives for Swedish support to disabled people in
India have been explored like its inclusion into the ICDS, Integrated
Child Development services. In 1987 an evaluation of the SIDA support
prog7 amme was carried out by Miorner. Continued SIDA involvement
was strongly recommended, but "'Hie future support should be focused at
operational and epidemiological research and rehabilitation".
In February 1988 the Government of India submitted a request to SIDA
for rehabilitation of cured leprosy patients and other disabled people.
It should be noted here, that some people with leprosy who are infected
and infective remain undetected even in areas where the control pro
gramme is well organized. It is not easy to motivate people to come
forward for a medical treatment, which does not answer their felt needs,
namely to cure their disabilities and remove the stigma which they
’I
7
suffer from. Only when services are put into perspective, and they see
other people with leprosy cured and rehabilitated will they be available
for treatment, and then eradication can become a reality.
The present discussion concentrates on those people for whom medical
treatment has been completed and those districts where the MDTcontrol programme has reached the maintenance phase. That means
that the programme has been going on for a number of years and the
incidence has been reduced below 5/1,000. At that stage further medical
inputs will have little impact on the prevalence unless they are coupled
with rehabilitation in a wide sense.
Visits to three states
In order to get a direct knowledge of the situation of disabled people in
general and those disabled by leprosy in particular as well as the
rehabilitation services in the field, the delegation visited three states
apart from the capital New Delhi. In each of the states two-three
districts were visited.
Orissa
The population of Orissa is 26.3 million on a surface of 155,782 square
kms. The state is divided inh 13 districts.
.f
h,
Orissa is one of the highly endemic states in India with a leprosy
prevalence of 12.1 per thousand before the introduction of MDT which
reduced the prevalence rate to 7.8 per thousand till 1987. The National
Leprosy Control Programme started there in 1954, and the National
Leprosy Eradication Programme was started in 1982. It is estimated that
there are still 242,000 leprosy cases in the state. There are five voluntary
agencies involved in leprosy work.
Ganjam District - one of the six where MDT was introduced in 1983 was visited by the team accompanied by Dr Pani, Joint Director fo Health
Services, Dr T'P Patro, Distr. Leprosy Officer, and the Chief Distr.
Medical Officer, Dr Mrs B Dev.
A comprehensive review Report of the Multi Drug Regimen Activities in
Ganjam District was presented to the team by Dr Pani and Dr Patro.
8
Ganjam District was one of the first districts selected to be in the MDT
Programme. It is supported by SIDA through WHO.
The district is fully covered with eight Leprosy Eradication Units, one
upgraded Urban Leprosy Centre, two Leprosy Rural Centres and one
twenty-bed temporary Hospitalisation Ward.
Until December 1988, more than 29,000 new leprosy cases were detected
through voluntary reporting and surveys. A total of near 42,000 cases
were screened for MDT and started on treatment. Almost 29,000 have
completed MDT and been declared cured and released from treatment.
It is remarkable that the number of active cases on record every year has
not decreased since the MDT Programme began. The proportion of
children (persons below 14) among new cases has gone up from 14%
(1982-83) to 29% (1987-88).
On the other hand, the incidence rate has indeed dropped from around
14/1,000 (1982-83) to less than 2/1 000 (1987-88). Also, there has been a
significant drop in the disability rate among new cases.lt has decreased
from 8% to 2%, and this is of course an important issue for the present
deliberations.
There are certain drawbacks which have to be pointed out. Though theit
are facilities for reconstructive surgery, only 3 cases have been tackled
during this period. There is no active physiotherapy unit, no foot-weai
centre, no vocational placement, no rehabilitation unit and no attempt at
social and economic integration into society. There is a fully operational
Regional Rehabilitation Centre at Aska but few visible links between
Ganjam District and the centre.
A visit to a Leprosy Colony, about two kms from the Leprosy x reatment
Centre, showed the predicament of people who had or had h ad leprosy ;
they were a social and economic discard of society, their healthy
children receiving no education. Most of the people there earned their
living from begging. There were several who had deformed hands and
feet and trophic ulcers. Microcellular rubber chappals were worn only
by a few.
The team visited thfe National Institute of Rehabilitation Training
Research (NIRTAR) about 35 kms from Bhubaneshwar. It has
prosthetic and orthotic facilities, an operation room, a library, a
%
9
vocational training centre including ergotherapy, a physiotherapy
department, teaching facilities for 190 students in all aspects of
rehabilitation and treatment of leprosy patients in the general ward.
The Director of Health Services, and the Joint Director of State for
Leprosy expressed their keenness and desire to aid in any project of
comprehensive rehabilitation services for all types of disability including
leprosy based on a community approach.
The Secretary of the Department of Health completely subscribed to the
technical views presented to her and oflered to help out in the best
possible manner.
Maharashtra
The population of Maharashtra in the 1981 census as given as 62,7
million and the surface as 307,762 sq kilometers. 2/3 were living in rural
areas. It is the third largest State in India. It has a long history of
leprosy work. The entire State is now covered by the National Leprosy
Eradication Programme.
The urban slums are posing a new threat to social and individual health
because of poverty, malnutrition and unhygenic conditions. In Bombay
40% of the 8 million residents live in slums, and out of all people with
leprosy in Maharashtra 1/6 are found in Greater Bombay.
During the tour of Maharashtra, the team was accompanied by Dr
Sontakke, the State Leprosy Officer, and Dr Yellapurkar, WHO
Consultant. The visit began with informative discussions with
Government officials. Thereafter they visited a number of institutions
and projects in the state like the Industrial Cooperative and
Rehabilitation Centre in Poona. There, disabled people of different kinds
were working together, running a modern workshop and making a
profit to allow reasonable wages and a contribution to the rehabilitation
of others also. Gandhi Memorial Leprosy Foundation in Wardha has
field work, training and education and research on its programme. A
near-by locality showed us the only instance of leprotics living integrated
in the society. This w’as said to be the result of a long and systematic
public education. Even children at school were taught and educated on
the subject. One way of inducing a positive attitude was to organize essay
competitions, which had become quite popular.
10
Mahatma Gandhi used to describe Maharashtra as a beehive of social
workers. The field of leprosy is no exception. There are 32 voluntary
agencies in the field of leprosy work. The scope of their actmUes has
expanded from running "Leprosy homes" to providing proper hospital
facilities, reconstructive surgery, physical therapy, industrial and agri
cultural rehabilitation, training of various categories of leprosy wor ers
and research.
In order to get to know a cross-section of perspectives on rehabilitation
as well as on leprosy work, two meeting were held in Bombay aim some
35 NGOs took part representing both agencies working in the field of
leprosy and others working for the welfare of different categories of
disabled people.
The following issues were highlighted among many others:
1. The insufficiency of Government grants and the often complicated
of-----technical support and
procedure required to obtain them. The nee<d----
expert advice.
2. The advantages of integrated and comprehensive (multidisciplinary)
rehabilitation linked to the medical treatment and started simultaneous
ly; and as a pai t of this, vocational training.
3. The necessity to transform care and protection homes into Rehabilita
tion Centres.
4. The need to give priority to children of leprosy patients and special
services for women. The families where one or more members are
affected also need special support.
5. The reasons for a national conference of agencies involved in leprosy
rehabilitation treating comprehensive and integrated rehabilitation.
This should be preceded by workshops on related subjects su h as the
role of different categories like social workers and paramedical workers
6. The lack of documentation on rehabilitation, which should be
prepared, translated and made available to the agencies.
7. The suggestion to'set up a buffer agency to guarantee bank loans and
provide technical advice on marketing, production and quality control.
11
8. The need for training to produce technical aids locally; in particular
footwear for people with leprosy.
Tamil Nadu
The population of Tamil Nadu is a good 48 million on a surface of 130,069
sq kilometers.
The team tour to Tamil Nadu began with a visit o Chingelpattu District,
one of the endemic areas in the state. The MDT Programme was started
in 1986 with the assistance of UNICEF, funded by SIDA and the Leprosy
Mission. Since then the prevalence has been brought down from 11 to
8/1,000.
The team visited the Central Leprosy Teaching and Research Institute
where we held discussions with Dr N Bhatia (Deputy Director in
Charge), Dr K S Rao (Deputy Director in Charge) and Dr P S Rao (Head
of Epidemiology). The District Leprosy Officer of Chingelpattu, Ashok
Caradan, also attended the discussions. The centre is concerned
primarily vdth curative services, research and the training of
orthopedic and other medical officers. The Centre has no social
rehabilitation component in its programme. Rehabilitation is supposed
to be provided by the ten rehabilitation homes situated in the state and
run by the Jail Department. Although these homes have provisions lur
vocational training for people with leprosy, only a lowdd priority is given
to this aspect of rehabilitation. Strict discipline and regimentation
frequently provoked patients to leave the homes.
The centre undertook a survey in 1988 of 100 people with leprosy who had
formed a colony near their premises an$ who earned their living
through begging in Madras. In the beginning of the survey, 20 people
were found to be bacteriulogically positive. A high proportion of them
were not taking treatment and only 6 had received MDT, even though
the programme had been going on in Chingelpattu District for over two
years. The people in the colony were not motivated to avail of treatment
facilities from outpatient and field clinics located quite near to them,
apparently because of extreme social, economic, and psychological dehabilitation. The team visited the colony, named Bethal Nagar, and
talked to the people living there. In sum, it was evident that the men and
women were eager to give up begging and to work if they were provided
with the means including some financial assistance to begin with. The .
team also visited the Scheiffelin Leprosy Research and Training Centre
V
12
■ ■ Discussions; Were held with the Director, Dr Benjamin, Dr
in Karigiri.
Paul Brandt and Dr Kumar Jesudasan. The Centre has launched a
rehabilitation scheme known as Care after Cure with support from the
Baptists in Sweden (Svenska Baptistsamfundet). They aspire to follow up
all the individuals treated in the Gudiyatham Taluk, who have been
released from control after being declared as cured. The data collected
will be used to identify the following categories:
a) Those with correctable deformity and disability, who will be
provided with facilities for physiotherapy, and occupational therapy,
b) Those with loss oi sensation of hands of feet, who will be taught
how to look after their limbs to prevent injuries. Many of them will
require special footwear or other protective aids to protect their
hands and feet,
c. Those with impaired vision, who may require surgery or special
ophthalmic care and
d) Those who are primarily handicapped and require some form of
economic assistance.
At Vellore, the team visited the Worth Trust (The Workshop for
Rehabilitation and Training of the Handicapped) and met Dr Boose
Cros, who elaborated upon the activities of the Trust. The Trust has ten
centres which provide schooling, industrial training and employment to
nearly 400 handicapped people, including people with leprosy. The
production units of the Trust, which employ disabled people, compete
with organized industries and generate enough income to meet all costs,
including those for training and development. The Trust is, therefore, a
selfsupporting enterprise and is a model of a successful, integrated
rehabilitation project. At Vellore, the production units provide training
to all disability groups for two years, and thereafter the Trust assists the
workers in securing jobs in industry.
'nW
Finally, the team was able to make a brief visit to the Community Health
and Development Centre (CHAD) in Vellore, where they were
introduced to Dr Jayaprakash Muhiyhil. They were told that the centre
is designed to provide care and rehabilitation to 200,000 persons in the
district and that its rehabilitation scheme adopts domiciliary approach.
13
Reasons for a comprehensive rehabilitation
in leprosy treatment
With a comprehensive rehabilitation is meo'it the sum of rehabilitative
measures leading to equalization of opportunities and integration into
society for the person with disabilities. This is true for all disabi
lity groups, but in the case of leprosy removing attitudinal barriers, fear
and prejudice, has a higher priority than otherwise, as these barriers
are so much stronger. The action programme on rehabilitation includes
the following:
(i)
(ii)
(iii)
early detection, diagnosis and intervention;
medical care and treatment (inch physiotherapy);
social, psychological and other types of counselling and
assistance;
(iv)
training in self care activities;
(v)
provision of technical aids, mobility aids and other devices;
(vi)
special education services;
(vii) vocational training, placement in open or sheltered employment
and
(viii) follow-up.
Each facet of rel abilitation discussed exists singularly or in combina
tion in the different centres visited by the team in India, However, the
presence of all the factors described are essential for an effective
rehabilitation programme. The most pertinent example may b that of
surgery. It can be instrumental in making re-integration possible, when
it is part of the whole rehabilitation plan. On the other hand, it can
actually hinder re-integration when people are taken away from their
ordinary environment for a long period of time, reinforced in his or her
identity as a leper" and further alienated from the same society into
which he/she should have been integrated.
*(
A rehabilitation programme aimed at integrating disabled people into
society should be based in the community, the rural village or the urban
slum. Experience has shown that 70% of the rehabilitation of all disabili
ties can take place in the village, and another 25% at the sub-district,
taluq level. Not more than 5% require treatment at the district or state
levels. The most important person in this programme would be the local
supervisor. She (in most cases the worker is likely to be a woman)
should be recruited from the village/community, so that she is accepted,
14
understood and actually controlled by the local population which m
take the fXw-up »f people who have been trained and prepared away
from home.
Rehabilitation planning for the disabled person and supervision of
services will be done by the multipurpose rehabilitation worker,reha i
litation assistant, social worker, occupational therapist, physiotherap
and doctor. The community based rehabilitation (CBR) programme
must be aimed at maximizing the use of local resources and
strengthening the existing social networks such as the family, schoo ,
panchayat and temple to ensure that rehabilitation is integrated an
complete.
The staff employed in the leprosy eradication programme will require
training in comprehensive rehabilitation. Similarly the rehabilitation
staff working with other disability gioups must be educated in the needs
of people, with leprosy. Experienced MDT staff can be used in the
training of other rehabilitation personnel on the needs of persons wit
leprosy. The sharing of knowledge and experience by and between bot i
groups is essential to the success of the programme. People who have
suffered leprosy and women would be given special consideration to get
training and to be teachers/trainers themselves.
It is very essential that the situation of disabled people and in particular
of those with leprosy should be taken into consideration in all public
services. Donor agencies like SIDA can play an important role by
including these aspects in development co-operation programmes like
social forestry.
Reasons for an integrated rehabihtation
With integrated rehabilitation we understand services with and for
different disability groups without restraints connected with the original
!
Leprosy control has traditionally been kept as a separate, vertical activity
characterized by .the.leprosarium, the leprosy village and other such
institutions often far removed from the rest of society. It was repeatedly
brought home to us that people with leprosy can be denied access to
15
ordinary hospitals and other health services when suffering from other
diseases or acute conditions. Still, it came as a surprise that the District
Rehabilitation (DRC)-scheme lacks provisionb for them and that leprosy
is not even mentioned in the textbook for the DRC-staff. (Presumably,
this will be corrected with time.) The separate dispensaries, schools,
social institutions and regulations have been administered by a
specialized staff. This is the case with the MDT- programme. The
original project proposal submitted to SIDA follows the same pattern by
taking cured leprotics apart and’ merely adding some provisions for
other disabilities.
The mission has investigated the advantages and disadvantages of o
vertical approach, and it concluded that the arguments for a vertical,
medical control programme in highly endemic areas are not Quite
applicable when it comes to rehabilitation.
Certainly, it is an important step forward to include rehabilitation in the
leprosy programme. One can foresee, that the reduced incidence of
leprosy leaves large numbers of burnt out cases to be rehabilitated, and
also that specialized and often committed staff will have less medical
therapies to perform. From this point of view, rehabilitation is. a logical
continuation of the MDT-programme. It should be remembei d
however, that there are other resources to tap also.
c
Some rehabilitative measures are specific for leprosy disabled like
reconstructive surgery or the provision of some protective devices. It is
also true, that leprotics may not get the attention they need in general
services. Both these aspects have to be considered in a future, integrated
programme.
Since it has been shown above that segregation is the main cause of
handicap for leprotics, and that integration is the aim of rehabilitation,
the rehabilitation programme itself should be integrated. Such a
programme demonstrates that the disabilities following from leprosy
are not different from other disabilities; be they sensory, locomotor or
visual. As a matter of fact, the World Programme of Action concerning
Disabled Persons repeatedly asserts that ' Services for disabled persons should
be provided, whenever possible, within the existing social, health, education and labour
structures of society".
I •.
16
As mentioned earlier, several rehabilitation programmes are being set
up in India. Apart from the DRC-scheme there are important state and
NGO projects. There is an obvious risk for collisions between the
programmes, unless they are co-ordinated. The resources, which are
still small for a national coverage, would be better utilized. In an area
where there is one physiotherapist for example, it would be un
practical to look for another to do leprosy work exclusively. Similarly, in
the large areas where surgery for acute conditions is lacking, it would
be strange to organize surgical facilities to correct leprosy deformities
and nothing else.
With regard to voluntary agencies, quite a few were visited which
specialized on leprosy work only. Some of them were performing a very
dedicated and unselfish work, still they reinforced segregation. A couple
of our informants were of the opinion that these agencies even upheld
the stigmatization. Disability organizations only exceptionally included
leprotics into their programmes, but several of them declared their
willingness to do so in the future. Their interest could be stimulated, e.g.
through seminars.
Conclusions and recomniendations
It has been concluded by the mission that time is ripe to complement the
Leprosy Eradication Programme by rehabilitation measures. It is also
clear that the services should cater for people with different disabili
ties and not only such that follow from leprosy. This is the integration
aspect of the services foreseen. Still, within the services planned,
priority will be given to the so called burnt out leprosy cases. Also,
within this group, women and children will be given special attention.
Rehabilitation in this context will be comprehensive in that it combines
all the actions and interventions which promote social integration, i.e.
social, medical, pedagogical and others.
; 4
It is recommended that the programme is divided into two phases: the
first phase consisting of planning, preparation and training: the
second creating rehabilitation services in two or three districts. The
districts should be located in different parts of the country selected
among those which have a SIDA-supported MDT-programme.
For the overall supervision and co-ordination the naming of a steering
Committee is recommended with representatives from the ministries,
17
first and foremost those of Health and Welfare, SIDA and non
governmental agencies.
Likewise, for the running and monitoring a working-£TQUP should be
composed and a short-term consultant contracted to assist it. Their first
task would be to make a detailed plan and a time schedule for the first
phase of the programme.
During the first phase, which would last one year, the following
activities would be carried out:
1. Select districts and devise the organizational set-up of the develop
ment projects; the distribution of roles between government and NGOs,
such as organizations of disabled people and organizations catering for
various disability groups;
2. Designate an implementation organization through which the SIDA
funds would be channeled and define its role clearly;
3. Work out a plan of operation and a budget for the second phase of the
project;
4. Identify the staff on different levels which would carry out the
projects in the districts chosen and take part in the development work;
starting with master-trainers;
5. Translate into hindi and other languages and produce the VfHOmanual
"Training in the Community for People with Disabilities" and David
Werner's "Disabled Village Children";
6. Identify and adapt other texts already existing;
,v
7. Organize seminars and workshops on subjects like:
- comprehensive rehabilitation emphasizing the social aspects,
- changing attitudes using media and information campaigns,
- specific measures for rehabilitation of people with leprosy,
- specific measures for children with leprosy or with leprotic
parents,
- roles of government and non-governmental agencies, with
emphasis on organizations of disabled people,
18
- community involvement and participation in rehabilitation and
local production of technical aids.
8. Revise the curriculum in the training of DRC-staff and leprosy-staff
to include leprosy and rehabilitation and enable them to work together
and work in a co-ordinated, uniform manner;
9. Carry out studies on subjects like the situation of women with
leprosy; ’
10. Make an index of relevant organizations and services existing in
India,
11. Organize a Congress to launch the programme.
The second Dha$e would start in the second half of 1990. By that time,
two or three districts will be selected for the pilot projects according to
the plans worked out earlier. The development of the programme should
be monitored and assessed by the steering committee and the short-term
consultant before the programme is expanded to further districts.
Budget
Estimated costs for Phase One
Translations and adaptation manuals
Printing
Seminars
National conference
Public awareness campaign
Short-term consultancies; nationals
Working-group activities
Miscellaneous
100 000
150 000
1 100 000
1000 000
500 000
150 000
50 000
100 000
TOTAL Rupees
3 200 000
Equivalent SEK
SEDA consultants
Unforeseen
1400 000
400 000
200 000
TOTAL SEK
2 000 000
Nr 3/Asien-iURHUI
,S I D A
Health Division
A-K
BMl/asn
%
TERMS OF REFERENCE
1988 12 07
CL FC?
DRAFT TERMS OF REFERENCE
FOR PREPARATORY MISSION
REHABILITATION PROGRAMI-1 E_^
ON SWEDISH SUPPORT TO 1-INDIA
BACKGROUND
Sweden has supported the Multi Drug Treatment
Programme 1MDT) within the Indian Leprosy
.Eradication Programme since 1978. one can
results of the MDT in that more and more P^i
are declared cured. Many of them need rehabili
tation both medical social and economic rehabrlrSIDA deceived in February 1988 a request
from Ministry of Finance (DEA) ^o^w®^Sdist?i?tS
to a rehabilitation programme in the M
*1
financed by SIDA, which are in the maintenanc
phase”.
In the discussions regarding the Indo:S^^/5odevelopment cooperation for the period 19 /
1991/92 way
SIDA and
has decided
considered
the request
in
posit!^
to send
a fact finding
mission to India in January 1989.
It has been decided to engage International Child
Health Unit, University of Uppsala (Mr Gabor
Tiroler) and the Swedish Institute for the
Handicapped, Stockholm, (Mr Tomas Lagerwall) to
or two
participate in the mission together with
Indian consultants.
On the basis of the Indian request and on the
direction of DCO-New Delhi the consultants shall
- discuss with GOI the size and the geographical
location of a pilot rehabilitation project,
- visit and discuss ongoing rehabilitation projects
both Government and NGO schemes,
- design ana make recommendations with regard to
coverage and size of a pilot rehabilitation
project where leprosy patients will be given a
priority,
- give a brief oral a d written report before
leaving India and,
.. .1
• 4
I-
a final written report with draft project document
for a pilot rehabilitation project before the end
of February 1989.
20
Annex 2
LIST OF PERSONS MET AND ORGANIZATIONS VISITED
GOVERNMENT OF INDI
1.
H.E.. Ms Saroj Khaparde, M.P.
Minister of State for Health & Family Welfare
2.
Dr Ashish Mukerjee, M.S., Ph.D.
Add i t iona1 D.G.H.S.
Government of India
3.
Mr R. Daya 1
Additional Secretary
Ministry of State for Health & Family Welfare
4.
Dr B.N. Mittal
ADG (Lep), DCHS
Government of India
5.
Mr S.S. Varma
Secretary, Ministry of Welfare
Government of India
6.
Mr R.S. Pandey
Director
Ministry of Welfare
Government of India
GOVERNMENT OF OR ISSA
1.
Mrs S. Narayanaswami
Secretary
*
Minister of State for Health & Family Welfare
2.
Dr H.C. Mishra
Director of Health Services
3.
Dr Mrs B. Devi
Chief District Medical Officer
Ganjan District
4.
Dr T. Pani
Joint Director of Hea’th Serviced (Le.p. & Tub.)
5.
Dr T.P. Patro, HD, D.L.O.
Ganjam, Berhampore, Orissa
6.
J-
i.
Dr H. Sahu, WHO Consultant, NLEP
21
7.
Dr
DANLEP Programme
Cuttack
8.
Dr
DANLEP Programme
Cuttack
GOVERNMENT OF MAHARASHTRA
1.
Mrs S. Modi
Secretary, Social Welfare
2.
Dr Mrs
3.
Dr V.D. Sontakkey
Joint Director
Ilea 11 h Services
4.
Dr Yelapuruar
WHO Consjltant
NLEP, Maharashtra
VOLUNTARY HEALTH ASSOCIATION OF INDIA
1.
Dr Anita Rama Rao
DAN IDA
1.
Dr B.J.L. Sorenson, Chief Coordinator, DANLEP, New Delhi
UNICEF
1. ‘
Dr Knutsson
Director UNICEF Office
WHO
1.
2.
3.
4.
5.
"J
Dr D.B. Bisht, DPM/SEARO
Dr N.K. Shah, PCD/SEARO
Dr Uton M. Rafei, HSI/SEARO
Dr Mikovich, WR India
Dr C.K. Rao, WHO Consultant, Leprosy & CD
INSTITUTIONS
Orissa
NIRTAR - Dr Hamadas & Staff anj staff of RRTC
i.
22
Maharashtra
1.
AIIPMR - Dr Radhakrishnan 6 staff of RRTC&DRC
2.
Vima la Dermatological Centre
3.
Maha ra sht r.
4.
Bombay Leprosy Project - Dr Ganapathi & Dr Atul Shah
5.
National
Bhat
6.
DHARAVI - Leprosy Project - Dr Gopa Kothari
7.
Udhay Dham Talegaon - Mr Chaphekar
8.
Anand Gram
9.
Poona District Leprosy Committee and
Dr Jal Mehta
Centre
10.
Leprosy Research Centre - Dr N.A. Antia & staff
11.
Tapovan, Amaravathi - Mr Bhagwant Singh Dalwari
12.
Gandhi Memorial Leprosy Foundation - Shri S.P. Tare
1*3.
Sevagram Village
Lokait Seva Mandal (SHARE) - Mrs Pushpika Fretcis
Institute for Equal Opportunities of the Handicapped
Dr Mrs Indu Patwardhan
Band Ran World Memorial
Tamil Nadu
Ch ingleput
DLO, Dr Ashok Vardhan, Deputy Director
CLTK1
Dr K.S. Rao
Dr Bhatia
Dr P.S. Rao
Schefellin Leprosy Research Training Centre, Karigiri
Dr Benjamin
Dr Paul Brand
Dr Kumar Jesudasan
WORTH - Katpadi
Dr Bose Cruz
CMC, Vol lore
Dr Jaya Prakash MOLAYIL
I
Mrs N
Leprosy
.i..-
.
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ft
The disability process and Community Based
Rehabilitation
An overview of the terminology and some of the principal ideas
The definitions and concepts related to disabilities and to rehabilitation
in a wide sense have been formulated by the UN and its specialized
agenci s and adopted fully or partially by governmental and non
governmental organisations concerned. (The UN World Programme of
Action Concerning Disabled Persons, the UN Manual on the Equalization
of Opportunities for Disabled Persons and the WHO manual Training in
the Community for People with Disabilities are the main documents to
refer to.) The following is an attempt to review the terminology and
principal ideas and to relate them to the situation in developing
countries.
The disability process follows a disease or a trauma, if they are not cuied,
and it is divided inot three stages impairment, disabilitY_and handigaih
- Impairment is related to human organs, denoting the loss of one or the
disturbances in its function.
- Disability is related to the individual as a whole, meaning the lack or
restriction of a function (like moving around, hearing or speech).
Disabilities have been divided into eight groups, largely on the bsis of how
the disabled person or his/her surroundings experience them. They are
durable or permanent states, and the di.jcase or trauma that caused
them has more often than not become irrelevant. The groups are :
1. Fits (mainly epilepsy)
2. Difficulty with learning (as in mental retardation)
3. Difficulty with hearing and/or speech (this includes deafness)
4. Difficulty wth seeing (this includes blindness)
5. Strange behaviour (mainly psychoses)
6. Lack of feeling in the hands and/or feet (mainly leprosy)
7. Difficulty with moving (because of weakness, deformities or
amputatioi )
.JJ,.
8. Other disabilities ( alcohol- and drugabuse, chronic respiratory- or
circulatory diseases,.allergy etc.)
5
- Handicap is a social phenomenon occuring when an individ al cannot
fulfill his/her role in a given society after getting an impairment or a
disability. Thus, a disabled person may live normally in one social
situation be handicapped in another.
Poverty and handicap are linked to each other. Poor and underprivileged
groups are more exposed to h ilth hazards and accidents than the welloff. When they are stricken by one, they have fewer opportunities to get
care than the well-off, who have access to treatments, medicines or
technical aids of the kind existing in the West. Serious disease of
disabilities worsen the economy of a family already poor. Therefore,
disability projects can be seen as an element in development cooperation
and in the fight against poverty.
The concepts of impairment, disability and handicap correspond to
measures aiming at the equalization of opportunities.- or equali.tY and full
participation.
Impairments and disabilities should be prevented. Persons who have a
disability must get rehabiltation. Furthermore, an adaptation of the
society is needed for those who can neither eliminate their disability
through training nor compensate for it through a technical aid.
- Prevention should eliminate the occurance of psychical-, physical- or
sensorial injuries or diseases.If it cannot, it should hinder that they lead
to permanent impairments. Then, we talk of secondary prevention.
- Rehabilitation, stri ly seen, starts after acute treatements such as
operations, pharmacotherapy or physiotherapy. It includes all measures
which reduce the impact of disabling and handicapping conditions and
make a social integration possible. Habilitation is a term used in relation
to children, who have not acquired the abilities normally associated with
their age. In such a case there is no question of re-gaining a capacity.
.:;k '
Community . used Rehabilitation, CBR, involves measures taken at
community level to use and build on the resources of the community,
including the impaired, disabled and handicapped people themselves,
their families and their neighbourhood. It is further described Ixdow.
Y^catignal rehabilitation is the sum of the measures which make it pos
sible for a.disabled person to secure, retain a suitable employment
and thereby promote the integration or re-integration into society.
3
* •
- Adaptation of the society demands a legislation which insures the same
opportunities for persons with disabilities as those enjoyed by others.
Consequently, all kinds of discrimination must be abolished. The
environment must be made accessible for all. Consumer advocacy is
needed, and organisations of disabled persons have a very essential role
to play. On the one hand, they should take part in controlling and
running services for disabled persons, and on the other hand they should
set positive exainples as peers for them.
*
To achieve an equalization of opportunities, a redistribution of resources
and wealth will be required. The same applies to rehabilitation
technology and facilities, which are at present concentrated within urban
areas, controlled and enjoyed by the privileged minorities.
The new approach of Community Based Rehabilitation
During the seventies it was realized by many, that the rehabilitation
services developed up to that period and supported by organisations such
as the WHO and ILO were inadequate or even irrelevant to the needs in
developing countries. The institutions with their specialists are not only
costly and exlusive; in many instances they are also more beneficial to the
service providers than to the clients. Conventional rehabilitation as
exercised there all too often lead to the very segregation it is meant to
eliminate.
■ V
That was why Community Based Rehabilitation, CBR was started. In
1979 an experiment ve. sion of a manual -Training Disabled Persons in
the Community- was worked out at the WHO by Gunnel Nelson, Padmani
Mendis and Einar Helander. The manual contains training programmes
based on observations of spontaneous, and informal rehabilitation
performed around the world with addition of professional experience
collected by the authors and a large number of reference persons. The
manual was tested in nine countries and comments were collected. An
evaluation nn ting was held in 1982 with participants from the
experiments. The authors made extensive field trips and collected
comments from disabled persons and their families, primary health
workers and others who had been involved like physiotherapist doctors
and teachers. After this, the manual was submitted alterations and
improvements.
It has been translated into at least 27 languages and printed in more
than 100, 000 copies. It has subsequently been distributed to nearly all
countries in the world. Many countries have adapted the manual to their
r
conditions. In Hong-Kong for example a manual for use in urban areas
has been produced.
Between 1984 and 1988 a numbi of top experts in different fields reviewe
the different chapters of the manual. Taking their views into
consideration a new version has been elaborated.
In addition an evaluation methodology has been designed and tested lor
measuring quality and quantity of rehabilitation services. Efficiency and
effectivity are measured both in relation to individuals and to
communities. Parameters used are such as a) the number of disabled
children integrated into regular schools, b) the number of disabled adults
gainfully employed and c) the creation of organisations of disabled
persons.
During 1989 the final, printed version of the manual will be published. It
contains some 800 pages with texts and accompanying illustrations to be
used directly by lay people. The language has been systematically
simplified, and not more than 1,800 different words are used. Like before,
the different sections can be used separately. They number 31 training
packages and guides for community leaders, persons with disabilities
and their organisations, local supervisors and teachers. The manual will
be distrbuted from the WHO headquarters.
The GBR approach has uiree main components viz,
i community involvemenL
ii a simplified technology and
iii an appropriate service delivery systeim
io j.
I
!
This approach is expected to meet the needs of 70 per cent of all disabled
persons as compared to conventional, institution based rehabilitation
which does not cover more than 1-2 per cent at present in most
countries. Institutions and more sophisticated services do have their
place in the CBR approach also, if they support community efforts, serve
as referralpoints for more complicated cases and provide trainin? for
rehabilitation personnel. Possibly, some of the special institutions could
help manage CBR-services. Still, the distribution of resources and
personnel should have a relationship to the service-pyramid, in which
70% of the population are catered for in the community, 20% at district
level and only 10% require services at tertiary and quaternary levels of
specialization.
5
# *
10%’
national
Z 20%'
district
70%
community
level
In the CBR ideology, rehabilitation is viewed as a means for people with
disabilities to achieve health. {Health in t rn is taken in its wide sense
as the "state of complete physical, mental and social well-being and not
merely the absence of disease ...".) Consequently, the social elements in
both the aims and the means are constants -be they explicit or implicitin all CBR-activities.
CBR can be said to be , Primary Health Care, PHC applied to the field of
rehabilitation; it is based on the same conepets. CBR contains essential
rehabilitative measures which are appropriate in each community.
Essential is used here with the same implication as in essential drugs At
is not only adaptable to but also founded on local needs and resources.
From this it Allows that CBR measures are affordable on the one hand and
making full use of available resources on the other.
1
’!
-
~
CBR services may be tied into the PHC network or be coordinated with it.
Services on higher levels, institutions and specialists can then
referral
points for more demanding cases and sites for the training of personnel.
Local supervisors, corresponding to Village Health Workers, are those
who carry out the work in the field together with disabled persons, their
families and local people. They are supposed to detect and register
persons with disabilities, establish their needs for rehabilitation, select
the training material, find a trainer, follow-up the rehabilitation with
assessments and records and finally to refer the person to oi^er services
(if they are available) when need be. In some places they are volunteers
like the Red Cross Youth or members of religous organisations.
Elsewhere they are employed more or less formally by health- or
I
6
7
education services.In turn tin get support from Intermediate Level
Supervisors, who may be Rehabilitation Assistants, Nurses, Therapists,
Social Workers or the like.
Both the WHO and the UNICEF have formally recommended CBR to
replace the conventional services, while the 1LO has a slightly different
interpretation of the same basic ideas. The WHO Global Programme for
the current period has set the target that 50 per cent of all countries will
initiate CBR programmes.
Although CBR from the management point of view first and foremost
belongs to health services, there is an absolute need for involvement by
other branches of administration and society. The fact hat this is a
prerequisite for national programmes is expressed in the World
Programme of Action:
They ”should be an integral component of the nation's general policy for socio-economic
development.’'"Each ministry or other body within »e public or private sector
responsible for, or working within, a specific sector should be responsible for those
matters related to disabled persons which fall within its area of competence.
Governments should establish a focal point (for example, a national commission-..) to
look into and follow the activities — of various ministries, of other government
agencies and of non-govei ..mental organizations.”
In all of the above mentioned activities it is desireable that the persons
with disability remain in their own communities. They should have
access to the regular services for others like schools, health, social
services etc. and get through them any extra support needed. They
should take part in all decisionmaking concerning them.
When it comes to formulating or assessing projects for disabled people,
one should examine who will actually benefit. We should consider as
targets not only the person with a disability but also the family and the
community.
1
MODIFIED MULTI DRUG TREATMENT REPORT OF
BANGALORE (U) DISTRICT
FOR THE MONTH OF
199
I E
Place :
Name of Centre
Date :
MB
1.
Total known cases before start of MDT
2.
No. Screened
3.
No. Found fit for MDT
4.
No. started on MDT at the commencement
of programme
5.
SURVEY & DET. AFTER THE COMMENCEMENT OF MDT
A.
DURING THE MONTH
No. Examined
PB
TOTAL
No. of cases det.
No. with deformites
Adult
Adult
Type of Survey
Adult
Child
Child
General Survey
School Survey
Random Survey
Contact Survey
Vol. Reporting
B.
TOTAL ADDED UPTO END OF MONTH (Cummulative)
General Survey
School Survey
Random Survey
Contact Survey
Vol Survey
6. No. ADDED TO MDT AFTER COMMENCEMENT OF MDT
(after the No. of cases started at the commencement of MDT)
A. DURING THE MONTH
No. added subsequently during the month
No. added till the end of month
B.
Total cases brought under MDT (cummulative)
from start (No. started at the begining
and those added later)
7. No. DELETED FROM MDT
A. DURING THE MONTH
a)
By RFT
b)
By Death
c)
L.C.A
TOTAL
i
Child
MB
B.
PB
TOTAL
TILL THE END OF MONTH (Cummulative)
a)
By RFT
b)
By Death
c)
L.C.A
TOTAL
8.
I.
No. OF PATIENTS UNDER MDT AT THE END OF MONTH
No. treatment took during the month
a) under MDT
b)
II.
under Mono
REMAINING PATIENTS AT THE END OF THE MONTH (defaulters)
a)
under MDT
b)
under Mono
c)
Not taken treatment
9.
No. UNDER SURVEILANCE
9.1
RFT cases at the end of last month
9.2
No. RFT added during the month
9.3
No. deleted from Surveilance
(RFT, Death, LCA etc.)
9.4
No. under observation
9.5
No. examined during the month
9.6
No. Relapsed (only confirmed by D.L.O
or consultant)
10.
No. OF SKIN SMEARS TAKEN during the month
10.1 Found +ve
10.2 Found -ve
10.3 No. of smears cross checked during the month
ANTI LEPROSY DRUG REPORT
CLF
DDS
25
50
100
No. of Drugs on Stock at begining of the month (OB)
No. received During the month
No. spent During the month (consumed)
Balance of Stock (closing balance)
Signature & Seal
50
100
REF
150
300
r;
MONTHLY REPORTING FORM
r-
national leprosy eradication programme
STATE/U .T.
DISTElCT/s
19
MONTH/QUARTER
URBAN
MB
PB
r™ ■' RURAL
i MB,
PB
■mm .»«
■aeaMaMBBaaMr^wa^wataaoKA*- ««m*«aamM
ENU
Number of persons exami
ned during the month
1.
«n» ma rra «■»
«cv Vna vxa C3» cob ■=» asv.caB «»• c=» raw
am a=«
«k* «sw «ca «l=»
*9
2.
Tot. cases det. during
the month
2.
a. By population
Survery
TOTAL
MB
PB
EXAM
<
-.Eir————
—-
«=> csa «-*» cw «*■ an» «e> cz* r*9 ccj >va •=»• e=J cn»
2.
c*s> tn»
t_s» rr=B
•Tarw»7-( mvwr. -«**.•>'. ?
■*-
«
£x
<Z3
r^a
J
£b. By contact Survey^'
EX
—g^T“——™—
2.
‘2.
c . By voluntary
EX
. EN
d. By School
Survery
■
EX
'”e“n
e . By a ny ot he r
method
a «Ba am aoa ■» ks» mob bbob ma e» Ban au raw raa csw «*□ oca «na er» «xm *.=• <ca kj cr.» ra «z» oxa c=a &a era e.-a «aca oa
3.
Cross Checking :
aoa c-a ca az» caa ®a <=» cia ua cr-.a ■»-' c=a •=» <s* «xa <=a <» *E-a tL-» . -jct ceaa w-a «»
3.
u=* ora o.a cjb *:-j» a ••?-* «na
a. No. of Pts .Cross Chec
ked for drug consum
ing tabs with the Pts.
«a* ao .ca ea ■* «mb ana «a» •» eta tat»
«xr* «naora
«x» ma ma «aa ora vea cna r» rw erm era aw vra <=» era «
3.
b. No.of Pts. found consum
ing tab regularly.
3 .
c. Nd. of Pts. examined for
consumption by urine check
•rw cm ma v-a ata «ca ma «ed br*
«» e^B «■ mm«c« «t* «na rr* en «r« osa
3.'
4.
Cases registered :
a. No. Reg. till the end
of last month
oe» aaa
5.
<• a
u a cjb
w
bm ai=a
«r» m *«a ma «=i
ma ma r-» «-a <-a» r.-a ■
d. No. found +ve for urine
tes t
~
4.
«sa «n» ma «ra <=u
irja caa «»■ •=• cn «• <a» txa waa <=> *^» c=>
«=»
«=»
b. No. Reg. during the
report ingame nt h_&
■** *=
i
a • No. cases discharged as
cured / RFT
«C» M. C* *■
VW MM MW
BO. «?■ «w
m ^9 BSJg «UM
r'™ «W CSM MM CS» *«. «
5.
b. No. discharged as dead
5.
c. No. discharged as left
t he a re a
5.
d. Total discharged during
the month
*•*«» «ua aaa cca mb* «sb «oa bob ■*-> ma «> aaa ma ■=» «ca ce» ana «a aca «o» ca* m» ca
6.
«-»<=■«• <s» er»|x.
No. of cases on record at
end of month
an
«=» n> a,
♦" wr».on..MM., an^r ■ ■
«^»«3a
«c»oc*
<»«» «za
|
I
i
Contd
2
2 :
J
cr.
URBAN
MB
PB
7.
RURAL
MB
PB
total
MB
PB
Number of new cases under treat
ment at the end of last month,
■»
m CM ABB «B9B OSV «BI C=» «=E» r* MB* <XM
tOM CTU CEM aw
M «■ CU» «a» «=.W K?» CKM «T» B-. CM»
• • -7.a^V/ith dapsone monotherapy
7 .b.With multi drug treatment
aoaa mdv ma eaa
amb «=» ma mm oo*
asa «s* ana st-* a-* cm
an era i» aoa aza* c_» exaa aaa oca v*
em cm km
Number of registered cases
treated during the month
8.
aw waLa ua aaaaaaa ana rra ao* a=-u ooa <^acic> km» %aa cwto. oub <a co csa can mntoru. c=» *m«?» cna
8 .a.With dapsone monotheraphy
ana atsa aav an rea aaa aca ma cm aaa co cw exa r» caaa
«r» cam «jb «n caa «x» c=* t=r»
ca csa oca «»
exauoa
8 .b.With multi drug treatment
•aw..»'Cr*»’’*J'aa»c-Me^>aw«aa«waaarjMw\Mi<n»r^ I n—v.cii'm sarannwray—awwy- i>a —1 a»Maaa»wwrT.-*Mb W aw.vrcwi cmm.-v* 11 ...w
.'.twjmk -.*<.-.
9. a.Number of newly registered
cases having disabulity (of
grade 2 and above)
•m-ww
iwMiai ■ t—iu iii-r iwic. j^i
—igim i r.. i.nu —.it.nr
— —• a^aaCW* Bra aifcBia i ■■■
rrv «’ -MW a-iMT- rr: .-jc -javmr“iMrK Waf»>v-
10. Num ter of new child cases
(0-14 Yrs. registered during
one month.
— -^aMc*mMMaaMacaww
aa-Maaf*^u.«*vt>u««^«*VM* ’jrn acaja—i^iw;aii i’B^w—^-c^mcwjiccwm -
11. Num ter of registered
patients examined for AEB
£ sme ar /s 1 id)
11. a.No. of Pts. found positive
w ■ i.i r
!
c—MbMMruMaaNMacaMaralMaMacwrMaMrMcu- tMn-.-cauWaaani aa*a"ar ■>!
m-
12. In-Patients
12 .a. Number of registered, in
patients at the.end of
last month
12 .b. FJum&er'of^registereS^i n-~~
patients during the month
12.c . Number of in-patients dis
charged during the month
«u» CM
«9M MOB exx CO CKM
*1
CCM CC «W n C3B CM C=B ** CSS WB *-» MSB
ABM AX* 9S9 AB* 0BB
12.d. Number of in-patients at
the end
13.
No. . of re 1 apse . pat ie nt s ’ re giste.red during the month
14
No. of cases referred for
suspected, resistance during
the month
e^r-n i.u f >■<
. -vr-m>w«'*bi
]5i. Number of cases referred for
Surgical procedures during
?l the month
16. No. of old cases under treat
ment for which smear is to
16 .a. No.of smears actually taken
•-“*
rxa *=w iW cx3 «®» «-» «n ko*
m
«■* «n» era
era «* •*«»
«*• «• tr> aw aza
«*• «ra 4 • ««■ a*
«■» ae=»
16 ?b. No examined
17. No. of cases completed treat
me nt to be. foil owe d-up
clinically
17.a. No actually assessed
Clinically
•W
»w wamawaama e=J» cav cna na mm cm
ariLm r-ara « r»<=m
tea aoe avar ctm «w «»
Contd
3
'A
-: 3 :
. _ URBAN
\MB
PB
13 .
MB
' RURAL
PB
1
No. of in ative cases to be
followed bacteriologic ally
total
MB
13.a.No. actually followed up
19.
Total No.of smears examined
(col .11 + 16.b + 18.a)
— *■»
19.a.No sent for cross
«=3»ae«
*“ c=’* cx—
We-wn-r
check
ra eus tn «usa «ar» «x±* ca« ra> f.-t»
cm
m «n
19 .b.No. of variations reported
in the month +ve as -ve
Negative as positive
“~fc
cr*r?» eat »aBe?ie» <=!> tjt» wjb n-at Vc« <■=» en» kb exam r-w se>r-rv
B I difference
I ■
20 .
,■■■■
~.-|——^
7 ir~ — /-.
■UM HBBBIBIL
.
! •_ 1 ,1
—■I.n
Tot. No. of Slums
>»«■» «=>■=.« a. » -•<=. e-» «»«=. «=» ura «. «=» uu-.
20. a. No. of Slums without
Lep . cases
™”
«■«* *■ n> m <a» can •=• ana m an on e. u can e.-n i
b.No. of slums with only
PB cases
c.No.of slums with only
M.S. cases
d.No. of Slums with both
M*B. & P.BO cases
No. of Slums with No
data
l
DATE
PLACE :
SIGNATURE
NAME :
designation
POSTAL ADDRESS
HEziLTH EDUCATION ACTIVITIES
Group meeting
MMr'aaB)IH|iW4*n ■ aiiiMMWiMMi * t aw*.. iaBi M ..a, i_ wr—j~rnwi—
Health talks
Film Shows
Exhibitions
:
n i—imn ■'■ iMf
PB
Lepr Rev (1995)66, 224-228.
■ ■]
J
Repeatability of nerve thickness assessment in
the clinical examination for leprosy
I
gm
JB
w
a
C. KOLAPPAN? R. SELVARAJ,
ABDUL KHUDOOS, B. N, APPE GOWDA.
MANJULA DATTA & R. PRABHAKAR
Tuberculosis Research Centre, Epidemiology Unit, Tamil Nadu,
India
Accepted for publication 2 December 1994
miff
X
Ifl ■i
l:...
