Title

Initiating the debate on Resurgence of Infectious Diseases and the Indian Society

Creator

Anand Zachariah

Madhukar Pai

Prabir Chatterjee

Date

1998

extracted text

I
medico friend circle
Initiating the debate on

Resurgence of Infectious Diseases and the Indian Society
Anand Zachariah, Madhukar Pai & Prabir Chatterjee
(on behalf of the participants of the Preparatory Meet [held at Community Health Cell, Bangalore on Sth April 1997]
for the MFC Annual Theme Meet 1997)

The Context
When we in MFC decided on "Resurgence of infectious diseases" as the theme for the
annual meet in December 1997, we were not aware of the fact that the WHO had chosen
"Emerging Infectious Diseases - Global alert, Global response" as the World Health Day theme
for 1997. This interest in resurgence of infectious diseases seems to have started in the late
1980s with the HIV pandemic and the appearance of several multi-drug resistant pathogens.
These events occurred after an era where most infectious diseases had been controlled in the
West and appear to have sent shock waves through the Western scientific community. Several
Committees and Conferences were organized on this issue, primarily in the USA. The interest
was heightened with the Ebola outbreak in Africa and Plague in India and the international
attention they received.

In the last few years we have noticed this 'fear" of emerging infectious diseases not only
in scientific writings but also in popular media like newspapers, books and cinema. Deadly
haemorrhagic infections were reported to be surfacing - books like Richard Preston's The Hot
Zone and movies like the Dustin Hoffman starer Outbreak rekindled the fears raised during the
Ebola outbreaks in Zaire. Books like The Coming Plague (Laurie Garrett) and The Andromeda
Strain (Michael Crichton) spelt doom for a world where killer plagues could destroy humankind!

What are emerging and re-emerging infections?
"Emerging infectious diseases: newly identified andpreviously unknown infections
which cause public health problems either locally or internationally" (WHO). Recent emerging
infections include HTV, Ebola haemorrhagic fever, Creutzfeldt-Jakob disease, Hepatitis C,
Vibrio cholerae 0139, Legionnaire's disease and Lyme disease.
"Re-emerging infections: the reappearance and increase of infections which are known,
but hadformerly fallen to levels so low that they were no longer considered a public health
problem" (WHO). Tuberculosis has made a massive comeback thanks to HIV; diseases like
plague, malaria and kala azar which had been reasonably contained are resurgent; cholera has

1

/^s
I

medico friend circle
Initiating the debate on
Resurgence of Infectious Diseases and the Indian Society
Anand Zachariah, Madhukar Pai & Prabir Chatterjee
(on behalf of the participants of the Preparatory Meet [held at Community Health Cell, Bangalore on 5 th April 1997]
for the MFC Annual Theme Meet 1997)

The Context
When we in MFC decided on "Resurgence of infectious diseases" as the theme for the
annual meet in December 1997, we were not aware of the fact that the WHO had chosen
"Emerging Infectious Diseases - Global alert, Global response" as the World Health Day theme
for 1997. This interest in resurgence of infectious diseases seems to have started in the late
1980s with the HIV pandemic and the appearance of several multi-dmg resistant pathogens.
These events occurred after an era where most infectious diseases had been controlled in the
West and appear to have sent shock waves through the Western scientific community. Several
Committees and Conferences were organized on this issue, primarily in the USA. The interest
was heightened with the Ebola outbreak in Africa and Plague in India and the international
attention they received.

In the last few years we have noticed this 'fear1 of emerging infectious diseases not only
in scientific writings but also in popular media like newspapers, books and cinema. Deadly
haemorrhagic infections were reported to be surfacing - books like Richard Preston's The Hot
Zone and movies like the Dustin Hoffman starer Outbreak rekindled the fears raised during the
Ebola outbreaks in Zaire. Books like The Coming Plague (Laurie Garrett) and The Andromeda
Strain (Michael Crichton) spelt doom for a world where killer plagues could destroy humankind!

What are emerging and re-emerging infections?
"Emerging infectious diseases: newly identified andpreviously unknown infections
which cause public health problems either locally or internationally" (WHO). Recent emerging
infections include HIV, Ebola haemorrhagic fever, Creutzfeldt-Jakob disease, Hepatitis C,
Vibrio cholerae 0139, Legionnaire's disease and Lyme disease.
"Re-emerging infections: the reappearance and increase of infections which are known,
but hadformerlyfallen to levels so low that they were no longer considered a public health
problem" (WHO); Tuberculosis has made a massive comeback thanks to HIV; diseases like
plague, malaria and kala azar which had been reasonably contained are resurgent; cholera has

1

been reintroduced into countries and continents where it had previously disappeared; dengue
outbreaks are being reported in parts of the world.

