The dreaded Japanese encephalitis now has the whole of eastern UP in its grip. Thousands of children have fallen victim to it – most are dying, while survivors suffer severe retardation. Meanwhile, Mulayam Singh’s State Government was busy entertaining Bill Clinton in Lucknow and trumpeting the claims of having made Uttar Pradesh an ‘Uttam Pradesh’ – ‘ Ideal State ’!
Liberation discusses the epidemic and its wider implications with Professor Rama Baru of the Centre for Social Medicine and Community Health, JNU.
The epidemic of Japanese encephalitis in UP should be seen as part of a broader pattern of resurgence of communicable diseases in their epidemic form. The fact is that there are several small epidemics occurring all over the country; but only the large epidemics, which endanger urban centres and middle classes, get media attention.
The growing privatisation of India’s health services in times of globalisation, accompanied by the longer legacy of weak public health services infrastructure, and the vast variation in availability and quality of services have steeply heightened the deprivation – both regional and socio-economic. Barred from access to health services, people are resorting more and more to informal practitioners (as shown by the last two rounds of NSS data) and chemists’ shops.
Poor infrastructure impacts on surveillance and monitoring of diseases – the ability to predict and therefore prevent the outbreak and spread of communicable diseases. As a result, though communicable diseases break out every year, Governments unable to prevent these from assuming epidemic proportions. Studies of the Adilabad gastroenteritis epidemic of a few years back showed that another factor causing mortalities was the breakdown of the referral system. Testimonies of the affected taken at the district hospital and the private city hospitals showed that medical care was unavailable at the local level. The testimonies also revealed the shocking amounts of money that poor families, in desperation, spent on emergency health care during the epidemic – a sign of criminal negligence on part of the State. This is the story of most epidemics that our country witnesses every year.
But the larger story goes beyond that of health services. We need to ask – and learn from the answer – the fundamental question – ‘Who is dying?’ My experience of tracking epidemics (mostly from newspaper reports) reveal that Maharashtra , Orissa, MP are the foci of diseases in their epidemic form – ranging from malaria, gastroenteritis, Japanese encephalitis and leptospirosis. One finds that epidemics have a social pattern. They occur in predominantly tribal areas, marked by multiple deprivations – of livelihood, food – of which health is just one. Take the example of the gastroenteritis epidemic in Adilabad in 1998: studies showed that farmers there had been out of work for nearly four months and had been subsisting on tubers. The Public Health authorities traced the epidemic to the lack of chlorination in the drinking water – but this is only part of the story. It ignores the fact that acute hunger weakens the body’s immunity, as a result of which people succumb to infections.
To understand epidemics, we must put hunger and deprivation back in the picture, and look beyond the ambit of health services alone. The State, rather than addressing the factors that create fertile grounds for an epidemic situation, restrict their role (and the role of the health services) to the prevention of mortalities. Hunger is a form of violence inflicted by the State – for which there is no accountability. One can transfer the Chief Medical Officer or the Health officials, for a breakdown of health services – but who is responsible for the acute hunger that breeds epidemics in the first place? If we take epidemics as our lens, we can see a highly globalised society, from which certain classes have benefited, but an underclass has been decimated by hunger and disease. Remember that the massive figures of epidemic deaths are just hospital deaths – there are likely to be far higher uncounted figures for real mortality.
It is this context that we must view the encephalitis epidemic in Eastern UP. It is well documented that the agricultural labourers and small farmers, as well as poor artisans like weavers of Eastern UP have been on the brink of starvation for long. Beyond doubt, in this condition of chronic deprivation, the Japanese encephalitis epidemic was a horror waiting to happen. Far from being a ‘hand of God’ - a natural calamity – it was in fact something that could well have been predicted and prevented. The fundamental issue of employment and hunger demanded to be addressed. In addition, not only could the cycle of transmission (in most cases, via the pig and mosquito) have been interrupted, and the Government could have prepared itself to treat the early patients. The neglect of the State Government of UP in all these respects is truly callous and criminal.
Finally, what does the resurgence of communicable diseases in their epidemic form tell us about the impact of globalisation? Take the case of China – why was China unable to contain the SARS epidemic? China had built an impressive public health system – barefoot doctors upwards – post-revolution. However, China subsequently closed down its epidemiological surveillance mechanisms – and the Chinese experience shows that markets cannot take on those complex and interlinked functions of predicting and preventing epidemics. There are no individual solutions to communicable diseases. Public health is a collective mechanism and the State cannot abdicate its responsibility for it.