Summary The assessment of the thickness of the superficial peripheral nerve
trunks to document nerve involvement is an important aspect of clinical
examination in case finding for leprosy, and is usual!} done by trained
paramedical workers (PMWs). This assessment is subject to vanability and has
implications on the outcome of the survey. 1 he present study proposes to
quantify this variability. In this study. 242 individuals, consisting of 50 neuritic
cases. 143 nonneuritic cases of leprosy and 49 normal controls, selected from the
records of the trial of BCG prophylaxis in leprosy in South India, were examined
bv a doctor and paramedical workers. Repeatability of nene thickness assess
ment for ulnar and popliteal nerves between the medical officer (MO) and the
PMWs was quantified using Kappa statistics. The Kappa values for repeatability
between the MO and the PMWs ranged from 0-45 to 0-54 and 0 52 to 0-69 for
ulnar and popliteal nerves, respectively. The implications of the variability tn
nerve assessment are discussed.
4
«
lb
Of
A- ;
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iiti
fcp-
■
r
1
ffe
lip
■
Introduction
’
Leprosy surveys very often employ trained PMWs for screening the population.
examines the individuals diagnosed by the PMWs as having leprosy for con
The clinical examination for the diagnosis of leprosy includes the palpation o sup$e
peripheral nene trunks, especially the ulnar and popliteal nerves in order to ass^.s
thickness. The proper assessment of nerve thickness is essential for the ^ia^n°way to |
classification of disease. The clinical examination by palpation is the on
diagnose nerve thickening and, in neuritic leprosy, the assessment of nerve
is often the only means of diagnosis.
.
crit^H
Since the clinical assessment of nerve thickness is not based on objec i
:
variability between 2 assessors or the same assessor at 2 different times
* Correspondence: Tuberculosis Research Centre. Epidemiology Unit, Madras 600 031,1
224
0305-7518/95/066224 + 05 SI-00
|
Repeatability o f nerve thickness assessment in leprosy
225
I
i
| eCted. Neuritic leprosy constitutes about 14% of the prevalent cases of leprosy. But
If proportion of leprosy patients with peripheral nerve trunk involvements will be
Jch higher. Therefore the variability in clinical assesment of nerve thickening is likely
1 have a considerable influence on the estimates of prevalence rates so obtained. This
jiudy presents an attempt to actually quantify this variability.
I
i
I
Materials and methods
Lee the prevalence of thickened nerves among the general population is very low, the
Ldy sample is selected to include a fair proportion of individuals with thickened ner\ es.
L selected 242 subjects, consisting of 50 (21%) patients with neuritic leprosy, 14?
Ij9%) with nonneuritic leprosy and 49 (20° o) normal controls, from the records of the
South Indian Chingleput trial of BCG prophylaxis in leprosy. The assessment ot
^peatability was carried out between 8 PMWs and 1 MO who were engaged in the
jCG Prophylaxis Trial in leprosy and had at least 10 years experience in1 the clinical
aamin. n for leprosy. Out of the 244 selected. 242 were examined by the MO (2 were
jot available for examination). Following the examination by the MO of an individual,
achof the 8 PMWs examined him her independently. The interval between the MO and
MW examination for any individual varied between 0 and 7 days. The PMWs recorded
ieirfindings independently on a separate precoded sheet without knowing the findings
ofthe other PMWs and the MO. Each single examination was independent of any other
lamination.
The findings of the clinical examination were recorded on the prescribed form in a
recoded format for each individual. While assessing the nerves, both thickness and
insistency were assessed and recorded.
I
■
l!
>
katistical analysis
measurement of interexaminer agreement
foppose ^at each of a sample of n subjects is rated independently by 2 examiners on a
scale consisting of 2 categories:
t
i
First examiner
Second
examiner
Positive
Negative
Positive
Negative
a
c
b
d
A measure of agreement is the mean pair agreement index Pq, which is obtained as
p
PQ = number of agreements/Total No. of pairs
i
i
I
226
C. Kolappan et al.
This varies considerably with the prevalence. Any characteristic with a llow
Ow
prevalence will have a higher value for d and a higher repeatability, i.e. the value of
Pq is inflated. Thus it is clear that except in the most extreme circumstances some degr^
of agreement is to be expected by chance alone.
Let us consider an index that assumes the value 1 when there is complete agreement.
Let Pq denote the observed value of the index. Let Pe denote the value expected on the
basis of chance alone.
(
The obtained excess beyond chance is Pq - Pe, where the maximum possible excess is.
1 _ pe. The ratio of these 2 differences is denoted by Kappa (K) and is defined by
/ Wh ’■
Hi’
r
K
If
t•
II
K= (PO-PJ/(1 -Pel
Kappa is a measure of a chance corrected agreement between 2 ratings. A value of
‘ + 1 ’ for Kappa indicates complete agreement. A value of ‘O’ implies agreement no better
than chance. Negative values indicate more disagreement than expected by chance.
In this study, interobserver variations were measured using the Kappa statistic for
the chance corrected agreement as described by Fliess . This approach was preferred
because of its ability to quantify the maximum possible agreement on abnormalities.
if
ft
11;
Results
4
vL
H 3:
ft"
11
Bln: ■
/■Al
In leprosy surveys and control programmes, PMWs are used for screening purposes
only. Case diagnoses are made by MOs whose clinical examination is considered as
standard. In this study the variability between the standard examiner (MO) and test
examiner (PMW) was assessed for each of the 8 PMWs independently. The prevalences
of thickened ulnar and popliteal nerves of the study population were 23% and 26/c,
respectively. The prevalences of altered consistency of the same nerves were 5-5% and
9-2%, respectively. Since the prevalences of altered consistency were low in the study
population, the findings on consistency are not reported here. Table 1 s110^^
distribution of various categories of study population as seen by the MO and P
The study population consisted of a reasonable mix of all types of leprosy in v hich neryj
thickening could be expected. Table 1 shows the number of individuals examined
s
PMW. The MO had examined 242 cases, out of which at least 212 had been examined y
!
Table 1. Distribution of the study population according to disease status
■!
r
r-
Number examined by the PMWs
I
Case category
MO
1
2
3
4
5
6
7
Maculo anaesthetic
Tuberculoid
Neuritic
Lepromatous
30
16
44
10
39
28
45
30
16
49
11
43
28
49
31
16
50
11
43
28
49
31
15
48
11
41
24
48
29
16
49
10
41
28
48
29
15
49
10
41
26
49
31
Suspect
Normals
35
17
50
14
49
28
49
Total
242
212
226
228
218
221
219
Borderline
|Sp'.i. ; ■
■il
Sh ft
F'hi
■
15
49
11
41I®
«28 aJ
49
49 >-
226
■ ■'■I
Repeatability o f nerve thickness assessment in leprosy
|jble2. Interobserver agreement in the assessment of nerve thickening
Kappa Statistics
1
I
i
Jri
No. of
nerves
assessed
Ulnar
nerve
Kappa
424
452
456
436
442
438
452
436
0-50
0 51
054
0 53
0-49
0-45
0-47
0-49
(95°o C I)
Popliteal
nerve
Kappa
(95% C I)
(0-40, 0-60)
(0-41. 0-60)
(0-45. 0-63)
(0-44. 0 62)
(0-40, 0 58)
(0-36, 0-55)
(0-38. 0-56)
(0-40. 0-58)
0-69
0-57
0-59
0-56 054
0 55
0-58
0 52
(0-60. 0 79)
(0-48. 0 66)
(0-49. 0-68)
(0 47. 0-65)
(0-45, 0-63)
(0-46. 0-64)
(0-49. 0-67)
(0-43. 0-61)
achPMW. Table 2 shows the Kappa statistics for ulnar and popliteal nerve thickness
issessm
between the MO and each PMW. It is seen that the Kappa values for the 8
PMWs for ulnar thickening ranged from 0-45 to 0-54. The corresponding ranges for
popliteal nerve thickening was 0-52-0-69.
!
I
I
Discussion
llie sample is selected in such a way that a satisfactory level of prevalence of study
iaracteristics can be ensured in the study population. The study was also confined to
xrve thickening, since this is the sign that will be used for case detection in the field, and
krefore other signs such as nerve tenderness and sensory deficit were not looked for.
The repeatability of a qualitative measurement like the thickening of a nerve is
tyendent upon the 2 components of variability, namely the biological variability and
measurement variability. Dr Noordeen1 has reported spontaneous regression of
tokened nerves in leprosy patients (biological variability). In the present study, the
^logical variability is minimized by having the paired examinations for each observer
Uthin 7 ys. It is therefore reasonable to assume that the interobsen er variation in this
Wy is almost entirely due to the measurement variability. There is a certain inherent
of precision in the method adopted for the assessment of nen e status. Obesity,
Ration and the size of the corresponding nerve in the contralateral limb are the
that influence the decision on nerve thickness status. Since the above-mentioned
^ha are subjective in nature rather than objective, the repeatability as expressed by
Kappa statistic is not very good. Earlier studies2,3 have studied the repeatability for
diagnosis of leprosy between MOs and between the MO and senior PMWs,
Actively.
^.Neelan et al.3 have studied the repeatability of diagnosis and classification of early
S iii*11 leProsy among medical officers. They have not, however, studied the repeatI j y of nerve thickening assessment in that study. Gupte et al.2 reported Kappa 1
J
f°r agreement between 3 pairs of examinations for assessment of
j J^ess with sensory deficit. They had studied nerve thickening not in isolation bi
|
total clinical examination. However, they did not study ulnar and popliteal nerve
-
u
,-J.----
228
C. Kolappan et al.
thickening separately as was done in this study. The objective of the present study w
view nerve thickening as a clinical sign by itself. Therefor* a complete examination -T?
patients was not carried out and only their nerves were examined. This was expected
eliminate expectation bias due to knowledge of the case status of the individual. Int?
present study the Kappa values for ulnar thickening range from 0-45 to 0-54 and
popliteal thickening from 0-52 to 0-69. According to the classification of Landis &Kq^ I
Kappa values of between 0-4 and 0 6 could be taken as moderate agreement. We note I ■
that agreement is better for popliteal thickening than for the ulnar thickening but for ||
both nerves it is still only moderate.
In view of the above findings, it would appear that one cannot expect more thana
moderate level of reliability for a clinical examination undertaken by PMWs with respect
to nerve thickening. However, standardizing PMWs and selecting those with high levels
of interobserver agreement would minimize measurement errors, especially in rapid |f
prevalence surveys.
I
it
•
Conclusion
•
i
■ v-'N* < 4V
.. v
, -v
a
wl
The assessment of thickness of ulnar and popliteal nenes is an important aspect of Ife
routine clinical examination. Leprosy screening examination is usually carried out by O
trained PMWs. Each PMW acts as an independent screening test and the MO acts as the ||
confirmatory standard test. In this study, the repeatability of nerve thickening assess- I
ment between the MO and the PMWs was studied. The study shows that the Kappi I
statistic for interexaminer repeatability varies between 045 and 0-69. The present study I
underlines the fact that this clinical sign (nerve thickening) assessed in the clinical I
examination for leprosy is a soft parameter and even experienced workers show I ■
considerable variability in its assessment. This may be kept in mind while assessing jltfroduc
prevalence in large surveys.
|
I Footdr o
Sjl^l0,16
II Lepr
References
■Urrow
1 Noordeen SK. Epidemiology of (Poly) neuritic type of leprosy. Lepr Ind. 1972; 44: 90-6.
2 Gupte et al. Inter obsener agreement and clinical diagnosis of leprosy for prophylaxis studies, in
’
1990;62:281-95.
option* I
3 Neelan PN. Noorden SK. Ramu G. Desikan KV. Prabu KPM. Christian M. Inter-observer vanau
diagnosis and classification of early lesions of leprosy. Lepr Ind. 1982; 54: 485.
|®an th.
4 Fliess. Statistical methods for rates and proportions. 1984:
159-^ I My a
5 Landis. Koch. Measurement of inter obsener variation in a categorical data. Biometrics 1977, '
i’teross.
s I
.I..;?'*
’
I
I
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fefents
[fcratio
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1^75 Is
medico friend
242 circle
243
bulletin
May-June, 1997
Immunity, Ethics & Control of Leprosy
B.R. Chatterjee
President, Indian Association of Leprologist,
Leprosy Field Research Unit, Jhalda.
Since a mycobacterium, M.leprae, is associated with
leprosy, it is an infectious disease. Indeed this assertion
comes handy to combat superstitions that surround the
cause and effect of leprosy. It is carried a bit too far
however when public advertisements assert that it is one
of the least infectious diseases. This statement is wholly
scientifically wrong. What they mean to convey is that
leprosy does not occur easily. The scientifically correct
• ■ assertion should be : while getting infected is quite easy,
nfection does not automatically result in leprosy, the
disease. And, this phenomenon, transformed into scien
tific jargon would imply that human ability to contain the
infection and prevent development of clinical leprosy is
high. This also means, mobilising of protective immunity
to leprosy is the rule, and occurrence of leprosy as a
disease is rather infrequent.
Now since the word immunity is brought in here, we will
use a few words to explain how it relates to leprosy.
Immunity normally connotes resistance. However, the
immune process and, the immune system is not that
simplistic. Immunity can both be protective, as well as,
devastatingly damaging to health. Of the various im
mune processes, delayed type hypersensitivity, or DTH,
is one such process that can do a lot of damage to host
tissues.
We all know what happens to a patient of tuberculosis
with excessive DTH there is liquefaction at any site
where M.tb is lodged, and in matter of weeks both the
patient's lungs will be destroyed making living impos
sible. In the normal run, i.e., in patients not excessively
hypersensitive, DTH offers temporary retreat though, in
the way of casseation, sealing off of the affected part with
dead tissue and cessation of blood supply making the
bacilli in it dormant and the infection latent—M.tb are
aerobes. This is far from being a protective response and'
can break down any time.
The Immune Process
In leprosy, DTH, as manifested by Type-I reactions in the
so called paucibacillary leprosy (Indeterminate, tubercu
loid, borderline-tuberculoid, or BT, and neural, or
polyneuritic leprosy) bring with them neuritis and
deformity (initially reversible), lesional exacerbation and
dissemination (intensity of neuritic pain may drive a
patient to commit suicide) and transient, low-grade
bacillation. A BT patient that is nominally bacteriologically positive, will become positive of a grade that will be
easily detectable in a skin smear. If the neuritis is not
promptly treated with steroids and/or neurolysis, deforBackground paper for the MFC Annual Theme Meet, Dec.
1997.
mfc bulletin / May-June, 1997
2
mity which is initially reversible with the subsidence of
the reaction, will be permanent after suffering a few such
reactive episodes. Similarly, since the reactional site
provides ideal sancturies for M. leprae to resurge, the
paucibacillary (PB) disease will slowly become
multibacillary (MB)— a reaction site has a low PO2 and
pH, both conditions favouring M.leprae multiplication.
Further, with increasing bacillary load, the lipids of
M.leprae that are notoriously immunosuppressive add to
the suppression with incremental loss of immune re
sponse of the cell-mediated (CMI) variety, with the
antibody component becoming hyperactive, producing
large quantity of antibodies that do not protect but add
an extra dimension to the disease in Erythema Nodosum
Leprosum (END, called in leprological jargon a type-II
reaction. This is an acute vasculitis resulting from
deposition in small blood vessels of something like a
small embolus consisting of bacillary fragments that ties
up the abundant antibodies which, in turn combines with
complement. This is really an immune-complex disease,
is very painful and relieved only with steroids or
thalidomide, and clofazimine. After healing, thick scars
are left behind on the skin, and repeated attacks leave
the skin in a cosmetically revulsive state and the normal
texture of the skin does not return even after years of
recovery.
disease due to various reasons. The important cause for
downgrading are these reactive episodes, and a common,
cause of reactions are some anti-leprosy drugs, notably
dapsone. Notwithstanding whatever has been said in
defence of its anti-reaction role, I am convinced this drug
dapsone is the most destabilising of all anti-leprosy drugs
and almost all those begging on the streets, or at the
places of pilgrimage with badly deformed hands, legs, feet
and eyes are largely the result of indiscreet treatment
with dapsone that they were taught to go on taking for
life to prevent relapse.
The other reaction-inducing agent is concurrent crossreactive mycobacteria—these are quite frequently en
countered in attempted culture to grow M.leprae, and
many a scientist has gone through this experience c
‘growing’ M.leprae, when actually they isolated the co
existing cultivable mycobacterium that behaved intially
quite fastidiously as if they were indeed non-cultivable.
Immunocytes of LL-BL leprosy, while non-responding to
M.leprae, are easily stimulated by non-leprosy mycobac
teria inducing release of the cascade of cytokines. This
leads to DTH, and the oxidative metabolic burst in the
phagocyte, leading to production of toxic oxygen and
nitrogen radicals, the lethal chemicals that damage the
lysosomes, releasing the lytic enzymes in them that can
kill both the bacilli and their phagocyte sancturies.
Reaction & Deformity
To Dapsone or not to Dapsone
All aspects of the disease of leprosy, and morbidity arising
from it are reaction-related. These reactions are always
occurring at a micro-level. Only when they are clinically
obvious and cause much suffering do we call them
reactions. The basis of leprosy pathology is reaction,
appropriately called immune-pathogenesis of leprosy.
The term immune-pathogenesis should imply that patho
genesis of leprosy is immune-mediated.
Unless these immune-mediated dimensions are under
stood, appreciated and always kept in mind, and guide
our actions, rational designing and delivery of anti
leprosy chemotherapy or immunotherapy is not possible
In the spectral classification of leprosy, we have two
extremes—at one end lie the TT-BT types that are prone
to DTH, and bacilli are but rarely encountered with ease;
at the other extreme are the so-called multi-bacillary
leprosy, the borderline lepromatous and true, or polar
lepromatous leprosy. In our country de novo lepromatous
are vary rarely encountered (I have seen only two so far
in my over 30 years of dealing with leprosy), and are quite
deceptively normal looking unless when you take a skin
smear that is highly positive. Almost all the BL-LL cases
that we see had started with tuberculoid, or indetermi
nate disease, and have downgraded to BT or BL-LL
The guidelines of the Directorate General of leprosy, that
can be taken to mean the WHO, to leprosy staff (of all
grades, from the State Leprosy Officer down to the field
level supervisor and paramedical worker) strictly advise
the workers to continue with dapsone in full dosage (100
mgm a day for an adult), reaction or no reaction. How I
wish I could make these jet-setting leaders in leprosy to
suffer the pain of leprous neuritis! And it is not just the
pain. The most unacceptable aspect of it is the muscular
weakness, the sensory paralysis and a continuing,
smouldering pathology in the nerves that I strongly feel
becomes a life-long association.
I cite here a small pasage of an Editorial article from a
group of Latin American Leprologists—“From the point
of view of evolution, it is important to bear in mind, that
f
mfc bulletin / May-June, 1997
peripheral neural damage and its side-effects frequently
follow a course which is independent from the systemic
manifestations of the basic disease. This means that in
‘leprologically inactive" patients a progressive exacerba
tion of their neuropathies may occur... from the practical
point of view, this implies that ‘dermatological discharge"
does not necessarily coincide with ‘neurological quies
cence" of the disease"" (Int. J. leprosy, 1983 : 51: 576-586).
Charosky, Gatti and Cardoma are but a small group from
a vast pool of highly experienced leprologists from South
America that base their observations on meticulous
clinical and pathological observations over long years on
large number of patients. I have a feeling that their
observations and conclusions are ahead of time. Unforunately these Latin Gurus of leprology are hardly ever
referred to in contemporary literature, leave alone be
seriously considered.
Fortunately, due to the presence of clofazimine in the
regimen for multi-bacillary leprosy, Type II reactions
(ENL) occur but infrequently with somewhat diminished
severity. But the regimen for PB leprosy does not enjoy
this privilege of clofazimine. As mentioned earlier, a large
majority of our MB cases arise from Immuno-clinical
downgrading of PB leprosy, and it should be quite obvious
that these patients should also receive the reaction
sparing benefit of clofazimine. I now hear that the WHO
is looking for a suitable group/institution to initiate a
study on the role of clofazimine in type I (DTH) reaction
in PB leprosy. It was in a WHO-sponsored DGHS
organised workshop at Jamshedpur in 1983 that this
author showed the value of clofazimine in preventing
type I reactions if it was used as a routine. Clofazimine
was recommended as a preventive of type I reaction, not
as a cure after letting it develop. Unfortunately, when the
type I reactions do set in, clofazimine alone usually does
not help; it has to be supplemented with corticosteriods
for a suitable duration, i.e., until clofazimine asserts
itself as its effect is slow in coming. I have been treating
hundreds of cases at our small pay clinic essentially
without DDS; it has to be mentioned that the cases that
gravitate to our clinic are mostly MDT (WHO) failures.
I do not want to invite trouble of a type I reaction—I use
clofazimine as a compulsory component of PB treatment.
Against all the incessant publicity of the WHO regimen's
virtue, I cite the sane voice of a late veteran, Dr. Stanley
Browne, in the context of ENL reaction of MB leprosy—
“While stopping dapsone may not always result in rapid
improvement in ENL, it is incontestable that resumption
3
of dapsone therapy in such patients, even in minute doses,
will often precipitate a recurrence of the signs and
symptoms of ENL” (Int. J. Leprosy, 1967 :35 : 395-403).
This was 30 years ago, pointing an accusing finger at
DDS on causation of reactions.
Until the 1960s, we were somewhat helpless, as DBS was
the only drug available for leprosy. That does not apply
now, and there is no need for the whole programme to be
strait-jacketed into just one regimen proposed by the
WHO after very limited hospital-based studies. DDS can
be easily substituted with clofazimine in PB lep
rosy, and temporarily or permanently withdrawn
from the MB regimen as there are two other drugs
in the regimen.
o
The whip, reaction or no reaction, DDS must be continued
in full dosage, might as well mean: deformity or no
deformity, DDS must be continued. Now, deformity is
often a very deceptive phenomenon in leprosy. It may, or
need not be a spectacular development, meaning, devel
oping with obvious visual impact. One often finds the tell
tale wasting of the hypothenar or thenar eminences, or
the grooving of the dorsum of the hand due to the slow
paralysis of the interossei. Paradoxically, it is the acute
onset deformities that are more easily reversed and
corrected, and there is very little one can do to reverse
the deformities/disabilities that are late and slow in
coming. However, in both situations, withdrawal of DDS,
introduction of clofazimine in the PB regimen, or raising
its dose in MB regimen, with a short course of steroids
has almost always a salutory effect on checking the
progression of deformity/neuritis, and its slow reversal,
unless it has been more than one year in developing.
At the Deoghar district MDT project, this author served
as a consultant, which position he resigned after two
years when the leprosy directorate objected to his
modifying the regimen whenever called for. One of the
number of consultants that followed me objected to this
modified regine—by then all the MDs, superviors &
PMWs were conviced of the usefulness of withdrawing
DDS in reactive or non-responding patients. When the
concerned NMS (non-medical supervisor) explained how
reactions could be rapidly resolved with DDS withdrawal,
the consultant advised introduction of steroids without
suspension of DDS. The NMS said something that
silenced the said consultant—Sir, your advice is like
bandaging a person after thoroughly bashing him up.
Needless to say, all the staff in Deoghar district now
4
follow this modification—no ‘expert’ could change their
conviction.
So where does ethics stand here? Be ethical and obedient,
or change course under an expert guide? I have always
questioned the need for consultants if consultants were
simply to follow a set pattern for all situations. Then you
do not need a consultant, you need a manager !
Therapeutic Intervention in Children
We had followed the clinical evolution (as relevant to
leprosy) of hundreds of children in our Jhalda study
areas. Lesions of leprosy developing in them were
recorded, but we never put them on treatment but they
were put on observation with a physical check-ups every
3 months. We never even told their parents about their
leprosy. Every child resolved his/her lesion spontane
ously. Even if a stray child was diagnosed by the leprosy
Mission staff who run the leprosy control unit in Jhalda,
we would counsel the parents not to give the dapsone.
Because of our very frequent visits, and our generally
taking care of their minor medical needs also, the parents
cooperated, and neither they, nor we had any occasion to
regret our intervention. The rationale is simple. Children
in these areas almost universally develop self-healing
minor lesions, and this inconsequential early lesion is
like an immunisation. Why intervene with treatment and
interrupt this immune process? Medical ethics dicates
any case diagnosed as leprosy must be put on treatment.
Rationality dicatates that the child patient (one can
hardly call the child a patient, that small spot is a part
of living) be allowed to evolve with his early and limited
leprosy under the watchful eyes of the health worker,
ready to intervene if there is any sign on non-containment. Which is ethics : compulsory treatment, or
non-intervention under adequate surveillance?
Elimination of Leprosy by 2001 AD?
Under the pressure of the WHO, and the World Bank, the
Government is now frankly resorting to grossly unethi
cal, if not illegal practices. They have to meet the deadline
to show elimination of leprosy, meaning reaching a
prevalence of one case or less per 10,000 population, by
the year 2001 AD. The World Bank has advanced a loan
of over 3 billions of rupees on this assertion. How do they
propose to achieve this miracle? Prevalence is being
mfc bulletin / May-June, 1997
projected as a better index of success than incidence, or
crude new case detection rates (NCDR)! And how is this
reduction of prevalence, and of course NCDR, which
currently, even by official estimates is a staggering
450,000 cases annually, or around 4.5 per 10,000 popu
lation, is to be achieved? Give a one day regimen to PB
cases, and a 28 days all-bactericidal regimen to all known
MB cases and declare them cured, and remove them from
the register! Never bother to look for what happens to
them, the bacilli they have been harbouring, or the
disease they have been suffering.
Has any infectious disease been controlled/eradicated by
chemotherapy alone?
Now, is that what you call ETHICS?
Don't do any survey to detect cases, don't do any
absentees retrieval, or any post-MDT surveillance. Be
cause they all have been cured! About the deformed, the
ulcerated, the economically and socially displaced, that is
not the job of the leprosy directorate to bother about any
way!
Normally, the NGO working in leprosy have been
catering to the needs of about 15% of the patients. By, and
after 2001, they are going to have to shoulder the whole
burden of the problem, because after 2001, apparently
leprosy will have been eliminated—a few straggling cases
that may have escaped the dragnet will be treated in an
integrated set up. Who are they deceiving, these Inter
national experts?
The count down has begun! By 2001, they are sure to
show less than 100,000 cases in the country. Any group
of leprologists/epidemiologists that have looked at the
situation with a dispassionate view in any area undergo
ing MDT have come up with a 3-4 folds rate of prevalence
over that shown in government returns. What we do ?
Pray or fight ?
There are other areas, notably the combination of drugs
in the MDT regimens that we follow, where the WHO is
not ready to concede that mistakes have been made in
their undue haste to ‘eradicate’ leprosy. I propose to write
another piece highlighting these inconsistencies, and
suggesting alternatives.
f
&
Resurgence of Infectious Diseases and the Indian Society
/
microbial genetics
BIOLOGY
ECOLOGY & POPULATION
spread of vectors
drug resistance
migration
insecticide resistance
sanitation
population growth
drugs & vaccines
RESURGENCE
OF
COMMUNITY
dengue
cholera
urbanization
development
pollution
ecological destruction
food supply
community inaction
plague
special groups
HIV
Gender inequity
public health crisis
malaria
vulnerability of children
kala azar
irrational care
poor surveillance
diagnostic technology
reduced health expenditure
professional apathy
ECONOMY & POLITICS
market economy
privatisation
corruption
structural adjustment
legal control
poverty
media
A Zachariah, M Pai, P Chatterjee
HEALTH SYSTEMS
I
r
mfc bulletin / May-June, 1997
6
ANNOUNCEMENT
Medico Friend Circle Annual Theme Meet
Theme
Resurgence of Infectious Diseases
Date
December 27-29, 1997
Venue
Sevagram, Wardha
The topic will be discussed under the following headings:
1.
International perspectives.
2.
National perspectives
3.
Case studies of local responses
4.
Public Health system response
The diseases focussed on are :
1. Malaria,
2. Dengue,
3. Plague,
4. Kala azar,
5. Cholera,
6. HIV,
7. TB
We would invite papers on broad perspectives and case studies of local responses to individual
problems. Kindly send papers to :
Dr. Anand Zachariah,
Medicine Unit I,
CMCH, Vellore,
Tamil Nadu 632 004.
Background Papers
1.
Resurgence of Malaria
—A case study
Ravi Narayan
2.
Re-emergence of Kala azar and Indian Society
—A Case study
Prabir Chatterjee
3.
Dengue haemorrhagic fever in Delhi
Yogesh Jain & Sathyamala
4.
*Drug resistance and irrational therapy
Delhi Group
5.
Anti-malarial policy system and resurgence
of infectious diseases
J.P. Mulliyil and Madhukar Pai
7
mfc bulletin / May-June, 1997
7.
*Resurgence of TB
Thelma Narayan
8.
“Of Cholera and Post-Modern World” EPW
August 22, 1992
P. Mohan Rao
9.
HIV/AIDS
Anand Zachariah
10.
Contextualising Plague—A reconstruction
and an analysis EPW, November 19, 1997
p 2981-2989.
Imrana Qadeer.
11.
Epidemiological Overview of Infectious diseases,
resurgence in India
Pankaj Mehta, Manipal Hospital, Bangalore
12.
Rethinking Public Health : Food, hunger and
mortality decline in Indian history
(Presentation at School of Social sciences, JNU)
Sheila Zurbrigg
13.
Resurgence and Children
Sanjeev Lewin,
St. John's Med. College, Bangalore.
14.
*Market economy and infectious disease resurgence
Requests sent to Ghanshyam Shah) CSCM,
Economic impact of resurgence of infectious diseases
Rama Baru) JNU and Abhay Shukla, Pune
(if the above do not agree, to plan modification of “Communicable Diseases : Costs and expenditure ,
RJH Vol. 2 No. 1 Jan-Mar 1996)
15.
Urbanisation
Agricultural development
Ecological changes and resurgence of Infectious Disease
Dr. Vanaja, Bangalore
16.
Community participation in vector Borne
Disease Control : Facts and Fancies,
Ann. Soc. Belg. Med. Trop. 1991, 71 (Suppl-I) 233-242,
Dr. P.K. Das Vector control
Res. Centre, Pondicherry.
17.
Clinial Re-appraisal series
C. Sathyamala and Yogesh Jain
Articles of general critique
1.
2.
From Philanthropy to human Rights.
Amar Jesani
Social Medicine for Holstic Health. An alternative response to present crisis. Rudolf C. Heredia. EPW
Dec. 1, 1990.
*Not yet confirmed
mfc bulletin / May-June, 1997
8
Resurgent Tuberculosis in New York City :
Human Immunodeficiency Virus, Homelessness, and the
Decline of Tuberculosis Control Programs
Karen Brudney and Jay Dobkin*
Introduction
Methods
Reported tuberculosis (TB) cases in New York City have
been increasing since 1979 after decades of steady
decline. The epidemic of infection with the human
immunodeficiency virus (HIV) is oftern blamed for this
resurgence. Although a substantial part of the increase
may well be due to concomitant HIV infection, significant
social, economic, and historical factors contributed to
increasing tuberculosis rates several years before the full
force of HIV infection was felt. The growth ofhomelessness
among urban drug abusers in the 1980s paralleled the
spread of HIV infection, greatly complicating tuberculo
sis treatment and probably promoting further spread of
this infection. In this report we document the enormous
treatment failure rate caused by noncompliance among
patients with tuberculosis and at high risk for HIV
infection. We trace the decline in TB control programs
that materially contributed to the failure rate, and we
suggest some new (and old) solutions.
All inpatients at Harlem Hospital Centre with suspected
or confirmed TB were evaluated by one of us. Only
patients with culture-confirmed Mycobacterium tubercu
losis nvere included in this analysis.
Central Harlem has been the area in New York City with
the highest rate of TB since before 1960. It has seen a
more dramatic increase in TB than any other area in the
city during the past decade (table 1). It has also been'an
area of unemployment, poverty, and high rates of drug
and alcohol abuse and the acquired immune deficiency
syndrome (AIDS). During the past 10 to 15 years, the
scourge of homelessness has been particularly brutal in
Harlem, with streets of abandoned buildings and empty
lots turning certain areas into “no-man’s land”, and two
- massive shelters for the homeless earning notoriety as
breeding grounds for crime and the spread of infectious
diseases.
Because of the concurrent increase in AIDS and tuber
culosis, we prospectively studied all patients with TB
admitted to Harlem Hospital, a 700-bed public hospital,
from January 1, 1988 to September 30, 1988. Our
purpose was to ascertain and docuipent factors that
might predict loss to follow-up, as well as to determine
a more exact rate of HIV infection among those with TB.
The detailed interview included information on the
patient’s previous tuberculosis history, current housing
situation (what type of dwelling it was and who paid for
it, current address, and whether there was heat or hot
water), employment status, alcoholism, drug use, sexual
partners, and transfusion history. Charts of patients
whose diagnosis was made after discharge or death, when
a specimen whose smear had been negative subsequently
grew M.tuberculosis, were reviewed. All patients were
encouraged to undergo HIV testing, which was per
formed, after informed, consent, by the standard ELISA
method with western blot confirmation, Patients with
acknowledged HIV risk factors who refused HIV testing
were deemed HIV positive if severe oral candidiasis was
documented on examination by one of the authors. Each
patient was given an appointment to the Harlem Hospi
tal chest clinic at discharge. Patients with symptomatic
HIV disease were also given an appointment to the
infectious disease clinic. At 4-month intervals, the
records of both clinics were searched to determine follow
up frequency. All patients who failed to keep clinic
appointment were entered into the hospital’s computer
system to determine whether they had come to any other
clinic or had been readmitted to the hospital. At the end
of 8 months and again at 15 months, a list of all patients
lost to follow-up was compared with the New York City
Department of Health Bureau of Tuberculosis computer
ized registry to determine whether patients had been
admitted to other hospitals, entered treatment in another
chest clinic, or died.
Background paper for the MFC Annual Theme Meet,
December, 1997
* Reprinted from the Journal of Public Health Policy, Winter 1992, p
435-450
I
mfc bulletin / May-June, 1997
9
Table I
Sexual Partner : Patient who had heterosexual contact
with a partner in an HIV risk group.
Tuberculosis Rates 1969-1989*
Crack abuser : Patient who denied all HIV risk but
admitted to smoking “crack” cocaine.
Year
Central
Harlem
New York
City
United
States
1969
121.2
36.4
19.37
1970
135.0
32.8
18.22
1971
131.7
32.6
17.07
1972
123.0
28.8
15.79
1973
103.3
26.6
14.77
1974
105.5
25.6
14.25
1975
105.5
27.2
15.95#
1976
75.4
27.3
14.96
1977
64.2
21.1
13.93
1978
52.2
17.2
13.08
1979
50.9
20.1
. 12.6
1980
78.6
19.9
12.2
1981
79.9
22.4
11.9
1982
104.0
22.5
11.0
1983
109.0
23.4
10.2
1984
90.7
23.0
9.4
AIDS-related complex (ARC) : Patient with HIV-related
symptoms not meeting CDC, AIDS criteria.
1985
110.9
26.0
9.3
Results
1986
130.4
31.4
9.4
1987
134.9
31.1
9.4
1988
158.9
32.8
9.1
1989
169.2
36.0
9.5
* New cases per 100,000 population.
# National reporting criteria changed effective 1975.
Definitions
Intravenous drug abuser (IVDA): Patient who used drugs
intravenously at any'time in his or her life.
Homosexual : Men who have had sex with men.
Homeless : Patient who lived in the streets or one of the
shelters for the homeless.
Unstably housed : Patient who had lived in rooming
house for less than 6 months, stayed with someone but
paid no rent, or lived in a drug treatment centre and had
no plans for future housing.
Unemployed : Patient who had not worked for 1 year or
more.
Sporadically employed : Patient who had worked occa
sionally during the preceding yer.
Employed : Patient who had worked until developing
symptoms of TB, or elderly patient employed for more
than 20 years and retired at the time of TB diagnosis.
Alcoholism : Daily consumption of more than three beers,
one bottle of wine, or 1/2 pint of hard liquor or a history
of alcohol-related illness (upper gastrointestinal bleed
ing, alcohol-related seizures, pancreatitis, or cirrhosis).
AIDS : Patients meeting Centres for Disease Control
(CDC) criteria for AIDS.
Tuberculosis was diagnosed in 224 patients from January
1, 1988 through September 30, 1988. The group was
predominantly male (79%), with high rates of alcoholism
(53%), homelessness or unstable housing (68%), and
unemployment (82%) (table 2). Of 193 patients on whom
the information was available, 50 (26%) had been
previously treated for TB, and nearly all of them
admitted that they had never completed treatment. Over
two-thirds of the patients reported HIV risk factors, and
80% of those tested were positive for HIV antibodies
(table 3). Among crack abusers 49% were women com
pared with only 21% of the total study population. Of six
crack abusers who denied risk factors, three were HIV
positive. Of the 66 tuberculosis patients without HIV
risk, nine of 24 who consented to testing (38%) had
positive HIV antibody tests.
mfc bulletin / May-June. 1997
10
discharged patients, 99 never returned for outpatient
follow-up or renewal of medication, and an additional 49
failed to complete 3 months of treatment. A total of 19
patients (11%) were cured, died of other causes while on
treatment, or remained on therapy at the end of the study
period.
Table 2
Demographic Features of 224
Consecutive Tuberculosis Inpatients
Feature
%
No.
Male
79
177/224
Alcoholic
53
103/196*
Homeless
45
85/189*
Unstably housed
23
43/189*
Stably housed
32
61/189*
Compliant
Unemployed
82
171/208*
AIDS/ARC
40
89/224
Table 4
Compliance and Outcome of 178 Patients Discharged
on Yuberculosis Treatment
Age, mean years ± SD: 42.5±12.4
*These denominators include only those patients on whom the
information was obtained and are therefore less than the total 224.
HIV Risk Factors and Seroprevalence in 224
Tuberculosis Patients
No.
(%)
(%)
Cured
7
(4)
In treatment
10
(6)
Died of AIDS
2
(1)
Total
19
(11)
99
(56)
<3 months treatment
49
(28)
>3 months treatment
11
(16)
159
(89)
Noncompliant
Table 3.
Factor
No.
No.HIV
Infected
(%)
IVDA*
124
(55)
88/97
(90)
Homosexual
10
(5)
9/10
(90)
Sexual Partner 3
(1)
3/3
(100)
Crack abuser# 21
(9)
3/6
(50)
Denies risk
66
(30)
9/24
(38)
Total
224
(100)
112**/140 (80)
*
No follow-up treatment
Lost to follow-up
Total
** Includes six patients with HIV risk factors who declined HIV
antibody testing but were deemed HIV positive by diagnosis of oral
condidiasis.
Within 12 months of discharge, 48 of 178 patients (27%)
were readmitted with confirmed active tuberculosis at
least once (table 5). Almost all of those discharged were
again lost to follow-up, with 20% admitted a third time
as of April 1989. In a multivariate logistic regression
model, noncompliance was significantly associated with
homelessness, alcoholism, and the absence of AIDS or
ARC (table 6). Women were somewhat more likely to be
noncompliant than men (97 versus 87%), and crack users
were totally noncompliant. Female gender was border
line in significanc as a factor contributing to noncompliance in the regression model.
A total of 48 patients (21%) had extrapulmonary disease,
of whom 27 had pulmonary tuberculosis as well, and 21
had only extrapulmonary disease. Of the 203 patients
whose sputum grew M. tuberculosis, 104 had at least one
positive smear for acid-fast bacilli (AFB), and 99 had only
negative smears. A total of 178 patients were discharged,
and 46 died during hospitalization. Of those discharged
89% failed to complete treatment (table 4). Of the 178
Noncompliance among patients with asymptomatic HIV
infection was the same as among patients who were
uninfected with HIV. Non-compliance among patients
with ARC or AIDS, however, was significantly lower than
among those without ARC or AIDS (75% [42/56] versus
96% [117/122]; x2= 15.5; p = 0.0001). Among the patients
with AIDS or ARC who were lost to follow-up, 4 of 40, of
85% of the total, were homeless.
* Includes two homosexual IVDA.
# Denies all HIV risks but admits smoking crack cocaine.
11
mfc bulletin / May-June, 1997
Table 5
Outcome of 48 patients Lost to Follow-up and Read
mitted with Active Tuberculosis*
No.
Outcome
Died hospital
7
Remain in hosital
1
Discharged
40
Again lost to follow-up
35#
Placed in TB homeless shelter
1
Follow-up < 30 days
4
effective outpatient program that would have $18 million/year to spend by 1973, given the projected closure of
500 beds by that time. The task force outlined the
requirements of such a program:
Clinic hours should be adjusted to the needs of the
patient. Include trained residents of poverty areas
in clinic and home care staffs. Provide domiciliary
care and chronic disease care facilities and appro
priate living quarters for TB patients who need
them. Integrate the care of TB drug addicts and TB
alcoholics in the developing community programs
for addiction and alcohol control.
Factor
Odds Ratio (85% CI)
p Value
AIDS or ARC
0.08(0.02-0.34)
<0.001
Homeless
2.61(1.34-5.08)
<0.005
Ten years after the Lindsay Task Force report was
issued, amidst New York City’s fiscal crisis, the nearly
1,000 designated TB beds were virtually gone, and the
private sector now diagnosed more than one-half of all
new TB cases, cutting the city’s inpatient expenses even
further (3). The combined city and state expenditures for
the outpatient activities so strongly recommended 10
years earlier were less than $2 million. When the New
York City TB rate increased in 1979 for the first time in
decades, another task force was appointed, this time by
the Council of Lung Associations of New York.
Alcoholic
4.57 (1.07-19.50)
<0.05
In its report in 1980(4), this task force alleged :
Male sex
0.12(0.01-1.15)
0.06
^Culture positive
#Of these patients eight were admitted a third time with active
TB.
Table 6
Factors Associated with Noncompliance:
*By multivariate logistic regression.
Historical perspective
In 1968, a special task force appointed by then Mayor
John Lindsay published a comprehensive report detailing
the strengths, weaknesses, and future priorities of the
New York City TB Program. At tha time, $40 million was
being spent annually on TB in New York City in 21 health
department district chest clinics, seven “combined clin
ics” operated jointly by the Department of Health and the
Department of Hospitals, over 1,000 designated TB beds
in hospitals throughout the city, and a small number of
beds for New York City patients in New York Stateoperated TB hospitals (2). Almost all the TB beds in new
York City were in municipal hospitals, with the voluntary
hospitals referring to these facilities patients with or
suspected of having TB. The average cost per hospital day
was $ 97.93 per patient on July 1, 1968, and a patient
with TB had a average length of stay over 100 days(2).
The task force recommended earlier discharge, the
elimination of 100 TB beds annually, and an expanded
It must be strongly suspected that the increase in
newly reported cases in New York City is in part the
result of fiscal neglect of the TB problem in the
State’s largest city. The resurgence of the disease,
a bitter reversal of the expected trend, is related to
a failure of both health authorities and government
at all levels to muster a public health program...... At
federal, state and local levels, public health funds
allocated to TB are inadequate, in some instances
so grievously inadequate as nearly to amount to
dereliction and default on legal mandates.
New York City’s fiscal crisis in the mid-1970s led to a
drastic cut in appropriations for all public health pro
grams, TB included. New York State progressively cut
back its contract, which had accounted for 50% of the
support for New York City’s TB control activities,
terminating it entirely as of September 30, 1979 (5).
Federal support in the form of public Health Service
monies decreased 80%, from a peak of $ 1.4 milion in 1974
to $ 283,000 in 1980 (4).
In 1978, between $23 and $25 million was spent on TB
in New York city, well below the $ 40 million being spent
12
annually between 1968 and 1973, and taking inflation
into account, the reduction was far greater (4). Inpatient
costs now comprised 93% of the total, compared with 80%
in 1971. The dramatic decrease in beds and inpatient
days had been accomplished, but outpatient expenditures
not only did not increase correspondingly, they were in
fact cut (4,5). In 1978, $1,630,000 was spent on TB “public
health control” services, including all the TB activities of
the New York City Department of Health, far below what
had been spent, given the cut in inpatient costs (4,5).
(Calculating annual costs is impossible as the New York
City Department of Health did not make budgetary
appropriations programmatically until quite recently.)
None of the outpatient services recommended by the task
force 10 years earlier were being offered. The number of
health department chest cinics had been cut from 22 to
9 (5). Neither public health nurse home visits nor health
aide home visits were taking place since the mandated
staff increase had not occurred. The number of contacts
identified per TB case had dropped, and drug treatment
programs to which patients reported daily for their
methadone had received no impetus to screen or treat
patients for TB despite the fact that the increased
incidence of TB among intravenous drug users was
known long before the appearance of AIDS (6).
The incidence of TB in New York City continued to
increase during the next 10 years (table 1), with only
minor additions in allocations to the public health control
aspects of the problem (7-9). The federal government
funded a new pilot project beginning in 1980, the
Supervised Treatment Program (STP), in response to the
increasing number of TB patients failing to complete
treatment. A group of patients was identified who wre
clearly at high risk for treatment failure, including those
who repeatedly failed clinic appointments, alcoholics,
and patients with psychiatric problems that impinged on
their ability to take their TB medication. The program
mandated daily visits to the homes of patients who met
these criteria, with direct observation of the patient
ingesting his or her medication, and had an excellent
success rate, with 90 to 95% of its patients completing
therapy, cured (7). The federal government failed to
increase funding to enable expansion beyond the initial
pilot project level, and neither the state nor the city
contributed significantly to enlarge its scope in the
intervening years (1). By 1989, only five or six workers
were assigned to this program, which therefore include
mfc bulletin / May-June, 1997
a maximum of 40 to 50 patients annually from the entire
city, a fraction of those eligible.
Furthermore, STP did not include the homeless, one of
the criteria for enrollment being a permanent residence.
As the homeless population increased during the 1980s,
with crowding and unsanitary conditions in the shelters
where masses of them were housed, the classic historical
conditions for the spread of TB were recreated. Given this
background, the advent of AIDS and the rapid spread of
HIV among intravenous drug abusers, large numbers of
whom inhabit the shelters, created a potentially explo
sive situation.
Discussion
Compliance with medication is a universal problem
among patients with asymptomatic and/or chronic dis
eases, long ago noted among hypertensive individuals
(10). Once therapy has been intiated, tuberculosis usually
becomes both an asymptomatic and a chronic disease
(11,12). Although the recommended duration of tubercu
losis tratment in the United States was reduced to 9
months more than a decade ago, and to 6 months more
recently, noncompliance has remained the major obstacle
to eliminating what is essentially a curable disease (1315).
Non compliance with medication in general does not
correlate with education level, socioeconomic status, age,
sex, or marital status (13,16). Alcoholics, drug users, and
the homeless have a particular^ high rate of noncompli
ance and are likely to fail ambulatory treatment (17-20).
Although it has been shown that a patient’s beliefs about
or ^ier Alness, that is, the cause, the seriousness, and
the likelihood that a prescribed treatment will help, can
influence compliance (10), the relative importance of the
illness to the patient, particularly when asymptomatic,
depends on the stability of other factors in the patient’s
life. To a patient dependent on alcohol or drugs or unable
to assume continuity of shelter, the importance of taking
a pill or keeping a clinic appointment diminishes drasti
cally,
Housing status was clearly a very important predictor of
noncompliance in our study, with patients who were
frankly homeless and patients who floated from one
rooming house to the next doing equally poorly, signifi
cantly worse than patients with stable housing. The
patient population of this report reflects the increasingly
publicized inner city housing crisis that has grown
mfc bulletin / May-June, 1997
unchecked for the past decade, as well as the chronically
prevalent problems of alcoholism and drug use. Although
central Harlem may be an extreme case, these problems
are by no means unique to this community. Tuberculosis
is a growing problem in impoverished populations, with
concomitantly higher noncompliance rates in the other
boroughs of New York City, as well as in Washington,
D.C., Boston, and San Francisco (17-19,21).
