Resurgence of Malaria
Item
- Title
- Resurgence of Malaria
- Creator
- Ravi Narayan
- Date
- 1997
- extracted text
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THE NATIONAL MEDICAL JOURNAL OF INDIA
VOL. 10, NO. 4, 1997
157
Resurgence of Malaria
The resurgence of malaria in the last decade has become a matter of serious concern
for health professionals, policy-makers and planners. The epidemics in Andhra
Pradesh, Manipur, Nagaland, Rajasthan and West Bengal in 1994 and in Assam,
Maharashtra and West Bengal in 1995. were characterized by high morbidity and
mortality and increasing evidence of the spread of Plasmodium falciparum infection
around the country.
The classical public health approach, even now dominated by biomedical perspec
tives, had described and studied this resurgence and identified technical, administrative
and operational failures within the context of the national malaria eradication prog
ramme (NMEP). Resistance to chloroquin and vector resistance to insecticides have
been highlighted as major obstacles. The rising cost and shortage of insecticides and
antimalarials, inadequate coverage by residual insecticides and inadequate surveillance
have been seen as complementary causative factors.1
However, there is increasing evidence that the malady is deeper. The resurgence
is symbolic of a collapse of the ‘public health system’ and ‘primary health care sys
tem’ in the country. Some factors leading to this collapse have been there for a long
time while others are the result of the recent liberal ecomonic policies that have se^p
a decreasing investment in health and a rolling back of state intervention in pul^B
health.
t
The First of these broader contributing factors is the near absence of a reliaffle
surveillance system, plagued by shortage of laboratory technicians at the primary
health centre level and male multipurpose health workers at the Field level—who
between them would form the surveillance team at the grassroots. While the existing
MIS (management information system).has shown a plateau at 2 million cases per
year in the last few years, indirect evidence collected by the NMEP/MRC (Malaria
Research Centre) suggests a gross underestimate, with the actual numbers being
closer to 30 million per year. Therefore, there is an urgent need for ‘a district level
surveillance system' if response by the public health system has to be prompt and
effective to the resurgence of malaria or any other communicable disease?
The second factor is the continuing irrational management of suspected malaria
cases by general practitioners and specialists. A plethora of irrational injections,
antibiotics and antipyretics are still being used, even when the NMEP has provided
guidelines in ‘National Drug Policy on Antimalarials'.’There is a tendency to exag
gerate the prevalence of chloroquin resistance and there are concerted efforts to
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THE NATIONAL MEDICAL JOURNAL OF INDIA
VOL
10, NO. 4, 1997
promole mefloqum as the new 'wonder'drug'. Studies presented recently at a national
seminar have highlighted the role of chloroquin in inhibiting haem-dependent,protein
synthesis in the parasite, the implication of which is that increasing the dose of chloro
quin (a cheap, effective, and adequately available remedy) would probably overcome
the resistance problem rather than costly alternatives.' The dangers of overuse and
misuse of mefloquin have also been highlighted in a recent report.5
Similarly, while personal protection measures are important in the short term, the
recent efforts by international public health agencies to socially market ‘insecticidetreated mosquito nets' (ITMNs) as a ‘magic bullet’ are likely to be counterproductive.
This will divert funds and attention to a top-down, vertical distribution and marketing
programmewhen community-oriented and integrated bio-environmental approaches
are perhaps more sustainable. An IDRC/WHO publication6 has also cautioned that
ITMNs may not be easy to implement and sustain on a large scale in routine health
interventions; and this advise needs to be heeded.
A recent independent expert group has taken a broader social-economic-culturalpolitical approach to epidemiological analysis and identified a host of interesting
issues which have contributed to the resurgence of malaria.’These include malariogenic
development strategies; the inadequate involvement of voluntary agenices, general
practitioners or the community in the national programme, the increasing loss of
public health skill and competence at various levels of the health care system; the
increasing corruption and political interference in health care decision-making; the
confused dialectics of centre-state responsibility in health and the decrease in health
care expenditure. Other studies taking broader socio-epidemiological approaches are
identifying factors such as migrant labour and agricultural development.’"’ Recognition
of the need for this shift is only very recently getting some emphasis in international
research reviews.10
The time has come for health policy planners to move away from narrow biomedi
cal approaches seeking technological fixes to a much broader social and communityoriented paradigm shift in research, problem analysis and action initiatives. In the
absence of this, malaria and the re-emerging communicable diseases will continue to
represent not only a failure of our public health system but also of our research
methods.
REFERENCES
1
Director General of Health Services, Ministry of Health and Family Welfare. Malaria control. An attempt.
Community Education Booklet, National Malaria Eradication Programme, New Delhi, 1996.
2 John JT. An Indian point of view. Lancet 1997;349:31-42
3 National drug policy on antimalunals (Chairmant.Director General of Health Services). New DelhiiNational
4
3
6
Malaria Eradication Programme, Directorate General of Health Services. May 1993.
Padmanabhan G. Newer drug targets in the malarial parasite In: Abstracts nJ the third national seminar on malaria
and other tropical diseases. University Grants Commission/Bangalorc Univcrsity/Sociciy of Applied Genetics,
1997.
VHAI/SOCHARA. Towards an appropriate malaria control strategy: Issues nJ concern and alternatives Jor
action. New Delhi:Voluntary Health Association of India. 1997.
Lcngcler C. Canani J. Savigny Don de. Net gain: A new method Jar preventing malaria deaths. IDRC/World
Health Organization, 1996.
7 Pai M, Zachariah A. Rose W, Satyajit S, Vcrghesc S, Joseph A. Malaria and migrant labourers—Socio8
9
10
epidemiological inquiry. Economic and Political Weekly I997;XXX11 (16). 19 Apr.
Muralecdharan VR, Vccraraghavan D. Aniimalartal policy in the Madras Presidency: An overview of the early
decades of the twentieth century, Med Hist 1992;36:290-305.
Bradley D, Narayan R. Epidemiological patterns associated with agricultural activities in the tropics with special
reference to vector bomc diseases. EJJeci.t/Agricuhurul Development on Vector Borne Diseases. Food and
Agricultural Organization Monograph. AGLMISC/12/67.
Anderson J, Maclean M. Davies C.Mulariu research: An audit nJ international activity. Prism Rcpon No. 7 Unit
for Policy Research in Science and Medicine. London:Thc Wellcome Trust. Sept 1996.
RAVI NARAYAN
Community Health Cell
Society' for Community Health Awareness Research and Action ■
Koramangala
Bangalore
Karnataka
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