Is there a problem?
There is now so much hype and hysteria about this issue (one reviewer called it
"Outbreak of hype") that it is hard to find literature that offer opposing viewpoints. Was all this
hype created by the infectious diseases lobby to attract more fimding to the study of infections?
Some people feel this may be the case - since more funding went into chronic life style related
diseases like cardiovascular diseases and cancer. The US Centres for Disease Control (CDC) has
launched a major campaign to publicise the problem of emerging infections as a part of which a
new journal called Emerging Infectious Diseases is being published.
z

Critics point out that many of these so called emergent infections may have been with us
for many ages. With better diagnostic facilities we may be discovering them now. In quantum,
newer infections may contribute very little to the global burden of illnesses. The Ebola outbreak,
for instance, claimed a total of 315 lives, 3000 times fewer than the number of people killed
worldwide each year by measles.

Why discuss this theme in MFC?
There does not seem to be much doubt that we are facing a resurgence of specific
diseases in India. Kala-azar was a disease under control in the early 1970s and has come back in
a big way - 75,523 cases (definitely an underestimate) were reported in 1992. The malaria
situation in India has been steadily worsening with focal outbreaks with high mortality, alarming
increase in urban malaria, emerging dominance of P. falciparum, and the development of drug
resistance. The frequency and magnitude of Dengue epidemics has been increasing with the
outbreaks occurring in many towns and cities (Delhi and Devanahalli near Bangalore are recent
occurrences). From the first case of HIV described in 1985, conservative estimates are that 1.75
to 3 million people in India are affected by the epidemic. The 8th pandemic of cholera, caused
by a new strain V. choleras 0139, started in south India in 1992, is spreading all over the world.
While these diseases have had obvious public health impact, other infections are becoming more
evident: filariasis, Japanese B encephalitis, anthrax, leptospirosis etc. Admittedly, in the absence
of good epidemiological information it is difficult to decide whether these latter infections are
resurgent or not

Many of us in MFC have been personally affected by these illnesses and other have been
involved in epidemic and disaster situations. Some of us have done research on these infections
while others have done reviews on the wider issues involving them. This personal dimension
seems to be reflected in the urgency with which the theme for the meet was adopted and the
enthusiasm with which subsequent discussions have been held.

Does this resurgence reflect some kind of a widespread phenomenon in our country?
Here we would like to draw a distinction between the western emphasis on the new and
emerging infections and our problem of resurgence of pre-existing infectious diseases problems.
2

There is a widespread perception that the resurgence of infections is related to various social,
political, economic, demographic and ecological changes. The 'crisis' in public health is also
being debated. Is there truth in this perception and if so, how can we draw the links between
societal changes and the resurgence.
MFC has in the past always discussed the broader social and political aspects of any
health issue. We have, as a collective, never confined ourselves to exclusively technical or
medical issues. By offering alternative perspectives we have enriched our own understanding
and have also contributed to the building up of a critical, holistic analysis of health issues. While
the issue of "Resurgence of infectious diseases” will be discussed in the following months in
many ways in many places, MFC's mandate would be to initiate a critical debate on the wider
issues which encompass the theme.

How could MFC discuss the theme?
The participants of the Preparatory Meet felt that the MFC debate should focus on:

1. the Indian context
2. resurgent infections which pose a major public health problem to us (rather than new
or emergent infections)
3. broader social issues in addition to the technical/medical issues.
The specific diseases that could be used for the debate are: malaria, dengue, plague, kala
azar and cholera, HIV and TB. Issues like antibiotic resistance could also be discussed.

A list of societal factors which contribute to resurgence was drawn up by the participants:
Environment & Population
♦ development strategies as a cause of resurgence.
♦ urbanization and its role in disease resurgence.
♦ migration and population movements in disease transmission.
♦ ecological destruction and environmental factors in resurgence.
♦ agricultural development and its importance (eg. green revolution and its impact on
vectors borne diseases).
♦ food supply, undemutrition and its links to infectious diseases.