Homelessness has become the blight of urban life in the
United States, and the publicly funded solution, mass
shelters, may have created more problems than it has
solved. Despite official denials by the agency that runs
them of the existence of tuberculosis in the New York City
shelters, there is no doubt that the dsease is well
established there. In a recent study, 1,853 homeless men
attending a shelter-based clinic in New York were
screened for tuberculosis. The overall infection rate was
42.8%, with 100 cases of active tuberculosis (6% of those
screened) (22). In a survey of all the shelters in the New
York City shelter system, 3% of 810 residents actually
admitted that they had tuberculosis and were in treat
ment or supposed to be in treatment (23).
The connection between HIV infection and tuberculosis
was first noted among the newly arrived Haitain immi
grant population in the United States and , subsequently
described in urban IVDAs (24-28). Given the high
background rate of tuberculosis infection in both groups
and the immunosuppressive action of HIV, it was
predictable that active TB rates would be high.
Although it has been assumed that the rising rate of
tuberculosis in New York City largely reflects coinfection
with HIV and that active tuberculosis in HIV infected
patients represents reactivation of old infection, a sub
stantial amount of primary tuberculosis may also exist.
This seems increasingly likely as morej individuals with
together
inadequately treated tuberculosis are crowded
(
with highly susceptible HIV-infected homeless people.
The alveolar macrophage's ability to inhibit intracellular
multiplication of the bacillus when first infected depends
on its activation by immunologically primed CD4 lympho
cytes (29), and patients who are immunocompromised are
far more likely to progress from primary infection to
active disease (30). The radiologic picture of pulmonary
tuberculosis in AIDS patients is atypical of reactivation
disease since cavitation is less common and middle or
lower lobe infiltration more common (31). Although this
pattern parallels the appearance of reactivation in other
13
compromised hosts, such as diabetic or lymphoma pa
tients, it is also compatible with primary infection or
reinfection.
One prospective study evaluating tuberculosis risk in
HIV-infected methadone maintenance patients found
that seven of eight active cases occurred in patients
known to be purified protein derivative (PPD) positive
(32), but no data were provided on the housing status or
likelihood of reinfection or primary infection in the study
population.
The report by McAdam and colleagues of a 42.8%
tuberculosis infection rate in the clinic of one New York
City homeless shelter points to the likelihood of spread
of tuberculosis within this shelter with its high HIV risk
population, particularly since length of shelter residence
there was independently associated with both infection
and active disease (21). Point-source spread of tubercu
losis in another homeless shelter has been documented
by phage typing the organisms (22), and is likely to occur
in similar settings. A 19% prevalence of isoniazid (INZ)
resistant tuberculosis among homeless patients recently
reported from a New York City hospital raises the
ominous prospect of substantially greater difficulty in
treating this already refractory group (33).
The resurgence of TB in the AIDS era is surrounded by
ironies. Increasingly potent antituberculosis agents are
powerless to overcome massive noncompliance. Tubercu
losis, among all the serious complications of AIDS, stands
out simultaneously as both the most curable and the most
contagious to the HIV negative population. Regaining
control of epidemic tuberculosis will be difficult and will
require effective approaches to hardcore issues also
common to the AIDS epidemic: poverty, homelessness,
and substance abuse. The AIDS epidemic has created
severe financial stress on the health care system in many
communities. It would be tragic mistake to divert vital
resources to AIDS activities from essential public health
programs like tuberculosis control.
In combating resurgent tuberculosis in New York City,
long abandoned strategies will need to be reinstituted for
homeless and non-compliant patients: prolonged initial
hospitalization, residential TB treatment facilities, and
aggressive community-based supervision. Strong posi
tive incentives will have to be offered, both because they
have demonstrated efficacy among noncompliant substance-abusing patients in the past, and because, how
ever costly, they will ultimately be less costly than the
mfc bulletin / May-June. 1997
14
multiple hospitalizations documented in our study popu
lation (19,34,35). Mandatory confinement, erroneously
promoted by some to control AIDS, may in fact be needed
to effectively treat some recalcitrant TB patients.
14.
Addington, W.W. ‘Patient Compliance : The Most Serious
Remaining Problem in Control of Tuberculosis in the
U.S.,” Clin. Chest Med. 76 (1985) : (Suppl: 741-43)
15.
Reichman, L. ‘Compliance in Developed Nations,” Tuber
culosis 68 (1987): (Suppl: 25-9).
As our data demonstrate, noncompliance with treatment
for tuberculosis is both massive and predictable. Identi
fication of patients likely to be noncompliant during
initial hospitalization is possible and should be coupled
with an aggressive supervised treatment program. Un
fortunately, the needed resources and, more importantly,
the needed commitment for such an effort have yet to
appear.
16.
Hulka, B.S. Cassel, J.C. Kupper, L.L., and Burdette, J.A.
“Communication, Compliance and Concordance between
Physicians and Patients-' with Prescribed Medications,”
Am. J. Public Health 66 (1976) : 847-53
17.
Centers for Disease Control. “Tuberculosis Control among
Homeless Populations,” MMWR 36(1987): 257-60.
18.
Slutkin, G. “Management of Tuberculosis in Urban
Homeless Indigents,” Public Health Rep. 101 (1986): 48185.
Acknowledgments : The writers thank Ms. Julia Farrell for expert
assistance in preparation of the manuscript.
19.
This article is reprinted, with permission by the American Lung
Association, from the American Review of Respiratory Diseases
144(1991) : 745-49.
Yeager, H., and Medinger, A. “Tuberculosis Long-term
Care Beds. Have We Thrown Out the Baby with the
Bathwater?” Chest 90 (1986) : 752-54.
20.
Dudley, D. “Why Patients Don't Take Pills,” Chest
76(1979): (Suppl: 744-79).
REFERENCES
21.
McAdam, J.M., Brickner, P.W., Scharer, L.L., Crocco,
J.A., and Duff, A.E. “The Spectrum of Tuberculosis in a
New York City Men's Shelter Clinic (1982-1988),” Chest
97 (1990) : 798-805.
22.
Nardell, E., McInnis, B., Thomas, B., and Weidhhas, S.
“Exogenous Re-infection with Tuberculosis in a Shelter
for the Homeless,” N. Engl. J. Med. 315(1986): 1570-75.
23.
Struening, E. “A Study of Residents of the New York
City's Shelter System.” Report submitted under contract
to the New York City Department of Mental Health,
Mental Retardation and Alcoholism Services, June 1986.
Revised April 1987.
1.
New York City Department of Health. Tuberculosis in
New York City 1988. New York, 1990.
2.
New York Lung Association. Report of the Task Force on
Tuberculosis in New York City, 1968. New York, 1968.
3.
New York Lung Association, Tuberculosis in New York
City 1977. New York, 1978.
4.
(Ref. is missing)
5.
New York Lung Association. Tuberculosis in New York
City 1978. New York, 1979.
6.
Reichman, L.B., Felton, C.P., and Edsall, J.R. “Drug
Dependence, a Possible New Risk Factor for Tuberculosis
Disease,” Arch. Intern. Med. 319 (1979); 337-39.
24.
Pape, J.W., Liautaud, B. Thomas, F., et al. “Characteris
tics of the Acquired Imunodeficiency Syndrome (AIDS) in
Haiti,” N. Engl. J. Med. 309 (1983 : 945-50.
7.
New York Lung Association. Tuberculosis in New York
City 1982. New York, 1983.
25.
8.
New York Lung Association. Tuberculosis in New York
City 1983. New York, 1984.
9.
New York Lung Association. Tuberculosis in New York
City 1984-1985, New York, 1987.
Pitchenik, A.E. Cole, C., Russell, B.W., Fischl. M.A. Spira
T.J., and Snider, D.E. “Tuberculosis, Atypical
Mycobacteriosis and the Acquired Imunodeficiency Syn
drome among Haitian and non-Haitian Patients in South
florida,” Ann. Intern. Med. 101(1984) : 641-45.
26.
10.
Eraker, S.A., Kirscht, J.P., and Becker, M.H. “Under
standing and Improving Patient Compliance,” MMWR
36(1987): (Suppl. 1:1-15).
Suhderam, G., McDonald, R.J., Maniatis, T., Oleske, J.,
Kapila, R., and Reichman, L.B. “Tuberculosis as a
Manifestaton of the Acquired Immunodeficiency Syn
drome (AIDS),” JAMA, 256(1986) : 362-66.
11.
Fox, W. “Compliance of Patients and Physicians : Expe
rience and Lessons from Tuberculosis. I,” Br. Med. J. 287
(1983) : 33-37.
27.
Pitchenik A.E., Burr, J., Suarez, M., Fertel, D., Gonzalez.
G., and Moas C., Related Disease among 71 Consecutive
Patients in whom Tuberculosis was Diagnosed,” Am Rev.
Respir. Dis. 135 (1987) : 875-79.
12.
Fox, W. “Compliance of Patients and Physicians : Expe
rience and Lessons from Tuberculosis. II,” Br. Med. J. 287
(1983) : 101-5.
28.
13.
Sbarbaro, J.A. “Public Health Aspects of Tuberculosis :
Supervision of Therapy,” Clin. Chest Med. 1(1985) : 25363.
Hewlett, D., Duncanson, F.P., Jagadha, V., Lieberman, J.,
Lenox, T.H.„ and Wormser, G.P. “Lymphadenopathy in
an Inner-city Population Consisting Principally of Intra
venous Drug Abusers with Suspected Acquired Immuno
deficiency Syndrome,” Am. Rev. Respir. Dis 137 (1988)
: 1275-79.
I
15
mfc bulletin / May-June, 1997
29.
30.
31.
32.
Sathe, S., and Reichman, L.B. “Mycobacterial Disease in
patients Infected with the Human Immunodeficiency
Virus,” Clin. Chest Med. 10 (1989):445-63.
DesPrez, R., and Heim, C.R. “Mycobacterium tuberculo
sis,” in Mandell, G.L., Dounglas, R.G., and Bennett, J.E.,
eds. Principles and Practice of Infectious Disease. 3rd ed.
New York : Wiley, 1990 : 1877-1906.
Pitchenik, A.E., and Robinson, H.A. “The Radiographic
Appearance of Tuberculosis in Patients with the Acquired
Immune Deficiency Syndrome (AIDS) and Pre-AIDS,”
Am. Rev. Respir. Dis. 131 (1985) : 393-96.
Selwyn, P.A., Hartel, D., Lewis, V.A., et al., “A Prospective
Study of the Risk of Tuberculosis Among Intravenous
33.
34.
35.
Drug Users with Human Immunodeficiency Virus Infec
tion,” N.Engl. J.Med. 320 (1989) : 545-50.
Pablos-Mendez, A., Raviglione, M.D., Ruggero, B., and
Romox-Zuniga, R., “Drug Resistant Tuberculosis Among
the Homeless in New York City,” N.Y.State J.Med. 90
(1990): 351-55.
McDonald, R.J., Memon, A.M., and Reichman, L.B.
“Successful Supervised Ambulatory Management of Tu
berculosis Treatment Failures,” Ann. Inter. Med. 96
(1982) : 297-302.
Schieffelbein, C.W., and Snider, D.E., “Tuberculosis
Control Among Homeless Populations,” Arch. In
tern. Med. 148 (1988) : 1843-46.
Dengue mosquitoes make an appearance in High Court
The dozen-strong contingent of Aedes aegypti, dead and alive, were produced before the divisional bench
Express News Service
New Delhi, May 1
AEDES aegypti, or the dengue-causing mosquitoes,
which last year claimed over 400 lives in the capital,
finally made an appearance in Delhi High Court today.
Brought before the bench of acting Chief Justice Mahinder
Narain and Justice S.K. Mahajan by the scientists of
National Institute of Communicable Disease, the dozen
strong contingent of Aedes aegypti were brought to the
court in six test tubes.
Besides the NICD scientists, hordes of MCD doctors also
accompanied them. The larvae—eggs which produce this
deadly mosquito—was also produced before the court in
a polythene bag.
They were produced before the court on the directions
given yesterday, when the bench had expressed its desire
to have a look at the deadly mosquito and its larvae.
Both the judges inspected the Aedes aegypti—both dead
and alive—with the help of magnifying glass before
hearing the resumed arguments by the MCD counsel on
the measures taken by the civic body to check the spread
of dengue fever this year.
Apparently dissatisfied with the claims of the civic body
about the measures and action plan, the bench which suo
moto initiated action against the local bodies, noted:
“Strangely, the government action plan, submitted by the
Union Health Ministry and the MCD did not mention any
awareness campaign.”
Coming down heavily on the MCD, the bench also asked
the authorities to involve the information and broadcast
ing ministry in giving wide publicity to the preventive
measures against dengue.
During an hour-long arguments on various scientific and
civic causes which lead to its breeding, Dr. S K Sharma
of the MCD informed the court that about 32 catching and
two mobile vans are operating round-the-clock in the city
to prevent its breeding.
He, however, denied to disclose their locations and said
that “If we disclose the catching stations, there is
possibility of furnishing false information by the MCD
staff.”
When the bench asked whether the MCD has idenfified
the area where dengue mosquitoes and what action had
been taken so far to prevent the disease, Dr Sharma said
that “we can do nothing without the co-operation of the
people.”
Dengue mosquitoes breed in any water-catching or
storage container in shaded or sunny place including
barrels, drums, jars, pots, plant saucers, tanks, cisterns,
bottles, tins, tyres, pans, roof gutters, drip pan of
refrigerators, drains, cement blocks, cemetery urns,
bamboo stumps and other palces where water gets
collected.
Source : Indian Express, 2.5.97
16
mfc bulletin / May-June, 1997
CONTENTS
• Immunity, Ethics & Control of Leprosy
Author
B R Chatterjee
• Resurgence of Infectious Diseases and the Indian Society
A Zachariah, M Pai, P Chatterjee
Page
1
• MFC Annual Theme Meet, 1997 (Announcement)
5
6&7
• Resurgent TB in New York City
K Brudeny and J Dobkin
8
• Dengue Mosquitoes make an appearance in High Court
Indian Express
15
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I
A
ANNEX to fig. 1. (Flowchart)
r
Essential steps and inputs required for inter-sectoral collaboration and community
participation in vector-borne disease control programmes.
Introduction
The shift in emphasis from malaria control by specialized organisations to malaria control follovying the PHC
approach with community involvement and integrated in the health services sytem has resulted in a welcome
addition of new vector control tools and strategies suitable for "community participation such as impregnated
mosquito nets.. However, (malaria) disease vector control requires specialists with a background in applied
epidemiology, operational research and programme design and management special expertise.
The design of locally appropriate interventions should start with a situation analysis, including the collection of
sufficiently detailed data on the epidemiology, vector biology and behaviour, and human risk behaviour.
Without expert input it is likely that precious resources will be wasted.
An essential part of achieving community participation is the creation, where possible, of alliances (inter and
intra-scctoral collaboration) between MOH malaria and vector control specialists and conmiumty based"partners in health", such as NGOs. churches, compames, plantations, schools, etc. The parsers become
local vector control implementing agencies, invoh ed in local planning and management. The malana specialist
and the public health system provide technical and other essentia! support, including official endorsement
WHO's malaria and s ector-borne disease programmes should pros ide long-term ads isers. and other techmca
support to desclop and maintain specialist capacity svithin endemic countries.
Step 1. Awareness of problem
The health services or the media report the problem to the (local) Government. Several steps should already
have been taken by the (district) public health services: confirmation of the problem and rapid response
measures if necessary. Government (health) authorities need to be involved when special emergency measures
are required or when a long-term progamme needs to be established. Because the problem may be due to die
for reviewing the situation, and recruiting and commissioning experts to conduct a situation analysis an prepare
a report with recommendations for action to be taken. The health services should have their own everts in the
(malaria) programme. However, ideally an experts group is formed from experts m umversiUes NGOs as we
as from the control programme. The experts group may be supported technically and otherwise by a techmeal
agency such as WHO.
Step 2. Situation analysis
behaviour, and its breeding sites need to be identified. Available literature should be reviewed and con
other investigators established.
Step 3. Presentation and discussion of report and recommendations
A draft report of all observations with literature review is prepared and a control strategy is proposed to address
the problem in the most cost-effective and locally appropriate way possible.
The report is first discussed with the taskforce and government officials. A decision is taken about
action to follow. A final report with preliminary plan of action is then prepared for presentation to the
°f
.
■7
//
services, the ’’partners” (local and external) and the community (for ethical reasons they should always be given
feedback), including the media.
Step 4. Operational research to develop or adapt a control strategy
Operational research is needed in many situations to adapt existing strategies to the local situation, to develop
improved control tools, or to evaluate the cost-efficacy of certain methods under local conditions. The end
result should be a proposal for a control strategy which is cost-effective and makes optimal use of locally
available resources. The MOH taskforce assigns local experts and assures the availability’ of the necessary
resources. The experts may include experts who participated in the situation analysis but usually specific
expertise is required for the trials. The experts may be assisted by external experts from WHO or elsewhere. In
some cases WHO and aid organizations may provide long-term expertise from outside.
Step 5. Preparation of Integrated Plan of Action
The experts propose not only a strategy but also an institutional policy (who will be inyplyed). Both should be
endorsed by the MOH taskforce. In most cases the MOH disease control programme, the local "partners" and
the community will have to be involved in the preparation of a detailed integrated plan of action that gives tasks
and responsibilities to all parties involved. The POA should give overall objectives and specific objectives. A
detailed activity programme with identification of resources and timeframe is prepared for each specific
objective.
Step 6. Implementation of a vector-borne disease control programme
Implementation of the POA ideally requires a minimum of input from (scarce) experts and generally
understaffed and under funded public programmes. A local, community-based "partner" or programme
implementation agency (PIA) may provide many of the required inputs. Important is that the Government
(MOH) is fully behind the programme and provides official endorsement. The experts may provide essential
assistance in the micro planning, advice on selection of equipment and supplies, the contents of IEC and training
material, interpretation of monitoring data, limited staff training, advice for programme adjustments. If wellplanned, the need for expert input, although essential, can be kept to a minimum. The experts may be supported
with the above activities by external, long-term, technical advisers. The (specialized) health services may assist
with certain activities, such as microscopic diagnosis, susceptibility testing, vector species identification,
training of spray men, etc. External donor assistance can through the government programme also be used to
support integrated programmes, including NGO partners.
6a. management, monitoring and training
Ideally, a local "partner" organization (or PIA) takes care of local management issues. This should
include routine monitoring and evaluation of the programme. Experts should assist with the design of
the system and the interpretation of the data. Training of "partner" (PIA) personnel or community
members in specific activities can be provided incidentally by experts and specialists from the
specialized government programme.
6b.financing, equipment and supplies
Depending on the recommended strategy a local "partner’’ (PIA) may be able to incorporate the
programme in already ongoing activities at no additional cost with available equipment and supplies.
However, where additional equipment and/or supplies are needed, for example insecticide, the disease
control programme manager could provide this.
6c. Information, Education, Communication and promotion for community action
IEC is the task of the government but local community-based "partners" are usually best-placed to
create community awareness. A well designed and targeted promotional campaign is sometimes
required to turn community awareness and knowledge into action. This usually requires special
expertise and may have to be supported by the MOH and external partners organizations.
J
6d. specialized activities
Implementation of specialized activities requiring special training and probably a salary. Local
’’partners” can sometimes to a limited extent take care of this, for example a laboratory technician or
pesticide appiicaiuis (already available on plantations). In other cases, the government special
programme provides this input for short periods (spray teams). A local partner may then assist with
the logistics.
6e. community action
community involvement can be classified into several categories: 1) passive, for example allowing a
spray man to enter the house; 2) limited active, for example usmg IMNs, 3) full active, for example
taking care of the environment to control vector breeding
»^>£Kj-do you have a IxitteijJat^iflcaLiuH * uxainplcL hoic ?
Whatever the level of community involvement, their participation in the plarming is essential. As a
minimum requirement, the community should understand and endorse what is being done on their
behalf. Misunderstandings have in the past often led to lack of collaboration and even opposition.
Step 7. Programme adjustments following monitoring and evaluation
The transmission dynamics of vector-home disease change continuously. The control programme may induce
further changes.
The local Programme Implementation Agency should continuously monitor relevant indicators (designed by
experts) and conduct special evaluaUons from time to time. Experts should assist m the interpretation of the dat
and propose programme adjustments when necessary. The necessary adjustments should be discussed with all
partners and a new POA may have to be prepared.
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a lesson f?lan on malaria: convert it into word file
Subject: a lesson plan on malaria: convert it into word file
Date: Thu, 02 Dec 1999 17:14:04 +0500
From: ashtekar <ashtekar@giasbm01.vsnl.net.in >
To: sochara@blr.vsnl.net.in
LESSON PLAN ON MALARIA
It was the month of Savan. Yashodabai was working in her onion plot. In the
afternoon she got chills and fever. She had to return home. At night, she
sweated and the fever went off. The next day she could work and had almost
no illness. But the same things repeated the day after, forcing her to go
to the township doctor. Here she got an injection and few pills but there
was no cure. The fever came day after day in that week making her very
weak. Haribhai the village health worker gave her some tablets and she was
all right after two days.
Did such a thing ever happen to you?
That was malaria. There can be no other sickness giving chills and fever
every other day. It is common in villages in rainy season, as there are
more mosquitoes, We can treat it with few tablets. We will learn a few
things about malaria in this chapter.
1. What is malaria?
Malaria is the commonest fever illness in our villages. Minute germs called
plasmodia cause this illness. The germ spreads through mosquito bites.
After the bite it takes a week or two for the illness.
The illness comes in two types since the germ has two subtypes.
x- - - . The common
illness is because of Vivax germ. This is simpler to treat. The other type
is falci-parum germ,, which gives a more dangerous illness.
illness, Both the
illnesses can be dangerous if we do not treat.
Few tablets can cure malaria effectively. But mosquitoes are the real
problem.
2. Why do we get malaria?
We all get mosquitoe bites. Anopheles mosquitoe, which abounds in villagescauses malaria. It takes the germs of malaria from a sick person, breeds
them in its stomach. After 10 days the mosquito is ready to give it to others.
The bite, injects few germs inside us. These then reach the liver through
blood. They breed there within a week or two. The germs now are in new
forms, ready to infect blood cells. After getting inside the red blood
cells they eat the cell, much like grain insects. Within 48 hrs, the
attacked cells burst open, releasing many more germs. These then attack new
cells. Every time the cells burst open in batches, we get chills and fever.
This bursting happens every alternate day.
If we have two batches of germs breaking blood cells on separate days, we
get chills with fever every day.
So, we lose blood cells & hemoglobin in malaria. This gives the weakness
till blood cells are replaced.
3. How does malaria spread?
Mosquitoes spread malaria. They pick up germs from a person taken ill with
malaria. But it needs special forms of germs to spread. These forms- male
and female cells of germs-are ready in that person's blood after 10 days of
getting sick.
The mosquito- the straight-backed anopheles type --is responsible for
spreading the illness. The mosquito breeds in fresh water-stagnated or
flowing. Often it is the pools of rainwater or wastewater collecting in our
neighborhood.
The mosquito bites in evenings and nighttime. Once it has germs inside it,
the insect remains infective till it dies. Remember that it can live for a
month or so.
The mosquito can fly around for a km, So one just pool can threaten every
house in the village. So think of water pools in the whole village as well
as the one near your own house.
4. How to make out malaria?
1.1.1 Fever with chills
Any fever coming with chills and every alternate day is surely malaria, The
fever breaks with a sweating.
Illness
Day 1
Day2
Day3
Day4
Fever, holiday, fever sequence
Fever everyday
12/2/99 7:37 P\
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l/'A
a lesson plan on malaria: convest it into word file
If the chills and fever come daily, think of other illnesses also given in
the fever chart.
The usual malaria fever is moderate-between 100 to 103F. Sometimes it rises
even higher.
1.1.2 Sometimes chills may be missing
• In children cidlls may be absent.
• Persons having had incomplete treatment of fever may have no chills.
• In some areas,, malaria fever may have no chills.
• Falciparum malaria often comes without chills.
1.1.3 Headache, bodyache, ill feeling and vomiting at times.
Malaria gives intense headache and bodyache,. Backache is common. One feels
very ill and weak. Some get vomiting or just the sensation of it (nausea).
One eats poorly,, as happens in so many illnesses due to germs
1.1.4 Check spleen
Check it under deft ribs. Spleen
"
often gets tender and bigger in malaria
after a week of fever. This happens, as spleen has to store the debris of
broken blood cells. Do not expect this to happen on the first few days. It
is prominent in chronic malaria. Spleen swelling is more common in children.
1.1.5 Take a blood smear
Take a blood smear on a glass slide and get it checked in the health
center. (It is surer if done during chills and fever.) If the smear shows
the piasmodium germs, it is sure malaria. But if it does not show these
germs, do not say it is not malaria. Remember that only about 10% smears of
fever cases show malaria germs.
1.1.6 A falciparum sickness is differenc
A falciparum sickness causes fever. The fever may continue for days, unlike
Vivax malaria, «hich has intermittent fever, The fever is often higher than
the Vivax malaria. It can affect brain, kidney
) ' '
etc, often leading to death.
Watch out if you happen to be in known falciparumi areas.
5 . Is malaria dangerous?
Yes. Sometimes!
• The usual vivax malaria illness often cures with simple treatment,
• If it is a pregnant mother, malaria can cause an abortion, premature
childbirth, or a iweak and small baby. All these are bad effects indeed.
Start treatment the same day.
• Untreated malaria-any type- can ccause
-severe anemia and weakness.
• Is your area known for falciparum malaria
----- 1 (check with the primary health
center or ANM) ? If yes, take care!
Falciparum malaria illness is a great risk, if it affects brain, the person
shows confusion, delirium, confusion and even unconsciousness,
-------- -- when brain
gets swollen, pulse is slower and vomiting is prominent. Check neck for
stiffness. It may be stiff in brain illness due to infection. Send every
such person to the hospital.
2
If it hurts kidneys, one gets dark urine. This is called blackwater
fever. It may clog and shut the kidneys. This is very dangerous.
Sometimes the person with falciparum malaria is cold and sweaty. This is
called algid malaria. This too is dangerous.
6. Can we treat malaria in the village?
’ "
1_
Yes, and with simple tablets. C
Chloroquine
is the main drug. Primaquine is
necessary for killing sticky/lingering forms of the germs in
blood and liver. If you are sure it is malaria, even without blood
report,
give the following treatment:
1.1.7 Anybody above 13 years
Day
chloroquine
Aspirin or Paracetomol Primaquine
Dayl (first dose)
4 tabs after food
2 tabs
After 6 hrs of first dose
2 tabs with food
2 tabs
Day 2
1 tab in morning and 1 in evening.
2 tabs as needed
Day 3
As above
As above if necessary
2 tabs with meals
Day 4 ,5 & 6
Stop
Stop.
2 tabs daily.
1. Always give these tablets with food or meals
2 of 5
12 2 99 7:37 P?
a lesson plan on malaria: convert it into word file
2. Explain the side effects of chloroquine.
3. The cure of fever comes after 48 hrs of starting treatment
4 . Take blood smear before treatment
1L
Pe0?1!: are yerY sensitive to Chloroquine; they vomit after taking
the tablets. In such cases give antacid tablet with the medicine. Or give
tab famotidine 30 minutes before the medicine.
6. Chloroquine injection is necessary if pt vomits tabs even after all
precautions. Refer such person to doctor.
7. You can give chloroquine in pregnancy.
8. RARELY Primaquine can give breathlessness when swallowed See the
drug-info table for more details
1.1.8 Chloroquine dose for children
Age
First dose
After 6 hrs
2nd day 3rd day
0-1 yr. One half
l/4th
l/8th
l/8th
1-4 yr. 1
half
1/4 th
l/4th
4-8
2
One
Half
Half
9-13
3
1& half 1
1
For a baby, syrup is better. (50 mg per 5ml)
1.1.9 What if chloroquine fails?
If chloroquine fails to cure within 3 days: Give combined pill of
Sulfodxine + Pyrimethamine. The adult dose is 2tabs at once after food.
1.1.10 Is there any Ayurvedic cure?
You can try Chirayata, but do this only in vivax arc
areas. Do not take any
chance with Falciparum malaria. The dose of Chirayat:a, available as
Chirakin tab is one tab 3 times a day for 10 days.
8. When to refer a patient with malaria fever
No cure within 72 hrs of starting chloroquine treatment (or any
antimalarial).
- Very high fever (above 104F)
Any signs of brain illness like confusion, convulsions, unconsciousness,
and neck stiffness.
• Dark colored urine,
• Severe anemia with malaria
9. How can we avoid malaria?
Here are some simple precautions!
1.1.11 Eliminate water collections
First of all, take care of the wastewater from your own home. Dig a soak
pit. Request the neighbors to do the same, If every house takes care, we
will be free of mosquitoes. But mosquitoes can fly around for a km, so look
for other pools in the village.
In rainy season, there are many more pools. The village panchayat will have
to eliminate all such pools.
1.1.12 If the pools can not go, try one of the following things:
• Spread Paris green or waste crude oil on the pond. Ask the PHC worker
about how to do this.
• You can spread thermocol granules on the pool. These float for months on
the pool and prevent mosquito breeding. Under these granules,, the larvae
can not breathe.
■ If the pool is going to stay for long, get special fish like guppy from
the PHC staff. These fish eat up mosquito larvae.
• If there are too many mosquitoes, get the village homes sprayed, inform
the PHC about this. They will decide about spraying. Spraying leaves
pesticide on surfaces for as long as 6 months, except when people wrongly
smear it with something- cowdung, mud or paint.
1.1.13 At home
Use bed nets, and tell others how good a net is. You can soak the nets in
keothrine. This stays for six months and kills mosquitoes perching on the net.
Apply mustard oil or other repellants on the body to ward of mosquitoes.
(Bad mustard oil can give dropsy, even if massaged)
1.1.14 Think of water in farms
Open irrigation systems and wasteful watering practices create pools,
breeding mosquitoes. Drip irrigation eliminates this problem. In some
districts, rice fields are the source of mosquitoes. Ask agricultural
experts in the Panchayat samiti if this problem can be solved. As a rule,
water standing for more than week causes mosquitoes, so let it off in between.
1.1.15 In travel
When travelling to another village/town where malaria is too common, one
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12 '2 99 7:37 PM
a lesson plan on malaria: convert it into word file
can get mosquito-bites. One can avoid the illness by taking 1st dose of
Chloroquine once every week. Take it the day of entry to the area.
10. Summary table
Cause of malaria
Germs spread by mosquito bites. Germs are of 2 types-Vivax
(less dangerous) and falciparum (dangerous)
Symptoms
Fever with chills in most cases. Sometimes just fever.
Diagnosis
Mainly clinical
See fever chart and for other illnesses
Test
Send blood smear to PHC.
Treatment
Chloroquine for 3 days, followed by primaquine for 5 days. Also
give anti-fever medicine. All tabs after food. A child needs small doses.
Dangers Pregnant mothers can have an abortion, pre-term delivery, and small
baby.
If it is falciparum malaria, illness may affect brain, kidney etc. Remember
signs.
Prevention
Prevent mosquito breeding. Prevent mosquito bites
Think of watering practices
11. Some important tips
• Fever with chills; every alternate day is no other illness but malaria.
See next line
• Malaria fever may come every day.
• Chills stay for 010-30 minutes. One feels helpless, but it goes off
There is no medicine for chills, just give blankets.
• Children may get just fever, no chills.
• After treatment, it takes nearly tow days for fever to stop coming.
Explain this to the patient, else they go to doctor for injections.
• Give all tabs after food; repeat tabs if pt vomits the medicine. Try
famotidine before chloroquine, or antacid with chloroquine. This prevents
vomiting.
• Weakness stays for a week due to loss of blood cells. Rest and food cure
the weakness.
12 . Reference material
1. Fever-general principles of treatment
2 . Fever flow chart for adults
3 . Fever ready reckoner (table)
4 . Drug info table: see chloroquine, primaquine and aspirin
13. Further reading
14. Learn these simple skills
■ Checking spleen
• Checking neck stiffness
• (Other fever skills)
• Making a blood film
• Making a soak pit
• Spotting mosquito-breeding sites
• Soaking bed nets in keothrine
Questions
Choose one of the given answers, mark with
1.1.16 Malaria illness is due to:
Mosquitoes
Germ infection due to mosquito bites
Rainy season
1.1.17 It is surely malaria if someone has
Fever
Fever with chills
Fever with chills every alternate day
Fever and cough
1.1.18 Which of the following statement is true
Blood smear is always positive for germs if it is malaria
Blood smear test shows tells us about the type of malaria-vivax or falciparum
Blood smear test is essential before we starting chloroquine treatment
Blood smear test tells about ..
1.1.19 Which of the following statement is true?
Chloroquine is useless if it is falciparum malaria.
Chloroquine cures any fever
We should not give Chloroquine if the woman is pregnant.
Chloroquine -
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12/2/99 7:37
a lesson plan on malaria: convert it into word file
1.1.20 The best medicine for malaria is:
Chloroquine and some fever remedy
Chloroquine, primaquine and some fever remedy.
Injections and IV saline
Single dose of malaria tablet.
1.1.21 Arrange the following statements in order of importance in
prevention; with most imp action the top.
Use of bed nets by all people
Eliminating all stagnant pools in the village
Treatment of every fever case
Applying mustard oil at bedtime
1.1.22 Strike out the wrong statement
It takes one before mosquito eggs finally develop into adults, so a weekly
action on ponds and pools is good enough.
1.1.23 Which of the following statements about Falciparum malaria is wrong?
This illness may appear as just fever.
Along with fever it may cause confusion, convulsions even unconsciousness.
This illness is rarely dangerous.
1.1.23.1 Fill the gaps
If chloroquine fails to work cure in 3 days, we should try the combined
pill of
Tab of-or
take care of fever as well as aches and pains of
malaria.
Chloroquine irritates stomach, so we should give
with it, or
----- half hour before chloroquine.
----------- j_s necessary for curing lingering forms of malaria germs.
Exercise on:
Attitude and beliefs:
Mark the statement, which you feel as the most correct one:
1.1.23.2 About malaria prevention
Treatment is easy but prevention is difficult.
Soak pits are not rewarding, as there are other breeding places.
Rainy seasons brings malaria with it, you can not prevent it.
Nets are costly, difficult to manage and many people dislike nets.
1.1.23.3 In treatment of malaria;
Injections are a must.
Saline for curing weakness is necessary.
Injections are necessary only if the patient is serious.
5 of 5
12/2/99 7:37 H
•v
Building Capacities of Women's
Groups on Women's Health
District Level Training Modules
MALARIA*
August '99
developed by
CHETNA, Ahmedabad
for
Ministry of Health and Family Welfare, New Delhi
*Chapter written by CHC team
Malaria and Women's Health
MQlQriQ and Women's Health
District Level Training Module
2 hours
Learning Objectives
At the end of the session the participants »li learn about
> spread of Malaria
signs and symptoms of Malaria
> vXa ment and preven{,on of Malaria
> e^,n0?^S0,MalanaepS
ettea ol Malar,a on household routine
Design
Tirne in
minutes
Methods
75
60
treatment of Malaria
I5
30
Discussion
Discussion,
Activity 1, and
;■----------------- j.
—■—------.^Storyjehing
___ ____ Discussion
discussion
on da,,yTRolePiay
prevention and
Material Required
Blackboard and chalk <
Z)baStetOrany
TOeb
D^^eITra;n;nsAfodule
1
Malaria anil Women ’5 Health
Note for the trainer
Welcome the participants.
You may start the session by saying....
“Dear friends,
Malaria is a commonest fever in our country. There will be hardly any one of us who had
not contacted Malaria, once in a lifetime. Every year in our country many people have
Malaria and many die due to this fever. Let us learn about Malaria today so we can take
effective steps to prevent it.”
Ask the participants, whether they know about fever with shivering. What do they call
it? Make a list of the names they suggest. Once the list is developed, use the local
term instead of the Malaria. For example, Malaria is known as 'Tadhio Tav" (in
Gujarati). Use this local name of Malaria during the whole training in Gujarati.
Majority of people all over the country know about the symptoms of Malaria Ask
them to list the signs and symptoms. Write them down on black board or flip charts
If they miss-out any point you add it.
To explain the spread treatment and prevention of Malaria, introduce Activity 1 story telling. You may read it in advance and tell the story in an interesting way in
your own words. Ask the questions given along with the story. Make sure that they
have internalized all the points to be remembered.
> Ask them to perform a role-play depicting a woman, who has contacted Malaria and
how the household routine gets disturbed. How to introduce the role-play is given in
>
Play a game- Activity 3-"Find the correct answers” to evaluate the participants
learning.
Note: If there are other mosquito borne diseases common in your area please
discuss them during this module
District cvel Training Module
2
Malaria and trurnen's Health
Points to be Remembered by the Participants
mosTJto HPfSC type.offeveris sPread through the bite of female anopheles
hwHh
carries malaria germs (malarial parasites) from a malaria patient to a
Malaria
TheSe mosc'uitoes breed in clean, stagnant water
Malaria is classified as a water related disease.
Signs of Malaria
> Shivering followed by high fever
> Headache
Fever comes down with perspiration
> Fever usually comes in alternative days
peraonX'^art hamhwal iaKhere ““ alS° be severe ^dache. The
person may start babbling or become unconscious.
Spread of Malaria
>
"
qui'° blle from 3 female anopheles mosquito.
person that person, may develop MalanTStnTsdayT3'
h"*5 3 he3"hy
hese mosquitoes breed in clean, stagnant water.
Treatment of Malaria
Ensure the following
orenotVer 'S riSin9-
' tabte
W°rker
™" help 10
S,3rt lhe ,real™™' S'He will give chloroquine
i AstSSS SKI^destroyed^ue^to MaSaK'0^
like, green gram (mungSZI Mungfoup Tu?SS
(black gramjdal, Ghana (bengal gram) dal etl
e'C
PUlSes
' Mun9dal' Udad
' o^cZe^MalaXremed'eS SUggeSted here™th
Prevent repeated
Treatment of Malaria Under the National Malaria Control Program
XtnKaK'gaSdS'^KXZpcrc:^Tfor*he PHC 3pd
!o sen: KS
?l,r“ ~
(PHC) twice a week. Here the trainedHat?ratcX?^
Health Centre
malaria! parasite In the blood, if the biood sliders posm^iZK K ma.aria
District evel Training Module
3
9
Malaria and Women's Health
parasite is present in person’s blood than the person is given radical or active treatment
nffSh'"
P"maquine- Treatment is according to the instructions of Medical
PHCs dispensaries and hospitals all over the country. The malaria inspector is a key
member of the team, he directs anti- mosquito measures.
The state government has also opened Fever Treatment Depots (FTDs) and Drug
istribution Centers (DDCs) in villages which are run on voluntary basis by a voluntary
worker, teacher social worker, etc. At FTDs chloroquine tablets are given to fever
cases and blood slides are taken for examination while at DDCs only chloroquine
tablets are given to the patient with fever. These tablets are also sold in shops.
Prevention of Malaria
Mosquitoes, which spread Malaria, breed in clean stagnant water. So cover the
water utensils, big water storage container and pits around your house
Get your house sprayed with anti Malaria spray. Do not wipe the spots of the spray
at least for three months.
y
Pour used oil in the stagnant water of the big pits
Breed gambuchi fish in the lake
If possible use mosquito net while sleeping. If financially viable use impregnated
bed-nets.
Fumigate your house with Neem leaves.
Grow a bush of damro or tulsi near your house
If possible apply neem oil on the uncovered body part before going to sleep.
To avoid repeated infection of Malaria and have a healthy life there are herbal
remedies, which are been used by people since years, it may be promoted:
Chiretta
Andrographis
Paniculata
Boil 60gms of Chiretta in two glasses of water and reduce it to half a
glass. Add 60 gms of Tulsi leave to the hot decoction, cover and let of
for an hour. Squeeze out the leaves into the decoction Strain and
drink Dose: 1 cup thrice a day for 3-5 days
Tulsi, Holi
Basil
Mix 10 gms of Tulsi leaves juice with 5gms of powdered black pepper
to be given to the patient in the cold stage of fever. One may also add
jaggery of sugar. The decoction must be sipped slowly.
Guduchi
Tinospora
Cordifolia
Six tea spoons of the juice must be given three times a day.
Neem
Azadirachta
Indica
Neem bark is most useful, though the leaf has a role. 2 ounces of
neem bark bruised, 1 teaspoon cardamom and coriander and 20
ounces of water boil for 30 minutes. Grind 2-3 fresh neem leaves and
2-3 coms of black pepper with a few drops of water. Dose- 2 ounces to
be given before the fever rises.
District eve! Training Module
4
Miliaria and Women's Health
When can a Community know about Malaria Epidemic (spread in community) in
their area?
Some warning signals to lookout for, otherwise many lives may be lost before action is
taken.
>
'n number of fevor cases during the transmission season of malaria-from
July (beginning of monsoon) to November.
Intermittent rainfall at intervals of 5 to 7 days in monsoon.
Increase in number of breeding places either due
to rains or badly managed
irrigation channels.
News of malaria epidemic in neighbouring areas.
No insecticide spraying activity in the past six months or more.
High fevers with shivering followed by deaths.
Effect of Malaria on Women's Health
orofounri^r.^ imn? ePiSOdes Of malar,a 030 lead to abortion and stillbirths. These have
considered verv i P
l0.n^(in Our society. where a woman’s childbearing capacity is
anaem^ 2
T T ' ‘
3 WOman'
is alre4 weak and
m aZion t^ he s^Pnnn f
We'9ht bab'eS’ affectin9 the start of their lives. Thus
in a snrinl
t < 4, '
r°m he symPtorns °f malaria directly, she indirectly suffers
social context where her capac.ty to produce healthy, living children is in danger.
Useful Health Education Material
> Malaria Control in Villages, VHAI Tong Swasthya Bhawan
, 40 Institutional Area,
Near Qutab Hotel, New Delhi-110016, Language-Hindi
' BhaZ'. NewZhZ
'
M'niS,ry 0' Hea"h and Fa"*
Nim,a"
isoZrZZ'3™’’ GU,aua‘ Sahilya prakash P-B.No.70, Anand, District Khada388001, Gujarat, Language-Hindi, Gujarati, English
District eve! Training Module
5
Malaria and Women 3 Health
Activity 1 Find the
Correct Answers
Objectives
To evata16 the learning related to signs, symptoms, treatment and preventton of
Material Required
Blank paper slips, pen, small basket
or any container, ball (if the ball is not available
make a ball out of old cloth)
Preparation
tarldsymptoms inth^paper^iiprwme 'T Prepara"°n- Wnle
write/drawthe followtng symptoms
V.
Severe headache
Fever with rigors
Vomiting
Body-ache
Rash on the body
Feel very hot
Fever at the same
time
SymPI°m
Pne SliP' You
>
Fever recedes with
perspiration
> Fever on alternate day
> Running nose
Coughing
Toothache
Weakness
Fold the paper slips and keep them
Method
y
^d
in a basket.
Ask the participants to sit in a circle.
opposite side.^o^hatTt^cl^for' someti^^^th h6 C'rCle' Y°U St3nd faC'n9 the
of the circle. You stand facing the
the women will exchange a ball from one woman to another
y°U
oNncoire'ct'^ave a
,he s,i? is -rect
SiVen
ClaPPin9
the group You can ask the wnm^tn h
’ f he answer ls
you can explain to
etc
Pask the woman to do an activity like bark like a dog, jump like a frog
At the end of the game you may repeat the signs of Malaria to refresh their memory
bistricf eve! Troinin}; Module
6
Malaria and Women 'v Health
Of
VOur hands
hanrlc w/ifh
Wash your
with soap
'r Keep you nails cut
Do not sleep in Mosquito net
Cover the water pits
> Eat leafy vegetables
z* Make a smoke of neem leaves
> Apply neem oil on the uncovered
body parts before going for sleep
> Pure used oil in the big water pits
Ensure the anti Malarial spray in the
house regularly
> Wipe of the spots of the spray
immediately after the spay
> Every day have a bath with clean
water
> Never let the water get logged near
the hand pump and stand post
> Always keep the big water
containers open
Breed Gambuchi fish in the village
>
Cover all available big water
storage containers
7
Malaria and Women's Health
Activity 2- Story-Malaria, a Concern of Rampur Village
This is Rampur village. There are about 530-600 houses in the villanp
S^kes LlThphe^l^
But....
along ™th water, Malaria epidemic has affected the village. Majority of houses have
one or two persons suffering from fever wth rigors, seve?e body-ache and head aX
The fever comes down with perspiration. Since the viliagers are not gettina the correct
treatment they continue to get repeated bouts of Malaria.
Champaben is worried. She does not know how to overcome this problem She
approaches the village health worker and talks about the problem.
Inn ^alth w°rker Samaiubhai called a village meeting. Everyone, young and old oirls
and boys, men and women came to attend the meeting. Samaiubhai explained that9
Malaria spreads through mosquito bite. Tnese mosquitoes breed in clean staonlnT
water. He mentioned that Champaben got us water at our doorstep but we ® not
manage it properly. The collection of water has become a breeding ground S
mosquitoes and therefore the Malaria fever has came with it He explained that we he,,.
mJ' l1Up?e w,ater pit,s' 'he ”aler “hto'hers need to be covered, stagnant water nexl to
he stand post need to be drained away He also explained that eve^one has Io
fumigate them houses wUh neem leaves, particularly after sunset. This will help to get rid
off the mosquitoes from the house. He atso promised that he will spray anti Malana
liquid in the houses to kill the mosquitoes
y
,vldldria
He urged every one to take precautions to prevent Malaria immediately Next day early
in the morning the villagers got together. They started covering the water nits In toe bta
pus they poured the used oil, they drained of the water logged next to he standoost
Samtubhai got Gambuchi fish, and put it in the village pond. He along with Ms olhe '
workers started spraying in the house. He also took the blood sample fo the Malar a
testing and started the treatment of choloroquine He repeatedly toto all the v “age to
complete the course of the treatment.
villager io
Champaben was very happy to see the enthusiasm of the villagers With the constant
watch on the preventing aspects of Malaria. Samajuben could Control Malaria in her
village.
Ask the following questions:
What was the reason of malaria epidemic in Rampur village?
What steps they took to solve the problem of Malaria?
What else could have been done?
District cvel Training Module
8
>>
Malaria and Womens Health
Activity 3-Role-Play
the routi^eoTlhrhouTeTa’T"/9etMaiana« affects all
abortion or premature deiivery or giv^lS
P^rform^ roPe^ptayMo'depieVlhts^^may ‘give the foUo1 Malar'H The Pai^C'Pant3 can
^°^ow,n9 points prior to performing
the role-play.
•* ^Thths0'^
10
She got mataria twice in
is pregnant too.
e wea^- She feels tired and giddy. She
> She can not perform all the household work.
5 IheXTn oTe X2
Please Note:
ASK the participants to devetop the end keeping their socio coitura, s.tuation ,n view.
District cvel Training Module
9
IS'
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
I o’- action
What has been the follow up action
In everyone aware of the contents of the bye-laws
III) Die 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?
1)
II)
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?
li) 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 rCivic Society'"
Organised by Malaria Jaivika Niyantrana Samithi
At KMC, Attavar on 6 - 7th April, 1999
D OFFICE Idlers of Apnl 1999 du
-
iii) Have the MRC visiting teams studies helped to identify spceial 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 ( ARE
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?
hi) 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 arc 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
l> OH K I Irtlcrsof April IWdoc
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 arc involved in the educational system should be made aware
ol 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)
Whai activities could they do? Who would facilitate this and how?
in)
Arc there any educational modules available for malaria training in school ‘ college
curriculum
B)
How can the media he involved in health education?
v) What arc 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?
ii)
What could be the composition of such committees?
in)
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 OFFICE IcticfS of Aptil I999<kx
ii)
Mow can it be applied / evolved in Mangalore city?
iii)
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 arc 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?
(c) Fisheries department?
(0 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?
>|c^c
if: >|o|c
!' 1'f I II I’letter of April !'>•>• J.x
*3^.
PROBLEMS AND STRATEGIES OF MALARIA CONTROL IN ORISSA
INTRODUCTION
RUHSA has been involved with NGOs of Orissa in Human Resource Development for
health care since 1993. Through participatory needs assessment processes malaria was
identified as a major health problem in Orissa. As part of a first phase intervention 625 NGO
staff were trained on malaria in a comprehensive manner. All of them were taught how to
obtain blood through finger prick method and make a thick and thin smear in addition to
health education. Some of them were able to apply the principles learned in their project areas.
However, it was realised that the first phase of training was not adequate. There was a
need felt for a more comprehensive planning to control malaria in Orissa. Therefore, some
NGOs who were earlier trained were invited for a 3 day workshop at RUHSA and a strategic
planning exercise was carried out by the team of NGO personnel from Orissa as well as staff
from RUHSA who had earlier participated in the malaria control programme in Orissa.
.
As an initial step we identified the problems faced in malaria control in Orissa.
Subsequently a problem tree was also developed to facilitate easy planning. Against each
identified problem a suitable strategy was identified. The following pages list the problems
identified and the corresponding strategies for each of the problem.
The problems of malaria control relate to all the three following areas.
Diagnosis
Treatment
Prevention
1
PROBLEMS
1. Long Distances
STRATEGIES
a. To train local health volunteers
b. Establish
(DDC)
Drug Distribution Centres
Chloroquine
Paracetamol
c. Establish
(FTD)
Fever Treatment Depots
Chloroquine
Paracetamol
Slides/Lancets
This problem of long distances can be overcome by identifying
and training the following categories of volunteers and
personnel to report on various aspects of malaria epidemiology.
Sentinel surveillance centres may also be started.
2. Scattered Habitations
1. Establish Mobile Health Facilities
This implies that the following categories of personnel would
be trained in collecting blood smear and or at least provide
presumptive treatment.
Persons
- Volunteers
- Health Workers
- Link Health Workers
- Postmen
- Panchayat Members
- Teachers
- Preachers
-NGO Staff
They would carry the following materials
- Slides
- Lencets
- Chloroquine
- Paracetamol
2
They would conduct the following activities
- Collect Smear
- Provide presumptive treatment
- Train local volunteers on smear techniques
3. Poor Communication
To develop link person
4. Poor Surveillance
Activities to promote surveillance
- Identify and develop sentinel surveillance centres
- Train Health Workers & Volunteers to report on
fever cases and take blood smear for microscopy
- Create Awareness on giving blood for testing
- Malaria Camps conducted periodically
- Link Health Workers to be introduced
Link health workers are trained in smear technology
and would link up with microscopists for quick
diagnosis. They can also provide presumptive
treatment.
- Work with government spray technicians in
facilitative insecticide sprays where indicated.
- Time bound programmes in interior areas
- Seasonal Programmes
- Improving existing facilities
- Empowering the community - Health Education
- Impregnated bednets with skills in
treating nets periodically.
Workers and the Activities
Volunteers
Trained workers
Trained workers
Project Personnel
Health workers
Health workers
5. Lack of trained persons
Reporting Fever Cases
Blood Examination
ABER
Reporting case/type
Reporting cases
No. of Cases treated
No. of Cerebral Malaria
- Train village volunteers
- Train NGO workers
- Smear Techniques
- Microscopists
3
6. Lack of equipments
Existing
- Map Centres with Microscope
- Map Centres with Technicians
- Map Centres regularly working
Future - facilitate new microscope
Identify NGOs with Trained Health Workers
Microscopes may be provided to organisations based
on demand for equipments based on smear collection
7. Cost of Test
- Channelise the Government resources to NGOs
- Make people aware of Government facilities
- Make people contribute according to ability
8. Improper Diagnosis
- Refresher Training
- Smear Preparation Training
- Microscopy Training
- Motivation of laboratory technicians
- Monitoring & Support
9. Delayed Diagnosis
Levels of delays
Smear
2
U
Lab
1
Y
Diagnosis/Reports
3
V
PatientAVorker
- Focus on specified months of year
- NGO person using Govt, equipments
- Planning with the PHC
- Request PHC - smear - day once in a week
- Planning with higher officials for instructions
Pressure from Higher Officials for accountability from above
PHC
Motivation, Rapport & Community
Demand from below
4
1.0. Inadequate involvement
ofNGOs
- Drug Distribution Centres (DDC)
- Fever Treatment Depots (FTD)
- Mobile Health Facilities (MHF)
- Volunteers
- Health Workers
- Link Health Workers
- Postmen
- Panchayat Members
- Teachers
- Preacher
-NGO Staff
- Maintain rapport with the PHC
- Regular reporting of cases & drugs used
- Carrying out studies on herbal medicines
- Orientation Programme for GOVT & NGO
- Training HW/Volunteers/MHF
- Community education - dosage/regular
treatment/usefulness of Govt, medicines
11. Inadequate Govt
Efforts
- Rapport building with Govt staff
- Lobby and advocacy
- Demand creation through community
- Sensitisation of Govt by NGO
- Strengthening PHC on malaria control
- Spraying, Larvicide support to NGOs
12. Lack of Knowledge of
Service Providers
- Training of Trainers
- Publications distributed free
- Use of Media
- Refresher Training at PHC
- Personal contact
- Seminars for Senior Level Personnel
13. Lack of medicines
- Rapport with Govt for Govt medicines
- Include small amount in NGO proposals
- Philanthropic donation of medicines
- Free samples Medicines
- Encourage patient to purchase the medicines
5
14. Lack of awareness :
Effective communication on the following aspects of malaria
listed below and using any strategies.
1. Cause
2. Manifestation
3. Consequences
4. Treatment
5. Prevention including personal protection
Strategies
- Message through cultural programmes
- Health education on malaria
- Village level meetings
- Street plays
- Puppet shows
- Multimedia publicity
- Education by Volunteers
- Capaigns/Padyatras
- Flash Cards
- Handbills
- Posters
- Video Shows
- One to one education
- Group education
- Others
15. Trust in indigenous
system of medicines
(ISM)
- Present only proven medicines
- Study effectiveness of ISM
- Herbal medicines through community
based research
16. Lack of Personal
Protection
- Keep surroundings neat & clean
- Use of mosquito nets
- Mosquito repellants cream
- Consume full dose of medicines
- Study on the use of neem based
repellants
- Mosquito proofing of all room/building/
bedrooms where feasible
- Use of mosquito mats in sleeping places
- Electricity operated
- Lantern operated
6
17. Uncontrolled Mosquito
Breeding
- Avoid stagnant water
- Keep area dry & clean one day in a week
- Clean the surrounding
- Study neem based repellants
18. Tribal Malaria
In interior inaccessible areas
systematically promote impregnated
bednets.
In addition use other strategies
identified for problems relating to long
distances, scattered habitation and poor
communication
May need a local conference on Tribal malaria
involving malaria experts, NGO personnel, community
representative and traditional practioners.
Malaria Control - Implementation Plan
1 Planning conference at start of programme will identify agreed strategies
2. Organise Training ofTrainers 30 participants x 10 programmes
3. Trained trainers will train others
4. Assignment to NGOs for next step
5. NGO capacity building for malaria
Project Formulation
Curriculum designed based health education
6. District level planning by NGO (? Lead NGO) and or DAGs
Motivate trained persons to work at district level
7. Motivate interested NGOs to participate in malaria control
8. NGOs to integrate malaria control programmes with ongoing NGO programmes
- NFE
- Health Programme
- Self Help Groups/Credit Unions
- Agriculture Programmes
- Community Development Programmes
7
9. Working with Government
a. Have recognised FTD/DDCs as much as possible
b. Maintain continuous supply of diagnostic materials and drugs
c. Submit timely and regular report on material usage
d. State level - advocacy on appropriate policy
e. District
- to enlist support of district officials
- to plan for spraying with Government team
f. PHC
- to utilise available diagnoistic facilities
- to refer cases needing additional treatment
- to utilise available medicines as needed and available
10. Key activities to be implemented would include:
1. Health Education
2. Support to diagnosis
Smear Technician
Microscopists
3. Provide Treatment
LHW
FTD
DDC
MHF
Malaria Camps
Study herbal
medicines
4. Provide impregnated bednets
to interior tribal habitations
5. Work with Government to obtain
materials for diagnosis and
treatment
6. Work with Government to carryout
periodic spraying
7. Carryout sentinel surveillance
Dr. Rajaratnam Abel
HEAD of RUHSA Department.
//MALSTRAT.DOC//
8
/ ,
TRANSMISSION CONTROL THROUGH COST-EFFECTIVE AND SUSTAINABLE
INTERVENTIONS IN SOUTH EAST ASIA REGION
V. P. Sharma
Malaria Research Centre
20 Madhuban Delhi 110 092
Abstract
Malaria situation in the south east asian countries of the
WHO has been described bringing out the current strategies cf
malaria control. The trend in vector control is to use organic
phosphate insecticides and synthetic pyrethroids.
pyrethroids. Insecticide
treated mosquito nets are being introduced in malaria control in
almost all countries of the region. Cost effectiveness studies
have revealed that ITMN per capita cost may be about equal as
compared to DDT but DDT spraying lacks effectiveness in malaria
control. ITMN are cheaper than OP and SP insecticides but impact
on malaria varies depending on the vector and the implementation
strategy. Since SP compounds are being used in the IRS and bed
nets it is important to take up basic research and monitoring of
SP resistance in malaria vectors and their sibling species.
Sustainable malaria control requires the selection of insecticide
which is lethal to the vector, safe, and affordable. Because of
the hazards associated with the chemical control of vectors, high
cost of insecticides, and the problem of resistance, selective
application of insecticides iiss indicated. Bioenvironmentai
methods of malaria control are low cost, indigenous, eco-friendly
and sustainable. The first line of attack on malaria should be
the application cf bioenvironmentai methods of malaria control.
In places where bioenvironmentai interventions are not feasible,
ITMN and or a mix of interventions with selective spraying may
give sustainable malaria control.
1.
Introduction
Southeast Asian region of the WHO reported 3,706,694 cases
and 8,053 deaths due tc malaria in 1996. Since realistic malaria
incidence and deaths figures are not available WHO estimated
25,924,348 malaria cases and 30,816 deaths in 1996.
]Figures for
1997 are provisional but the reported and estimatedL cases and
deaths due to malaria were 2,969,909 cases and 4,203 deaths and
25,810,010 cases and 27,540 deaths respectively. Contribution of
SEARO countries in terms of % malaria cases and % deaths due to
malaria, out of a total figures in 1997 were: Bangladesh 2.18 &
10.83; Bhutan 0.29 6c 0.32; India 78.01 Sc 16.42; Indonesia 5.71 &
3.42; Maldives nil & only 1C imported cases; Myanmar 3.57 &
67.61; Nepal 0.21 Sc 0; Sri Lanka e". 94 & 1.41; and Thailand 3.1 &
not available.
WHO data brings cut chat in this region India
contributes highest malaria incidence i.e., 78.01 malaria cases
and Myanmar contributes highest deaths due to malaria i.e.
67.61%. National Anti-Malaria Programme (NAMP) of the Government
of India reports 2.5 to 3.0 million malaria cases annually,
It
may be noted that on the basis of reports received till 25-2-1999
there has been a decrease in malaria cases in 1998
compared to
1997 i.e. from 2,526,509 to 2,070,909 and Pf cases from 981,263
to 904,408, and deaths from 808 to 642. NAMPs surveillance system
is inefficient and lacks adequate man power. Therefore
malaria
incidence data provides yearly trends of malaria and not the
realistic figures. This is illustrated by the fact that in 1992
a group of scientists in Malaria Research Centre estimated
38
million malaria cases based on the consumption of chloroquine.
World Bank estimated 0.95 million disability life years (DALY)
due to malaria in 1993. Similarly deaths due to malaria reported
by the vital statistics of the Government of India were 1,85,000
in 1985 against c 200 reported by the NAMP (GOI) .
The malaria
scenario in India is far from satisfactory as illustrated by the
following observations.
In 1977, the high risk malarious population (doubling of SPR
(1)
in last 3 years) in the country was 219 million (24.57%).
This
population lives in 135834 (23.13% villages and 303 (69.90%)
districts (NAMP).
(2)
In 1995 the targeted population for spray was 158.34 million
and % spray coverage was 73.34.
In 1996 targeted population for
spray was 161.51 million and spray coverage was 48.04%. In 1997
targeted population was 164.75 million. Each year atleast 55-60
million high risk population is not included in the target
population requiring spraying (NAMP).
(3)
Expert committee of NAMP identified 29 towns with SPR
(in any of the last 3 years) .
10
(4)
India's 7.8% (68.66 million) population contributes 40%
malaria cases, 68% P. falciparum cases and > 50% deaths due to
malaria. Malaria control in this population has been unattainable
since the launching of the NMEP, and in this population
indoor
residual spraying had failed to interrupt malaria transmission.
(5)
Chloroquine resistance is widespread and accounts for 35-40%
P. falcipa.rum
Resistance to chloroquine has surfaced in
fa.lcipa.rum cases.
P. vivax and since there is no systematic
monitoring
of
resistance the problem of vivax resistance may be the tip of the
iceberg. Resistance has also appeared against Sulphalene/
sulphadoxine pyrimethamine combination, mefloquine, and quinine.
although very small foci in case of last two drugs.
(6)
In the last 3 decades malaria has occupied new ecotypes
created under the 5 year plans.
Malaria control in these new
ecotypes requires local knowledge
of malaria transmission and
integrated approaches.
This would require human resources
development, intersectoral coordination community participation,
health impact assessment and application of geographical
information system to prepare annua1 plans for sustainable
2
malaria control.
A flexible and completely decentralized
epidemiological approach in malaria control would be desirable.
(7)
Indoor residual spraying for 4-5 decades has resulted in
vector resistance, exophilic vector behavior, high residues in
the environment and harmful effect on human. health. Incessant
spraying has results in diminishing returns. Therefore selective
use of insecticides is indicated. Areas of research that may be
given priority are (i) estimate of the true incidence of malaria
(morbidity and mortality figures) ; (ii) where the deaths are
occurring and why, and (iii) stratification of malarious areas to
bring out malaria receptivity and vulnerability to plan focused
attack on malaria.
Roll back malaria therefore faces inter alia
above challenge in obtaining sustainable transmission control.
2. House Spraying in Southeast Asian Region
Malaria
There are > 16 malaria vectors in the SEA region.
control in the rural areas is carried out by indoor residual
DDT was the first insecticide used in Malaria
spraying (IRS).
In areas with poor epidemiological impact of DDT, other
control.
DDT (50% instead of 75%
insecticides replaced the use of DDT.
WDP recommended by the WHO) is manufactured in India by Hindustan
Insecticides Ltd. In 1997 targeted population for DDT was 123.7
million population. DDT has been banned in agriculture. As per
the Government policy 10,000 mt. of DDT can be produced by the
HIL for NAMP, but DDT production has not exceeded beyond 50007000 mt in the last decade or so.
Further, the use of DDT in
malaria control should be phased out and banned by 2005 AD. DDT
is sprayed in malaria control in Myanmar. DDT spraying in
Thailand will continue till the stocks iast. No other country in
UNEP is
the region is using DDT in malaria control,
contemplating ban on the use of DDT by the year 2007 AD. In India
in —
malaria
control,
in areas with DDT resistance, HCH was used
i-- 2. 11—
this
insecticide
has
been
but due to sub-acute toxicity of HCH,
and
HCH
In areas with DDT
banned beginning from April 1997.
In
1997
in malaria control.
resistance malathion was sprayed
:
41.38 million population is targeted for malathion spray.
Malathion was used in Sri Lanka and few other countries, Vector
resistance and pungent smell of malathion are two strong
deterrents in its acceptability and therefore coverage is low .
Odorless malathion may be a good option to increase its spraying
coverage.
Synthetic pyrethroids (SP) have been introduced in malaria
control in the region. In India deltamethrin and cyfluthrin have
been used in malaria control in high risk populations or to fight
epidemics. IRS of deltamethrin in Ghaziabad district, U. P. India
by the Malaria Research Centre reduced
An. culici facies
densities to almost negligible levels and completely interrupted
malaria transmission. Synthetic pyrethroids were introduced in
malaria control by the NAMP in 1995 in An. culicifacies areas.
However the experience of NAMP has not been so spectacular.
In
3
'Maharashtra the decline in SPR was 42.4 to 43.8%; in Karnataka
the decline was 38 to 59% and in Tamil Nadu 65%. Spraying reduced
cases in Gujarat as well.
The impact of SP spraying was
therefore far from satisfactory.
Since more and more synthetic
pyrethroids are in demand in malaria control, there is a need to
♦"I
apply some restrictions in its application in malaria
X A V— X O -1. .
In this connection it is important to mention that: (i) in
An.
gambiae s.s.
in West Africa pyrethroid
resistance
rapidly
developed in areas with DDT resistance; (ii) in An. gambiae s.s.
and kdr gene confers cross resistance to other pyrethroids; (iii)
knockdown time is a good indicator of incipient resistance, and
monitoring can provide vital information on the possible
involvement of kdr gene; (iv) agriculture and domestic use of
insecticides will increase the level of resistance to synthetic
pyrethroids; and (v) in India synthetic pyrethroids are used to
protect crops from pest infestation,
Approximately 20,000 mt of
formulated products are used in agriculture. Most of it is
Cypermethrin followed by felverate, and small quantities of
deltamethrin, alphamethrin and lambdacyhalothrin.
Per capita cost of spraying in 1998 are: DDT 1g/ sq.m, for 2
rounds Rs. 13.81; malathion 2g/ sq.m. 3 rounds Rs. 42.75; lambda
cyhalothrin 2 5 mg.m. 3 rounds Rs. 4 9.39; deltamethrin 2 0 mg/sq . m.
2 rounds Rs. 4 9.51. Alphacypermethrin © 25 mg/sq.m. 2 rounds Rs.
32.5
and at 40 mg/sq.m. 1 round cost is Rs. 25.39. Table given
below gives per capita cost of malaria control with various
insecticides .
COMPARATIVE
COST OF INDOOR RESIDUAL SPRAYING (IRS)
CONTROL (1998 Prices in Indian Rupee)
IN
MALARIA
INSECTICIDE
COST/mt
OTHER COST PER CAPITA
per million Cost
RELATIVE COST
DDT = 1
DDT (50%WP);
ig; 2R;
150 mt/m.
72,601
2,916,000
13.81
1
Malathion
(25%WP);
2g; 3 R;
900 mt/m.
40,316
6,468,000
42.75
3.1
L-cyhalothrin
(10%WP);
0.025g; 2 R;
18.75 mt/m.
2,496,000
2,590,000
49.35
3.5
Cyfluthrin
(10%WP);
0.025g; 2 iR;
18.75 mt/m.
2,496,000
2,590,000
49.39
3.6
4
Deltamethrin
(2.5%WP);
0.02g; 2R;
60 mt/m.
780,000
2Z 714,000
49.51
3.6
A - cype rme t hr in
(5%WP);
0.025g; 2 R;
37.5 mt/m.
800,000
2,447,000
32.5
2.4
A-cypermethrin
(5%WP);
0.04g; 1 R;
30.0 mt/m.
800,000
1,391,000
25.39
1.8
There is an annual increase in the cost of insecticides and
labour and therefore increase in the spraying cost has made field
operations difficult. Due to financial crunch about 50% of the
targeted population receives the spraying. Targeted population in
itself is about half of the population requiring spraying. Taele
below gives the trend of per capita cost of spraying in -he last
15 years.
COMPARATIVE PER CAPITA COST* OF MALARIA CONTROL IN INDIA
Deltamethrin
YEAR
DDT
HCH
Malathion
1984
3.4
3.7
19.9
1992
9.11
10.59
33.89
38.18
1998
13.81
42.75
49.51
61.7 ITMN
Indian Rupee
UNEP
UNEP is
is organizing
organizing workshops
workshops for
for a convention to ban dirty
dozen chemicals. DDT is on the top of the list. WHO is in favour
of the continued use of DDT.
Two UN agencies have divergent
views on DDT.
This position should be resolved.
co develop a
Field operational research is important to
Some
priority
areas
of field
rational vector control strategy,
initiated
on
the
mode of
should
be
research are : (i) studies
in
malaria
vectors
and
resistance
inheritance of insecticide
vector
biology
in
relation
'ii)
studies
on
their sibling species;
to control;
(iii) development of integrated control strategy
applicable in various ecotypes of malaria; (iv) cost effective
and safe application of insecticides;
(v) countermeasures to
insecticides;
tackle the problem of insect resistance; and (vi) improvement in
the spraying technique to ensure uniform deposits of insecticides
on the walls.
3.
Monitoring of Resistance
Resistance in malaria vectors is monitored at the larval and
adult stage.
WHO provides insecticide susceptibility test kits
for this purpose.
However monitoring of insecticide resistance
is not done on regular basis.
Based on the results of monitoring
of vector susceptibility in India insecticide resistance against
DDT and HCH in An. culicifacies has been reported from almost all
parts of tne country and to malathion from Gujarat and
Maharashtra.
In An. stephensi vector resistance in adults is not
a
problem as vector
control
is
based
on
larvicidinq.
Unfortunately there are reports of resistance to organ:
phosphate larvicides in An.
stephensi,
and therefore
An.
stephensi control should switch over to Bacillus thuringiensis H14 .
In other vectors the problem is exophilic vector behavior
thus mosquitoes do not come in contact of the sprayed surfaces,
Recent researches have revealed that
that: Anopheles imosquitoes are
invariably a species complex e.g. An.
An . culicifacies; comprise of 4
sibling species viz.
species A
A,3,C
, 3 , C and D.
Response to
insecticides varies from one sibl
sibling
ing species to another.
Also
vectorial capacity varies greatly e
e.g.
. g. An. fluviatilis comprises
Of^
of S,T and U sibling species.
Of the three sibling species
species S is the vector and therefore monitoring of resistance in
only species S is important.
Priority areas of research in monitoring of insecticide
resistance
are:
(i)
systematically
monitoring
of
the
systematically
susceptibility status of malaria vectors and their species
complex against insecticides used in public health.
This should
be done in a networking mode; (ii) diagnostic concentration of SD
compounds should be determined for each vector species;
(iii
shelf life of SP impregnated papers should be determined, and a
period of full efficacy should be indicated for monitoring
resistance; (iv) as and when resistance develops to synthetic
pyrethroids it may be desirable to study the impact of SP
resistance on the efficacy of ITMN; and (v) WHO may consider
designating a collaborating centre for the use of PCR to detect
kdr gene.
4. Cost Effectiveness Studies on Bed Nets
We have examined the cost effectiveness of insecticide
treated mosquito nets (ITMN) in comparison to the indoor residual
spraying and also the impact on malaria API. Table given below
6
gives the results of 4 field studies carried out in Orissa
against the vectors An. fluviatilis and An. culicifacies; and in
Assam against the vectors An. minimus and An. fluviatilis. Table
below gives the cost comparisons of 4 field studies carried out
under the auspices of MRC. Per capita cost of bed net programme
was low and varied from Rs. 15.58 to Rs. 26.75. However the
impact on malaria reduction was about 50% or so. In no experiment
ITMN interrupted malaria transmission. It may be noted that in
RESULTS OF FIELD STUDIES ON THE COST EFFECTIVENESS OF INSECTICIDE
TREATED MOSQUITO NETS IN INDIA
Assam
Orissa I
Orissa II
Orissa III
26.75
15.58
23.80
22.02
190
73
243
437
166
437
327
301
Treated
106
-44%
194
-20%
14 9
-11%
312
-5%
No net
108
+48%
329
-25%
329
-25%
417
+39%
Treated
51
-73%
121
-50%
74
-55%
133
-59%
No net
270
+ 269%
227
-48%
227
-48%
275
-9%
Per capita
cost, 3 year
average
IMPACT ON API
1st Year
Treated
No net
2nd Year
3rd Year
Africa widespread use of ITMN can reduce overall mortality by
about a fifth. For 1,000 children protected, on average about 6
lives can be saved in the age group 1-59 months every year. The
impact of ITMN on clinical episodes of malaria is also pronounced
halving the attacks in stable malaria transmission areas in
7
Africa. ITMN in Asia and Latin America also reduced significantly
the number of clinical attacks of malaria in areas where the EIR
was <1. Therefore there is no evidence where ITMN may have
successfully interrupted transmission. This happens with IRS
provided spray coverage is >95% with a potent insecticide and the
vectors are endophilic. Table below gives the cost of ITI4ISJ as
calculated in 1997.
Per capita cost varied from Rs. 23.7 to Rs.
32.65. This cost was calculated on the basis of one million bed
nets. The per capita cost is lower when bed nets are purchased
COST
OF INSECTICIDE TREATED MOSQUITO NETS
(1997 Prices in Indian Rs.)
Insecticide
Dose/ sq.m.
& Quantity
per net/dip
Quantity
Cost
Per capita
2 dips/yr Nets+SP+other
Cost
Deltamethrin
(2.5%)
2 5 mg
12.5 g
15.0 mt
14.2+10.8+1.2
26.2
Cyfluthrin
(10%)
50 mg
6.25 g
7.5 mt
14.2+17.25+1.2
32.65
L-cyhalothrin
25 mg
3.125 g
3.75 mt
14.2 + 8.30 + 1.2
23.70
Note : 0.6 m. nets/m. population; Size : 3mxlmxl.75m
12.5 sq.m.
from open market and quality is determined by experience. However
when bed nets are ordered in bulk with standard specifications
acceptable to the international organizations, this cost becomes
high as shown in the table below.
CURRENT PRICES OF INSECTICIDE TREATED MOSQUITO NETS (> 50,000)
Single; 75 denier
(70x180x150 cm)
Double; 75 denier
(100x180x150 cm)
Family; denier
(130x180x150 cm)
Rs. 218.4
Rs. 260.51
Rs. 281.71
Rs.
43.7
Rs.
52.10
Rs.
56.34
Rs .
9
Rs .
11
Rs .
15
1st year
Rs. 61.7
Rs.
74.10
Rs.
86.34
2nd year
Rs . 63.5
Rs. 76.30
Rs.
89.34
8
3rd year
Rs. 65.48
Rs. 78.72
Rs. 92.64
4th year
Rs. 76.66
Rs. 81.38
Rs. 96.27
Sth year
Rs. 70.05
Rs. 84.31
Rs. 100.26
In comparing the cost with DDT IRS the cost of ITMN is
equal to twice as expensive depending on the options of 1 or 2
dips and distribution pattern,
However data collected from the
field on the impact of DDT on various vectors show very poor
impact on malaria API.
This is illustrated by the malaria API
recorded from areas where DDT IRS was carried out to control
malaria.
Impact of DDT oni malaria API in districts with An.
dirus; An. minimus and An. fluviatilis
in Arunachal Pradesh
(1986-1995): East Saing 44.50-100.65 API, Lohit 15.37-125.29 API,
Subansir 17.32-32.67 API; Assam (1986-1995) Keonjhar 6.16-25.1
API; Karbi-Anglong 15.63-25.23 API, NC Hills Haflong 10.44-26.95
API; Mizoram (1986-1995) Aizwal 17.66-28.22 API, Lunglei 24.4282.79 API, Chhimtuipui 19.53-36.97 API.
Impact on API in areas
with An. culicifacies and An. fluviatilis was: Gujarat (19841994) Panchmahal 10.42-28.76 API, Orissa (1986-1995) Dhenkanal
7.25-23.20 API, Keonjhar 22.02-49.00 API, Koraput 12.79-19.36
API, Mayurbhang 15.18-28.82 API, Phulbani 21.75-43.49 API,
Sundergarh 15.55-31.52 API.
In An. culicifacies areas the impacc
on malaria API was: Madhya Pradesh (1986-1994) Jagdalpur 12.5925.00 API, Ranker 16.94-51.27 API; Maharashtra (1986-1994)
Gadchiroli 10.3-26.95 API, Tamil Nadu (1986-1995); Ramnathapuram
3.47-26.29 API, U.P. (1990-1995); Sonbhadra 11.32-42.18 API.
In
An. sundaicus areas the impact on malaria API was Andman and
Nicobar islands (198-1995); Nicobar islands 17.81-60.57 API .
Therefore against all vectors DDT spraying is not productive in
malaria control.
ITMN is a cost effective strategy when examined
against the use of IRS DDT.
HCH has been banned in malaria control.
However malathion
is still sprayed to control malaria. Spray coverage of malathion
is poor and it is not very productive in areas with An.
culicifacies species C as malathion rapidly induces resistance.
Pungent odor of malathion is another reason of poor coverage.
ITMN are cheaper compared to malathion. A DFID project on the
ITMN in Surat (Gujarat) has reported better control- of malaria by
using ITMN against the spraying of SP compounds in An.
culicifacies areas. Success of ITMN would depend on the health
education, socio-economic and behavioral factors, vector biology,
particularly the biting time etc. A well organized ITMN programme
did not reduce malaria transmission because of these factors in
An. culicifacies areas in Mandla (M.P.).
In another project
funded by the TDR,
DDT supervised spraying Vs. ITMN revealed
that ITMN is superior to DDT spraying.
However from both these
9
trials it was abundantly clear that for the success of
<
ITMN
health education is absolutely essential and therefore social
scientists should be involved in developing appropriate message
for the communities.
Research is required on the (i) delimitation of areas where
ITMN would be more cost effective in comparison to other methods
of malaria control.
Cost of nets produced by the industry- is
very high and therefore research in social marketing of bed nets
and indigenous production of nets should be emphasized;
(ii)
monitoring of SP resistance in areas with ITMN;
(iii)
effectiveness of ITMN in areas with emerging SP resistance; and
(iv) studies on the use of SP compounds in agriculture and its
impact in the evolution of resistance in malaria vectors.
5. National Policies on Insecticide Resistance
DDT (50% WP) @ 1 gm/ sq. m. 2 rounds are sprayed in area
where the vectors are still susceptible
suscept ible to DDT.
However
monitoring of resistance is inadequate and epidemiological impact
of spraying is often unreliable.
Therefore DDT is still sprayed
against An. culici facies, An. fluviatilis,
An. minimus, An.
dirus, and An. sundaicus.
In areas where DDT resistance was high
and there was rising trend of malaria. HCH was sprayed @ 200
mg/sq. m. 3 rounds each year.
There is a strong environmental
lobby to ban the use of chemicals in vector control.
The main
targets are the organochlorine compounds, particularly DDT and
HCH.
Monitoring of residues by various agencies revealed that
residue levels in almost all food items were very high and there
are neither any regulation nor quality control procedures to
regulate the residues. HCH was also more harmful due to presence
of other isomers e.g. alpha and beta isomers which have
pronounced toxicity. Therefore beginning from April 1998 HCH has
been banned in public health and this is being followed rigidly.
In agriculture DDT and HCH has been banned.
But due to low cost
of DDT and the fact that NAMP has been pressing for the use of
DDT in malaria and Kala Azar control, the Government of India hai_
fixed a ceiling of 10,000 mt DDT to be used by the NAMP. Further
the
GOI has directed that use of DDT should be phased out so
that by 2005 DDT is banned in the country.
In areas with
resistance to DDT and HCH malathion was sprayed @ 2 gm/sq m. 3
rounds.
Malathion was very effective in malaria control but An.
cul ici facies developed
resistance
rapidly
in Gujarat
and
Maharashtra leading to triple resistance.
In areas, where species
C is prevalent use
of compounds in agriculture has induced
resistance in An. culicifacies.
Therefore in species C areas
malathion should not be sprayed. Beginning from 1995 synthetic
pyrethroids are finding increasing use in malaria control.
So
far Tamil Nadu, Maharashtra, Karnataka, and Gujarat have sprayed
SP compounds in malaria control.
The spraying has been in areas
where An. culicifacies
is the vector and almost epidemic
situations prevail. Spraying of malathion is not recommended in
An. culicifacies species C areas instead it is a good insecticide
10
f°r species
Cost wise DDT is the cheapest insecticide
followed by malathion and SP compounds are most expensive. The
budgetary provision is too small to cover the entire country
either by malathion or SP compounds. Therefore DDT spraying would
continue, although it completely lacks epidemiological impact.
Enhanced malaria control project envisages phasing out of
chemicals in malaria control. SP compounds would be used
selectively in IRS. Insecticide treated mosquito nets would
replace IRS wherever feasible and found cost effective. Tables
given below give the comparative toxicity of the insecticides in
vector control. Toxicity should be an important criteria in the
selection cf an insecticide.
In the control of An. stephensi Temephos is used, but in
almost all towns malaria is rising and in some towns epidemics
have been recorded. Bacillus thuringiensis H-14 is being
introduced in the control of An. stephensi. Bt is still not
recommenced for use in potable water and therefore Temephos would
continue in the treatment of potable water. There is a lot of
interest in the integrated control to minimize the use of
insecticides in agriculture and public health . The following
technologies are being introduced in India in malaria control.
Insecticide treated mosquito nets/curtains; selective use of
insecticides, bioenvironmental malaria control; biolarvicides ;
and repellents. Research is required on the i) cost effective
integrated vector control; ii) biological control methods; iii)
application of CIS in planning malaria control; iv) biology of
sibling species in relation to control; v) rapid health impact
assessment methods, technique to delay the onset of resistance
and combating resistance; and species specific vector control.
6. Rational Use of Insecticides
Rational use of insecticides in public health requires
careful consideration of a variety of factors. Safety is an
important consideration in the selection of an insecticide. All
pesticides are injurious to human health and environment.
Insecticides persist in the environment and some of these do not
breakdown and recycle in nature, contaminate food chain,
interfere with the immune system, destroy biodiversity and
beneficial fauna. The choice of insecticide in vector control
should be guided by the lack of its capacity to recycle in nature
and rapid biodegradability. In this context replacement of CH
insecticides by organophosphorous, carbamate and synthetic
pyrethroids is advisable. However replacement insecticides are
more toxic, costly, damage biodiversity and interfere with the
immune system.
It is therefore imperative that insecticides are
used selectively, under special situation and in emergency. Table
given beiow gives relative hazards of various insecticides used
in malaria control in India.
11
RELATIVE HAZARDS
QF DIFFERENT INSECTICIDES USED
CONTROL IN INDIA
Insecticides
Per capita requirement
of insecticides
(a.i. in grams)
1. Cyfluthrin
2. Deltamethrin
3. Lambdacyhalothrin
4. Malathion
5. Lindane
6. Fenitrothion
7. DDT
8. BHC (All isomers)
1.5
1.2
1.5
180
18
180
60
18
IN MALARIA
Risk ratio as
compared to
deltamethrin IRS
0.7:1
1:1
3 :1
9.6:1
23 :1
40 : 1
59:1
76:1
Basis of calculation : The average sprayable area of the house i
150 sq.m, with five inmates. Therefore per capita area is 30 sq
Therefore
research should be directed
on the methods of
integrating these insecticides in vector control. In areas with
the problem of insecticides resistance application of replacement
insecticides is indicated e.g. DDT followed by malathion, and SP
compounds. Use of SP insecticides in IRS should be avoided and
reserved for the ITMN. Cost is an important consideration and it
should be examined in relation to the epidemiological impact of
spraying. Spraying of insecticides in populations which are
either resistant or show pronounced exophilic behavior is
unlikely to produce epidemiological impact and therefore
alternate strategies should be used. In this connection NEERI,
Nagpur (Table below) has suggested selective use of ITMN instead
of mass distribution from toxicity considerations.
RELATIVE RISK OF INSECTICIDE TREATED MOSQUITO NETS
Insecticide
Strategy
Per capita
Risk ratio
insecticide
as compared to
(a.i. in gms.) deltamethrin
mass
1. Deltamethrin
Selective
Mass
0.03125
0.375
0.08:1
1:1
2. Cyfluthrin
Selective
Mass
0.625
0.75
0.09:1
1.10:1
0.03125
0.375
0.20:1
2.40:1
3 . Lambdacyhalothrin Selective
Mass
12
Note; Data sujgo'ssti ibtet. elective use of ITMN is safest method,
safe as compared to IRS. The average
Mass use of rSftR
IT5W is
safe
sprayable arsa, is
as 112.5 sq.m, and 3 bed nets are
required for a
of? 3..
It is als-o advisable to examine the current use of
insecticides in agriculture to decide on the insecticides to be
used in vector control. Research therefore should be directed on
the integrated control of malaria and development of new
technologies in vector control. In the control of urban malaria,
malathion fogging is in demand all over the country. Malathion
fogging is very expensive , hazardous to human health and as a
routine control measure does not produce epidemiological impact
on transmission. This should be discouraged or banned. There is
also an increasing use of a variety of insect repellents. Most of
these use allethrin compounds. These repellents are injurious to
human health and their use should be avoided. Neem based
repellents are equally effective and safe and should replace the
allethrin based repellents.
7. Sustainable malaria control
Sustainable malaria control would depend on the vector and
their biology.
In India malaria control is based on DDT,
malathion and synthetic pyrethroid spraying. An. culicifacies
transmits 65% malaria cases in the country. NAMPs 80% efforts go
in the control of
An. culicifacies. DDT spraying does not
produce epidemiological impact and therefore it should be
stopped. Table given below gives the contribution of each vector
in the transmission of malaria. Malathion spraying induces
resistance in An. culicifacies species C in about 2 to 3 years.
Spraying of OP
Role of Anopheles Mosquitoes in Malaria Transmission
Malaria
Vectors
Anthropophilic
Index
Major
Species-wise Contribution (%)
Malaria +s
Pf +s
Malaria Vectors of India
65
12
An. culicifacies
An. stephensi
55
05
Major Malaria Vectors of Regional Importance in India
An. fluviatilis
An. minimus
An. dirus
++
+++
+++
13
15
5
3
30
5
5
Major Malsurisi Teator of the Coastal Areas
An. sundaicus
. 039
Note: Broad c;; t.
.
predominantly
zoophilic and a&:thrx^5QphiXic; ++-r anthropophilic.
.001
zoophilic;
Insecticides- in agriculture also induces resistance in
species C. Therefore malathion spraying should not be done in
areas with Species C. However in areas with species A malathion
spraying is. very effective and it takes a long time to build up
resistance in species A. It may be noted that malathion sprayinc
is not accepted by the communities because of pungent smell. In
order to overcome this problem odorless malathion should be
Malathion spraying
reduces vector populations
sprayed.
dramatically to low levels and interrupts malaria transmission.
Therefore after interruption of transmission spraying should be
withheld until there is evidence of active transmission. An.
stephensi transmits about 12% cases in the urban and semi-urban
areas of the country. IRS is not feasible in the urban areas and
therefore larval control and source reduction are the main
strategies in malaria control. Health impact assessment,
municipal bye laws and Bacillus
thuringiensis
H-14 may be
introduced in urban malaria control to increase impact and
enhance sustainability of the field operations.
An. sundaicus
transmits < 0.01 malaria cases and malaria control based on DDT
spraying had no impact on the API. In the Car Nicobar island
installation of one way sluice gates and the introduction of
larvivorous fishes reduced malaria API
from c 100 to < 10.
Installation of sluice gate in one more creek will eliminate
malaria from this island. Such a low level of malaria was not
attainable with the spraying of DDT.
An. fluviatilis comprises
of three sibling species designated as S,T, and U. Species S is
the vector but environment pollution and major ecological changes
displaces this species by non-vector species T and U. Therefore
in areas where An. fluviatilis
is the vector agricultural
developments may displace this vector.
An. minimus, An. dims
and An. fluviatilis are the vectors in
north eastern states.
Vector control
is problematical because of pronounced exophilic
vector behavior. Insecticide treated mosquito nets have been very
productive in malaria control.
In attaining sustainable malaria control our first line of
attack should be the bioenvironmental methods of malaria control.
There are a very large number of examples of sustainable malaria
control from throughout the world e.g. Tennessee Valley Authority
(TVA), USA; and from Malaysia, Indonesia, Caribbean islands,India etc. Successful malaria control would depend on the vectors
and human settlements. It may be difficult to apply these methods
where population density is low e.g. in NE states human
population is 50-100 per square km as against in the plains of
India where the population density is 300-1000 per sq. km.
Control in low population settlements is
expensive
and
is
<
implementation difficult. ITMN technology may be superior.
14
co^^teievV=f°nmenta1
methods eliminate transmission
and
where
In
in the
^ontlot
f
?S sucucessful demonstrations were made in the
control of rural,r urban.
urban, industrial and coastal
and coastal malaria.
^urrently bioenvironmental
— malaria control is in progress in
■ J
’
in
Karnataka.
in
imnlement^i-‘
1C-f
Karna
taka.
In
villages
under
the
methodsmalaria
malariahas
hasbeen
beenwiped
wipedout
out in
about 2
Ot v these
iSe methods
district,
with 35 YnnnrS’ In Kolar dl
strict, I"
Kamasundaram PHC in 6 sections
-educed XTiT/
°ne introduc
tion of larvivorous fishes
population1 one
introduction
-ia ,API from
theil
™aria
fr°m 41.8
41 ■8 m 1993 to 4.1 in 1997 and now
Karakattp PH^V1.
c°f active transmission. In Hassan district
X XU waf 77W^
a5'000 P°Pulation in 30 villages malaria API
in 1996 =r,H i □ ■ al}d introduction of fishes reduced API to 19.71
107 villa^
cc no
In Banavara pHC of the same district in
rediJ^P
ln 555,000
' 00 Popnlation
population introduction
introduction of fishes in 1995
iSi Per
lat-API
154
6
in
1995
API from 154.6 in 1995 tO 70 in 1996 and 5.2 in
operations caPita cost
cost (inclusive of salary of staff) of
of field
to
Rs
.
4.36
when
maintained ?meS
Rs ’ 4-36
a separate staff is being
government Hasid the transfer of - t'ChnO1°9y to
tO the_
on the experience in Karnataka bioenvironmental
methods have been introduced in the
Biopnvimnm^
I'T*methods
—
j-ix cue entire state of Maharashtra.
Bioenvironmental
are also
also
<
Hardwar qB
methudS 3re
eco
“friendly. A study in BHEL,
Hardwar
showed
73 f
h h that
h3t the residue
reSidUe levels of HCH and DDT were 27 and
J-5 times higher in
m soil and 20.2 and
;
bloodhigher
8.1 times higher in whole
blood
samples
from
Bahadrabad
(Control) as compared
to
OOtheS
WTeS(brrespectively
eSPeCtiVely fr
°m Bahad
rabad” (Eon^ol)"
below inBHEL
S tab;/’
''
110
™
611
"21
interventions).
(bioenvironmental interventions) . The data is give
MEAN CONCENTRATION OF
OF HCH
HCH AND
AND DDT
DDT IN
IN SOIL,
SOIL, WATER AND WHOLE BLOOD
SAMPLES FROM BHEL AND BAHADRABAD
BHEL
(Bioenvironmental control)
HCH
DDT
Soil(ug/kg)
Water(ug/1)
Whole blood
(ug/1)
Bahadrabad
(Chemical control)
HCH
DDT
2.26
3.68
61.12
270.51
ND
ND
0.18
0.07
1.2
4.71
24.30 ’
38.31
15
The total cost ici tthe first year was Rs. 41 lakh to cover
the entire state. In Gujarat bioenvironmental malaria control was
linked with income generating schemes of tree plantations and
edible fish culture. An estimated one million trees were planted
which have improved the environment besides the wealth it would
provide in due course. Edible fish culture in village ponds
generated enough income to take care of malaria control including
the staff salary. Table below gives the production of edible
fishes in Nadiad. Part of the money generated was spent in laying
underground drainage. Interventions have already started in
ESTIMATED INCOME FROM FISH CULTURE AND EXPENDITURE ON MALARIA
CONTROL IN NADIAD TALUKA
1 . Ponds suitable for fish culture
201
2 . Total area of ponds
481 ha.
3 . Income @ Rs.9091 /ha./year
Rs.43,72,771
4. Expenditure on fish production
Rs.14,50,215
5. Net income per year
Rs.29,22,556
6 . Bioenvironmental malaria control cost
@Rs.4.97 per head, actual project cost
Rs.17,39,500
Net savings per year
Rs.11,83,056
Ahmedabad
city
to
control
malaria
and
dengue,
Bioenvironmental methods are superior to chemicals in many ways
as shown in the table below, Cost wise bioenvironmental methods
are the cheapest and require very little expenditure on th
maintenance.
BIOENVIRONMENTAL VS. CHEMICAL MALARIA CONTROL STRATEGY
Concern
Bioenvironmental
Control
Chemical
Control
Long term
Long term
Seasonal
Seasonal (R)
1. IMPACT
a)
b)
c)
d)
e)
Malaria
Vectors
Parasite (R)
Human Health
Environment
16
2. SUSTAINABILITY
a)
b)
c)
d)
Cost
Returns
Skills
Technology
+
Low to High
Local
Local &
Universal
3. GAINS
a)
b)
c)
d)
Other Diseases
Development
Indian ethos
Community
High
Diminishing
Training
Sophisticated &
Time Limited
□
Linked
Isolation
+ Response
? Response
+ = Positive;
- = Negative;
Source: Sharma, V.P. 1998a.
R = Resistance;
? = Doubtful
Therefore in the control of malaria our first line of attack
should be the application of bioenvironmental methods. Selective
IRS should be carried out if indicated strongly. Selection of
insecticide should depend on the vector susceptibility and
endophilic behavior. In areas which are not suitable for IRS and
implementation of bioenvironmental methods is not feasible
insecticide treated mosquito nets should be used in malaria
control. If IRS is to be carried out and malaria has been
successfully controlled the budget of malaria control should be
diverted in the environmental management to reduce malaria
receptivity. Such an approach would be an ideal solution to
attain sustainable malaria control in the country. Areas of
priority research in the sustainable malaria control are: (i)
application of remote sensing (RS) geographical information
system (GIS) in understanding malaria transmission dynamics and
early forecasting of malaria epidemics. GIS should also be
applied in the preparation of annual plans of malaria control;
(ii) studies on larval ecology to reduce malaria receptivity;
(iii) biology of sibling species complex of malaria vectors in
relation to control; (iv) health impact assessment in the
environment impact assessment; and (v) search of new biological
control agents.