Economy & Politics
♦ political and economic factors causing resurgence.
♦ market economy, privatization and liberalization and its impact on resurgence.
♦ widening socioeconomic disparities.
♦ governmental indifference and reduced expenditure on infectious diseases.
♦ economic impact of resurgent diseases (eg. loss due to the plague epidemic in Surat).
♦ media panic and responses to outbreaks.
♦ media bias in reporting outbreaks (eg. little emphasis on outbreaks which occur in remote
areas).
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Health Systems
♦ collapse of public health systems in the country with disappearing public health
competence.
♦ poor diseases surveillance and poor quality of epidemiological information.
♦ professional inaction/apathy in resurgence.
♦ irrational therapy and its role.
I

Community
♦ non-involvement of the community in disease control.
♦ poor application of lessons learnt from history.
♦ vulnerability of specific groups like migrants, children and women.
Many more such issues could be discussed and debated before and during the meet The
figure depicts the broader sociopolitical context in which the resurgence occurs. Any of the
factors highlighted in the picture could form the core of a background paper/case study. To
clarify the broader context of the debate, it is important to adopt complementary approaches: to
focus on a specific disease and delineate the broader, societal issues involved in its resurgence;
and to discuss societal issues and identify how they are related to a specific disease. By adopting
both approaches, we would gain a better understanding of the underlying problems.
Getting the debate going

As a run up to the December theme meet in Wardha, the MFC Bulletin would cany
background papers on some of the major issues that have been identified. In addition,
background papers would also be circulated among MFC and interested non-MFC friends. We
would invite case studies on experiences in this area and discussion articles which could also be
communicated as background papers. We would invite individuals to provide personal accounts
of any 'close encounters' with infectious diseases, to highlight the personal dimensions of the
problem. MFC members may also want to organize regional meetings to discuss local
experiences.
There has been a general comment that the theme meet should be fairly focussed in view
of the broad nature of the topic. However, it was felt by the participants of the Preparatory Meet
that we should allow the informal discussion to evolve over the year, before deciding the actual
agenda of the annual theme meet It is therefore very important that all friends write their
suggestions to us and also send background papers as early as possible. Background papers
should ideally focus on the 3 key aspects already noted: 1. the Indian context 2. resurgent
infections rather than new or emergent infections 3. broader social issues in addition to the
technical/medical issues. Length of the background papers should ideally be not more than 5000
words. Case studies could use a informal, narrative format (2500 words). Personal experiences
could follow any style. (Contributions, if sent on floppy diskettes, could save us a lot of trouble!)

The theme meet will be coordinated by: Anand Zachariah, Madhukar Pai and Prabir Chatterjee,
Christian Medical College, Vellore. All correspondence may be addressed to:
Dr Anand Zachariah, Dept of Medicine Unit I, Christian Medical College, Vellore 632 004

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1

BACKGROUND PAPERS

1. Resurgence of Malaria
— A case study

Ravi Narayan

2. Re—emergence of Kalaazar and Indian society
- A case study

Prabir Chatterjee

3. Denoue haemorrhagic -fever in Delhi

Sathyamala &
Yogesh Jain

4.*Druo resistance and irrational therapy

Delhi Group

5. Anti-malarial policy in the 1930's
- some lessons

Muraleedharan
Madras I.I.T.

6. Current Public-health system and resurgence
of infectious diseases

7.^Resurgence of TB

8.

"Of Cholera and Post-Modern World” EPW
August 22, 1992

9. HIV/AIDS
tvernen £ A|bS

10.Contextualising Plague - A reconstruction
and an analysis EPW November 19, 1997
P 2981-2989.

11. Epidemiological Overview of Infectious
diseases, resurgence in India

12. Rethinking Public Health t Food, hunger
and mortality decline in Indian history
(Presentation at School of Social
sciences, JNU)

13. Resurgence and children

J.P.Mulliyil and
Madhukar Pai
Thelma Narayan

/

.P.Mohan Rao

’

Anand Zachariah
th Qe] I

Imrana Qadeer

Pankaj Mehta,
Manipal Hospital
Bangalore.

Sheila Zurbrigg

Sanjeev Lewin,
St.John's Med.Col lege

.. .2

2

14.*Market economy and infectious disease
resurgence
Economic impact of resurgence of
infectious diseases

i
!
1
!

Requests sent to
Ghanshyam Shah J CSCM,
Rama Baru
1 JNU
and Abhay Shukla, Pune

I

if the above do not agree, to plan modification of “Communicable
Diseases : Costs and Expenditure", RJH Vol.2 No.1 Jan-Mar 1996.
IS. Urbanisation
Agricultural development
Ecological changes
and resurgence of Infectious Disease

I

I Dr.Vanaja, Bangalore
I

16. Community participation in vector Borne
:
Facts and Fancies
Disease Control
Ann. Soc. Belo. Med. Trop. 1991, 71
(Suppl—I) 233-242.

Dr.P.K.Das
Vector Control Res.
Centre. Pondicherry.

17. Clinial Re-appraised series

/ C.Sathyamala and
Yogesh Jain

/

Articles of general cri t ique
Amar Jesani

1.

'From Philanthropy to Human Rights'.

2.

Medicine for Holistic Health' An alternative response
‘Social
EPW Dec 1, 1990.
present crisis.
Rudolf C. Heredia.

* Not yet confirmed

to