References :
We deeply regret that due to time constraints and the fact
that script was erased by mistake at the last moment references
could not be included in the paper.
17
MALARIA ERADICATION AND THE
SELECTIVE APPROACH TO HEALTH CARE:
SOME LESSONS FROM ETHIOPIA
Oscar Gish
control programs, such as the one against malaria, stressing instead the integration of
these programs mln horizontal community-based health systems. Malaria control
programs, however, have not been integrated well—or in some cases at all—into
primary health care networks. An analysis of the Rlhiopian experience, as part of the
worldwide malaria cradicatmn program, illustrates the political and economic forces
that have worked against (he move from vertical to integrated malaria control
activities, and from vertical to integrated health programs more generally.
In 1969 the World Health Organization sounded the retreat in its 15-ycar global war
to eradicate malaria. In much of the world the heavily subsidized, military-style cam
paigns that had mobilized hundreds of Ihousands of workers armed with DDT and
anltmalanal treatmcnls had not managed to interrupt transmission of the disease
Reported cases were on the rise, both the malarial parasite and its mosquito vector were
becoming reststant to the drugs and pesticides being used against them, and exlcrnal
donors and national governments were tiring of the continued costs of what was to have
been a lightning strike Io eradicate this costly disease once and for all. Analysis of the
underlying reasons for the campaign’s failure conlribuled to the formulation of
the primary health care (PHC) concept as the basic international strategy for heallh
improvement. The Primary Heallh Care Conference held in Alma-Ala in 1978 was Io
have ended the period of vertical disease control programs, such as the one against
malana; mtegration was the word of the day, anti popular participation was Io be the
basis of unproved heallh and health care systems.
Now, 14 years later, the question of integration remains on the agenda. Malaria
control programs have not been integrated well—or in some cases at all—into PHC\_)
networks; indeed, the transformation (or perhaps corruption) of PHC into so-called sclcchve PHC offers clear evidence on a broader plane (if any such evidence is required)
hat vemcal programming is, in fact, slill alive and doing well. An analysis of
the Ethiopian cxpenencc, as part of the worldwide malaria eradication program will
International Journal of Health Services, Volume 22, Number 1, Pages 179-192, 1992
© 1992, B;iywoo<l I’liblishing Co.. Inc.
179
180 / Gish
Malaria Eradication Programs / 181
illustrate the political and economic forces that have worked against (he move from
historical background
favor nnh?0
°f
WOrld Heal,h
vo.ed overwhelmingly in
overwhelmingly
in
favor ol the creation of a worldwide malaria eradication program. The
early results of
campaign were spectacular: India, which was reported to have had as many as 75
mtllton cases and 800,000 annual deaths from the disease, was able to reduce the
number of known malarta cases in 1965 to 100,000 after an eight-year campaign The
effort expended in accomplishing this decrease was enormous, requiring the deployment
m X,counmrteT0FP£OP'C
‘abletS- Simi'ar reSU,1S were 3chicved
m other countr.es. For example, m 1964 Indonesia reported only 8 000 malaria cases
compared wuh 120,000 five years earlier. In 1967, Pakistan, then LluTng Bangladesh
em/rted hthe A
>n<i ^ai'and 0"ly 16’00° (1’ P'
Similar succ“ses were
reported ,n the Americas, the eastern Mediterranean, and (he eastern Pacific However
progress could be reported tn Africa south of the Sahara, at least partly because no
overall ma'arta eradication effort was undertaken in this part of the world V
lat?inIT iqM? °fT,“ CradiCaliOn Pr°granl WCre ^‘ively simple. Since
Ury 1
bcen knQwn that mosquitoes spread malaria These
osquttoes rest on the walls of houses when they have fed. DDT a recently available
houTlX 1 effCC1,iVe PCS,iCidC’ WaS ,0 be Sprayed
,he insid‘ -he walls of every
house ocatcd tn a malarious area. About 30 days later the houses would be visited again
and selected occupants gtven blood tests. If the disease was confirmed an antimabrial
rug usuall y chloroqume, would be administered. This program of biannual fumigation
.»
““
In . Sre«
Selling the Concept
Obv.ously, a worldw.de disease eradication effort requires some central coordinalintj
' V. ,n the case of malarta that coordinating body was WHO. In its diversity the
organ,zat.on has been more responsive to proposals coming from some of its member
states than others. Given the technical capacities as well as resources of the more
D C or
dC0Un'rM
lhC WWld' 11 iS n0‘ SUrpriSing 'hat VicWS hcld in W^ington,
D.C. or London or Moscow on the nature of health-related issues would carry teal
weight tn pohey making at WHO headquarters in Geneva. Also, during the period when
global eradication effort against malaria was being discussed, a signincant part of
Uni ! n7 /^unlhC CXCCp,iOn Of U,in America) cither was not yet part of the
Untied Nattons/WHO or else had only recently joined. The impetus for the malaria
States3"011
? “7’ 'hC rirS' PlaC,:’ fr°m lhC indus,riali^ countries-lhe United
ll l7>-“ w™'“
'«-
Gabrclc Gramiccia, a malaria c::
f
expert
who worked with WHO for 27 years, has
described the initiation of the malaria
..J campaign (quoted in 1, p. 26):
The salesmanship of the malaria eradication programme was superb, and raised both
interest and funds. One of the most effective methods used was a world tour by a
highly reputed malariologist-consultant who visited the minister of health of each
country and asked him how much was spent each year for malaria control. Once the
answer was obtained, he asked again, ‘What would you say to spending 20% more
for three years and then no longer a single cent for malaria?’ ‘1 would do it,’ was
usually the answer. ‘Then you are in favor of malaria eradication.’
The bases for optimism about the possibility of completely eradicating malaria were
the positive results obtained in some relatively marginal malarious areas during the
ten-year period following World War II, in particular the southern part of the United
Stales, southern Europe, and parts of Venezuela. Because eradication could be accom
plished in these areas, it was assumed that the same could be done elsewhere. But, as
Gramiccia points out, “malaria is not the same everywhere. Mosquito behavior, opera
tional capacity, available resources and the demands of other health problems vary from
country to country. Malaria could be eradicated in some countries, but not, despite
prolonged and expensive efforts, in several others” (1, p. 26).
Despite the questions raised about the feasibility of successful eradication programs,
the concept was accepted with enthusiasm by most health officials of independent third
world countries. This fact may be only partly explained by the inexperience and lack of
technical capacity of many countries. Professor D. Banerji, the distinguished Indian
public health authority, has summarized the history of the vertical campaign approach to
malaria in India as follows (3, p. 10):
The fact that despite their obvious over-riding importance, preventive services have
received a much lower priority in the development of the health service system of
India provides insight into the value system of the colonels of the Indian Civil
Service and, above all, the value system of the political leadership of free India. The
colonels did not appear to relish the prospects of dirtying their hands getting
involved in problems which required mobilization of vast masses of people living
in rural areas. The rural population raised in the minds of these decision-makers
the specter of difficult accessibility, dust and dirt and superstitious, ignorant, illmannered and illiterate people. Therefore, when they were impelled to do some
preventive work in rural areas, characteristically they chose to launch military style
campaigns against some specific health problems. Undoubtedly, because of the
enormous devastation caused by malaria till the early fifties, this disease deserved a
very high priority. But the programme became a special favorite of the colonels not
only because it required relatively much less community mobilization, but it also
provided them with an opportunity to build up an administrative framework to
launch an all out assault on the disease in a military style—in developing
preparatory, attack, consolidation and maintenance phases, in having 'unity of
command’, surprise checks and inspections, and in having authority to ‘hire and
fire’. Significantly, some of the followers of the colonels went so far as to compare
the malaria campaign with a military campaign.
The issues raised by Banerji are important in that the emphasis given to vertically
organized specific disease control programs, in contrast to more generalized integrated
and horizontally organized approaches to health, has in many parts of the world—as will
be discussed later in the Ethiopian context—tended to unbalance the whole of health
development systems. In practice, the vertical campaign approach has created barriers
to the possible development of technically integrated, community-controlled health
systems of the kind being advocated in the context of PHC. The campaign technique has
182 / Gish
Malaria Eradication Programs / 183
been fostered in particular by those who seek the basis of ill-health in the characteristics
of ■nd.v.dual diseases rather than in the “situation” of those diseases within overall
social structures. In the case of malaria, its coexistence and interrelationship with many
o her parasitic and infectious diseases, generally in the context of extreme poverty and
considerable malnounshment, are basic to the continued importance of the disease in so
Disillusionment
going wrong
reported cases. Although this was partly due to improved reporting, the experts accepted
that malaria in fact was on the increase in some areas at least. The reasons offered for the
dtfficulhes encountered by the eradication effort included: vector resistance to insec
ticides, parasite resistance to chloroquine; inadequate application of eradication tech
niques including poor case finding and premature moves into the consolidation phase of
control; shortage of experienced professional and field personnel; bureaucratic
mampulahon.of the program; the rising cost of all antimalarial activities; attacks on the
vertical approach of the program by integrationists; and, in particular, the loss of “will”
and related decline of financial support by donor agencies, especially the United States
Agency for International Development (USAID), which had been a key conceptual
political, and economic supporter of the program (2).
’
wa1snnm<fPa<wO'ST°rld
AsSembl>' decided that g|obal eradication of malaria
as not feasib e, at least in the foreseeable future, and instead recommended a strategy
of control. Following this decision and the related decline in country and donor agency
anumalarial activities, the overall number of cases reported worldwide (not including
Africa south of (he Sahara, which had never entered into eradication, and China, for
which data were not available) increased about 27a times. However, virtually all of this
increase occurred in southeast Asia; of the recorded increase of almost 5 million cases
between 1972 and 1976 (again, excluding Africa and China) all but 16,000 took place in
tha part of the world Subsequently, the number of cases reported in southeast Asia
declined from ns 1976 peak of 7.3 million to 4.3 million cases in 1978, a fall of over 40
percent (4, especially Table 1). By 1983 the comparable figure was 2.5 million. The
greatest part of the worldwide malaria problem remains in southeast Asia and Africa the
latter area reporting 4 to 8 million cases per year between 1972 and 1982 (5 p. 97)’ As
already suggested, the number of cases reported represents only the “tip of the (malarial)
iceberg The current number of people worldwide suffering from malaria annually is
estimated to be around 130 million (110 million reported clinical cases), while 270
million people are thought to be carrying the parasite (6, p. 2).
There were.at least two major reasons for the large reported increase in malaria that
followed the 1969 World Health Assembly resolution. One was the persistent resistance
by national malaria organizations and their remaining international supporters to any
move away from an eradication strategy toward one of control. In most cases the
isolated and well-funded structures that had been created to support the eradication
program were inappropriate for a long-term control strategy; in addition, the malaria
bureaucracy seemed to have taken on a life of its own. Administrators within the malaria
service feared the repercussions of having to fire or retrain such a large labor force, and
the efforts of public health policy-makers and administrators to integrate the programs
with the general health services caused an ever-widening gap between the different
interest groups. Where hasty integration efforts were initiated they were frequently
poorly designed, resulting in systems that achieved neither the single-mindedness of the
vertical approach nor the potential stability of the integrated one.
The other major reason for the dramatic increase in malaria following the World
Health Assembly’s 1969 resolution was the absence of any clear definition of exactly
what was meant by malaria control, as opposed to eradication. The goal of eradication
and the consequent vertical campaign approach to malaria was justified by the argument
that with sufficient spraying supplemented with case treatment it would be possible to
interrupt transmission of the malaria parasite and thus see the complete disappearance of
the disease; in contrast, a control strategy contemplates the long-term reduction of
morbidity to a level where it no long poses a major public health threat. The basis for the
creation of independent malaria organizations and the input of a large volume of
resources, at least as measured in Africa and Asia, into these structures was justified by
the expectation that malaria would be done away with everywhere—both nationally and
internationally—and forever. However, if control was to be the target it then became
necessary to weigh expenditures directed against malaria in keeping with other priority
areas, at the very least those within the health sector. In 1969, however, the proponents
of the strategy change had no clear guidelines to direct this transition and the PHC
approach and its implications for specific disease control activities was still almost a
decade away. In any event, it remains the case that malaria “control based on eradication
principles still dominates, despite the fact that eradication is no longer believed to be a
viable concept under prevailing conditions. The legacy of eradication is probably the
single most important factor constraining control programs from developing new
strategies” (6, p. 17).
VERTICAL VERSUS HORIZONTAL
Recent events have highlighted the differences between these two classic approaches
to health care. In somewhat oversimplified terms, the “verticaiists” favor categorically
specific, hierarchically organized, discrete disease control programs, and the “integralionisls” favor horizontal health care delivery systems as the basis of a mixed strategy
of disease control/health-promoting activities. Not surprisingly, in practice these two
ideal tendencies have often been brought together to a greater or lesser degree.
The verticaiists are accused by the integrationists of being overly narrow, of not
appreciating the social causation of most disease and hence essentially social nature of
its prevention, of seeking only technological solutions to problems that arc better
approached through improved forms of human organization, of attempting to impose
external technological hierarchies upon people rather than working through organized
communities, and finally, of having failed too often in their past efforts (even their
successes are said to have been mostly unique events, e.g., smallpox) and in their
continuing zeal for the vertical campaign approach, to be blocking the pathways leading
to improved, integrated health care systems. On the other hand, the integrationists arc
184 / Gish
Malaria Eradication Programs / 185
lack of appreciation of hierarchical diccini ^
the progress that has atrea^^^^
'
vcc,ors’ of romanticism and
“> apprecuxe
through
h
gh sspecific
Pcclf'c disease control campaign-
type activities.
The international conference on puc
..
September 1978 reflected within the health seem
„
S°V'et Un'°n
Hs more immediate impact has been felt in the^e
,ndustr,alizcd countries,
arc many reasons for this; two will be cited here O Cvel°Pcd Parls °f 'he world. There
narrow the wide gap in heahh status between e X^a d
'0
that the limited health resources available to third
.
Poorer countries; the other,
PHC approach not only more relevant but ne h
'TC0Unlnes aPPears to make the
me late ^s and early^197X saw"ome^ a,S°
^ada‘ for them.
world underdevelopment: away from growth o^n5!1" 'T*""8 ab°Ul 'he nalUrCof lhird
indicator of development and t„w"J oth rs
t,
PrOdUC, 35 'hC aln'0S'
^distribution, and L provisio^ati^
“
important implications for the health sector- ,h.
dlscussion carried
longer be perceived as being a result primarilv fn'Pr0V<'nlCnl of People’s health need no
need it wait upon that growth, but rather as some h^” h8™*"101 "'''“h31 pr°dUCt’ nor
the failure of the venial malaria'sXgyto ^W"CdevcloPmcnh °" 'he one hand, and
created new possibilities for the heali^scctor 17°
8031 of cradlca,ion- 00
other,
strategy-the creation and/or provision for all of TlbaS''C nCCds
access to such services as education and h^i.h Jn dC<'Cnt Slandard ot nutrition, full
and enhanced possibilities for people to take ’ n Cmploynlcnl (wa8c or otherwise),
leads to a reexamination of thinking about the c^userofTeal'haVd0'^'31 Pr°CCSSCS-
ways of creating the former while limiting the latter
zr'
8|
The Ethiopian revolution of 1974 laid the political basis for the decision, in principle,
to integrate the country’s separately organized, vertical malaria control (formerly
eradication) program with the nation’s overall health system. However, the now revolu
tionary government was concerned about a possible lack of international support for this
move. Thus an international group (the third such one) was assembled in 1977 to
formally review the Ethiopian malaria effort and recommend on its future. The group
comprised representatives of the Ethiopian government, WHO, and USAID. The basis
of the invitation to USAID to take part in the review was that agency’s long involvement
with the Ethiopian malaria program. As the Ethiopian government wanted a properly
objective and external evaluation of the country’s malaria experience, it rejected some
proposed WHO and USAID nominees to the team who had previously been involved in
the Ethiopian malaria effort.1
Background to the Campaign
aWhcaUh^7uX,'^LnyT
r ^
THE ETHIOPIAN EXPERIENCE
Aima-Ala in
shift in thinking about the nature of third
m
’ pOlCntiall>' ™POHant underlying
httic doubt of the conferenci■A,lh°Ugh
“
•raditionaf views a
more or less vertical terms did begin to explore new, PHC-rclatcd strategics for the
accomplishment of their goals, usually against great odds; such is the case of the
Ethiopian malaria control program.
the^coT'
SC'
'hC bCSt
- »= >—
--
disease control programs and <, no i ion '
COnlinUlng
Ca,CSOTical
addition and not su^isinX aMca Jm.."T fW,dcly bascd pHC structures. In
between verticalists and integratinnists are based'm aPParCn‘ 'nlellCC,Ual s,roggles
— - 3—tse. mLy event,
Systematic study of malaria in Ethiopia began with Italian surveys conducted during
the years 1936-1941. These surveys demonstrated that malaria was generally dis
tributed in regions below 2,00() meters, although there were marked variations with
place and season. Further surveys were conducted by the British during the 1940s and
1950s. In the 1950s, malaria-control pilot projects using DDT fumigation techniques
were initiated under WHO, UNICEF, and/or USAID sponsorship. Within these pilot
project areas malaria transmission was never totally interrupted, although insecticide
application was demonstrated to be efficacious in reducing the parasite rate. The failure
to achieve complete interruption of transmission was attributed to incomplete
geographic coverage and fumigation, and frequent movements of population. It should
be stressed that even under pilot conditions these projects failed to accomplish eradica
tion within the demonstration areas. Despite this failure, plans for eradication of malaria
in Ethiopia proceeded with the establishment of various centers and training programs
and, in 1959, the creation of a National Malaria Eradication Service. It was not until
1967, however, that the plan of operation for malaria eradication was formally adopted
by the Ethiopian government and the concerned external donors, USAID in particular.
Under the plan, malaria was to be eradicated from Ethiopia by 1980. It is significant that
this formal eradication effort was entered into in Ethiopia at a time when the rest of the
world was on the verge of giving up eradication as a realistic goal, at least in the short or
medium term.
In fact, Ethiopia is the only sub-Saharan African country that formally entered into a
national malaria eradication effort. There were two basic reasons for this uniqueness.
1 The author parti'
’cd in this team on behalf of USAID.
186 / Gish
Malaria Eradication Programs /
One was that Ethiopia was then part of the Eastern Mediterranean Regional Office
(EMRO) of WHO, rather than the African Regional Office (AFRO), and while EMRO
entered into the international malaria eradication program, AFRO did not. The other
factor was Ethiopia’s extremely close political and technical relationships with the
United States, from which country, as already noted, the international malaria effort had
received its major conceptual, technical, and material support. A former WHO senior
malanologist has written, “When Ethiopia was persuaded to embark on malaria eradica
tion, by Dr. Pampana and Mr. Ray Fritz, Chief of USAID malaria ...” (2, p. 14). It is
clear that the goal of eradication did not originate with Ethiopians.
Although various types of pilot and pre-eradication projects were carried out between
the mid-1950s and the 1960s, they were all conducted at relatively modest levels. It was
only with the agreement reached in 1967 and signed in 1968 (hat substantial sums of
money began to flow into the Ethiopian Malaria Eradication (and later control) Service
(Table 1). All funding had been on a grant basis between 1952 and 1966, but from 1967
onward 94 percent had become Ioans and only 6 percent remained grants.
Overall, donor assistance for the support of terminal eradication schemes is always
easier to find than funding for general health services, which are primarily dependent
upon recurrent budgets. Most donors prefer to avoid becoming perpetually responsible
tor recurrent expenditures having no clear termination date. Just as a health facility
construction project is easier to fund than its later running costs, eradication campaigns
received funding partly because they promised only a short-term commitment, with a
logical end to donor support in sight. In addition, donors favored eradication schemes
because funds could be more easily monitored and results more effectively measured
when compared with inputs lo recurrent health budgets. Although these were not the
basic reasons for the international malaria effort, they were contributing factors and
played a role in the loss of international funding-support when governments began
integrating malaria control programs with the general health services.
The Campaign’
Two basic arguments had been put forward initially in support of the Ethiopian
malaria eradication campaign. One was that the eradication of malaria would assist the
“!’C„T,S.U£ °f nc7,lands for development; the other, and more significant one was that
an early major effort would interrupt transmission of the malaria parasite and lead
eventually lo its total disappearance. The strategy seemed quite simple; certain pcsticidcs killed the mosquito vector, therefore the primary requirement was lo
I fumigate
sufficiently (and properly) so as to break the chain of transmission. But in April 1976,
after many years of pilot studies and almost a decade of intensive attempts at eradicahon, n appeared to the EMRO/WHO Regional Malaria Advisor and the Regional
Entomologist “that the antimalarial programme has not brought about a definite
.nto\he
XedhLe
°n: - n™'™
’
"
Rega'd W 'he
r"P,>ns‘bih,y for lh'
Malaria Con.rol
i"
'he maurial has Bern
187
Tabic 1
Ethiopian Malaria Eradication and/or Control Program.
U.S. dollar grant and loan assistance, in millions of U.S. dollarsd
Grant
(joan
Total
F.Y. 1952-66
F.Y. 1967-75
Total
3.4(100%)
0.0 (0%)
3.4(100%)
1.5(6%)
24.2 (94%)
25.7(100%)
4.9(17%)
24.2 (83%)
29.1 (100%)
‘’Source: Internal documents of the Ministry of Health, Ethiopia.
improvement in the pre-opcralional epidemiological situation” (7). In addition, although
the data were subject to a number of reservations, the WHO Regional Advisors
were able to state with certainly: “the fact remains that transmission has never been
interrupted.”
With regard to the other major claim for the special malaria effort, namely that it was
necessary for the opening up of new lands, the same report concludes that “with due
reservations, it is possible to observe . . . that little progress, if any, has been registered
in the sectors under study during the period of observation despite regular spraying with
DDT. The situation appears to have remained stationary in ail the sectors from 19691973” (7). With regard to the Awash Valley, the country’s most significant new
development area, for the period at least from Oclobcr/Dcccmber 1974 to October/
December 1975, “the situation has worsened; with the difference between percentages
being highly significant, the parasite rale increased from 3.4% to 9.0% during that
period” (7).
Il appears to be beyond question that the malaria eradication effort in Ethiopia had
been misdirected. The basic justifications for the campaign had not been fulfilled;
interruption of transmission had not been accomplished, and there is little evidence that
the campaign had successfully facilitated the opening of new lands. In any event, a
separate national service was not required to lower the incidence of malaria sufficiently
in any particular area so as to permit it to be settled and exploited. In fact, more
concentrated activities in selected areas might even have been hindered as a result of the
more generalized malaria efforts.
Three new and quite different arguments were then put forward in the EMRO/WHO
report to justify the continuance of a separate malaria organization in Ethiopia. It was
claimed that: (a) the periodic epidemics of malaria that formerly appeared in Ethiopia
apparently had been controlled by the measures taken and there had been a significant
decrease in the number of reported cases; (b) a well-organized service able to extend its
scope within the existing health system had been created; and (c) the campaign had
made the population aware of the malaria problem (7).
A closer look al each of these assertions is revealing. The third claim (c) docs not
require any special discussion except to note that reports and other documents con
cerned with malaria in Ethiopia have consistently stressed that a primary reason for
highland populations’ resistance to occupying lower-lying lands was their knowledge
and fear of malaria. If this was indeed the case, it would seem to be at the very least
188 / Gish
Malaria Eradication Programs / 189
I"d
["°w“ “
Although it may be true (see below) that the periodic epidemics of malaria that
s m ther^T 'r r T”"
COn,rO"Cd *’3 resu“
eradication Xrom
in the first claim (a) above, it also should be noted that it was not neccssarv
an elaborate eradication campaign to achieve such a result. Effective con7rol efforts
designed to lower the level of the disease to some acceptabie level, wouid ha^umced
As argued earlier, an eradteation campaign presupposes a massive initial effort iustified
on the basts of a particular disease be,ng done away with once and fo aH rime as
appears to be the ca.sc wtth smallpox. Although this was the original basis for the malaria
»ssx“
made worse as a result of crop failures and resulting food shortages Te nrimarv
KS-
s*
rctZl * r111^ COndll‘OnS lh!“ wcrc resPonsiblc for the 1958 epidemic have ever been
oMhe md 'n lh0SC aTS; 'hUS’ ‘hCrC 'S n° cvidcnce as ,0 whether or not the operations
f the malaria service have had any effect upon the so-called periodic epidemics. In any
• as suggested earlier, it would have been possible to control periodic tlarc uos in
o'^r -d
less expense ways than through ihc continuous Ind cos
u p d
autonomous national malaria service.
y ' PP°rl ° an
It was also argued that even if special malaria operations had not interrupted the
trans,mss,on of the disease and perhaps not even prevented furthl Z U c
ep,dem.es of the 1958 type, at the very least they had reduced the incidence oZl
d seasc. In practice, it >s impossible to know whether this is the case as there were no
d ZT'Sn I?" I d:“a l0r malaria-rcla,eJ morbidity and mortality, nor were such
data developed later. In any event, over the years the methods for as css ng ma arh
operations and their results had been changed a number of times so Th mb
impossible to obtain any statistically valid comparisons over time Targets set iTtemtl
of reduced parasite rates had never been cxnrr^rd in
r iargcls set in terms
1"
and
I,",'." .«
.ernzr.
:: ■ i”“ p”“
p~».'
s of malana cases and deaths, or the operational costs of the program
"
theZcond cZI
I"
malaria SCrViCC had indCCd bCCn Crcatcd in Ellli0Pia
that up to $100 million had been spent for malaria eradication/control in the decade
preceding 1977/78, and approximately $50 million more over the succeeding five-year
period. In comparison, expenditures during the pre-1977/78 decade for all modem
health care averaged around $25 to 30 million per annum (less than $1 per capita). If the
initial intention had been to create a well-organized malaria service able to extend its
scope within the existing health structure, which is now claimed ex-post for the malaria
service, a far cheaper and more efficient method could have been devised. The relatively
large volume of resources and attention allotted to the malaria program has contributed
significantly to the difficulties surrounding the balanced development of the country’s
health services.
The first formal malaria review conducted in Ethiopia (May 1970) raised serious
doubts about the possibility of successfully eradicating malaria in even relatively limited
parts of the country; nonetheless, the recommended strategy was essentially more of the
same; continued eradication efforts. The recommendation was based at least partly on
the perceived weakness of the basic health services, compared with the malaria service.
In this respect, it is worth noting that the Malaria Eradication Service was then (1970)
spending about $5.8 million annually, while the whole of the rural health service
(nonhospital) received an allocation of only $2 million. At least part of the relative
weakness of the basic health services can be explained by this pattern of resource
allocation, although it is also the case that the external funds available to the Malaria
Eradication/Conlrol Service might not have been available for other health-related
activities.
The commitment of this first review team to the ongoing malaria strategy can be seen
from the following recommendation contained in their report: “It is not recommended
that Ethiopia embark on a Smallpox Eradication Program at the present time, but
intensive control measures should receive moderately high priority.” In the light of later
experience, i.e., the eradication of smallpox, this recommendation can only be con
sidered as an attempt to prevent health sector resources from being diverted away from
malaria. The composition of the review team—only those firmly committed to the
malaria effort—helps to explain the reluctance of the Ethiopian government to accept as
part of the 1977 review team similar members of the malaria establishment.
In 1972 a second malaria review team agreed with the 1970 group, in that “eradication
of malaria from Ethiopia is not feasible under present circumstances even in the
foreseeable future.” The team recommended some limited unification of the Malaria
Eradication Service (MES) with the basic health services in the delivery of multipurpose
health services to the population “so long as the primary responsibility of the MES
toward malaria is ensured by its strength.” Between 1972 and the malaria review of
1977, some attempts at joint multipurpose activities between the MES and the basic
health services were pursued, but the fundamental obstacle to integration remained—the
existence of two organizations with separate budgets, staffs, and administrations.
The review team of 1977 clearly expressed the view that the MES, by then the Malaria
Control Service (MCS), was initially created for purposes that had proven illusory and
that, as such, it had no legitimate reason for a continued independent existence. It was
also agreed that further discussions of integrated health activities and services would
likely prove to b" as fruitless as their predecessors in the absence of complete budgetary,
staff, and adm
rative (but not necessarily technical) merger of the MCS with the
190 / Gish
general services of the Ministry of Health. In any event, by 1977 it was clear that the
overall policy direction of the Ministry of Health was to integrate all specialized
programs into the general health services. Given the ministry’s responsibility for
organizing the whole of the national health effort, the financial, staff, and administrative
integration of the MCS (and other such special bodies) with all levels of the ministry’s
services was perceived to have become a necessary step.
Although the MES had already changed its title and stated goal to that of a Malaria
Control Service, in practice its overall use of resources, operational methodology, and
means ofcvaluation had changed hardly at all. To some considerable degree this general
critique can be extended to malaria programs around the world. However, if nothing
else, changed funding patterns have been forcing reexamination of past approaches to
malaria control in the more fundamental ways than are implied by mere changes
of name. One important part of this ongoing reexamination concerns overall funding
levels for malaria activities. Without in any way underestimating the obvious need for
resources, it should be noted that the very way in which malaria hierarchies had been
established tended to increase costs. The creation of autonomous malaria organizations,
usually in the interest ot more efficient management, has added considerably to the cost
of malaria control. In most countries the bulk of funding for malaria work had always
been drawn from national sources, primarily for the wages of personnel. Although
sometimes such salaries were initially externally financed, often as a way of encourag
ing countries to enter into malaria eradication campaigns, they increasingly came to be
bom almost entirely by national budgets. External funds were utilized for the foreign
exchange component of the programs, particularly pesticides and vehicles. Currently,
little of even this type of support is available. /As a result, new forms of national and
community malaria control activities have become important, forms in which, among
other things, it is not necessary to employ on a salaried basis great numbers of
fumigalors and related administrative and bureaucratic staff. Instead, specialized
malaria personnel arc intended to assist communities to “do for themselves”_ with the
full support of the health services—most of that which needs to be done for the control
of malaria (as well as other similar vector-borne diseases).
CONCLUSION: NEW DIRECTIONS IN MALARIA CONTROL
The very techniques that supposedly required virtual armies of salaried employees arc
now being played down in the antimalaria effort. Residual spraying, with its large costs
in pesticides and personnel, is being recommended only in selected areas. Mass
chemoprophylaxis is being blamed for the widespread resistance of the malaria parasite
to chloroquine, and as a result prophylaxis is being recommended only for selected
groups such as pregnant women and migrant workers. At the same time, personal
protection and disease management are being increasingly emphasized (9, p. 553).
Interestingly, these approaches are those most compatible with a PHC structure; they are
measures that can be implemented within communities by local people having only a
minimum of training and some ongoing support. Sloof (9, p. 551), in analyzing global
trends such as increasing urbanization, concludes that the increasing migration of pests
and nonimmunc people coupled with the growth of huge urban slums where breeding
sites abound will require more attention to larvicidal techniques and source reduction.
Malaria Eradication Programs / 191
while residual spraying, less acceptable in urban settings, will decline in importance.
Again, these measures can be implemented by communities led by PHC workers with
modest training, and certainly do not require the existence of independent malaria
control services.
The trained personnel of the malaria control services will have an important, if not
enhanced technical role to play in the new strategy. There is a demand for more
participation by third world experts in the research that is needed to develop new
pesticides and biologicals (5, p. 107; 10, p. 78). The search for an effective vaccine is
continuing. Trainers are needed to instruct PHC workers in malaria control. Residual
spraying teams will have a continuing role to play in responding to epidemics. However,
the highly structured and segregated role of the traditional malaria control services will
have to yield to one of supporting PHC structures. Such changes should strengthen the
capacities of the basic PHC services as a result of the additional financial, personnel, and
managerial resources they would gain. Increased efficiency in both the technical and
economic sense can be expected from the integrated utilization of staff, vehicles, and
other resources. The health services would be in a stronger position to support expanded
preventive and curative primary care coverage as well as gaining an enhanced capacity
for more effective sanitary and vector-control activities. However, part of the old
malarial establishment does not agree: Cowper (11, p. 490), in describing the future role
of USAID in world malaria control, still views malaria control programs as separate
unto themselves, supporting their own unique personnel, and making “maximum use of
existing . . . PHC systems,” but seeing the establishment of (hose systems as secondary
to, not necessary for, the success of a malaria control initiative.
In Ethiopia, the Ministry of Health had taken a number of the preliminary steps
necessary for the integration of the malaria service with the general health services. The
most important of those included: greater decentralization of services; a significant
increase in the number of trained health workers; improved capacities within the
Ministry of Health in planning, management, administration, budgeting, and account
ing; and the formulation of a ten-year indicative plan. However, the most important
long-term factor supporting the potential integration of malaria control into a viable
PHC system in Ethiopia has been the reality of the Ethiopian revolution of 1^74 in
which political power was taken out of the hands of a small feudal minority. As part of
this process, Ethiopians were involved for the first time in a dynamic political process
that initially organized virtually the whole of the population in peasant, urban, and other
civilian and military organizations. This organization of the Ethiopian population
allowed a number of new forms of health activity to be undertaken, including the
training and deployment of thousands of community health workers. Of course, the
county’s continuing political and military struggles, not to speak of the horrors of mass
starvation, arc currently making any progress in Ethiopia impossible in this or almost
any other area.
Of particular importance to the control of malaria and other similar vector-borne
diseases will be the implementation in Ethiopia and other low-income countries of a
mass approach to the control of specific disease vectors, including mobilization of the
population for such activities as the clearing and spraying of malarious areas. Without
the active participation of the mass of the Ethiopian people—no matter under whose
leadership, provided it has the genuine support of the population—it will not be possible
192 / Gish
to move 1forward in any foreseeable future toward the control and ultimate elimination
of malaria and the other communicable diseases
that continue to cause such massive
suffering among the people of the country.
CONTRIBUTORS
REFERENCES
'■ F»ridgrM Aal,arriadiM^er far£“'ern£c^^
1978 on 25-28
3’
4.
General. Thiny-lhird World Health Assembly
ReP°r'
:he DirectorGeneva, April 17, 1989.
y’ rov,s,onaI Agenda Item 29, A 33/13.
"
il'io3 Ia987d COn,r°l: PteSenl SilUali°" and
prospects.rtm, Rev.
6.
9.
10.
Direct reprint requests to:
Oscar Gish
Health Services, SC-37
University of Washington
Seattle, WA 98195
FREDRIK ANDERSSON is a research scientist at the Battellc MEDTAP (Medical
Technology Assessment and Policy) Research Centre in London. He received his
doctorate in health economics in the Department of Theme Research—Health and
Society at Linkoping University, Sweden, in 1990, where he still holds a position as
assistant professor. He is the author of The International Diffusion of New Chemical
Entities—A Cross-National Study of the Determinants of Differences in Drug Lag, and
coauthor with Bengt Jonsson of Ldkemedelsfdrmdnen (The Reimbursement of Pharma
ceuticals in Sweden). Dr. Andersson’s research interests include the assessment and
diffusion of new medical technologies, as well as pharmaceutical economics.
DEBABAR BANERJI is a professor at the Centre of Social Medicine and Com
munity Health, Jawaharlal Nehru University, New Delhi. After he graduated from the
Medical College, Calcutta, in 1953, his concern about the relevance of the Western
model of medical education and practice to India led him to work as a physician in
western Tibet and in the interior Himalayan tribal regions, in order to relate the practice
of Western medicine to the conditions in these regions. He has continued this line of
work at the National Tuberculosis Institute, Bangalore (1959-1964), at the National
Institute of Health Administration and Education, New Delhi (1964-1971), and in his
present position. Dr. Banerji’s publications cover a number of facets of the relationships
between health technology and people, and the formulation of people-oriented health
technologies and programs for India. A study of this relationship in 19 villages in
different parts of India for a period of 16 years (1972-1988) has been one of his major
research contributions, and is reported in part in Poverty, Class and Health Culture in
India (1982). Dr. Banerji is also the author of Family Planning in India: A Critique and
a Perspective (1971), and more recently Health and Family Planning Services in India:
An Epidemiological, Socio-cultural and Political Analysis and a Perspective (1985);
The Making of Health Services of a Country: Postulates and a Theory (1985); and
Social Sciences and Health Service Development in India: Sociology of Formation of an
Alternative Paradigm (1986).
GIOVANNI BERLINGUER is a professor of occupational health at the University of
Rome. After receiving his M.D. he became an assistant professor in hygiene and in
parasitology. He has been a member of the Italian Parliament since 1972; he was elected
to the Camera del deputati, then in 1983 was elected to the Senate, and was reelected to
the Senate in 1987. As a member of parliament, Dr. Berlinguer presented the law on
International Journal of Health Services, Volume 22, Number 1, Pages 193-196, 1992
C 1992, Baywood Publishing Co., Inc.
193
M
©
E>
■
I£
A
mwBMhWmb
tsO-a
SEA/RC52/R5
ROLL BACK MALARIA
The Regional Committee,
'Recalling World Health Assembly resolution WHA52.11 relating to Roll Back Malaria,
• Considering that malaria causes high morbidity and loss of productivity, particularly
among the poor and vulnerable groups, such as pregnant women, children and migrant
populations.
Recognizing the urgent need to accord high priority to malaria control,
Realizing the significant contribution of malaria to the burden of disease in the Region
and its adverse economic consequences for the poor, and
Noting that Roll Back Malaria represents a new approach to improving equity in health,
1.
2.
URGES.Member States:
(a)
to demonstrate national commitment towards the RBM initiative;
(b)
to promote and support the RBM initiative by integrating malaria control-activities
with the prevention and control programmes of other communicable diseases
within existing PHC settings and district health systems;
(c)
to mobilize resources for sustaining evidence-based strategies to ensure
concerted arid sustainable efforts for RBM;
(d)
to collaborate with neighbouring countries regarding activities related to, among
others, the monitoring of multi-drug resistance, vector resistance to insecticides,
and enhancing epidemic preparedness and response, and
(e)
to promote multiple preventive measures to reduce malaria transmission by locally
acceptable means and to ensure rational use of insecticides both in public health
and in agriculture and strengthen policy frameworks and guidelines to meet the
emerging requirements, and
REQUESTS the Regional Director:
(a)
to enhance the capacity of the programme for securing and mobilizing community
participation, intersectoral collaboration and cooperation to roll back malaria;
(b)
to develop the technical capacity of the public health delivery system, including
that of the private sector in the Member States, for prevention of malaria, early
diagnosis and prompt treatment, and
(c)
to identify the available resources in the Member States and extend the required
technical and financial support to help develop a network of experts and research
institutions to substantially improve the quality of the programme.
Sixth Meeting. 8 September 1999
School Health Education on malaria in Goa
. With an aim to make students in schools of Goa malaria literate; a systematic education
programme was devised and initiated in Goa in 1992 by Malaria Research Centre, Goa in
collaboration with Indian Red Cross Society, Goa. This programme was implemented in
phases starting 1992 when 81 schools were enrolled targeting 16211 students from 8th
to 10th Std. In 1994 this programme was extended to Higher Secondary classes up to
12th Std. and by 1998, 227 schools participated in the programme targeting 53462
students throughout Goa.
The aims and objectives of the programme were as under.
1. To introduce teaching on malaria in the entire state of Goa in school education
through Junior Red Cross (JRC) and Youth Red Cross (YRC) components in
Secondary and Higher Secondary Classes.
2. To train JRC and YRC counselors (Teachers) to impart malaria education to the
students.
r
3. To prepare curriculum on malaria and seek its ratification from Goa Board of
Secondary and Higher Secondary Education.
4. To reach community through these students and teachers so as to train and involve
people in the vector and disease control process.
5. To undertake field projects on malaria with the help of Red Cross counsellors and
volunteers (students) wherein the local community is exposed to the problem and its
remedial measures.
6. To prepare a cohesive force over a period of time in the community who would
practice the mosquito/vector control in their day to day life and also continue to
disseminate the self action idea to others in future.
Training of Red Cross Counselors: Thirteen State Level workshops have so far been
organised by the MRC and Red Cross for imparting Orientation training to 808 teachers
with the understanding that organisational and technical responsibility will be shared by
the red cross and MRC Goa Field Station respectively.
The technical aspects of training included lectures, preparing course material, hand outs,
audio visual aids, and films and exhibitions on malaria. 61 exhibitions were organised for
24133 students in 232 schools.
The exhibitions on malaria included:
1. Immature and adults of Anopheles, Culex and Aedes mosquitoes explaining the life
cycle and their distinguishing features.
2. Models of domestic and peridomestic breeding habitats. These focussed upon man's
negligence and indifference which may support the growth of mosquito populations.
3. The control aspects demonstrated, consisted of:
i)
Larvivorous fish such as Aplocheilus blockii, Rasbora daniconius, Gambusia
affinis and Poecilia reticulata devouring mosquito larvae and pupae.
1
ii)
iii)
iv)
V)
vi)
vii)
viii)
ix)
Bacillus thuringiensis and Bacillus sphaericus samples.
Expanded polystyrene be^ds (EPS) forming a top layer on the water in the
model of an unused well.
Models of air-tight overhead tanks and sumps, highlighting the mosquito
proof arrangements such as the lid assembly and the sieved overflow pipe
opening.
Models showing efficient drainage of water from terraces and water channels
to avoid stagnations responsible for mosquito breeding.
Personal protection methods such as mosquito nets and window screens.
In addition, blood slides with P. vivax and P. falciparum parasites were shown
under the compound microscope. Charts showing the life-cycle of a malaria
parasite, the need for early detection and treatment of malaria cases and the
importance of species-specific treatment of malaria were also displayed.
A set of panels highlighting variousjaspects of malaria in the urban and rural
settings were also exhibited.
Handbills containing tips on self-action for the prevention and control of
malaria were distributed.
Following syllabus was approved on malaria in Goa.
Standard VIII
Malaria Control:
30 marks
1 Life cycle of a mosquito
2. Breeding sites of mosquitoes
3. Symptoms of malaria.
4. Causes of malaria.
Standard IX
Malaria Control:
30 marks
1. Differentiation between a malaria and filaria mosquitoes.
2. Life cycle of malaria parasites.
3. Transmission of malaria parasites.
4. Bio-environmental control of malaria.
Standard X
Malaria Control:
50 marks
1. Bio-control of malaria.
2. Environmental management and source reduction in malaria control.
3. Treatment of malaria.
Projects and assignments:
Standard VIII: 20 marks
Standard IX: 20 marks
Standard XI 50 Marks
1. Causes of malaria
2.
Breeding sites of mosquitoes
3.
Life cycle of malaria paraites
4.
Symptoms and diagnosis of malaria
5.
Bio—environmental control of mosquitoes
6.
Treatment of malaria
7.
Projects and field survey
Standard XII 50 Marks
2
1.
2.
Community based malaria control programme
Engineering mathods of malaria control
Table: Progressive increase in schools and students under JRC and YRC
programmes in Goa from 1992 to 1998
YEAR
1992- 93
1993- 94
1994- 95
1995- 96
1996- 97
1997- 98
JRC
SCHOOLS
81
98
108
116
141
189
STUDENT
S_____
16211
19353
21018
28712
39395
41235
YRC
SCHOOLS
NIL
NIL
5
25
35
38
STUDENT
S_____
NIL
NIL
1115
7219
11532
12227
TOTAL
SCHOOLS
81
98
113
141
176
227
STUDENT
S_____
16211
19353
22133
35931
50937
53462
Reference Text for the Training of Teachers
A book entitled 'Elementary Malariology' has been published by the Goa Board of
Secondary and Higher Secondary Board authored by Dr. Ashwani Kumar
3
3)16-9-
Epidemic Diseases : ’Whose baby is it' ?
Sunil Nandraj
January, 1998
In the recent past there has been a resurgence of various epidemic diseases such as Malaria, Gastro-entitis,
Tuberculosis, Kala Azar, Filarisis, Goiter among others in different parts of the country. The morbidity and
mortality is increasing at a rapid pace with new areas being declared endemic. The resurgence is due to
various factors chief among them being environmental factors, lack of basic health services, poor
nutritional status of the people, lack of basic necessities, inadequate supply of drugs among others. The
government on its part is shirking its responsibilities of providing adequate funds for public health care
programs from its own resources and instead approaching bilateral and multilateral agencies for loans. The
most recent being a loan of Rs. 8910 million from the World Bank to combat malaria. This loan is to cover
the 100 most affected malaria districts in the states of Andhra Pradesh, Gujrat, aharashtra, Bihar,
Rajasthan, Orissa, & Madhya Pradesh where it is most rampant. The loan is to be utilised in training
technicians at the district level in the early detection of the malaria who will be known as link workers and
providing basic equipment such as microscopes for malaria detection in the public health care delivery
system.
The main focus of the policy makers, planners, administrators, politicians, media, international agencies,
voluntary agencies and others in the control of epidemic diseases has been on the public health care
system. The role of the private health sector has never been critically examined and the government has
not made sufficient efforts to involve them in control of the diseases affecting majority of the population.
Recent studies conducted have brought out that the private health sector is the dominant sector in health
and is utilised by nearly 60% to 70% of the people for their illness. These providers are mainly in the form
of practitioners practicing various systems of medicine, local healers, hospitals & nursing homes,
laboratories, medical colleges, corporate hospitals, blood banks among a host of other providers.
The government has not been able to involve the private health services in combating the various diseases
which should have been done on a priority as they are the major providers of care. It is quite shocking to
note that the official figures provided by the government regarding the number of cases treated and deaths
due to various diseases are available only from the public health care services. Furthermore the
government right from the central government to the municipal / panchayat level do not have reliable &
sufficient information in terms of their numbers practicing, functioning, type of care provided, number of
cases treated, nature of practice, standards maintained to mention a few indicators. There is inadequate
information from the private health services. This is basically due to the fact that the private health services
in our country function in a most unregulated and unaccountable manner. Even 50 years after
independence there are no legislation’s, rules, acts etc. for monitoring private hospitals & nursing homes in
India, except in the states of Maharashtra & Delhi. Where attempts are being made especially in the states
of Tamil Nadu and Bihar to enact legislation there is opposition from the medical fraternity. In the states
where there is legislation the implementation is found to wanting forcing consumer organisations to
approach the judiciary for proper implementation. The same problem is with regard to the diagnostic
laboratories, health clinics, nature cures, slimming centres, etc. etc. They do not come under any authority
and operate freely without any accountability. Qualified practitioners practicing different systems of
medicine are supposed to register themselves with their respective state medical councils, but the state of
affairs in most of the medical council is utterly diseased , with registers not updated, elections not held,
action against erring doctors being not taken, recognising sub-standard private medical colleges among a
host of other problems. The problem with quacks practicing is more alanning with the concerned
government departments such as police & health passing the buck to each other. The above clearly shows
that the government does not have sufficient information on the private health services operating in the
country and has not paid enough attention to monitoring them. Many developed economies which have a
large private health sector such as USA have strong regulatory mechanism for the functioning of the health
care services. In the absence of any such strong stringent regulations it has been totally left to the whims
and fancies of the providers.
Due to its unregulated nature it has led to various kinds of unethical and irrational practices being carried
out especially in times and areas of epidemics. Profiting from human misery especially when large sections
of population are affected due to disease it becomes a healthy business for the private providers. There are
no restrictions or guidelines for the fees charged by private providers. The charging practices are more
often exorbitant and irrational and without any basis. The treatment provided is based mainly on economic
factors than medical reasons. Some of the irrational & ethical practices quite well known and many of the
patients have faced are diagnosis not done properly, patients made to come back for more consultations,
over prescribing, over investigations, unnecessary surgeries, making patients stay for longer period than
necessary, administering saline drips routinely, pushing critical patients in the last stages to public
hospitals among a whole lot of other practices. Many families have been pauperized due to the high cost in
private health sector.
The private health care providers have never shared responsibility of involving themselves in the task of
combatting various diseases afflicting the people other than for their own financial goals. More important,
has the government envisaged a role and involvement of the private health sector in its diseases control
program. The policies and programs formulated become applicable to the public health services without
viewing health sector in its totality. Presently the government has resorted to taking loans for tinkering in
the public health care services by retraining' a few workers, buying more jeeps, holding international
seminars etc. The government should give up its ostrich like attitude and involve the private health care
sector by making it more accountable and monitoring its functioning and activities.
Firstly the government should carry out a census of the all private health providers operating in an
epidemic area. It is not difficult for the government to make private ractitioners/hospitals/nursing
homes/laboratories register with the local authority and insist on receiving periodic reports of diseases such
as Malaria, TB, AIDS etc. All notifiable diseases should be reported to the local authority on a periodic
basis. A random medical audit of the prescription prescribed by the doctors at the chemists shop would go
a long way in making the private providers recommending the correct line of treatment. There is an
compelling need to educate and create awareness among private health care providers (includes qualified
doctors) on providing the correct line of treatment for various diseases. Periodic medical audit of treatment
provided for inpatient care and investigations reports from the laboratories should be insisted upon. A
platform should be provided for regular meetings and exchanges between the private health sector and
public providers. There is a urgent need to draw up standards for clinics, hospitals, nursing homes,
diagnostic laboratories in terms of qualification of human power, equipment used, infrastructure facilities,
sanitary conditions among others. It is possible for the local authority to give recognition based on
standards being met, records received, medical audit reports to give a certificate which should be
prominently displayed and create awareness among people regarding the same.
Those not following the directives punitive action should be taken as health is a issue that deals with life
and death. This measures would make the private health sector more involved in diseases control program
and make it more accountable. Until the basic issue of involving the private health sector in combating the
various epidemic diseases are addressed any amount of money pumped either as aid or loan from bilateral
or multi lateral international agencies will not solve the problem. In the overall context there is an urgent
need to have a comprehensive health care which involves close inter-linkages between the public and
private health sectors that provides care to people which is accessible to the majority, of reasonable quality
and affordable.
Sunil Nandraj is a Sr. Research Officer at CEHAT, a non-profit research organisation in Mumbai.
Sunil Nandraj & Usha Sunil
Flat No 3:1, Bldg B-5
Alaknanda Co-op Housing Society
Sector 19A, Nerul
New Bombay 400706
India
Email:snandraj@hotmail.com
Phone (res) 91-022-7702399
Press Release
United Nations Development Programme • United Nations Children’s Fund • World Bank • World Health Organization
EMBARGO:
i’
1000 a.m., New York
time, Friday, 30 Oct
1998
Press Release WHO/77
30 October 1998
6
FOUR INTERNATIONAL ORGANIZATIONS UNITE TO ROLL
BACK MALARIA
The United Nations Children’s Fund (UNICEF), the United Nations Development
Programme (UNDP), the World Bank and the World Health Organization (WHO) have
joined forces to launch a new campaign to fight malaria, which kills more than one million
people a year.
The programme, “Roll Back Malaria”, seeks to reduce substantially the human
suffering and economic losses due one of to the worlds most costly diseases. Malaria
causes an estimated 300 to 500 million acute cases per year, with most deaths occurring
among children in Africa - nearly 3,000 die each day. It has been estimated that malaria
accounts for about 10% of the disease burden in Africa.
“Malaria is the number one health priority of people and leaders in affected
communities and countries, but their voices have not been heard,” says Dr Gro Harlem
Brundtland, WHO Director General. Roll Back Malaria was initiated when Dr Brundtland
was elected WHO Director-General in May. 'The human suffering is unacceptable and so
is the economic burden and impediment to progress. Africa and other regions with malaria
are responding and we must answer their call," she says.
Roll Back Malaria (RBM) is different from previous efforts to fight malaria. RBM will
work not only through new tools for controlling malaria but also by strengthening the health
services to affected populations. RBM will implement its activities through partnerships
with international organizations, governments in endemic and non-endemic countries,
academic institutions, the private sector and nongovernmental organizations. Above all, it
will be a united effort by the four international agencies concerned with malaria and its
effects on health and economic development.
Malaria is, above all, a disease of the young and of the poor, many of them children
who live in remote areas with no easy access to health services. But the use of simple
prevention and control methods has shown startling results: in trials conducted in The
Gambia, Burkina Faso, Kenya and Ghana, the use of bednets - which are treated with
biodegradable pyrethyroid insecticide was shown to effectively protect sleeping children
from malarial mosquitoes, resulting in dramatic reductions in deaths among children under
five years of age. Deaths were reduced by average of one fourth in these mega trials.
Press Release WHO/77
Page 2
Roll Back Malaria will seek to:
•
•
•
•
•
strengthen health systems to ensure better delivery of health care, especially at district
and community levels;
ensure the proper and expanded use of insecticide-treated mosquito nets;
ensure adequate access to basic healthcare and training of healthcare workers;
encourage the development of simpler and more effective means of administering
medicines; such as training of village health workers, mothers and drug peddlers on
early and appropriate treatment of malaria, especially for children;
encourage the development of more effective and new anti-malaria drugs and
vaccines.
"While strengthening the health sector is essential to Roll Back Malaria," says
UNICEF Executive Director Carol Bellamy, "the new strategy will be most effective when
families, communities, local leaders and other groups, such as shopkeepers and
schoolteachers, become fully committed and involved in the effort. In all of the countries
seriously affected by malaria, communities have already demonstrated that rapid
improvements in child health are possible when they are given the right kind of support
and encouragement. We are confident that this new initiative will be able to provide this."
Unlike most other major diseases in the world, malaria is spreading. As roads are
built, forests cut down, new mining areas opened up, habitats which favour the breeding of
mosquitoes expand, and what starts out as economic development often unintentionally
leads to an underperforming and sick workforce.
“The poor suffer the most from malaria,” says James Gustave Speth, Administrator
of the UNDP. “The international community must firmly commit itself to this new
partnership and to developing integrated actions that take aim at both malaria and at its
greatest breeding ground which is poverty. UNDP looks forward to working with its UN
and other partners in this worldwide campaign against malaria.”
"Making significant, sustained inroads in the battle against malaria urgently requires
a coordinated, focused initiative. Governments, international organizations, the research
community and the pharmaceutical industry must all play a major role. The World Bank is
committed to playing its part in the mobilization of resources needed to spur such a
coordinated response," says James D Wolfensohn, President of the World Bank Group.
For further information, journalists can contact Gregory Hartl, Health Communications and Public Relations,
WHO, Geneva. Telephone (41 22) 791 4458. Fax (41 22) 791 4858. Email: hartlg@who.ch .
All WHO Press Releases, Fact Sheets and Features as well as other information on this subject can
be obtained on Internet on the WHO home page http://www.who.ch/
I
I
Press Release WHO/77
Page 3
Malaria and economic development
Roll Back Malaria is being launched at a time of growing scientific interest and
investment in malaria, which still remains grossly underfunded.
"We and other groups of economist researchers are trying to determine the
consequences of malaria on economic development," says Jeffrey Sachs, Professor at
Harvard. "Our findings are striking. They point to Malaria as a major impediment to
economic development."
Poor health via disability from diseases such as malaria reduces incomes by as
much as 12 percent in some studies, a particularly important factor in developing countries
where a significant proportion of the workforce is involved in agriculture and other forms of
manual labour.
The evidence also suggests that the effects of improved health are likely greatest
for the most vulnerable - the poorest and those with the least amount of education.
New tools
Bednets: Large-scale field trials have conclusively demonstrated that the use of
bednets treated with biodegradable pyrethroid insecticide can protect children from dying
from malaria. Do-it-yourself approaches to insecticide treatment of nets are now available.
Mapping: Based on satellite mapping and climatic information, the distribution of
malaria can now be determined at the community level.
For countries participating in RBM, national malaria information will be integrated
with regional information to produce a comprehensive national malaria control map, as
part of the international mapping of the disease.
The information will allow a better estimation of the burden of malaria and the
population at risk, and hence a better assessment for RBM. It will also provide more
reliable and area-specific information for national and international advocacy for malaria
control. Where RBM operations have started, information on the availability and quality of
health services and the results of monitoring and evaluation will be added to the data
base.
Bringing treatments to the people: In Africa, the RBM will create a network of teams
to go into villages and analyze treatment and prevention practices at the household and
community level, the availability and quality of health care by the public and private sector,
and potential local partners. The RBM will provide technical and financial support for each
analysis through this network at the district level.
Treatment at home can be greatly facilitated by simple packaging of drugs; fast
acting rectal caps can rescue life-threatening disease in children.
Most victims of malaria die simply because they do not have access to health care,
or their cases are not diagnosed as malaria. In addition, life saving drugs are often not
available.
Press Release WHO/77
Page 4
"These tools will greatly help in bringing the attack where it matters, says Dr. David
Nabarro, newly appointed leader of the central team for Roll Back Malaria, headquartered
at WHO in Geneva.
Research breakthroughs
Researchers are investigating a wide range of activities in malaria are severely
underfunded, but investment is increasing thanks to a new Multilateral Initiative for Malaria
research (MIM). The new techniques being investigated include ways of preventing the
mosquito parasite from infecting the mosquito.
“A number of scientists are trying to make the mosquito resistant to the parasite,"
says Fotis Kafatos, Director-General of the European Molecular Biology Laboratories in
Heidelberg, Germany. "Using the most sophisticated techniques in molecular genetics we
are discovering an array of novel possibilities."
Several vaccine candidates using the latest breakthroughs in vaccine technology
are undergoing field testing in Asia and Africa and in US volunteers, while the whole
genome (a complete set of hereditary factors) of the malaria parasite is being sequenced.
"This will create completely new opportunities," says Dr. Harold Varmus, Director of
United States National Institutes of Health (NIH), which is one of the leading drivers in the
MIM. "Malaria is a global concern. We are gearing up our support for research both here
and abroad.”
New discoveries have led to many different approaches to a malaria vaccine, with
many of the possibilities already undergoing human trials. However, scientists estimate
that it will take 7-15 years before an effective malaria vaccine is ready.
Vaccines taking advantage of DNA research may provide one of the best hopes.
One possibility is being developed by the US. Naval Medical Research Institute, the US
Agency for International Development and partners in Ghana, Australia, France and the
US private sector.
“Our work in relationship to WHO objectives is focused on producing multi-gene
DNA vaccines designed to reduce morbidity and mortality of malaria in young children in
sub-Saharan Africa," says Dr. Stephen Hoffman, of the Naval Medical Research Institute.
The major project is entitled MuStDO 15.1 (multi-Stage DNA vaccine operation), which is a
15-gene malaria DNA vaccine.
Researchers hope to initiate clinical trials of this new vaccine within 18 months. Dr.
Hoffman has just published the first proof of the principle that DNA vaccines are
immunogenic in normal, healthy humans.
Another promising vaccine candidate has just begun field trials in the African nation
of the Gambia. This new recombinant protein vaccine, RTS,S, developed by SmithKline
Biologicals, would prevent the malaria parasite infectious stage from entering or
developing within liver cells of human beings. Such vaccines would prevent the severe and
life-threatening consequences of malaria in non-immune individuals.
Press Release WHO/77
Page 5
Another approach is to develop a vaccine that prevents transmission of the malaria
parasite from one infected person to another person. This type of vaccine would block the
development of the parasite in the mosquito, thus preventing the parasite from infecting
someone else. This transmission blocking vaccine is under development by scientists at
the US NIH, in collaboration with WHO/TDR. The NIH has recently initiated a major
Malaria Vaccine Development Programme aimed at ensuring the production of clinical
grade materials for use in clinical trials.
A different asexual blood stage vaccine type is based on a cocktail of antigens. One
such synthetic peptide vaccine, SPf66, developed by Manuel Pattaroyo working at the
Institute de Inmunologia in Bogota, Colombia, has been tested in field trials in South
America, Africa and Southeast Asia. It has only been partially effective to date. Dr.
Pattaroyo is using sophisticated biochemical methods to improve its potency.
The leading scientific journal Nature published this week research from Kenya,
Thailand and Malawi which shows that pregnant women living in malarious areas develop
a unique immunity which protects them from malarial infection. Professor Bernard Brabin
of the Liverpool School of Tropical medicine, who is a co-author of the paper, and has
worked for 20 years on the subject of malaria in pregnancy, says that it is the most exciting
scientific development in this field for decades and could open the way for developing a
vaccine to protect pregnant women from malaria.
Public private sector collaboration
Because malaria is largely found among poor people in poor countries, the private
sector can not engage fully in research and development. A public-private sector initiative
is being set up to circumvent the problem. The New Medicines for Malaria Venture will be
financed by public sector and philanthropic bodies. The private sector will primarily provide
facilities and staff. Industry is committed to making this work, says Harvey Bale, Executive
Director of the International Federation of Pharmaceutical Manufacturers Associations.
The four UN-System organizations contribute unique expertise
UNDP has committed to the following actions.
At country level, UNDP will:
1. Create capacity for integration of malaria-related action into national poverty
eradication policies, strategies and programs.
2. Strengthen, through Sustainable Human Development activities, the balance of action
among state, private sector, civil society and communities themselves, to ensure that
people have access to basic social services and productive assets.
3. Work through the UN Resident Coordinator system to encourage collaborative
programming in support of intersectoral action and resource mobilization.
At regional/sub-regional levels, UNDP will:
1. Support links between Sub-regional Resource Facilities (SURFs), providing technical
referral services to country offices and the Roll Back Malaria resource support
networks.
2. Collaborate with WHO Regional Offices to strengthen capacity of relevant regional
inter-governmental organizations (ISO) in support of Roll Back Malaria.
At global level, UNDP is providing continuing support for the UNDP/World Bank/WHO
Special Programme for Research & Training in Tropical Diseases (TDR), which has as a
Press Release WHO/77
Page 6
major focus the development of drugs and tools for malaria control and adapting research
in local settings.
UNICEF will:
1. Provide support to intensified malaria control efforts via its country programs.
2. Work with Government & NGO partners to:
• give special attention to reducing the terrible toll of malaria on young children and
pregnant women;
» further strengthen support for community-based and local action to improve health
and nutrition;
• focus on making insecticide treated mosquito nets available to all families that need
them and on ensuring that every child with malaria has access to early and effective
treatment;
• mobilize leaders (community, district and national) to make effective malaria control
a priority.
3. At international level, raise additional funds for country activities, and focus support on
10 of the most severely affected countries in the next two years.
4. Take lead responsibility for developing an impregnated bednet resource network.
The World Bank Group strongly supports the Roll Back Malaria global partnership.
Malaria has a major impact on social and economic development. Consequently, the Bank
has committed to:
1. Increase World Bank investments in malaria control and research;
2. Facilitate resource mobilization to support RBM;
3. Enhance a more effective involvement of Departments of Finance, Economics,
Infrastructure, Agriculture and others to become full partners in reducing malaria as an
economic factor;
4. Explore innovative finance mechanisms to deliver support;
5. Support research on the economic aspects of malaria;
6. Help establish private-public partnerships with industry on new malaria products.
Together with Roll Back Malaria partners, the Bank will actively pursue these activities
through its country programs and research agendas. Malaria must be reduced as a
negative factor on macro-economic growth.
WHO will be coordinating the Roll Back Malaria project. Project Countries and affected
populations have identified malaria as a priority health issue. Activities will cut across
WHO programs & regions to:
1. Support governments & partners:
• strengthen the health sector to better tackle malaria;
• monitor the geographic spread of malaria;
• measure results and outcomes of action;
2. Improve technical efficiency & capacity:
• build & support technical support networks, regional and local;
• invest in the development of new methods, tools and capacity strengthening
through research networks and programs;
3. To improve resource allocation, utilization and mobilization:
• local/national: promote concerted action by stakeholders
• regional; establish resource networks;
Press Release WHO/77
Page 7
•
global: supporting partners for common action and sharing information on malaria,
programs and resources.
Global Malaria Rates*
REGION
CLINICAL CASES
AFRICA (South of the Sahara)
270-480 million estimated**
AMERICAS
(Including Brazil)
(Brazil alone)
2.2-5.6 million estimated
1.1-2.8 million reported
MIDDLE SOUTH ASIA
(Including India)
(India alone)
2.6 million reported
2.1 million reported
ASIA WEST OF INDIA
(including Afghanistan)
(Afghanistan alone)
0.5 million reported
0.3 million reported
EASTERN ASIA & OCEANIA
(Including Thailand, Vietnam
and The Solomon Islands)
(Thailand, Vietnam and
The Solomon Islands alone)
0.5 million reported
EUROPE
(Including Turkey and
the former USSR)
12 000 reported
1.0 million reported
* Estimates of global malaria mortality are 1 million deaths a year, and occur primarily in
African children under five years of age.
** Included in this total, there are 140-280 million estimated cases of malaria
in children under the age of five.
Source: WHO, 1998
For further information, journalists can contact Gregory Hartl, Health Communications and Public Relations,
WHO, Geneva. Telephone (41 22) 791 4458. Fax (41 22) 791 4858. Email: hartlg@who.ch .
All WHO Press Releases, Fact Sheets and Features as well as other information on this subject can be
obtained on Internet on the WHO home page http://www.who.ch/
T??cS-
WORLD
R
E
G
I
O
HEALTH
REGIONAL OFFICE F
ORGANIZATION
SOUTH-EAST ASIA
REGIONAL COMMITTEE
Provisional Agenda item 1(
Fifty-second session
SEA/RC52/7
22 July 1999
|N
1 A
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ROLL BACK MALARIA AND MAINSTREAMING OF
ANTI-MALARIA ACTIVITIES IN
HEALTH SECTOR DEVELOPMENT
SEA/RC52/7
CONTENTS
Page
Executive Summary
iii
1.
INTRODUCTION
1
2.
BACKGROUND
1
3.
OPERATIONALIZATION OF RBM
3.1 Enhanced Diagnosis and Treatment of Malaria
3.2 Disease Transmission Control
3.3 Enhanced Surveillance
3.4 Health Sector Development
3.5 Community Mobilization
3.6 Advocacy
2
2
3
4
5
5
6
. 4.
REGIONAL SUPPORT NETWORKS
4.1 The Assets
4.2 Support Networks
6
6
6
5.
INITIATING RBM ACTION AT COUNTRY LEVEL
7
6.
ROLL BACK MALARIA ACTION PLAN
8
7.
POINTS FOR CONSIDERATION
9
SEA/RC52/7
Page iii
Executive Summary
Roll Back Malaria is a global initiative against malaria implemented through health sector
development that could foster broad-based support for effective anti-malaria intervention to
achieve sustainable reduction in malaria cases, especially among the poor who have little
access to health services.
As different from previous approaches to malaria control, RBM, as a social movement
for better health, draws its strength through improved health sector development. This would
facilitate the mainstreaming of malaria control activities into the health system, integrate its
implementation through the provision of health care to the poor in a package delivering care,
combined with other common diseases and linked with other health programmes.
Under the Ten Guiding Principles, RBM utilizes the existing infrastructure and available
resources for malaria control to implement the Six Strategies of RBM in the SEA Region:
• Enhanced diagnosis and treatment of malaria (e.g. new diagnostic test, universal
access to treatment, combination drugs)
• Disease transmission control (cost-effective integration of vector control tools, e.g.,
insecticide treated nets, selective vector control, bio-environmental methods)
• Enhanced surveillance (rapid response, policy making, border malaria, and
monitoring progress)
• Health sector development (e.g., decentralization, health equity, package delivering
care, changing role from implementers of malaria control to leadership, regulation
and coordination).
• Community mobilization (empowerment of communities, evidence-based planning
and ownership).
• Advocacy (forum for advocacy, strategic investments e.g., mapping, new drugs and
vaccines, regional support networks e.g. drug policy, rapid response, etc., health
impact assessment, research on reform in health system).
RBM Action Plan envisages political commitment at all levels starting at the highest
level of governance. RBM functions through partnerships from the central to the local level
and works in synergy based on an Action Plan developed and owned by all partners. The
action plan for Roll Back Malaria is as follows:
• A preparatory phase of six months (ending 1999) for advocacy, establishment of
partnerships and resource networks, mainstreaming RBM in the health system, and
selection of endemic districts representing important malaria paradigms.
• A two-year (2000-01) period of piloting of RBM in selected districts and towns.
• Adoption of a countrywide RBM plan by all countries as a means of improving and
reducing malaria-related mortality Dy naif by 2010 and reducing it further in
succeeding years.
If
SEA/RC52/7
1.
INTRODUCTION
The fact that the poor and those with little access to health care are most affected, malaria is
now seen as a developmental and poverty issue. Therefore, the RBM concept and
partnership in malaria control as a social movement for better health should be addressed as
an integral part of health sector development.
Further,, the success of malaria control action will require a political commitment,
establishment of a sound legislative foundation to control malaria, optimal use of available
resources, establishment of intersectoral linkages, community empowerment, involvement of
the private sector/NGO and other health-related programme. The district health system
approach and decentralization of decision-making should form the strength of malaria
control. Border malaria, multidrug-resistant malaria, population migration, urban malaria etc.,
are important issues that need to be addressed.
The Intercountry Meeting of National Malaria Programme Managers in Pattaya,
Thailand, 22 - 27 February 1999, and the Meeting on Implementation of Collaborative
Activities on Roll Back Malaria, held in New Delhi from 4-6 May 1999, concluded that
mainstreaming of RBM into health sector development would enhance efforts in achieving
the objectives of malaria control.
2. BACKGROUND
In the SEA Region, the overall malaria situation has remained almost static during the last
decade with around 3 million confirmed cases annually. Distribution of malaria cases has
been uneven and about 10% of the population is exposed to the risk of drug-resistant
malaria. Malaria in Asia causes high morbidity, resulting in reduced productivity, loss of
family income with impact on economy in general. Death rate is lower compared to Africa but
it affects all age groups. In this Region, India contributes 80% of the cases while more than
65% of the deaths occur in Myanmar.
Appreciating the global concern about the deteriorating malaria situation, a Ministerial
Conference on Malaria, held in Amsterdam in 1992, endorsed the WHO Global Malaria
Control Strategy (GMCS). GMCS was subsequently endorsed by the Economic and Social
Council (ECOSOC) of the United Nations in 1995, and adopted by the Member Countries.
Dr Gro Harlem Brundtland, Director-General of WHO, initiated a new effort in May 1998
to Ho// Back Malaria (RBM). RBM envisages better access to malaria interventions to
millions of w.omen, children and men, who suffer from poor health equity. Further, RBM
draws its strength from past experience with emphasis on partnership, research groups,
evidence-based action, political support and civil society organizations. Mortality due to
malaria is expected to be halved by 2010 with sustained reduction in the succeeding years
and the resultant disease burden due to associated diseases. During 1999, this initiative has
been endorsed by resolutions EB103.R9 and WHA52.11.
SEA/RC52/7
Page 2
To make a difference for the prospects of poor people, the focus would be on
interventions that could achieve the greatest health gain possible. It would mean that during
the implementation process, RBM will be guided by the following principles:
Box 1: Ten Guiding Principles for RBM
•
RBM is a social movement supported by many partners, to reduce poverty and
promote development.
•
RBM is owned by all the partners
•
Decisions are made by consensus
•
Country priorities drive RBM
•
Partners function independently, but in concert
•
Partners contribute where they have a comparative advantage - or interest
•
Action plans are clear, evidence based, prioritized and adapted to local realities
•
RBM is about broadening and strengthening the capacity of health sectors to
fight all diseases
•
RBM is not a new agency or funding institution
•
Mainstreaming of RBM in the health system cannot be judged to be functioning
unless they have an impact on malaria.
In recognition of the fact that malaria is still a major public health problem, the
governments in the South East Asia Region spend large sums of money on malaria control.
Member Countries managed to shift malaria control from autonomous disease control
programme by integrating it into the general health services. There is still a need to ensure
appropriate priority and effective action to address malaria, within the context of health
sector development. With the new emphasis on health-led development, it will require new
ways of working and changes in the way resources are used. Therefore, RBM is relevant to
SEA countries.
3.
OPERATIONALIZATION OF RBM
The operationalization of RBM would be based on the following six strategies: (1) enhanced
diagnosis and treatment, (2) disease transmission control, (3) enhanced surveillance,
(4) health sector development, (5) community mobilization, and (6) advocacy. The health
sector and national partners assume the responsibility to carry out situation analysis and to
prepare RBM joint action plans at district, provincial and national levels, as appropriate.
3.1
Enhanced Diagnosis and Treatment of Malaria
(1) Early Detection and Prompt Treatment (EDPT)
New techniques, such as rapid antigen diagnostic tests, should be introduced on an
operational scale in certain epidemiological settings. RBM should ensure universal access of
drugs to the populations at risk, which means appropriate and affordable first-line
SEA/RC52/7
Page 3
anti-malarial drugs and effective second-line treatment at the periphery level. Access to
health care should also mean access to other effective anti-malaria measures, particularly
reduction of transmission. Development of new drugs and drug combinations are needed to
combat resistant malaria so as to prolong the life of existing drugs.
(2) Improving access to health care
Because of the poor quality of public sector facilities and the lack of public confidence,
private sector plays a dominant role in treatment. There is thus a need for an effective
regulatory function to protect public health interest and secure the quality of service rendered
by the private sector.
(3) Drug resistance
The epicentre of multidrug-resistant strains in Thai-Cambodian and Thai-Myanmar areas
along the international borders are considered a threat to the world as a potential source of
multidrug-resistant malaria.
Assessment of the changing patterns of drug resistance through monitoring of
therapeutic efficacy of anti-malarial drugs by using the WHO protocol should be conducted
at regular intervals, particularly when drug failures are reported by clinicians.
3.2 Disease Transmission Control
Under RBM, countries should adopt a truly integrated vector management (IVM) approach
and apply the best practices (Box 2) for sustainable transmission reduction.
Box 2: Application of Best Practices
•
Expanding the use of GIS (geographical information system) and RS (remote
sensing) for the monitoring of critical environmental determinants of malaria
transmission risk.
•
Obtain government commitment for IVM as best practice in vector control,
including malaria in health sector development and intersectoral action.
i
•
Strengthening of local environmental health services, where applicable, to
perform essential functions in support of integrated vector management.
•
Give ministries of health the proper regulatory powers within an effective legal
framework, to ensure that other sectors comply with their responsibilities in risk
management.
•
Pursue an active partnership with the District Development Officer to achieve
intersectoral action at the district level.
The process of IVM intervention should use evidence-based decision-making criteria to
arrive at the most cost-effective mix of vector management methods. Methods should
include the use of ITN, biological control and environmental modification.
SEA/RC52/7
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3.3 Enhanced Surveillance
(1) Malaria epidemics
Prediction of and early response to epidemics in unstable malarious areas should be a
national priority. Early recognition of epidemics is important in mobilizing resources to
prevent deaths. Box 3 gives the core indicators to assess morbidity and mortality due to
malaria on a continuing basis.
(2) Monitoring of drug resistant malaria
Regular assessment of changing pattern of drug resistance should be the basis for drug
policy to ensure effective treatment for malaria.
(3) Border malaria
Synchronized control strategies. Malaria along international borders is a serious problem.
Malaria control along the borders would greatly benefit from partnership under RBM through
a dialogue with neighbouring countries to act jointly in a synchronized intercountry, malaria
control strategy.
(4) Monitoring progress
Box 3: Core Standard Indicators
Impact Indicators
(1) Morbidity attributed to malaria
•
Number of cases of UM (clinical/confirmed) among target groups/unit population
•
Number of cases of SM (clinical/confirmed) among target groups/unit population
•
Number of MTF/per No. of treated patients. Reported according to each drug used
(2) Mortality attributed to malaria
•
Number of malaria deaths (clinical/confirmed) among target groups/unit population
•
Proportion of clinical/confirmed deaths due to malaria among patients with SM admitted
to a health facility
Outcome and Output Indicators/Operational Indicators
(1) Management of antimalarial drugs (percentage of health facilities reporting no rupture
of stock of antimalarial drugs during the past three months)
(2) Reporting coverage (percentage of districts regularly reporting the above to the
national programme on a monthly basis for the past 12 months)
(3) Universal access to effective treatment (percentage of priority areas having access to
treatment and referral system)
(4) Target population under personal protection (percentage of population in priority areas
under personal protection)
(5) Rapid response team (percentage of priority districts having early warning system and
trained rapid response teams)
UM: uncomplicated malaria, SM: severe malaria, MTF: malaria treatment failure
SEA/RC52/7
Page 5
3.4 Health Sector Development
(1) RBM is a social movement for better health
RBM, as a social movement for better health, should focus on providing access to the poor
who suffer from malaria the most. Therefore, RBM should be a part of poverty alleviation
action. The community and the private sector would have the opportunity to play important
roles in the delivery of effective anti-malaria interventions, particularly in primary prevention
and treatment of malaria. As a consequence, RBM should also be part of the changing role
of malaria control programme - from being a delivery agent to leadership, coordination and
regulatory function. Quality control and standard setting should remain the responsibility of
the government.
(2) Mainstreaming RBM
The RBM initiative has recognized the need to adhere to principles of decentralization and
local ownership of health programmes as basic principles in health sector development.
RBM should be an integral part of health sector development and work through the
primary health care (PHC) system for effective action against malaria. This will involve
transfer of resources, delegation of authority to district or sub-district levels and
empowerment of local authorities and communities to identify needs and priorities.
Strengthening of health sector development would facilitate mainstreaming of RBM and
benefit other health programmes.
(3) Strengthening district health system
RBM’s managerial capacity should be the lead in developing district action plan in line with
the package concept of health care. Information, education and communication (IEC)
activities should be intensified for both the people and providers at all levels, and
decentralized planning based on partnerships should lead to proactive action and optimal
utilization of resources.
3.5 Community Mobilization
The programmes should address health issues arising through enhanced community
awareness and knowledge about disease prevention, diagnosis and treatment, as well as
through local operational research activities. Bottom-up planning should be the core principle
where decision-making and planning capacity will be based at the level where the problem
occurs i.e. local-level planning, disease surveillance, monitoring of programme activities,
resource allocation, IEC, training, vector control etc. Epidemiological information would be
analysed at the local level for proactive action in developing evidence-based planning.
However, national-level competence and coordinating functions should be retained or
developed at the central level during the process of decentralization and thereafter.
'i,
SEA/RC52/7
Page 6
3.6 Advocacy
Creation of a forum for joint advocacy and resource mobilization as a common ground to
bring malaria to the forefront in health sector development. The forum would institutionalize a
mechanism for maintaining partnerships aimed at agreed joint action plan and implemented
in a concerted effort, exploring the possibility of redirecting some resources and giving
access to those who need them.
4.
REGIONAL SUPPORT NETWORKS
4.1
The Assets
The SEA Region has a strong infrastructure available for the implementation of RBM, as for
example:
• indigenous production of insecticides, drugs, mosquito nets, equipment, transport;
• training facilities for all categories of health staff and other functionaries;
• experienced technical personnel in malaria control and related areas;
• well-developed grassroots health infrastructure
• advanced centres of basic, applied and field research;
• a network of educational and research institutions, colleges, universities;
• WHO collaborating centres;
• indigenous resources to sustain the RBM initiative.
4.2 Support Networks
(1) Technical support
To countries to address core issues, review, monitor and act as channel of information on
priority issues such as:
• drug policy and monitoring drug efficacy;
• monitoring and evaluation of surveillance systems and epidemic preparedness and
response;
• disease transmission control, and
• advocacy through media communication and country partnerships.
(2) Regional network for rapid responses
In case of emergencies/epidemics, regional support network provides assistance with
emphasis on surveillance system, reviews of epidemics, dissemination of information, and
provision of emergency supplies.
SEA/RC52/7
Page 7
(3) Strategic investments
New areas of strategic investment should be closely linked with partnership initiative as to
ensure concerted and sustainable efforts for RBM. The areas identified include the following:
• Regional networks that will support multi-centre studies and fund-raising advocacy
to facilitate vaccines and new drugs development research and operational
research. Health policy research, such as socioeconomic research on malaria
integrated intervention and sustainable strategies; health indicators (incorporating
malaria) for situation analysis and rapid response incorporating information
technology; GIS (and possibly remote sensing) for analysis of the epidemiological
and ecological situation, including mapping of drug resistance based on monitoring
therapeutic efficacy.
• Utilization of health impact assessment in projects and mitigating strategies in the
improvement of health and research on reforms in health systems for planning and
implementation of RBM.
• There is an urgent need for more coordinated work in search of new drug with
partners e.g., the industry, UN Agencies (WHO, UNICEF) World Bank, research
organizations, etc. WHO should take the lead in negotiation with RBM partners in
the industry to convince them to make available the techniques at an affordable
price for developing countries.
5.
INITIATING RBM ACTION AT COUNTRY LEVEL
National commitment for action against malaria would indicate RBM is instrumental in
reducing inequity and promoting human development through mobilization of all resources.
Policy-making. National governments determine the goals, strategy, organization and
operating procedures for RBM. RBM involves a situation analysis and strategy development,
a process led by national authorities and involving partners. Action against malaria
mainstreams into the health system with partners in RBM providing support within the
context of sectorwide approach to health development. RBM should now be seen as a social
movement for better health. Instead of being sole implementers, the National Malaria Control
Programme should assume a new role of leadership, regulation and coordination.
Working with partners. Working ih partnership for common objectives, using agreed
strategies in a transparent manner with emphasis on local solutions to local problems. Within
the context of these principles, attempts are made to ensure that partners have sufficient
flexibility and autonomy to make the fullest possible contribution in a concerted effort to
RBM. WHO will establish a functioning partnership with a range of organizations at global,
regional and country levels. This will result in the development of a sustained capacity to
address malaria (and other priority health problems). WHO’s partnership in RBM will include
malaria endemic countries, UNDP, UNICEF, World Bank, bilateral development agencies,
nongovernmental organizations (NGOs) and the private sector.
Improve access to health care. Wider distribution of anti-malarial (first-line) drugs
through public and private sectors would reduce morbidity and mortality due to malaria.
Efforts to educate communities and individuals in the home treatment of malaria and on
strengthening support and supervision of treatment services, collaboration with professional
associations for quality assurance would prove rewarding and should be encouraged under
4
SEA/RC52/7
Page 8
RBM. Realizing that malaria is the disease of the poor who have little access to health
services, RBM should be considered as one of the priority areas in providing health care to
the poor. In this case, provision of health services should be a package delivering care to
other common diseases affecting local communities, such as anaemia, acute respiratory
infection, diarrhoea and intestinal worms, and it should be linked with other health
programmes such as MCH, IMCI, school health, health education, etc.
Selective vector control. Working with partners in implementing selective vector
control towards an integrated approach should replace traditional routine residual spraying
operations. Chemical control remains, nevertheless, the mainstay in this concept.
Forum for advocacy. RBM advocacy for change in the organizational set-up should
address the new role of district health managers. Emphasis should be on multi-sectoral
involvement and partnership development, community participation, local leadership for
participatory planning and supervision, political support e.g. Panchayat, Union Parishad,
other local government bodies, village development committees, etc., coordination of NGOs
and other social organizations, including the private sector. The forum represents all
possible leaders, e.g. political, administrative, technical, traditional, corporate, private sector;
interested groups, e.g. trade unions, environmentalists etc., and partners, e.g. international,
national, regional, provincial district and local levels. At the district level, this forum may be
called District Malaria Society or District Health Forum etc., while at the national level, it may
be called Inter-ministerial Coordinating Committee or RBM Core Group for Partnerships.
6.
ROLL BACK MALARIA ACTION PLAN
The strategic action plan for the SEA Region would comprise three phases:
(1) Preparatory phase (Till the end of December 1999)
•
Development of guidelines for implementation of the strategies
•
Political commitment at all levels
•
Formulation of national strategies and development of partnerships plan
•
Situation analysis leading to the selection of districts for the piloting of RBM
•
Establishment of resource networks to address the core issues in malaria.
(2) Piloting phase (1999-2001)
•
Situation analysis of the districts and identification of problems at the local level
•
Time-bound action plan for RBM
•
Advocacy for RBM, identification of partners, assignment of responsibilities and
resource mobilization
•
Integrated malaria control in synergy with health development
•
Assessment and lessons learnt.
(3) Operational phase (2001-2006)
•
A five-year RBM action plan to be developed by countries involving all partners,
vital inputs to come from the pilot phase and resource networks.
SEA/RC52/7
Page 9
7.
POINTS FOR CONSIDERATION
(1) National commitment to support the new role of malaria control programme
In the context of RBM, the malaria control programme will assume a new role of leadership,
regulation and coordination instead of being the sole implementer and delivery agent. To
meet these objectives, Member Countries need to develop sustainable broad-based
partnership with the private sector, health-related industries, medical associations, teachers’
associations, local governments and other related civil societies as well as other potential
partners, including donors.
What new policies are needed to sustain effective partnerships for RBM?
(2) A social movement for better health
RBM should draw its strength by mainstreaming malaria control activities as part of health
sector development. RBM should facilitate the provision of health care to the poor and those
who have little access to health care. Priority will be on the delivery of the package of health
care to malaria and other common diseases and linked with other health programmes. The
way in which the health system tackles malaria - particularly among poor people - is the key
element of the assessment of that system’s overall performance.
What changes may be needed in policies and mechanisms within the ministry of health
to facilitate mainstreaming of RBM in health sector development?
(3) Capacity building
Capacity building needs to be accorded the utmost priority. The RBM approach to capacity
development should ensure that malaria expertise should be available, wherever it is
needed, throughout the health sector. WHO’s assistance can be explored to support training
activities to create a core of motivated individuals with upgraded skills who would, in turn,
impart training to health personnel at different levels of health care.
>
How can the required human and other resources be mobilized?
(4) Strategic investment
The development of appropriate technology would strengthen RBM implementation. New
areas of strategic investment should be evidence-based and closely linked with partnership
initiative to ensure concerted and sustainable efforts in RBM.
How can partnerships in strategic investment be initiated?
(5) Regional support network
The available resources and expertise in the Region should be fully utilized. In order to
promote regional exchange of experience and information, there must be ways to create a
network of expertise among Member Countries to address priority issues, such as drug ’
policy and monitoring surveillance systems, epidemic preparedness and response, disease
transmission control and advocacy through media communication and country partnerships.
Under what mechanism could WHO foster regional support?
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103rd Session
EB103.R9
Agenda item 3
29 January 1999
5
Roll Back Malaria
I
The Executive Board,
Reaffirming the impact of malaria in constraining human development, and appreciating the
innovative concepts and operational mechanisms in the Director-General’s report on Roll Back Malaria,’
RECOMMENDS to the Fifty-second World Health Assembly the adoption of the following
resolution:
The Fifty-second World Health Assembly,
Having considered the report of the Director-General on Roll Back Malaria;
Concerned that the global burden of malaria is a challenge to human development and a
significant cause of poverty and human suffering, particularly in the poorest nations of the world;
Mindful of the efficacious tools currently available to reduce this burden, and the potential
fortheir more effective use within malaria-affected communities;
Welcoming the decision by the Director-General to establish a Cabinet project to support
rolling back malaria which works across the Organization;
j
Noting that Roll Back Malaria represents a new approach promoted by WHO, in which all
concerned parties are encouraged to work in a coordinated partnership, united by common goals,
consistent strategies and agreed methods of working, and that Roll Back Malaria is serving as a
pathfinder in bringing these concepts into operation in relation to other international health issues;
Commending the key features of the new approach, namely, increased focus on the needs of
people at risk, better response to those needs with evidence-based action, greater use of existing
tools, their full integration into the health sector as a horizontal programme, and innovative public
private partnerships to develop cost-effective products and tools in view of the emergence of drug
and insecticide resistance;
Appreciating the strong commitment to Roll Back Malaria from several heads of State, the
Administrator of UNDP, the President of the World Bank, the Executive Director of UNICEF, and
’ Document EB103/6.
J
EB103.R9
directors of other development banks, foundations and bilateral assistance agencies, expressed when
the global partnership was established in December 1998,
1.
ENCOURAGES Member States to reduce malaria-related suffering and promote national
development in a sustained way, by rolling back malaria and preventing its resurgence or
reintroduction, by:
(1) engaging a wide range of personnel and institutions involved in health systems, disease
control, and research, with representatives of civil society, the private sector, development
agencies and other sectors;
and, where relevant, by:
(2) ensuring that sufficient resources are available to meet the challenge of rolling back
malaria;
(3) establishing and sustaining country-level partnerships to roll back malaria within the
context of health sector and human development;
utilizing relevant technical expertise that exists within countries and regions in an
(4)
effective manner;
2.
REQUESTS the Director-General to draw on the whole Organization in supporting Member
States by:
promoting harmonized strategies and encouraging consistent technical guidance for
efforts to roll back malaria;
(1)
(2) working with them as they establish criteria for success in rolling back malaria, and
monitoring progress of country and global efforts within the context of health sector and
human development;
(3) promoting international investment in cost-effective new approaches and products
through focused support for research and for strategic public and private initiatives;
(4)
3.
brokering the technical and financial assistance that is required for success;
REQUESTS the Director-General:
(1) to report regularly on progress of the global Roll Back Malaria partnership to the
Executive Board and the Health Assembly, stressing the contribution that Roll Back Malaria
makes to the reduction of poverty, and reviewing the extent to which the partnership serves
as a pathfinder for effective joint action on other international health issues;
(2) to promote the aims and outcomes of the Roll Back Malaria partnership in relevant
intergovernmental bodies, organizations of the United Nations system, and - when
appropriate - other bodies committed to equitable human development.
Ninth meeting, 29 January 1999
EB103/SR/9
2
RBM/World Bank
RBM/WHO Project
The World Bank Group strongly supports the
Roll Back Malaria global partnership. Malaria
has a major impact on social and economic
development. Consequently, the Bank has
committed to:
Countries and affected populations have
identified malaria as a priority health issue.
Activities will cut across WHO programmes
and regions to:
7. Support governments & partners
► Strengthen the health sector to better
tackle malaria
► Monitor the geographic spread of malaria
► Measure results and outcomes of action
► Increase World Bank investments in malaria
control and research
► Facilitate resource mobilization to support RBM
► Enhance a more effective involvement
of Departments of Finance, Economics,
Infrastructure, Agriculture and others to become
full partners in reducing malaria as an economic
factor
► Explore innovative finance mechanisms to
deliver support
► Support research on the economic aspects
of malaria
► Help establish private-public partnerships
with industry on new malaria products.
A worldwide p^rtnefshli
to fight malaria, one of
the world's ino!
devastating dlseas
2. Improve technical efficiency & capacity
► Build & support technical networks in
affected countries
► Invest in the development of new methods,
tools and capacity strengthening through
research networks and programmes.
3. Collaborate and coordinate in order to improve
resource allocation and utilization
► Local/national: promote concerted action by
stakeholders
► Regional: establish resource networks
► Global: support partners for common action
► Share information on malaria, programmes
and resources.
Together with Roll Back Malaria partners, the Bank
will actively pursue these activities through its
country programmes and research agendas.
Malaria must be reduced as a negative factor
on macro-economic growth.
Ca
OKPANNENBORG
World Bank, 1818, H Street N.W.,
Washington DC 20433, USA
Tel: (+1) 202-477-1234
Fax: (+1) 263-470 0146
E-mail: epannenborgtn'worldbnnk.org
►
TOREGODAL
World Health Organization, 20 Avenue Appia
1211 Geneva 27, SWITZERLAND
Tel: (+41) 22-791-2660
Fax: (+41) 22-791-4198
E-mail: godalt'n who.int
A
RBM/UNDP
Malaria has important implications for health and
RBM/UNICEF
UNICEF will:
poverty. Effective responses will require broad
based support across sectors and the involvement
1. Provide support to intensified malaria
of a range of development partners.
control efforts via its country programmes.
UNDP has committed to the following actions:
At country level
1. Create capacity for integration of malaria-related
action into national poverty eradication policies,
strategies and programmes.
2. Strengthen, through Sustainable Human
Development activities, the balance of action among
state, private sector, civil society and communties
themselves, to ensure that people have access to
basic social services and productive assets.
3. Work through the UN Resident Coordinator system
to encourage collaborative programming in support
of intersectoral action and resource mobilization.
At regional/sub-regional levels
1. Support links between Sub-regional Resource
Facilities (SURFs), providing technical referral services to
country offices and the Roll Back Malaria resource
support networks.
2. Collaborate with WHO Regional Offices to strengthen
capacity of relevant regional inter-governmental
organisations (ISO) in support of Roll Back Malaria.
At global level
UNDP is providing continuing support for the UNDP/
World Bank/WHO Special Programme for Research &
Training in Tropical Diseases (TDR), which has as a major
focus the development of drugs and tools for malaria
control and adapting research in local settings.
► ►►► MINA MAUERSTEIN-BAIL
UNDP, 1 UN Plaza, New York,
New York 10017, USA
Tel: (+1)212-906-6349
Fax: (+1) 212-906-6350
E-mail: mina.mauerstein-bail@undp.org
2. Work with Government & NGO partners to:
► Give special attention to reducing the terrible
toll of malaria on young children and pregnant
women
► Further strengthen support for community
based and local action to improve health
and nutrition
► Focus on making insecticide treated mosquito
nets available to all families that need them and
on ensuring that every child with malaria has
access to early and effective treatment
► Mobilize leaders (community, district and
national) to make effective malaria control
a priority.
3. At international level, raise additional
funds for country activities, and focus support
on 10 of the most severely affected countries
in the next two years.
4. Take lead responsibility for developing an
impregnated bednet resource network.
DAVID ALNWICK
UNICEF, 3 UN Plaza, New York,
New York 10017, USA
Tel: (+1)212-824-6369
Fax: (+1)212-824-6460
E-mail dalnwick@unicef.org
•-
["m.i*
Guidelines on Community Mobilisation, Advocacy and Related Issues
Roll Back Malaria Initiative (WHO - SEARO)
Leadership
Rights approach to malaria control
Rights to malaria free environment
Rights to information on malaria
Rights to early diagnosis and treatment
Rights to low cost preventive strategies
Introduce malaria to CMs in meeting addressed by PM
Introduce malaria to SHMs in meeting addressed by CHM
Introduce malaria to SCS in meeting addressed by CCS/CHS
Introduce malaria to SHS in meeting addressed by CHM/CHS
Introduce malaria to Collectors in meeting addressed by CM/SHM
Introduce malaria in IAS training curriculum
Introduce malaria in State Training Centre programmes
Ensure area specific state plans in uniform format.
10,h plan to focus on malaria.
Organise National Conference on malaria each year
Organise state workshops on malaria each year
Identify pool of experts/consultants/implementers
Strengthen District Malaria Societies/leadership of Collectors
HRD on malaria leadership
In priority areas/states to have special officer for malaria under CM
Broad based national, state district malaria committees.
Define time bound goals/objectives in a participatory manner
Develop National/State pool of trainers on malaria
Identify and develop WHO Collaborating Centres on malaria with segmentation
- Technology
-IEC
- Community mobilisation
- Research, Evaluation and Documentation
Develop web-site/malaria on line
1
Advocacy
Training in advocacy at different levels
Issues in advocacy
Practising national guidelines
Treatment of malaria
Insecticide use
Inter-sectoral participation
Engineers
- Dams
- House construction
- Environment pollution
- Stagnation
- Manufacturing air coolers
Agriculture
- fanning
Scientific studies in traditional/herbal remedies
Local partners
- District level and below
Participative process of malaria mapping of district
PHCs
Malaria workers
NGOs
BDOs
Panchayat leaders
MLAs and MPs
Plan of action for district under leadership of Collector/District Magistrate/Commissioner
Plan of action at Block level/municipal levels
Same as above
Health workers
Health inspectors
Opinion leaders
Develop simple qualitative/participatory methods of planning and monitoring
Define role of panchayats in malaria control
Define operational problems relating to malaria control
List all panchayats block-wise - malaria/No malaria
List of DDC/FTD/MLV
Criteria for DDC/FTD/MLV
2
Selection of DDC/FTD/MLV
Training of DDC/FTD/NLV
Support - procedure of providing travelling expenses
Clear agreement with panchayat - MLV
Volunteers
Not government staff
Special project
Time bound
Travel expenses based on slides/frequency of travel
Likely independent evaluation
Role of NGOs/VOLAGs
Diagnosis
- Those with microscope and trained technician
- Train microscopists for those with microscope and no lab technicians
- Train smear technician where no microscope.
Treatment
Establish DDC/FTE)
Facilitate/support MLV
Training NGO personnel in malaria treatment
lEC/Education for health
Participate in preparation/modifying messages.
Educate community using appropriate strategies
Promote personal protection measures.
Vector Control
Take up anti larval measures
- Avoid water accumulation
- Larvicides
Take up bio environment measures
- Larvivorous fishes
Educating farmers on methods that prevent growth of mosquito larvae.
Motivating people to accept spraying in areas where decided and supporting spray
team.
Support spray team as appropriate either facilitating or helping in spraying.
Programme Implementation
To represent on district/block level committees
Capable NGOs to be involved in evaluation and monitoring
Capacity building of NGOs
3
Developing NGO resource centres for malaria control
Role of Private Practitioners
- GPs, RMPs and other unregistered practitioners to be utilised in malaria control
- CME programmes for allopathic doctors using uniform modules with minor
local variation
- Communicate malaria treatment guidelines through professional journals,
newsletters
- Pamphlets, booklets and handouts to be distributed to private practitioners
School Health Campaign
- Malaria month programmes
- Distribution of messages on malaria
- Anti malaria day in June
Specific activities
- Fever camps in schools - children to promote in community
- Environmental cleanliness
- Avoiding collection of water around schools
- Short anti malaria programme in schools
- Essay contests in schools
- Elocution contests in schools
Block level - 1st week
District levels - 2nd week
State level - 3rd week
Natural level - 4lb week
(Prizes of good value )
- Building malaria knowledge into school good value text books
Biology, Science, Economics, Maths
- NSS camps on malaria
- Special strategies for highly endemic and inaccessible areas
RESOURCE NETWORKING
Network of funding agencies
Network of implementing agencies/Human resources
- Programme planners
- Community mobilisers/organisers
- Behaviour change agents
- Data management personnel
4
Network of Research Institutions
- Technology
- IEC
- Community mobilisation
- Development studies/malaria
Network of experts/consultants
Network of key/varied/Govt. officials
NGO malaria network
IEC
There is a need for change in IEC strategies and sequencing
- Preparation of Acceptable messages with area specific variations if necessary
- Awareness creation phase
- TV spots/News interval/DD - others
- Newspapers
- Malaria month programme
- well planned
- better co-ordinated
- theme each year
- Wall messages
- Political support
- Knowledge creation phase
- Posters
- with all messages
- with key individual messages
- Pamphlets
- Flash cards
- Booklets
- Video for TOT - Master copy - encourage free copying
- Attitude change phase
- Video dramas - DD
- Video films - Cable TV
- Private TV producers
- Street theatre
- Through religious heads
5
- Practice change phase
- Support by PHC - with proper logistics/personnel
- Support by NGOs
- Support by private practitioners
- Increase budgets for IEC commensurate with plans
- Tendulkar. Kapil Dev - to give short talk/message on malaria
Short news write up for all professional journals.
District level malaria programme with press conference - Collectors
Elimination of Breeding Places/through community action
Incorporation into
- Agriculture department
- Irrigation department
- Water/sanitation department
- Fisheries
- Architects - water tank design
- Engineers/construction - Air cooler construction
Social marketing
Determine
Product - ITMN
Price
Process
Purchase
Treatment
Re-treatment
Storage
Washing
Promotion - IEC
Decide Acceptable
Incidence or level of adoption - how many
Spread of adoption - how fast
Duration of adoption - how long
Logistics
Ensure availability of product
Promote purchasing environment
Packaging
6
Neatness
Attractiveness
Confirm target audience - who should buy
Provide correct information on treatment/re-treatment
Clear myths and misconceptions
- What about safety for children - ?
- If children chew net - ?
IEC
- Knowledge
- Practice changes - use nets
- Value changes - Treated > Untreated
Marketing
Market segmentation
Free
Subsidised
Full charge
Marketing strategies - channels
Influencing channel members
Research and Development
- Malaria forecasting based on known weather patterns
- Mosquito patterns - entomology
- Effectiveness of Malaria Link Volunteers
- Simplified community based reporting and monitoring systems
- MIS - malaria specific
- Rapid Assessment Procedures in malaria
- Simple research/study designs for implementation by grass root level institutions
-PHC/NGO
- Identifying more grass root level Health institutions/NGOs to conduct research in addition to larger institutions
- Organise meeting of research institutions
7
REFERENCES
NMEP Epidemiology and Control of Malaria in India 1996.
VHAI/SOCHARA Towards an Appropriate Malaria Control Strategy 1997
NMEP Revised Project Implementation Plan 1997
WHO World Health Report 1999.
APAC, Facilitators Guide for Condom Social Marketing for Non Government
Organisations 1998.
6. NAMP Malaria and its Control in India. Country Scenario 1999.
7. NAMP. Gujarat State. Action Plan 1999.
8. UNDP/UNICEF/World Bank/WHO Roll Back Malaria. RBM action at country
level: the inception process 1999.
9. WHO/SEARO. Roll Back Malaria and mainstreaming of anti-malaria activities in
health sector development 1999.
10. V P Sharma/MRC/ICMR. Roll Back Malaria. Asian Concept 1998.
1.
2.
3.
4.
5.
//RBMGUIDE.DOC//
- Compiled by Dr. Rajaratnam Abel,
RUHSA, CMC-Vellore.
8
Roll Back Malaria
13 August 1999
This is the first in a series of notes prepared for members of the Global
Partnership to Roll Back Malaria by the Roll Back Malaria Project in the
World Health Organisation.
RBM Action at Country Level:
the inception process
Founding partners:
A Framework for RBM Action: the inception process - 13.08.1999 draft 2
Page 2
Contents
Page
1.
Introduction
3
2.
Critical Concepts of Roll Back Malaria
4
3.
Progress of the RBM Preparatory Phase
6
4.
Essential Actions of the RBM Partnerships
7
5.
Helping Communities to Roll Back Malaria
7
6.
Financial and Technical Support for the Inception Process
14
7.
Communication with the RBM Project
14
8.
Request for Feedback
14
A Framework for RBM Action: the inception process - 13.08.1999 draft 2
Page 3
1. Introduction
Malaria is increasingly recognised as a serious development issue.
There is evidence of a worsening global malaria situation. Malaria mortality
rates in Africa are rising. The malaria parasite is increasingly resistant to
commonly used antimalarial drugs. New epidemics are reported - some of
them in countries that have, until recently, been free of the disease. In many
countries, the resources of malaria control programmes are stretched to the
limit. Malaria contributes to widespread human suffering, particularly among
the poorest billion people in the world. It is a major constraint to economic
and social development.
The global initiative to Roll Back Malaria was launched in May 1998.
It offers a great opportunity for joint action to tackle the threat of malaria for
human development. It is vital that we seize this opportunity now and work for
the global goal of the initiative - to halve the global malaria burden by the year
2010.
Roll Back Malaria builds on past experiences.
The foundation of Roll Back Malaria is a succession of national and
international initiatives which have heightened the profile of malaria as a
development issue. Roll Back Malaria provides a new opportunity for the
thousands of malaria control personnel who have worked hard, often under
very difficult circumstances, and without recognition, to tackle malaria and its
consequences in recent years. It draws on the results of painstaking research in
the last decade.
Roll Back Malaria belongs in a wide health sector and development context.
The initiative to Roll Back Malaria will benefit from opportunities offered by
the reform of health sectors so that they better tackle priority health issues. It
benefits from development partnerships that are committed to seeing an
absolute reduction in poverty over the next few decades . It recognises that
communities are the key actors in rolling back malaria, and that national
authorities - and their political leaders - are in the lead in deciding, and
following through, actions to roll back malaria. It recognises the need for
continued investment to develop new interventions and products for more
effective action to roll back malaria.
A group of partners is taking forward the Roll Back Malaria initiative.
The President of the World Bank, the Executive Director of UNICEF, and the
Administrator of UNDP agreed to join the WHO’s Director General in October
1998 to found the global partnership to roll back malaria. Each
organization agreed to contribute to the global goal within the context of its
mandate. A broader group of partners came together in December 1998 and
consolidated the roll back malaria global partnership. Among the participants
were governments of countries affected by the disease, other donor agencies,
non-governmental organizations, international private sector representatives
and research groups. Since then alliances between partners - particularly
UNICEF, WHO, the World Bank and UNDP - have become strong and
effective, at country, as well as headquarters levels.
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Page 4
WHO’s participation in the initiative involves its country, regional and
headquarters staff, co-ordinated by a Roll Back Malaria “Cabinet Project”.
A time-limited special project has been set up under the direction of the
WHO’s Headquarters Cabinet to encourage a coherent WHO involvement in
the partnership. A strategy and workplan for WHO’s contribution have been
developed, covering the activities of groups within WHO Headquarters,
regional and country offices. The preparatory phase for the cabinet project will
last until December 1999, with implementation between 2000 and 2004.
Roll Back Malaria in Africa:
The WHO Director General and the Regional Directors of WHO’s African and
Eastern Mediterranean regional offices have proposed the spearhead for efforts
to Roll Back Malaria should be in Africa. Existing WHO initiatives for malaria
control in Africa will be taken forward as Roll Back Malaria in Africa.
2. Critical Concepts of Roll Back Malaria
2.1
New opportunities to Roll Back Malaria
Recent applied research has demonstrated that a range of available
interventions, when properly used, are highly cost-effective in reducing the
malaria burden within poor communities. These include
■
■
■
■
■
early diagnosis and prompt treatment of malarial illness, with antimalaria
drug combinations in some situations;
the use of insecticide treated materials - including bed-nets - in the home;
routine malaria prophylaxis or intermittent treatment during pregnancy;
surveillance, prediction of, and rapid response to epidemics;
widespread public awareness about malaria, its consequences, and ways in
which they can be avoided.
Up to now, many of these interventions have not been used to their full
potential. A more intensive effort to make them widely available to all including poor communities - would yield extra-ordinary benefits. This will
involve effective partnerships between all concerned to promote better health
and reduce the burden of malaria.
2.2
The six key elements of the strategy to Roll Back Malaria
The six elements of a strategy to Roll Back Malaria have received widespread
support. These build on the WHO global malaria control strategy, endorsed in
Amsterdam in 1992, with its emphasis on 1) effective management of malaria
including malaria outbreaks ; 2) rapid diagnosis and treatment of those who
are ill; 3) multiple and cost-effective means of preventing infection; and 4)
focused research to develop and test, and introduce new products. It includes
two additional elements: 5) a well co-ordinated movement through stronger
capacity to health sector and community-level effort, and 6) a dynamic global
partnership supported by a coalition of partners working within a common
approach. These elements need to be taken forward within an enabling
environment of strong in-country institutions and cross-sectoral collaboration.
A Framework for RBM Action: the inception process - 13.08.1999 draft 2
Page 5
The Roll Back Malaria Strategy in detail
Element 1:
Effective
Management
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□
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Element 2:
Rapid Diagnosis
and Treatment
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□
□
□
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Element 3:
Multiple Prevention
□
□
□
□
Element 4:
Focused Research
□
□
□
□
□
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Element 5:
Well Co-ordinated
Movement
□
□
□
□
Element 6:
Dynamic Global
Partnership
□
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□
Information about the malaria situation, and people’s needs, is used by public health
authorities to design and manage responses.
Regions and populations at risk of malaria epidemics are identified, and responses are
prepared, with the help of climate forecast and other data.
Families and community members are able to understand the malaria disease and take
appropriate and timely action to manage it
New, rapid, easy-to-use diagnostic tests are used in situations where malaria is endemic and
effective microscopy cannot be made available.
Pre-packaged effective drugs are accessible to parents and caretakers to enable a quick
response to malaria in children.
Quality health care services are accessible enough for those who need professional care.
People with severe malaria are referred to centers offering effective case management.
Anti-malarial drug resistance is monitored and action taken to ensure that health workers
treat patients with effective drugs (including short course combinations when relevant).
People at risk of malaria infection access and use insecticide-treated mosquito nets, and
other means of personal protection.
Mosquito densities are reduced through the right mixes of environmental, biological and/or
chemical methods for specific local situation.
Mosquito resistance to insecticides is monitored to guide the choice of insecticides and the
best strategies for their use.
Pregnant women at high risk of malaria infection take anti-malarial medication to improve the
safety of their pregnancies
Health sector action to roll back malaria needs to be supported by operational research to
investigate problems and adapt strategies.
Existing interventions - including care for people affected by malaria - become more
effective through the application of new knowledge.
Private industry participates in developing new, effective products that will benefit poor
people
A new, effective and affordable medicine to treat people with malaria is developed every five
years through public-private partnership.
The development of an effective vaccine against malaria is accelerated through a co
ordinated international initiative
New, ecologically safe insecticides - that protect households without causing long-term harm
- are discovered, tested and used.
Efforts to roll back malaria are implemented in a way which contributes to sustainable and
effective health care systems
Health systems take account of local situation when responding to the threats people as a
result of malaria
National health services, private practitioners and local healers work together to respond
effectively to malaria and other diseases.
Many organizations join in a synchronized effort to roll back malaria (including schools,
community groups, local business, government departments and NGOs)
Decision-makers in governments of malaria-affected countries adopt health policies,
strategies and plans that allocate sufficient financial, human and inter-sectoral resources to
roll back malaria.
Groups active at the community level work together - as a movement for improved health
and reduced malaria among people at risk.
National and community-level actions to roll back malaria are backed by a range of
partnerships in which the government, the private sector, foundations, research and
academic institutions, bilateral and multilateral agencies, NGOs and the media, have a stake.
Movements and partnerships are catalyzed by global advocacy efforts and adapted to local
realities: they are based on best available evidence
A Framework for RBM Action: the inception process - 13.08.1999 draft 2
2.3
Page 6
Principles of Roll Back Malaria
■
The Roll Back Malaria partnership is not a project or programme. It is a
social movement that is part of broader societal action for health and
human development.
■
The RBM strategy builds on past experience, is evidence-based, and
focuses on outcomes.
■
Community and country priorities should drive actions to Roll Back
Malaria.
■
The interests of the people, particularly people in poor communities — and
especially their children and women - are at the centre of the RBM
movement.
■
The RBM movement is supported by partners, who function independently
but in concert: the partners contribute where they have a comparative
advantage or interest.
■
The RBM movement is about building and strengthening the capacity of
health services to help communities tackle all illnesses that undermine their
well-being.
RBM will involve a range of sectors - such as education, agriculture and water
(irrigation).
3. Progress of the Preparatory Phase
The preparatory phase started during July 1998 and will be completed in December
1999. Some of the major achievements include:
■
Launch of the Roll Back Malaria initiative jointly by the UNDP, UNICEF, the
World Bank and WHO in October, 1998;
■
Consolidation of the global partnership at a global partners meeting held
December 1998;
■
Regional meetings with countries of West, East and North, Central and Southern
Africa, the Mekong, Central and South Asia;
■
Consensus on the RBM concept and principles among all countries in these
regions.
A Framework for RBM Action: the inception process - 13.08.1999 draft 2
Page 7
4. Essential Actions of the RBM Partnership
The essential next stage is for the Roll Back Malaria partnership to be effective within
malaria-affected countries. A range of actions - at global and regional levels - will
support the partnerships.
1. Initiate carefully planned processes to support consensus, establish partnerships
and support effective action within malaria-affected countries;
2. Ensure that country and regional offices of different partner agencies (including
WHO) have the capacity to support these processes;
3. Arrange for countries receive technical support, when they want and need it, in
order to help develop in-country capacity to build on successes of the past and
undertake appropriate action to Roll Back Malaria;
4. Mobilize commitment and resources from the global partnership to help countries
prepare their RBM strategies and to finance them as they move from conventional
malaria control programmes to Roll Back Malaria;
5. Implement a global advocacy strategy for roll back malaria;
6. Implement systems to monitor progress - at country, regional and global level;
7. Further develop the global partnership at annual meetings and other events;
8. Make strategic investments in research and other initiatives to develop effective
new products for diagnosis, treatment and prevention of malaria.
5. Helping Communities to Roll Back Malaria
Many communities are already taking action to reduce malaria-related suffering. They
are helped to do this by government, community-based organisations, research groups
and private enterprises.
The Roll Back Malaria movement should build on what is working well, increasing
its impact so that many more people benefit. Many Heads of State have already
agreed to take forward action to Roll Back Malaria: national officials are involved in
an inception process. The following steps - which are not always undertaken in a
clear sequence - are likely to be needed.
The Ministry of Health will usually take the lead, looking for a wide range of other
groups - inside and outside government — to help. If there is a National Malaria
Control Program, it will be fully involved, working with other parts of the Ministry of
Health.Other government departments, such as finance, local government and
education will also be involved.
All partners that are active at country level should be encouraged to become
involved in the inception process from the start - in particular UNICEF, WHO, WB,
A Framework for RBM Action: the inception process - 13.08.1999 draft 2
Page 8
UNDP, bilateral development agencies, regional banks (eg the African Development
Bank), non-governmental agencies, research groups, private entities and media groups.
The headquarters personnel of many of these organisations have already agreed to
work in partnership at country level. Coordinating mechanisms for their health work
may already exist in-country. Where possible, country representatives of partner
agencies should work through these mechanisms to ensure that each agency - whether
multilateral or bilateral, public, NGO or private - contributes to RBM according to its
in-country comparative advantages.
The WHO country offices have critical roles in supporting the RBM implementation
process. They have the potential of effectively functioning as a catalytic hub for the
RBM country level partnership. However, for this to happen, the WHO
Representatives need to be adequately engaged in the process and their offices
strengthened, managerially and technically. This will require in-depth needs
assessment of the Country Offices with a view of developing an efficient
decentralised management system in such priority areas as human resources
management, budget and financial management, logistics management, amongst
others. Based on the results of these assessments, the regional Offices will be better
poised to provide effective support to Country Offices on technical issues,
partnerships, programme implementation and management.
There is frequently scope for inter-countrv actions to roll back malaria, particularly
when malaria transmission is intense in border areas, and other health issues are being
addressed by countries working together (eg. as in the Mekong Region and other
situations).
It may be useful for partners to distinguish political, institutional and programmatic
dimensions of the inception process:
■
■
■
The political dimension is crucial because each country will drive its own
movement to roll back malaria. This calls for building awareness, generating
political support in country and encouraging commitment among key stakeholders,
including donors
The institutional dimension is important because different levels of government
(national, regional and local) each have a role; stakeholders (NGOs, media and
researchers) have important parts to play, and need to be able to work together
effectively; public-private partnerships will be established or revitalized;
transparent systems are needed to handle decentralised action and resources use
The programmatic dimension starts from an appreciation of health sector and
malaria control activities; it includes the planning and implementation of action to
expand access to, and improve the quality of, health care delivery (including
malaria activities), and defining a system to follow them up.
During the inception process, a clear statement about how different groups will work
together to address these dimensions, and so help reduce the malaria burden, should be
produced. This is referred to as the intention statement for action to Roll Back
Malaria. The following sections outline a framework for action during the inception
process.
A Framework for RBM Action: the inception process -13.08.1999 draft 2
Page 9
Programmatic Dimensions of the Inception Process
5.1
Undertake a quick, but accurate, analysis of malaria issues within the context
of wider health and development policies. The analysis should review the
situation on health sector development and actions to roll back malaria. Involve
people with malaria expertise in the analysis.
■
■
■
■
■
Start with a clear appreciation of what is already happening - how malaria
is affecting poor people, especially their women and children?
What is the strength of the information system? Can it adequately inform
decision-making about malaria and other health issues? How can malaria
risk maps be developed? Is an environmental assessment available?
Can people at risk of malaria access and implement relevant preventive
measures? Can they access effective treatment promptly? What are the
levels of drug resistance?
Are there systems for predicting and reacting to malaria epidemics? Howwell are they working?
How are people, civil society and government responding to the current
health situation? (Consider access to and quality of health care delivery,
including availability of medicines, community participation, private
sector, and management issues). Is the response affected by civil disorder,
conflict or natural disaster (floods, storm damage etc)?
In some cases this situation analysis may require systematic collection of
relevant information. The WHO RBM project has developed guidance for
situation analysis and for rolling back malaria in complex emergencies: this
can be made available on request.
5.2
Look for examples of sustained success - from within the country, as well as
from outside; use WHO and other agencies’ experiences to help identify best
practices.
5.3
Consider options for action - for doing much more - to help communities
Roll Back Malaria successfully, through wider health sector action and inter
sectoral development. Define the basic health interventions needed by poor
people: this will include interventions for the integrated management of
childhood illness, safer pregnancy, malaria prevention and treatment, etc.
Consider medium and short term plans for expanding access to, and quality of,
health care, and for rolling back malaria. Identify short (2 year) and medium
term (5 year) targets for action.
5.4
At the same time, identify the people (and organisations) who will be most
involved in the effort to Roll Back Malaria. Include civil society and providers
outside the public sector. Engage them in the analysis and planning work;
establish a consensus about what needs to be done.
5.5
Identify the resources that can be used to Roll Back Malaria - from within the
country, as well as from outside, recognising that these are not just resources
earmarked for malaria: they will be provided for health sector development.
Find out the existing human and financial resources available for rolling back
malaria within the country. Consider how they are being used. Might
A Framework for RBM Action: the inception process - 13.08.1999 draft 2
Page 10
additional resources be available - from within or outside the country? How
could they be mobilised? One way forward is to prepare an inventory of
potential existing resources at country level, and ways to mobilize them more
effectively. Consider the possibility of redirecting resources; consider ways in
which current resources might be used more efficiently. Ensure that there are
adequate skilled personnel available to use resources optimally
5.6
Establish a broad partnership of groups who are committed to joint action;
encourage government to raise malaria issues during high level dialogue with
donors and representatives of UN systems agencies; and establish how partners
will work together effectively. Keep the partnership under the spotlight ensure that the heads of delegations of development partner organisations are
kept informed of progress
5.7
Produce a statement of intent for the partnership, indicating what will be
achieved within five years, and milestones to be reached after two years;
develop a plan for a two year period which shows how different groups will
use the resources available to them to support community-level action to Roll
Back Malaria, and what will be achieved with them.
5.8
Mobilise resources from partners, use them to support community-level action
through health systems and efforts in other sectors, and monitor what is
achieved against the milestones in the plan
5.9
Establish and implement a system for monitoring and evaluation: define
indicators and mechanisms for monitoring and evaluation during the inception
process, ensure that resistance to drugs and insecticides is monitored.
Political dimensions of the Inception Process
5.10
Build a constituency for political support:
■ engage all prominent figures (Head of State, entire government, senior
political, religious and cultural figures);
■ stimulate debates in the national assembly;
■ encourage activities to mobilize societies around health issues and rolling
back malaria at community level;
■ encourage politicians to demand information and commit themselves to
getting results.
5.11
All this time, undertake high-level advocacy, with strong and accurate
messages, to catalyse a national movement to Roll Back Malaria, ensuring that
these messages are relevant to, and understood by, community-level groups. A
strong and visible publicity campaign to launch RBM at country level may be
needed early on. This will set the stage for people from all sections of the
community to participate in the RBM process from the beginning. The WHO
RBM project, and other partners, can help with materials - particularly with
examples of what it being undertaken elsewhere.
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Page 11
Institutional dimensions of the Inception Process
5.12
National efforts to RBM should contribute to a reduced malaria burden AND
benefits for the health sector as a whole. They should build on existing good
malaria practice, and good practice in institutional development. A wide
selection of stakeholders needs to be involved in analysis, strategy
development and action so that these institutional issues can be properly
examined.
5.13
Establish teams (or task forces, or committees) to take the work forward.
Consider at least two teams.
■ The first would be political, and involve the Head of State, government,
political representatives, civil society; it would be heavily involved in
advocacy work and catalysing the movement to roll back malaria.
■ The second would be technical, chaired by the Minister for Health or
her/his nominee, with representatives from service providers, those who
generate resources, other sectors, with a remit to plan health sector
development activities, oversee their implementation and monitor their
results.
■ A subcommittee of the technical body — the malaria control committee,
including the national malaria control programme and malaria experts in
the country, might be given responsibility for tracking the progress of
actions to roll back malaria, and advising on any changes that may be
needed.
5.14
Where possible, build on teams that already exist if they are able to take on
the challenge of RBM action. They may be working on other aspects of health
development (eg health sector reform, or the sector-wide approach). They may
be able to prepare the national RBM effort; indeed RBM may provide an
opportunity to energize these mechanisms. They may need additional capacity
(in terms of time and skills) to plan and implement the inception process
effectively.
5.15
Identify the people who will get RBM action rolling. A critical mass of
‘ movers’ is essential. These will be persons from within and outside
government, from capital cities and local communities, and from different
professional and business groups. They will be people with enough energy,
skills, influence and ability to get people involved. They will maintain a focus
on results. They will usually be busy people who will need to be persuaded
that Roll Back Malaria is a good issue for them to take on. The “movers”
should include representatives of development agencies wherever possible.
5.16
Build Consensus through meetings of interested partners. The building of
consensus among key stakeholders is a critical part of the inception process at
country level. An important step in the inception process is a meeting of
interested persons and groups at country level convened by the Ministry of
Health. This is usually described as the consensus building and inception
meeting. It could involve representatives of Government departments, civil
society, private sector and development partners. The purpose of the meeting
would be, among others, to, build consensus and start establishing intentions
for the national RBM effort.
A Framework for RBM Action: the inception process - 13.08.1999 draft 2
5.17
Page 12 *
Consider the institutional issues in Roll Back Malaria:
■
What contribution does the national malaria control programme make? Is
it integrated within wider communicable disease and public health
services? How does the national malaria programme contribute to malariarelated action within decentralized health sendees?
■
How are programmes such as the integrated management of childhood
illness, safe motherhood, programmes for displaced people contributing to
a reduced malaria burden?
■
What contributions do existing community development and primary
health care activities make to rolling back malaria?
In each case, how effective are these contributions? What are the gaps? To
what extent are they influenced - in some districts or regions - by external
factors, such as civil strife and conflict?
What is the potential for intensifying the impact of these efforts given current
levels of human and financial resources?
How could funds be made available for an increased effort in malaria control
within the context of wider health sector development?
5.18
Consider how to involve a wide range of groups in Roll Back Malaria
action:
Involve groups beyond the public-funded national health service.
■
Can private providers, traditional practitioners and NGOs do more?
■
How well are research groups involved?
■
Is there a place for more social marketing of preventive and treatment
measures? How could it be supported?
■
Is there a need to make more use of commercial channels to support RBM
action?
■
Are communities taking action to reduce the malaria threat within the
context of other social movements for health?
Seek w ays to build partnerships with groups that are ready to come on board.
New kinds of incentives and contracting mechanisms may be necessary to
work with these groups in enabling poor people to access the health care they
need.
A Framework for RBM Action: the inception process - 13.08.1999 draft 2
5.19
Page 13
Consider practical ways in which the Roll Back Malaria effort can
contribute to national health sector development
How could national efforts to Roll Back Malaria be designed so as to
contribute to strengthening health sectors? What might this mean in practice?
5.20
•
The malaria burden experienced by the people of a country is unlikely to
be reduced in a significant and lasting way without a well-functioning
health system. The Roll Back Malaria movement is not - in itself - taking
responsibility for strengthening the health system. However RBM action
should contribute to, and not undermine, this process.
•
In malaria affected countries, health systems cannot be judged to be
functioning well unless they have an impact on malaria. The way in which
the health system tackles malaria - particularly among poor people - is a
key element of the assessment of that system’s overall performance
•
RBM action should make a major contribution to health sector
development through focusing on outcomes (enabling poor people to
reduce their malaria burden) without reverting to vertically managed
systems. Guidance on this issue is available from the WHO Roil Back
Malaria project.
Consider the human resource capacity needs within the health sector for
effective action to roll back malaria
Many countries report that they are not easily able to address Roll Back
Malaria issues - particularly when the administration of health care is
decentralised. The main reason for this is that they lack the people with skills,
and time, to provide necessary inputs to technical and operational decisions
about malaria action. Where the capacity is available, it is not always used to
best effect.
In practice this may be reflected in the need for extra human capacity to ensure
■
■
■
■
■
the proper prioritisation of Roll Back Malaria outcomes within Health
Sector Development efforts,
the definition of these outcomes, and desirable actions to achieve these
outcomes, within the context of the malaria situation, resources available
for health sector action, reviews and evaluations of what has previously
been achieved through health sector action;
a transparent and justifiable process for the allocation of human and
financial resources for the achievement of these outcomes within the
context of public health, curative care, health education or related efforts
within the health sector,
reviews of the effectiveness with which these resources are used,
plans and actions for human resource development in relation to
communicable diseases in general and roll back malaria in particular.
Capacities have to be available at national level, but also - in decentralised
systems - at other levels where resources are allocated. In general, malaria
A Framework for RBM Action: the inception process - 13.08.1999 draft 2
Page 14
expertise has tended to be located within malaria control programmes, and not
made available more widely. For effective action to roll back malaria, capacity
should be available where it is needed - throughout the health sector.
WHO will work with partners to explore how Roll Back Malaria action can
best be incorporated within sector wide approaches to health development.
6. Financial and Technical Support for the Inception Process
WHO, through the Roll Back Malaria project, can offer limited technical and financial
resources to help countries conduct productive consensus building and inception
processes, and seed-com funding for action to Roll Back Malaria. It can also offer
technical support with specific actions that are critical to the success of efforts to roll
back malaria, as part of the wider effort to build capacity for RBM action. This is best
provided when a country-level parmership exists, and partners are able to agree on the
most appropriate inputs required of different partner agencies. Hence it is desirable
that all partners - under the leadership of the national authorities - are fully involved
in the inception process to the best of their ability. They should do their best to work
together in response both to health sector development issues - including the roll back
malaria effort - and acute worsening of the malaria situation difficulties associated
with epidemics, population movements, instability and conflict, and/or climate
variation.
7. Communication with the WHO RBM Project
The WHO RBM project operates to provide support to national RBM partnerships.
WHO staff - whether at headquarters, regional or country levels, work as one team on
Roll Back Malaria and similar health issues. Mechanisms to ensure efficient
communication between the WHO country office, the regional office and the project
HQ in Geneva, and with partners, are being worked out. At this time, all
correspondence should be communicated by e-mail, fax or normal mail and pouch to
the relevant regional office of WHO (Division of Disease Control, or equivalent). The
RBM project works closely with other global health initiatives (Stop TB. Tobacco
free, etc.) and there is value in exchanging experiences. It would be useful if the RBM
Project headquaners in Geneva can be kept informed of progress in the country
partnerships: of highlights as well as difficulties. Information will be fed back to
partners regularly.
8. Request for Feedback
Many recipients commented on the first draft: we have attempted to take these
comments into account. Please continue to comment on content, style, and subjects
for future notes. We anticipate that notes will be issued every 4 months.
Dr David Nabarro, Manager, World Health Organisation Roll Back Malaria Cabinet
Project e-mail: rbTn@who.int
wr2907c
3?^ <
DISASTER INFORMATION
Dear friend.
You, your family and community have recently experienced the most distressing disaster, i.e., the
earthquake. The horrific effect of this earthquake will be still fresh in your mind as well as in that
of other affected like you. Help has been coming in from different quarters, to as many people as
possible. The painful experience and its consequences are personal. The people around you would
be reacting to this unexpected event in different ways. Many a time you will find yourself alone,
not even able to talk about the disaster to others, especially since several of them too are not in a
position to either help or comfort. We feel it is imperative and vital for you to recognise these
feelings and personally make an attempt to recover in a healthy and positive manner.
Immediate (at the time disaster)
It is necessary to be aware of the various reactions during and after the earthquake. This will help
you understand your emotions, your behaviour and the recovery methods adopted by yourself. The
main aim of this understanding is to help you and others recover in a healthy and positive manner.
During the earthquake each one of you have experienced the massive loss of either human lives or
property or shelter or cattle, or all. The emotional reactions to the earthquake and the loss are often
not recognised and understood by many as being natural and expected, Let us examine the
immediate reactions of people to the earthquake.
® Shock and or Disbelief
Gujarat has often laced natural calamities like drought , cyclone, earthquake and floods. But this
earthquake struck at the most unexpected hour. You would have been caught unawares - totally
unprepared. But, in spite of this , you have worked hard to save your life as well as that of others.
Similarly , there would certainly be other in your community who have gone through the same
experience. However, some persons in the community would have reacted with shock and shown
decreased activity. Another common emotional reaction is to feel that the whole event was not real
but a bad dream, i.e. one of total disbelief.
• Panic
Panic at the time of undergoing very severe stress is common and normal. Hence for people to
panic at the time of a earthquake is normal. Just as an example, imagine a large number of people
entrapped in the rubble with a small space. It would only be natural that all of them will panic
and try to get out at the same time causing a stampede.
After the Earthquake
® Shock
You find it difficult to believe that disaster has actually happened - that the earthquake has ripped
hrouah leavmg behind so much death and destruction* All routine activities have come to a
standstill due to the earthquake and this adds to feeling lost. The all round confusion further
intensifies this.
RECOVERY MECHNISMS
Symptoms start decreasing in most people in a few weeks when they initiate some actions to
reorganise and rebuild themselves. After a few weeks/ months, even though the memories of ike
disaster remain, they do not stop you from going ahead with your life.
HOW CAN YOU RECOVER?
To promote recover we suggest the following to be done:
At a Personal Level:
X
X
>/
Listen to authentic information about the earthquake.
Do not believe in rumours that go around during such times.
Be together with family members.
Do not send women, children and the aged to far off places for the sake of safety as ibis
separation can cause a lot of anxiety to them and you.
Be with people from the same village, i.e. people you are familiar with, even if you arc' in
temporary dwellings.
Get back to a daily routine as soon as possible to make you feel that you are in control of
the situation.
Make it a point to talk about the earthquake share your experience and feelings with
your family, your parents, friends, spouse, siblings, acquaintances. This will help
ventilate/release your emotions.
Restart activities that are special to your family like having meals together, praying, playing
games, singing , etc.
Keep touching and comforting your parents, children, spouse and the aged in your family.
This will not only make you feel good but also make the other person feel the same.
Initiate and participate in rituals like collective, grieving, prayer meetings or gnjip
mournings if you have lost a near and dear one. This will help you come to terms with {lie
loss of the person .
Take part in rescue, relief and rehabilitation operations, if you are not hurt or qnly
slightly injured. Work is a good tonic for healing.
Keep in constant TOUCH in case of a member of the family having to be shifted to a far
off hospital or residence. Update him/her about yourself as well as find out about him/i^r.
This gives a feeling of being cared for.
Take time everyday to relax and have a good time by gathering together at a central
place/point, playing kabbadi, reading, listening to music, visiting shrines, singing hymks,
chanting prayers, reading scriptures.
Make time for yourself and a acknowledge and admit that you will not be always
functioning at your usual level of efficiency for a few weeks/months.
At the Community level:
Immediate
>/
Disseminate authentic information about the disaster and the help available either by
going around personally or using loudspeakers or posters/placards.
Organise groups for rescue operations. Help to remove debris, shift people to safe place,
help the disabled, and share food, water and medicines. Identify groups for each activity
and a leader for each group. The whole village should be involved in planning rescue, relief
and rehabilitation operations.
Listen u and encourage other people talking about the disaster, etc.
Encourage the group to focus on the special groups like the children, women, disabled and
elderly.
Organise people to present their needs and difficulties to the administrators in a collective
manner.
Bring together people of the community for sharing of grief/community mourning.
Organise self help groups to procure aid and to discuss emotions associated with the
disaster. Self-help groups should have people with similar needs. For example, people who
have lost family members could join together to grieve and later work on it.
Organise weekly meetings to share information and sing together.
Prepare yourself for delays and difficulties.
In Future
Seek information about help extended and organise groups to represent your village to seek
help/aid.
Actively mobilise action for reconstruction and rehabilitation work. Take care that this
includes all aspects of a community to be disaster proof, where agriculture, electricity, health
care, education, etc. are concerned.
Continue dialoguing with government officials and NGOs for a persistent effort on relief
and rehabilitation.
Compiled by NA TIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES,
BANGALORE.
PSYCHO SOCIAL CARE BY COMMUNITY LEVEL HELPERS
INTRODUCTION
The recent disaster in Gujarat was brought about by a devastating earthquake. This is
unexpected and unanticipated at this time. Thousands have either died or are reported
missing and several lakhs have been rendered homeless. In addition, there has been
extensive damage to all other property. Along with relief, rehabilitation and the care
of physical health and injuries, mental health issues need to be given importance. As
in other major disasters, the magnitude of mental health problems is enormous. Apart
from material and logistic help, the suffering human being will require human
interventions.
CARE OF PSYCHOLOGICAL PROBLEMS
Who is a Community Level Helper?
Any community when faced with a disaster of whatever magnitude, responds in its own
way to the situation. One such response is the reaction of several local people or groups
of people who immediately come forward to help in one way or the other in order to
alleviate the situation. They are the Community Level Helpers (CLH). They are a vital
link between the affected population and the helping agencies (individuals, NonGovernmental Organisations, Governmental Organisations).
At the early stages following disaster, most survivors are psychologically open and
willing to talk about their experiences. This may change later into a defensive, noncooperative attitude if time passes without attempts at providing help. Therefore, it is of
utmost importance that survivors are encouraged to seek help and talk about their
psychological problems as early as possible. This intervention will prevent the
persistence of problems and development of further complications. Remember, people
do however talk about themselves when given an opportunity to do so.
Psychological intervention can be provided to the family in the daily visits by monitoring
and noting down informatin - all by the CLIIs. Such visits are to be utilised for talking
about the survivor’s feelings and experiences, imparting health education, discussion of
health problems, motivating individuals to hold group meetings, and organising
educational activities.
•
No one who experiences the event of witnesses the event is untouched by it.
Disaster, depending on the nature and magnitude can cause enormous loss to life,
property and the environment of the area. Grief, sadness, anxiety, anger arc common in
such situations. Individuals find comfort and reassurance when told that their reactions
are normal and understandable in every way. Therefore, CLHs help to educate the
survivors about common disaster stress reactions, ways to cope with stressors and
available resources to respond to their needs.
1
•
Disaster results in two types of trauma
Disaster - affected population have individual and collective trauma. Individual trauma
manifests itself in stress and grief reactions, while collective trauma can severe the social
ties of survivors with each other.
•
Most people pull together and function during and after a disaster but their
effectiveness is diminished
A disaster survivor is confronted with multiple stressors. In the initial phases there is
much energy, optimism and altruism. There is often a high level of activity with low level
of efficiency. As the reality of losses becomes more clear, frustrations and
disillusionment set in, leading to more stress symptoms. This can impair the survivor’s
ability to make sound decisions and take necessary steps towards recovery and
reconsstruction.
•
Disaster stress and grief reactions are normal responses to an abnormal
situation
Stress reactions and grief responses are common in disaster survivors. Public
information about normal reactions, education about way to handle them, and early
attention to symptoms that arc problematic has hasten recovery and prevent long
term problems.
• Many emotional reactions of disaster survivors stem from problems of living
caused by the disaster
Disaster disrupts all aspects of daily life resulting in practical problems like finding
temporary housing, food, clothing etc. Timely and appropriate relief and support
measures arc very vital to help survivors handle the disruption.
•
Survivors respond to active interest and concern
Survivors will usually be eager to talk about what happened to them when approached
with warmth and genuine interest. Workers should not hold back from talking with
survivors out of fear of intruding or invading their privacy.
•
Support systems arc crucial for recovery
The most important support group for individuals is the family. Workers should attempt
to keep the lamily together and the members encouraged to be involved in each other’s
recovery. For those who arc orphaned or have become single, support from other groups
can be helpful.
2
Helping people help themselves
Listening
♦
♦
♦
♦
♦
Look at the person while he/she is talking : This indicates being interested in what
is being said.
Respond occasionally while listening : This makes the person speaking feel what
he/she is saying is being understood and taken seriously.
Avoid interruptions : Let the other person finish his/her thoughts. Do not interrupt
unless there is confusion and the details arc jumbled.
Be tolerant: Do not prejudge or moralise or condemn.
Empathise : Share the experiences of the other person as if they are your own. It is
based on the sensitivity and ability to recognise when the other person is going
through certain feelings or emotional experiences.
Ventilation : This process involves release of emotions and feelings. It is very important
intervention and should be used as soon as possible after the cartquake.
WHAT SHOULD YOU DO?
♦
♦
♦
♦
♦
♦
Listen carefully and attentively.
Maintain eye contact.
Acknowledge distress.
Do not interrupt.
Support by patting on the shoulders/hold the hand as they cry.
Do not ask them to stop crying.
Relaxation Exercises
Encourage survivors to undertake rclaxation/brcathing exercises regularly several times a
day. This helps them gain control over their agitation and anxiety.
♦
Instructions: The person should sit in a squatting posture and place his/her hands on the
knees. Then take a deep breath, hold it for a few seconds and slowly exhale. Encourage
him/her to do it for 5-10 minutes steadily and slowly. Repeat this at least twice a day.
FAMILY LEVEL
♦
♦
♦
♦
♦
♦
the Family as a group to share the losses
Encourage family members to contact relatives. This will help mobilise support and
facilitate recovery
Rituals like prayers, keeping the dead persons photographs, preserving the
belongings of the dead person or persons
Encourage the survivors to engage in meaningful activity as a family
Recreation like listening to Radio, TV or visiting melas
Resume normal activities of the pre-earthquake days with the family
2
♦ Support each other at home. Emphasise that the family should regularly undertake
activities together at home
COMMUNITY LEVEL
H Group mourning: Grief resolution should occur at the personal, family and the
community levels. Group Mourning is a process of mass grieving. It expresses
solidarity of the grief-stricken community and facilitates unity and collective action.
Such activities should be initially organised on a weekly basis, gradually on a
monthly basis, and later annually.
Group meetings: Group meetings are important activities where the community as a
whole participates. This stimulates the people to think, and brainstorm about various
themes for rebuilding the community.
Folk songs: Singing of folk songs about the earthquake tragedy, its impact and them
mourning. This helps people gather in a common place and share their grief.
Devotional songs: Singing devotional songs like hymns/bhajans, etc. is helpful.
Consider referral lo a menial health agency if the client:
is depressed and shows agitation, restlessness, and paces up and down
is a pathetic, immobile, unable to move around
discontent
mutilates him/herself
uses alcohol or drugs excessively
is unable to care for him/herself, e.g., docs not eat, drink, bathe, change into fresh
clothes
♦ repeats ritualistic acts
♦
♦
♦
♦
♦
♦
Consider referral to a mental health agency if the client:
♦
♦
♦
♦
♦
♦
♦
hallucinates - hears voices, sees visions, or has unverified bodily sensations
states the body feels unreal and fears he/she is losing his/her mind
is excessively preoccupied with one idea or thought
has the delusion that someone or something is out to get him/her and the family
is afraid he/she will kill him/herself or another
is unable to make simple decisions or carry out everyday functions
shows extreme pressure of speech - talk overflows
4
Tips to make you an effective community level helper
Dos:
Visit families regularly
Accept food or drinks like coffee or tea if offered
Help survivors to get medical care or other help if needed
Provide clear guidance about compensation or ways of getting it
Provide practical help whenever necessary
Facilitate networking among survivors
Contact relatives )e.g., writing letter) and appeal to them to meet and support
survivors
DON’Ts:
X
X
X
X
X
X
Do not promise things you cannot do or things beyond your control
Do not take decisions for them for c.g., marriage or money handling, etc
Do not get upset with the behaviour of survivors. Sometimes they are
unreasonably angry/blame you for causing trouble to them by your frequent visits,
or at times they might be very demanding
Do not miss appointments
Do not overburden yourself with lot of work
Do not take sides in family conflicts
Compiled by NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES,
BANGALORE.
5
PSYCHOSOCIAL ASPECTS OF DISASTER
MANAGEMENT
Dr. Mohan Isaac
Professor of Psychiatry
Department of Psychiatry
NIMHANS
Bangalore
Report prepared for the High Powered Committee on Disaster Management
Plan, Govt of India, Ministry of Agriculture, Krishi Bhavan, New Dellii.
z
'^7) 5
PSYCHOSOCIAL ASPECTS OF DISASTER MANAGEMENT
CONTENTS
1.
Introduction
2.
Psychosocial reactions to disasters
2.1
Historical aspects
2.2
Different phases of psychosocial consequences
2.3
Frequency of psychosocial problems
2.4
Determinants of psychosocial reactions
2.5
Specific psychiatric disorders
1.
Acute Stress Disorder
2.
Post-Traumatic Stress Disorder (PTSD)
3.
Bereavement and Grief
4.
Anxiety Depressive and Somatoform Disorders
5.
Alcohol and Drug Abuse
6.
Exacerbation of pre-existing disorders
2.6
Consequences of disasters on population with higher risk
2.7
Effects on rescue workers
3.
Principles of psychosocial interventions in disasters
4.
Current mental health infrastructure in india
4.1
Services for the mentally ill
4.2
District Mental Health Programme
4.3
Disaster Mental Health
5.
Psychosocial interventions in disasters
5.1
Full integration with overall relief and rehabilitation activities
5.2
Goal and focus of psychosocial interventions - strengthening local
resources
&
5.3
Provision of information
5.4
Helping people to help themselves
5.5
Establishment of Support/Information Centre
5.6
Training in mental health for primary care personnel
5.7
Information and training for community level workers
5.8
Involvement of other sectors and NGOs
5.9
Debriefing for rescue workers
5.10
Help for bereaved families
5.11
Help for the physically injured and their families
5.12
Help for severely mentally disturbed persons
5.13
Help for orphans/widows and others in special needs
5.14
Role of mental health sector/professionals
5.15
Need for a National Disaster Mental Health Team
5.16
Resource guide/manual
5.17 Researchon psychosocial consequences of disasters in India
5.18
6.
Resources available for psychosocial interventions in India
Bibliography
Appendix I - Resources available for psychosocial interventions in
disasters
Appendix II - Institutions which can iprovide
'' inputs
'
in training and research
in the area of Disaster Mental Health
Appendix III - Information Manual on Psychosocial Care for Individuals
Appendix IV - Information Manual on Psychosocial Care for Community
Level Helpers.
PSYCHOSOCIAL ASPECTS OF DISASTER MANAGEMENT
L
INTRODUCTION.
1.1
Disasters are of common occurance. A simple definition of disaster
is a “crisis situation in which demands far exceed capabilities” (Quarantelli 1985).
Disasters cause severe ecological economic and/or psychosocial dismption and
result in widespread damage and suffering. Occurance of disaster, both natural and
manmade have been steadily on the increase all over the world. It is estimated that
one in four people will experience a traumatic event such as a natural disaster,
internal conflict, war or violent abuse at some time in their lives (Larkin 1999).
1.2
The United Nations Disaster Relief Organization (UNDRO)
recognizes that “the smallest and poorest countries are affected most severely by
both natural and man-made disasters and the poorest and most disadvantaged
members of a disaster affected community are likely to experience the most
serious consequences” (UNDRO 1985).
1.3
The United States Agency for International Development estimates
that in this century, from 1900 to 1986, there have been 2392 major disasters
worldwide excluding the United States. Of these 86% (i.e. 2036) occurred in the
developing countries, causing 42 million deaths and affecting 1.4 billion
individuals. 78% of all deaths occurred in developing countries and 97.5% of all
affected individuals were located in developing countries. The observed ratio
between the number of affected individuals and the number of killed was only 2.9
for the developed countries while it was more than ten times greater (32.9) for the
developing countries (US AID-1986). Therefore, disasters occur more frequently,
kill disproportionately higher proportion of people and leave behind higher
proportions of affected individuals in developing countries.
1.4
Psychosocial aspects of any disaster are in general poorly
understood. They are often unrecognized and un-cared for. This is particularly
true for India. A national workshop on psychosocial consequences of disasters
held in Bangalore in 1997 noted with concern: ‘The current situation is
characterized by lack of awareness among the public, high stigma among the
population affected by disasters in seeking mental health care, lack of mental
health professionals and infrastructure, lack of professional leadership and
political unwillingness. In most situations the response has been ad hoc and short
term. There are rarely any long term studies or interventions” (NIMHANS 1997).
1.5
It is now generally well accepted that psychosocial consequences are
widely prevalent among populations affected by various types of disasters.
However, the psychosocial needs are generally seen as something too secondary' to
attract the attention of relief agencies, relief workers and governmental
organizations (Jaswal 2000).
1.6
Even when mental health interventions are undertaken to deal with
the psychosocial consequences of disasters, they are “unplanned, uncoordinated,
sporadic and often a one time activity. Poor coordination, lack of transparency and
hesitancy to commit to long-term endeavors hinders the adoption of mental health
component into the developmental process during the rehabilitation phase”
(Gandevia 2000).
1.7 There is an urgent need to recognize the importance of psychosocial
consequences of disaster and develop a policy as well as a specific plan of action
for psychosocial care of disaster affected population which can be integrated into
the overall disaster management strategy.
2.
PSYCHOSOCIAL REACTIONS TO DISASTERS
2.1 Historical aspects:
Both acute and long-term mental health and psychosocial consequences of
intensely traumatic events have been recognized for nearly 100 years. Trauma
related mental syndromes were first documented following wars. Although
observations of ‘‘battle fatigue and “shell-shock’1 were made following the two
world wars, it was the identification of trauma-related mental health consequences
in Vietnam war veterans in the United States which helped in the clearer
understanding of “reactions to severe stress”. Documentation of mental reactions
to the Holocaust and to a series of various types of natural disasters contributed to
the growing recognition of trauma related mental syndromes. One of the earliest
systematic civilian studies on the psychological reactions to disasters was carried
out by Erich Lindemann during the early 1940s. He conducted his classic study on
the survivors of a tragic night club fire in Boston in November 1942 which killed
491 persons (Coconut Groove night club fire disaster, Boston, Lindemann 1944).
Much of the mental health interventions for disaster survivors carried out today,
particularly for dealing with bereavement and grief are based on observation of
Lindemann. During the past 2 to 3 decades, there have been a growing number of
systematic research studies on the mental health consequences of disasters. The
disasters whose consequences have been studied include floods, earthquakes,
cyclones, ship wreck, nuclear disaster, terrorist bombing, ice storm, bush fires etc.
2.2.2 Different phases of psychosocial consequences following disasters:
The psychosocial reactions as well as the symptoms of distress and their
intensity are different at different points in time after the disaster. Three
discernible phases can be identified following a disaster as far as the psychosocial
consequences are concerned. The first is during and immediately after the event.
The intense emotional reactions which occur during this period may go on in the
same manner for a period of 4 weeks or more. This acute stress reaction’ is
sometimes also referred to as 'disaster syndrome'. “The immediate reactions
reflect the most horrifying dimensions of disaster and is related to severe physical
injury, exposure to extreme danger, witnessing death of close ones or mass deaths
and injuries, traumatic experiences of helplessness, hopelessness, separations and
the need to choose between helping others or fighting for ones own survival”
(WHO 1982). The second phase is the period after the first month to about 6
months after the disaster. The third phase is the period after 6 months during
which time some of the delayed manifestations of post-disaster stress may occur.
2.3
Frequency of psychosocial problem following a disaster:
A number of studies have been carried out in different parts of the world
and following different types of disasters to assess the frequency and magnitude
of mental health problems which follow disasters. Immediate as well as long term
effects, and consequences on special groups of population such as children have
also been studied. While various studies have suggested significant consequences,
others have suggested either little or no major negative effects (Lima et al 1988).
The variations in the magnitude of the problem reported by different authors may
be related to a variety of factors such as the research methodology and sampling
procedures adopted, criteria as well as method adopted for case identification,
assessment and classification, timing of the study, characteristics of the disaster,
social preparedness as well as other demographic background of the population
etc. Workers in the field of disaster mental health hold different views about the
nature and extent of mental health consequences. While many authorities believe
that disasters represent catastrophic events which produce adverse psychological
reaction to almost entire affected population, others suggest that the extent of the
problem may be overestimated and that psychological problems due to the
stressful event may appear only among people with a pre-existing vulnerability
(WHO 1992). Some critics argue that reactions to disasters are normative and
adaptive social responses which would undergo natural remission over time and so
should not be medicalized. However, for disasters in developing countries,
clinical observations, empirical evidence and research data indicate that
psychosocial consequences are usually significant and hence should be handled
promptly and effectively (Lima 1988, Jaswal and Gandevia 2000).
A ‘disaster syndrome’ represented by the immediate post-disaster reaction may be
present in upto 75% of victims during the first hours or days after the event (Duffy'
1988). During this period anxiety and anxiety related reactions may be extremely
common. Levels of anxiety remain high in the early weeks. However, by about
10 weeks, there is usually a significant drop. Overall psychological morbidity
tends to affect some 30 to 40% of the disaster population within the first year
following the disaster (Raphael 1986). By the second year, the morbidity levels
are lower but for some individuals exposed to certain type of disasters the
symptoms may remain chronic. A review of 52 studies which analyzed the
relationship between disasters and subsequent psychopathology showed that 7 to
40% of all subjects who were exposed to the disaster showed some form of
psychopathology such as generalized anxiety, phobic symptoms, psychosomatic
symptoms, depression and alcohol/drug abuse (Rubonis and Bickman 1991).
Meta analysis of these studies showed a positive relationship between disaster
occurrence and psychopathology. An increase of approximately 17% in the
prevalence rate of psychopathology was noticed in the disaster population as
compared with the prevalence rates in a pre disaster or control population
(Rubonis and Bickman 1991).
2.4 Determinants of psychosocial reactions :
World disaster report (1996) states that “many factors may affect how an
individual reacts to a traumatic event. The most important individual factor is the
level of personal loss and the meaning of that loss. Death of a spouse or child will
have a significantly greater meaning than loss of a home, career or personal
possessions”. Prior history of trauma, such as having survived the loss of another
relative, previous disaster losses, job loss, or unresolved grief from other events
may have an impact on disaster consequences as well as recovery from these
consequences.
Premorbid vulnerability as well as past liistory of mental
illness/treatment are also important predictors of psycho pathology' following
disaster (McFarlane 1990). It is also known from several studies that in addition
to background characteristics of the population, several disaster-exposure related
as well as post-disaster variables could be significant predictors of various
psychosocial consequences. Strong sense of self esteem, personal belief system
which enhances one’s ability to cope with stresses, perceived family support and a
strong social support system, and religious affiliation are all factors known to
modulate the incidence, pattern, course and outcome of psychosocial
consequences of disasters.
2.5 Specific psychiatric disorders that may occur following disasters :
2.5.1 Acute stress disorder :
Immediately after a disaster, large number of people may experience
symptoms such as shock, disbelief and numbness, sleeplessness, intense anxiety
and fear, anger, various bodily complaints, anticipatory anxiety, frightening
‘flashbacks' of the traumatic experience, nightmares, vivid memories of the
terrifying moment of trauma, despair and grief. In some people, these symptoms
may be more intense and significantly disabling. The syndrome is then referred to
as ‘Acute stress disorder’. According to the Diagnostic and Statistical Manual of
the American Psychiatric .Association (4th edition DSM IV). some of the important
criteria for acute stress disorder are
“The person should have been exposed
to a traumatic event in which he/she experienced, witnessed or was confronted
with an event or events that involved actual or threatened death or serious injury or
a threat to the physical integrity of self or others resulting in intense fear,
helplessness or horror”. “Persons also suffer from symptoms such as subjective
sense of numbing, detachment or absence of emotional responsiveness, reduction
in awareness of the surroundings, persistent re-experience of the traumatic event
by recurrent images, thoughts, dreams etc. flashback episodes, sense of reliving
the experience, marked avoidance of stimuli that arouse recollection of the trauma,
and symptoms of increased arousal such as difficulty in sleeping, irritability, poor
concentration, hyper vigilance, exaggerated startle response and "motor
restlessness”. The disorder usually occurs within 4 weeks of the traumatic event
and causes clinically significant distress or impainnent in social, occupational or
other important areas of functioning.
2.5.2
Post-traumatic stress disorder:
Post-traumatic stress disorder (PTSD) is characterized by symptoms
similar to acute stress disorder but lasting for more than 1 month. PTSD may
begin several weeks or months after the exposure to disaster and if untreated, may
run a protracted course. The symptoms of PTSD usually occur in 3 dimension
namely, (i) re-experiencing the trauma, (ii) avoiding stimuli associated with the
trauma and (iii) experiencing symptoms of increased autonomic arousal such as
difficulty in falling or staying asleep, irritability or outbursts of anger, difficulty in
concentrating, hyper vigilance and exaggerated startle response. It is estimated
that around 15% of those exposed to disasters will develop PTSD. Although until
recently PTSD was considered to be a purely psychological consequence of
disasters, accumulating evidence indicates that it may have a strong biological
component (Larkin 19990.
2.5.3 Bereavement and grief:
Grief refers to “the feelings and behaviours such as sadness, distress, anger,
crying etc accompanying the awareness of irrevocable loss (not necessarily but
including loss through death)’1. The term bereavement is used when the loss is
through death. Following disasters there may be grief for the loss of loved ones,
home, valuable possessions, livelihood etc. Factors influencing the manifestations
of grief include the individual’s personality, previous life experiences, past history
of psychological problems, the significance of the loss, the existing social network
and presence of other stressors. Usually grief reactions diminish in their intensity,
gradually over a period of several weeks after the disaster. But, for some persons,
grief may become chronic and may lead to severe depression.
2.5.4 Anxiety, Depressive and Somatoform Disorders :
Various diagnosable psychiatric conditions may occur following exposure
to disaster. These include anxiety disorders, depressive disorders and somatoform
disorders.
2.5.5 Alcohol and drag abuse :
Some follow-up studies of disaster affected populations have shown
increased use of alcohol and/or other psychoactive substances resulting in
substance use related problems.
2.5.6 Pre-existing psychiatric disorders :
Persons who are suffering from established psychiatric illnesses, those who
are in remission and those who have recovered from previous illness may have
greater vulnerability' to develop psychosocial consequences following disasters.
They may have exacerbation of their existing condition, relapse of episode or
recurrence of previous symptoms. Alternatively, spontaneous improvements may
even be observed. Persons with more severe forms of psychiatric illnesses and
mental handicap may be neglected exploited or abandoned following disasters.
2.6 Consequences of disasters on populations with higher risk:
There are certain sections of the disaster affected population who have higher
risk of developing various psychosocial consequences. These higher risk
population consist of children, women, the elderly, and the disabled. The nature
of the psychosocial consequences are similar to what occurs in normal adults
(described above).
2.7 Effects on rescue workers :
It is quite common for rescue workers involved in a disaster situation to
develop various psychosocial consequences. Workers may develop high levels of
stress, may be overwhelmed by the magnitude of the disaster and the enormity of
needs, and may experience feelings of powerlessness, helplessness and
hopelessness. Studies have shown that exposure to dead bodies can be particularly
stressfol.
3
PRINCIPLES OF PSYCHOSOCIAL
DISASTER AFFECTED POPULATION :
INTERVENTIONS
IN
The following principles of mental health care of disaster affected
populations should form the basis of disaster mental health intervention plans and
programmes at national, state and district levels. These principles were identified
by the Substance Abuse and Mental Health Services Administration of the United
States Department of Health and Human Services (SAMHSA 1994). The
principles are relevant for disaster mental health care planning anvwhere in the
world including India. The principles are follows
1. No one w'ho sees a disaster is untouched by it.
2. There are two types of disaster trauma - individual and community.
3. Most people pull together and function during and after a disaster, but
their effectiveness is diminished.
4. Disaster stress and grief reactions are normal responses to an abnormal
situation.
5. Many emotional reactions of disaster survivors stem from problems of
living brought about by the disaster.
6. Disaster relief assistance may be confosing to disaster survivors. They
may experience frustration, anger, and feelings of helplessness related to
Federal, State, and non-profit agencies’ disaster assistance programmes.
7. Most people do not see themselves as needing mental health services
following a disaster and will not seek such services.
8. Survivors may reject disaster assistance of all types.
9. Disaster mental health assistance is often more practical than
psychological in nature.
10. Disaster mental health services must be uniquely tailored to the
communities they serve.
11. Mental Health workers need to set aside traditional methods, avoid the
use of mental health labels, and use an active outreach approach to
intervene successfully in disaster.
12. Survivors respond to active, genuine interest, and concern
13. Interventions must be appropriate to the phase of disaster.
14. Social support systems are crucial to recovery.
4.
CURRENT MENTAL HEALTH INFRASTRUCTURE IN INDIA
4.1 Services for the mentally ill
The mental health infrastructure currently available in the country is grossly
inadequate to take care of the estimated mental morbidity. The number of trained
mental health professionals is just about 6000 for a county with a population of
one billion. The number of Psychiatrists in the country is only 3500. Mental
health services are provided through about 40 mental hospitals situated in different
parts of tlie country and general hospitals psychiatry units situated in most medical
colleges and large general hospitals in cities and towns. The total number of
mental health care beds in the country is only about 25,000. During the past few
years a private sector in the field of mental health care has been steadily growing.
A limited number of non-governmental organizations are also active in the field of
mental health care. There are few apex institutions carrying out service, training
and research in the field of mental health such as National Institute of Mental
Health and Neuro Sciences, Bangalore, and Central Institute of Psychiatry,
Ranchi. Most of the mental health services currently available in the country cater
to the needs of the urban populations and the rural areas are largely un-served or
under-served.
District Mental Health Programme
To take delivery of mental health care to the periphery', a district model
of mental health care programme involving the primary health care personnel has
been developed. This programme consists of training the PHC personnel in basic
mental health care and providing care to the rural populations through primary
health centres and district hospitals. This programme was pilot tested in Bellary
district of Karnataka state by NIMHANS. Now the Government of India has
adopted this decentralised and community based health care programme for
implementation in all the states in the country. Currently there are 22 districts in
20 states and Union Territories where the district mental health programme is
being implemented with support from Government of India.
4.2
4.3 Disaster Mental Health :
Till about a decade and halfback there was no expertise available in the
country' on mental health and psycho social aspects of disasters. However, mental
health professionals were involved in making efforts to integrate mental health
with disaster care, most notably after the Bhopal gas leak tragedy, Marathwada
earthquake and the Orissa super cyclone (Srinivasa Murthy 2000). The expertise
developed during these disasters can be utilized for disaster mental health planning
in the country.
5.
PSYCHOSOCIAL INTERVENTIONS IN DISASTER
5.1
Full integration with overall relief and rehabilitation activity :
Psychosocial interventions should be fully integrated with the overall relief
and rehabilitation activities right from the beginning following a disaster. The
mental health needs of the total population should be taken into consideration and
population and population-based interventions should be undertaken along with
clinic based, one-to-one interventions only for those persons in greatest need.
Goal and focus of psychosocial intervention - strengthening local
resources :
The goal of psychosocial interventions should be to restore the capacity of
communities to reconstruct and help themselves. The focus of such interventions
should be on strengthening family and kinship ties and re-establishing spiritual,
religious, social and cultural institutions and practices, that restore a framework of
cohesion and puipose for the whole community (Silore et al 2000). Indigenous
healing methods should be promoted. Local leadership structures should be
fostered and community participation in local level decision making should be
facilitated. Community action is known to influence the mind of the population
and represents an effective means of preventing and controlling reactions of
disquiet and desperation.
5.2
5.3
Provision of information :
Providing accurate and easily understood information about the disaster
itself, accessing resources, and instructions on what to do in a variety of situations
arising out of the disaster will contribute to reduction of stress of the disaster
affected population. Pamphlets and brochures could be specially prepared and
widely distributed. The mass media particularly the local media could be actively
involved. Information should be provided in a coordinated and unambiguous
manner.
Conflicting information from official authorities and diverse
interpretations of events related to the disaster from experts can seriously contuse
the public. Lack of adequate and accurate information from authoritative sources
can contribute to spread of unnecessary rumors. Provision of information and
instruction gives people a feeling that tlie situation is under control and in that
way, helps to control fear.
5.4 Help people to help themselves :
People should also be provided information about common emotional
responses to disasters and how to deal with them. It is necessary for members of a
disaster affected population to clearly recognize their feelings and emotions.
Information on not only how to recognize ones emotions but also how to make
personal efforts to recover in a healthy and positive manner and rebuild their lives
should also be provided. People should be enabled to effectively leam coping
strategies and promote their own recovery as well as recovery of others in their
community. Simple information booklet in the form of a manual on psychosocial
care for individuals has been developed by mental health professionals of National
Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore jointly
with Action Aid India (Bharat et al 2000). This manual which was developed
following the Orissa cyclone is currently available in English language and will
have to be appropriately adapted and translated for use in different settings.
5.5 Establishment of Support / Information Centre :
A walk-in information/support centre should be established at a convenient
location for providing crisis intervention and emotional support to affected
individuals, families who have lost some of their members, volunteer helpers and
rescue workers. Individual as well as group based early interventions can be
initiated at the centre for more severely distressed individuals and bereaved
families. The centre can act as a meeting place for all affected individuals and
families. Centre can also act as a place from where people can obtain authentic
information about the disaster. Self help groups can routinely meet at the centre.
There is difference of opinion about the blanket application universally of methods
such as ‘critical incident stress debriefing’ which may be very usefill as an earlyu
intervention in certain cultural settings.
5.6 Training in mental health for primary health care personnel:
Mental health and psychosocial care components should be integrated with
primary health care services and the primary care personnel should be provided
training in these aspects. Most people with emotional problems will not attend
any specially designated mental health care service. Many of them may not be
aware of the fact that they may benefit from mental health and psychosocial
inputs. Large number of people with psychological distress may consult the health
care centre with multiple bodily complaints, vague aches and pains and symptoms
such as weakness and tiredness. Primary health care personnel do not have the
knowledge and skills to recognize and manage common psychological problems
which occur to people following a disaster. Therefore mental health specialists
should develop suitable training packages and programmes as well as training
materials such as slides/transparencies, videos etc. on disaster mental health care
suitable for different categories of primary health care personnel. Mental health
specialists should also train all the primary health care personnel working in
disaster affected areas and supervise and support them to carry out simple mental
health and psychosocial interventions (Srinivasa Murthy 2000). Curricula for such
training programmes have been developed (WHO 1992). In the Indian setting, a
manual for medical officers on disaster mental health was developed and used for
training medical officers following the Bhopal gas leak disaster (Srinivasa Murthy
& Isaac 1987, Srinivasa Murthy et al 1987).
5.7 Information and Training for Community level workers :
Various types of community level workers (CLW) are an invaluable
resource following a disaster. Such workers include grama sevaks, anganvvadi
workers, basic health workers, lay volunteers. National Social Service (NSS)
volunteers, civil defense personnel and other similar groups.
Simple
psychological interventions can be provided by community level workers if they
are adequately informed and trained. Since most of them are likely to be from the
same area, they will know the population reasonably well and they can act as a
vital link between the affected population and various governmental and non
governmental helping agencies. A simple information manual was developed for
CLWs by mental health professionals of NIMHANS jointly with Action Aid, India
and is currently available in English (Kumar et al 2000). This manual helps the
CLW to understand the consequences of disasters and teaches him/her to provide
emotional support to the affected population. Practical guidelines for psychosocial
interventions by the CLWs at the individual, family and community level are
given in a simple and understandable manner. This manual can be translated and
adapted for use in different states following different types of disasters.
5.8 Involvement of other sectors and NGOs :
Sectors other than health such as education and social welfare and non
governmental organizations (NGOs) have a very important role in psychosocial
management of disaster affected population. They should be involved not only
during the inunediate phase following a disaster but also for the long term relief
and rehabilitation. Simple information manuals should be developed for each of
these groups (for e.g. teachers, personnel of NGOs) to equip them to contribute to
the psychosocial management of the disaster affected population.
5.9 Debriefing for rescue workers :
It is well known that rescue workers, helpers and volunteers involved in
disaster relief work also develop various levels of stress and other emotional
consequences. Therefore, it is necessary that all workers are given an opportunity
for emotional debriefing during their work and at the end of their work.
Debriefing involves going through, in detail, the sequence of events as
experienced by the worker and helping the worker to cope with stress adaptivelv.
Debriefing should emphasize the positive aspects of their work and help the
workers to achieve a feeling of mastery over the unpleasant features of disaster
work.
5.10 Help for bereaved families :
One of the groups that suffer the most severe stressful experiences and thus
requiring support and preventive interventions is the group of bereaved families.
The family should be helped to fully grasp the death of one or more of their loved
ones and accept the loss. The family should be helped to identify the dead body, if
possible, and be allowed to mourn for the dead appropriatelv.
5.11 Help for the physically injured and their families :
In most disasters, there will be varying proportion of survivors who are
physically injured, ranging from minor physical injuries to severe injuries such as
multiple fractures and crush injuries requiring procedures such as amputation. A
mental health liaison person or team assisting the intensive care/'surgical personnel
can go a long way in mitigating the emotional suffering of the physically injured
or ill and their family members.
5.12 Help for severely mentally disturbed persons :
Persons displaying grossly deviant behavior or other severe psychological
reactions as identified by the family, rescue workers, other community level
workers or health care personnel, should be referred to the mental health team for
assessment and management.
5.13 Help for orphans / widows and others in special need :
Major disasters create several groups of people with various kinds of
special needs. These include children who have lost both their parents, widows,
widowers, elderly parents who have lost all their children (who could have
supported them or looked after them), otherwise healthy persons who were made
completely disabled following the disaster for e.g. persons whose limbs had to be
amputated etc. The psychosocial and mental health needs of such groups are
quantitatively and qualitatively different from others. Their psychosocial needs
should be assessed and provisions should be made to address these needs.
5.14 Role of mental health sector / professionals :
It is generally accepted that the role of the specialized mental health sector
and mental health professionals should not be of routine and direct service
delivery in the disaster affected region. In all developing countries, since the
mental health resources are limited and mental health care infrastructure is poorly
developed, the demands on them are likely to be far greater than the resources
available.
Moreover, most people have great reluctance to seek or receive
attention and care, which is designated as ‘mental health’ due to widespread
stigma. Therefore, it is widely accepted that mental health care delivered through
the primary health care level may be more appropriate to the disaster victims'
needs. “The role of specialized mental health sector should relate to programme
design implementation and evaluation, to the training and education of primary
care worker, and to providing him or her continuing support tlirough consultation
and supervision"’ (Lima 1986).
5.15 Need for a National Disaster Mental Health Team :
Since disasters of varying magnitude strike India quite frequently, there is
need to constitute a small National Disaster Mental Health Team. It would be the
responsibility of such a team to develop a simple, standard, practical and well
structured educational and training package which can be adjusted to the particular
need of any state/region of the country as well as to suit the specific requirements
of different types of disasters. Such educational and training packages should be
developed for different categories of personnel such as lay volunteers, community
level workers, multipurpose health workers, school and college teachers, medical
officers, and other medical specialists etc. All support materials should also be
developed. When any major disaster strikes, the National Disaster Mental Health
team should be responsible for organizing and coordinating the state disaster
mental health team and initiating psychosocial interventions to the affected
community. Subsequently, it will be the task of the state/local mental health team
to provide training and continuing support to the general health sector, the
frontline grass root workers, other sectors of the disaster relief operation and the
community^ The trained primary care team will provide routine mental health care
to victims families and affected communities. The mental health specialist will be
available for assessment and management of difficult and referred patients.
5.16 Resource gaide/manual:
The National Disaster Mental Health team should develop a ^Resource
guide/manual’ within a targeted period of time as part of the preparedness
planning for dealing with the mental health and psychosocial consequences of
disasters. Such a guide/manual should provide clear and comprehensive
information and instructions on ‘what to do’ and ‘how to go about’ to deal with
psychosocial consequences.
5.17 Research on psychosocial consequences of disasters in India •
Although more than three quarters of major disasters in the world occur in
developmg countnes much of the research on the psychosocial effects of disasters
has been earned out among Western populations. Trans-cultural validity of
western diagnostic categories and classifications as well as usefulness of
intervention methods developed in western countries in non-westem settings have
been questioned. Effectiveness of indigenous methods of interventiS and
moderating effect of cultural factors on psychosocial consequences of disasters
need to be studied. Research can contribute to the understanding of ^crosscultural variations in frequency, symptomatology, temporal patterns and outcome
of psychological disorders” (WHO 1992). Therefore, there is a need to plan and
conduct research into vanous aspects of disaster mental health in India Findings
StraTegies^
contribute to better and more relevant intervention
5.18
Resources available for psychosocial interventions in India :
health professionals, institutions and N^taSTcoun^TvtillleX^idruse1
Hiey include videos, information manuals, manuals on mental health research
papers and reports. Appendix I gives details of such resources already available
Appendix I gives a list of major institutions in the country which can provide
inputs to traming and research in the area of disaster mental health Two
" TU
P^osocial care following disasters, one for individuals
and the second for community health workers, developed bv faculty of NIMH ANS
jomtly with Action Aid India after the Orissa Super cyclone arc included^
Appendix III and Appendix IV.
included as
6.
BIBLIOGRAPHY
1.
Bharat S, Chandrasekar CR, Kishore Kumar KV, Chowdhury P,
Parthasarathy R, Girimaji S, Sekar K & Srinivasa Murthy' R. (2000).
Psychosocial care for Individuals. Bangalore, ‘Books for Change’.
2.
Duffy JC. (1988). Common psychological themes in societies’ reaction to
terrorism and disasters. Military Medicine, 153, 387-390.
3.
Gandevia K. (2000). Killari: Psychosocial Health of a Village Ravaged by
an Earthquake. Indian Journal of Social Work (Special Issue) : Mental
Health Consequences of Disasters, 61:4, 652-663.
4.
International Federation of Red Cross and Red Crescent Societies. (1996).
World Disaster Report. Oxford, Oxford University Press.
5.
Jaswal S. (2000). Disasters and mental health. Indian Journal of Social
Work, 61(4), 521-526.
6.
Jaswal S & Gandevia K. (2000) (Eds.) Mental Health Consequences of
Disasters - Special issue of Indian Journal of Social Work, Vol.61, Issue 4,
October 2000.
7.
Kishore Kumar KV, Chandrasekar CR, Choudhury PC, Parthasarathy R.
Girimaji S, Sekar K & Srinivasa Murthy R. (2000). Psychosicial care for
community level helpers, Bangalore, ‘Books for Change’.
8.
Larkin M. (1999). Can post-traumatic stress disorder be put on hold ? The
Lancet 354, 1008.
9.
Lima RB, Santacruz H, Lozano J & Luna J. (1988). Planning for
Health/Mental Health Integration in Emergencies.
In Lystad M (Ed.)
Mental Health Response to Mass Emergencies. New York. Brunner/Mazel
Publishers.
10.
Lindemann E. (1944). Symptomatology and management of acute grief.
.American Journal of Psychiatry, 101, 141-148.
11.
McFarlane AC. (1990). The Australian Disaster: tire 1983 bushfires.
International Journal of Mental Health, 29, 36-47.
12.
National Institute of Mental Health and Neuro Sciences. (1998). Summary
and Recommendations of the National Workshop on Mental Health
Aspects of Disasters, Bangalore, NIMHANS.
13.
Quarantelli EL. (1985). What is disaster ? The need for clarification in
definition and conceptualization in research. In Sowder BJ (Ed.) Disasters
and Mental Health. Selected Contemporary Perspectives (pp 41-73).
DHHS Publication No. (ADM) 85-1421, Washington, D.C.
14.
Raphael B. (1986). When Disaster Strikes. Hutchinson, London.
15.
Rubonis AV & Bickman L. (1991). Psychological Impairment in the
Wake of Disaster : The Disaster-Psychopathology Relationship.
Psychological Bulletin, 109(3), 384-399.
16.
Silove D, Ekblad S & Mollica R. (2000). The rights of the severely
mentally ill in post conflict societies. Lancet, 355, 1548-49.
17.
Srinivasa Murthy R, & Isaac MK. (1987). Mental health needs of Bhopal
disaster victims and training of medical officers in mental health aspects.
Indian Journal of Medical Research, 86, Suppl. 51-58.
18.
Srinivasa Murthy R, Isaac MK, Chandrasekar CR & Bhide AV. (1987).
Bhopal Disaster-Manual of mental health care for medical officers,
Bangalore, ICMR Centre for Advanced Research in Community Mental
Health, NIMHANS, Bangalore.
19.
Srinivasa Murthy R. (2000). Disaster and Mental Health - Response of
Mental Health Professionals. Indian Journal of Social Work, 61(4). 675692.
20.
Substance Abuse and Mental Health Services Administration. (1994).
Disaster Response and Recovery': A Handbook for Mental Health
Professionals. US Department of Health and Human Services, Washington.
21.
United States Agency for International Development, Office of U.S.
Foreign Disaster Assistance. (1986). Disaster History, Significant Data on
Major Disasters Worldwide, 1900-Present. Washington, D.C.
22.
United Nations Disaster Relief Organization. (1984). Disaster Prevention
and Mitigation (Volume 2): Preparedness Aspects. New York.
23.
World Health Organization. (1992). Psychosocial Consequences of
Disasters: Prevention and Management, Geneva: Division of Mental
Health.
¥
Appendix I
RESOURCES AVAILABLE FOR PSYCHOSOCIAL INTERVENTIONS IN
DISASTERS
1. VIDEO ON PSYCHOSOCIAL CONSEQUENCES OF DISASTERS:
(Prepared by OXFAM, INDIA and NIMHANS, Bangalore). Tills 20 minute
video brings together the experiences of about two dozen experts and presents
the infonnation about the nature of mental health needs of the population, the
variety of approaches, the role of different community resources, the need for
professional involvement and the importance of the policy for disaster care.
The video has visual footage along with interviews.
The video is useful as a resource for sensitising policy makers and managers of
disaster programmes. Available from OXFAM INDIA, Bangalore.
2. INFORMATION BOOKLETS ON PSY CHOSOCIAL CARE:
Currently two booklets are available in ENGLISH. These were prepared in the
setting of the Orissa cyclone by ACTION AID, India and NIMHANS,
Bangalore in 2000. These address the needs of: (i) Individuals, (ii)
Community level helpers
These are self-help type of booklets with pictures and practical measures to
care for self and others. These need translation to various local languages.
Available from ACTION AID, INDIA, New Delhi.
3. ICMR, New Delhi Report on the HEALTH CONSEQUENCES OF
MARATHWADA EARTHQUAKE DISASTER WITH SPECIAL
REFERENCE TO MENTAL HEALTH.
Illis report provides information about the methodology' of studying the
morbidity as well as the interventions developed in the Marathwada
earthquake. This was the joint effort of ICMR, New Delhi and the
Maharashtra Institute of Mental Health, Pune. (Available from ICMR, NewDelhi).
4. MENTAL HEALTH CONSEQUENCES OF DISASTERS - a Special
Issue of Indian Journal of Social Work, October 2000 (pp 521-701)
This is a very- valuable publication from the Tata Institute of Social Sciences.
Mumbai. The issue has 12 articles on various aspects of the mental health
needs of the disaster affected populations. It contains both theory7 and case
studies of working with the different disasters in the country7.
This is valuable for the use of professionals (Available from Tata Institute of
Social Sciences, Mumbai).
' '7-
DISASTER INFORMATION
Dear friend.
You, your family and community have recently experienced the most distressing disaster, i.e., the
earthquake. The horrific effect of this earthquake will be still fresh in your mind as well as in’that
of other affected like you. Help has been coming in from different quarters, to as many people as
possible. The painful experience and its consequences are personal. The people around you would
be reacting to this unexpected event in different ways. Many a time you will find yourself alone,
not even able to talk about die disaster to others, especially since several of them too are not in a
position to either help or comfort. We feel it is imperative and vital for you- to recognise these
feelings and personally make an attempt to recover in a healthy and positive manner.
Immediate (at the time disaster)
It is necessary to be aware of the various reactions during and after the earthquake. This will help
you understand your emotions, your behaviour and the recovery methods adopted by yourself. The
main aim of this understanding is to help you and others recover in a healthy and positive manner.
During the earthquake each one of you have experienced the massive loss of either human lives or
property or shelter or cattle, or all. The emotional reactions to the earthquake and the loss are often
not recognised and understood by many as being natural and expected. Let us examine the
immediate reactions of people to the earthquake.
• Shock and or Disbelief
Gujaiat has often faced natural calamities like drought , cyclone, earthquake and floods. But this
earthquake struck at the most unexpected hour. You would have been caught unawares - totally
unprepared. But, in spite of this , you have worked hard to save your life as well as that of others.
Similarly , there would certainly be other in your community who have gone through the same
experience. However, some persons in the community would have reacted with shock and shown
decreased activity. Another common emotional reaction is to feel that the whole event was not real
but a bad dream, i.e. one of total disbelief.
• Panic
Panic at the time of undergoing very severe stress is common and normal. Hence for people to
panic at the time of a earthquake is normal. Just as an example, imagine a large number of people
entrapped in the rubble with a small space. It would only be natural that all of them will panic
and try to get out at the same time causing a stampede.
After the Earthquake
i
® Shock
You find it difficult to believe that disaster has actually happened - that the earthquake has ripped
through leaving behind so much death and destruction* All routine activities have come to a
standstill due to the earthquake and this adds to feeling lost. The all round confusion further
intensifies this.
RECOVERY MECHNISMS
Symptoms start decreasing in most people in a few weeks when they initiate some actions to
reorganise and rebuild themselves. After a few weeks/ months, even though the memories of the
disaster remain, they do not stop you from going ahead with your life.
HOW CAN YOU RECOVER?
To promote recover we suggest the following to be done:
At a Personal Level:
X
v
X
>/
Listen to authentic information about the earthquake.
Do not believe in rumours that go around during such times.
Be together with family members.
Do not send women, children and the aged to far off places for the sake of safety as iliis
separation can cause a lot of anxiety to them and you.
Be with people from the same village, i.e. people you are familiar with, even if you arc in
temporary dwellings.
Get back to a daily routine as soon as possible to make you feel that you are in control of
the situation.
Make it a point to talk about the earthquake share your experience and feelings with
your family, your parents, friends, spouse, siblings, acquaintances. This will help
ventilate/release your emotions.
Restart activities that are special to your family like having meals together, praying, playing
games, singing , etc.
Keep touching and comforting your parents, children, spouse and the aged in your family.
This will not only make you feel good but also make the other person feel the same.
Initiate and participate in rituals like collective, grieving, prayer meetings or gn/ip
mournings if you have lost a near and dear one. This will help you come to terms with Jhe
loss of the person .
Take part in rescue, relief and rehabilitation operations, if you are not hurt or qnly
slightly injured. Work is a good tonic for healing.
Keep in constant TOUCH in case of a member of the family having to be shifted to a far
off hospital or residence. Update him/her about yourself as well as find out about him/Ler.
This gives a feeling of being cared for.
■'
Take time everyday to relax and have a good time by gathering together at a central
place/point, playing kabbadi, reading, listening to music, visiting shrines, singing hymns,
chanting prayers, reading scriptures.
■?
Make time for yourself and a acknowledge and admit that you will not be always
functioning at your usual level of efficiency for a few weeks/months.
r
At the Community level:
Immediate
>/
Disseminate authentic information about the disaster and the help available either by
going around personally or using loudspeakers or posters/placards.
Organise groups for rescue operations. Help to remove debris, shift people to safe place,
help the disabled, and share food, water and medicines. Identify groups for each activity
and a leader for each group. The whole village should be involved in planning rescue, relief
and rehabilitation operations.
Listen o and encourage other people talking about the disaster, etc.
Encourage the group to focus on the special groups like the children, women, disabled and
elderly.
Organise people to present their needs and difficulties to the administrators in a collective
manner.
Bring together people of the community for sharing of gricf/community mourning.
Organise self help groups to procure aid and to discuss emotions associated with the
disaster. Self-help groups should have people with similar needs. For example, people who
have lost family members could join together to grieve and later work on it.
Organise weekly meetings to share information and sing together.
Prepare yourself for delays and difficulties.
In Future
Seek information about help extended and organise groups to represent your village to seek
help/aid.
Actively mobilise action for reconstruction and rehabilitation work. Take care that this
includes all aspects of a community to be disaster proof, where agriculture, electricity, health
care, education, etc. are concerned.
Continue dialoguing with government officials and NGOs for a persistent effort on relief
and rehabilitation.
Compiled by NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES,
BANGALORE.
PSYCHO SOCIAL CARE BY COMMUNITY LEVEL HELPERS
INTRODUCTION
The recent disaster in Gujarat was brought about by a devastating earthquake. This is
unexpected and unanticipated at this time. Thousands have either died or are reported
missing and several lakhs have been rendered homeless. In addition, there has been
extensive damage to all other property. Along with relief, rehabilitation and the care
of physical health and injuries, mental health issues need to be given importance. As
in other major disasters, the magnitude of mental health problems is enormous. Apart
from material and logistic help, the suffering human being will require human
interventions.
CARE OF PSYCHOLOGICAL PROBLEMS
Who is a Community Level Helper?
Any community when faced with a disaster of whatever magnitude, responds in its own
way to the situation. One such response is the reaction of several local people or groups
of people who immediately come forward to help in one way or the other in order to
alleviate the situation. They are the Community Level Helpers (CLH). They are a vital
link between the affected population and the helping agencies (individuals, NonGovernmental Organisations, Governmental Organisations).
At the early stages following disaster, most survivors arc psychologically open and
willing to talk about their experiences. This may change later into a defensive, noncooperative attitude if time passes without attempts at providing help. Therefore, it is of
utmost importance that survivors are encouraged to seek help and talk about their
psychological problems as early as possible. This intervention will prevent the
persistence of problems and development of further complications. Remember, people
do however talk about themselves when given an opportunity to do so.
Psychological intervention can be provided to the family in the daily visits by monitoring
and noting down informatin - all by the CLHs. Such visits are to be utilised for talking
about the survivor’s feelings and experiences, imparting health education, discussion of
health problems, motivating individuals to hold group meetings, and organising
educational activities.
•
No one who experiences the event of witnesses the event is untouched by it.
Disaster, depending on the nature and magnitude can cause enormous loss to life,
property and the environment of the area. Grief, sadness, anxiety, anger arc common in
such situations. Individuals find comfort and reassurance when told that their reactions
are normal and understandable in every way. Therefore, CLHs help to educate the
survivors about common disaster stress reactions, ways to cope with stressors and
available resources to respond to their needs.
1
•
Disaster results in two types of trauma
Disaster - affected population have individual and collective trauma. Individual trauma
manifests itself in stress and grief reactions, while collective trauma can severe the social
ties of survivors with each other.
•
Most people pull together and function during and after a disaster but their
effectiveness is diminished
A disaster survivor is confronted with multiple stressors. In the initial phases there is
much energy, optimism and altruism. There is often a high level of activity with low level
of efficiency. As the reality of losses becomes more clear, frustrations and
disillusionment set in, leading to more stress symptoms. This can impair the survivor’s
ability to make sound decisions and take necessary steps towards recovery and
reconsstruction.
•
Disaster stress and grief reactions are normal responses to an abnormal
situation
Stress reactions and grief responses are common in disaster survivors. Public
information about normal reactions, education about way to handle them, and early
attention to symptoms that arc problematic has hasten recovery and prevent long
term problems.
• Many emotional reactions of disaster survivors stem from problems of living
caused by the disaster
Disaster disrupts all aspects of daily life resulting in practical problems like finding
temporary housing, food, clothing etc. Timely and appropriate relief and support
measures arc very vital to help survivors handle the disruption.
•
Survivors respond to active interest and concern
Survivors will usually be eager to talk about what happened to them when approached
with warmth and genuine interest. Workers should not hold back from talking with
survivors out of fear of intruding or invading their privacy.
•
Support systems are crucial for recover)'
The most important support group for individuals is the family. Workers should attempt
to keep the lamily together and the members encouraged to be involved in each other’s
recovery. For those who are orphaned or have become single, support from other groups
can be helpful.
2
s
Helping people help themselves
Listening
♦
♦
♦
♦
♦
Look at the person while he/she is talking : This indicates being interested in what
is being said.
Respond occasionally while listening : This makes the person speaking feel what
he/she is saying is being understood and taken seriously.
Avoid interruptions : Let the other person finish his/her thoughts, Do not interrupt
unless there is confusion and the details arc jumbled.
Be tolerant: Do not prejudge or moralise or condemn.
Empathise : Share the experiences of the other person as if they are your own. It is
based on the sensitivity and ability to recognise when the other person is going
through certain feelings or emotional experiences.
Ventilation : This process involves release of emotions and feelings. It is very important
intervention and should be used as soon as possible after the cartquake.
WHAT SHOULD YOU DO?
♦
♦
♦
♦
♦
♦
Listen carefully and attentively.
Maintain eye contact.
Acknowledge distress.
Do not interrupt.
Support by patting on the shoulders/hold the hand as they cry.
Do not ask them to stop crying.
Relaxation Exercises
Encourage survivors to undertake relaxation/breathing exercises regularly several times a
day. This helps them gain control over their agitation and anxiety.
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Instructions: The person should sit in a squatting posture and place his/her hands on the
knees. Then take a deep breath, hold it for a few seconds and slowly exhale. Encourage
him/her to do it for 5-10 minutes steadily and slowly. Repeat this at least twice a day.
FAMILY LEVEL
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the Family as a group to share the losses
Encourage family members to contact relatives. This will help mobilise support and
facilitate recovery
Rituals like prayers, keeping the dead persons photographs, preserving the
belongings of the dead person or persons
Encourage the survivors to engage in meaningful activity as a family
Recreation like listening to Radio, TV or visiting melas
Resume normal activities of the pre-earthquake days with the family
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♦ Support each other at home. Emphasise that the family should regularly undertake
activities together at heme
COMMUNITY LEVEL
H Group mourning: Grief resolution should occur at the personal, family and the
community levels. Group Mourning is a process of mass grieving. It expresses
solidarity of the grief-stricken community and facilitates unity and collective action.
Such activities should be initially organised on a weekly basis, gradually on a
monthly basis, and later annually.
Group meetings: Group meetings are important activities where the community as a
whole participates. This stimulates the people to think, and brainstorm about various
themes for rebuilding the community.
Folk songs: Singing of folk songs about the earthquake tragedy, its impact and them
mourning. This helps people gather in a common place and share their grief.
Devotional songs: Singing devotional songs like hymns/bhajans, etc. is helpful.
Consider referral to a menial health agency ij the client:
is depressed and shows agitation, restlessness, and paces up and down
is a pathetic, immobile, unable to move around
discontent
mutilates him/herself
uses alcohol or drugs excessively
is unable to care for him/herself, e.g., docs not eat, drink, bathe, change into fresh
clothes
♦ repeats ritualistic acts
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Consider referral to a mental health agency if the client :
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hallucinates - hears voices, sees visions, or has unverified bodily sensations
states the body feels unreal and fears he/she is losing his/her mind
is excessively preoccupied with one idea or thought
has the delusion that someone or something is out to get him/her and the family
is afraid he/she will kill him/herself or another
is unable to make simple decisions or carry out everyday functions
shows extreme pressure of speech - talk overflows
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Tips to make you an effective community level helper
Dos:
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Visit families regularly
Accept food or drinks like coffee or tea if offered
Help survivors to get medical care or other help if needed
Provide clear guidance about compensation or ways of getting it
Provide practical help whenever necessary
Facilitate networking among survivors
Contact relatives )e.g., writing letter) and appeal to them to meet and support
survivors
DON’Ts:
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Do not promise things you cannot do or things beyond your control
Do not take decisions for them for e.g., marriage or money handling, etc
Do not get upset with the behaviour of survivors. Sometimes they are
unreasonably angry/blame you for causing trouble to them by your frequent visits,
or at times they might be very demanding
Do not miss appointments
Do not overburden yourself with lot of work
Do not take sides in family conflicts
Compiled by NA TIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES,
BANGALORE.
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