Co-Written by K Rajasekharan Nayar, Bindhya Vijayan & Muhammed Shaffi

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The  proactive strategies adopted by the Government of Kerala for controlling the COVID 19 pandemic have been appreciated world-wide. The strict enforcement of the age-old strategies and the almost near compliance by the people are exemplary. These may help in sailing through the pandemic to the next stage.  Unfortunately, the post-COVID time is coinciding with the monsoon season during which many other viral and bacterial infections can crop-up. Kerala has the long and painful history of a disease-ridden monsoon season. The health services try to implement several preventive measures during the pre-monsoon days. The important among them is the house to house survey and distribution of water disinfectants. Certainly, this is an important and routine activity which might control outbreak of some water-borne and water-related diseases and to some extend mosquito-borne diseases as well. Given the unusual monsoon activity, it may be possible to predict an unusual morbidity scenario as well. Therefore, what is required is a more evidence-based approach especially because of the extremely strained health system due to the pandemic.

The case of Chikungunya and Dengue

Kerala had reported outbreaks of Chikungunya and Dengue in many districts since 2006. Kerala state had the first outbreak of Chikungunya during June-July 2006 along the coastal areas of Alappuzha, Kollam, and Trivandrum districts and again during May-August 2007 in Pathanamthitta, Kottayam and Idukki districts. As on October 28 2006, of the 13,92,027 cases reported from several parts of India, 70,731 suspected cases were from Kerala. Entomological surveys in worst affected areas in Kerala have showed high Ae. aegypti  mosquito breeding in rubber plantations and in peri-domestic areas due to monsoon collection and fresh water logging.  In May 2007, another outbreak occurred nearly in  all the districts. During the survey it was found that, age seems to play a significant role in the manifestations of symptoms. Probably due to development of herd immunity, the Chikungunya outbreaks have reduced after the outbreaks but could surface again due to waning immunity profile.

Dengue Fever (DF) which means “bone-breaking fever” (origin from Swahili word) was recorded during the Jin Dynasty (265–420 AD) in China. The first epidemic was reported in Asia, Africa and North America in the 1780s, shortly after Benjamin Rush identified and named the disease in 1779. The same Ae. aegypti  mosquito is the vector for this fever as well. In India, it has been in existence since long and the first outbreak in epidemic form occurred in 1997 in  North India.  In Kerala, although periodic cases were reported since long,  the first major outbreak occurred in 2017 when several districts were affected with around 20000 cases which dropped to around 4000 in 2019.  The epidemic form of this viral infection occurred in this year in three states of India, ie. Kerala, Tamil Nadu and Punjab. In Kerala, this however, may surface again and could be a major threat during the ensuing monsoon season.

The outbreaks of Chikungunya and Dengue had inflicted considerable pain and misery. It also caused substantial and unexpected local, regional and national financial burden towards healthcare. Many hospitals were ill-equipped to handle the burden of the disease. The unexpected rush of people and the un-preparedness of the health care systems had given a space for the quacks and unregistered practitioners in rural areas to expand their hold in the affected areas. After the 2007 Chikungunya outbreak, the Kerala Development Report, 2008 reported that the limitations of the government health infrastructure forced the people to move to private health system which was also not able to handle the unusual disease burden in the rural areas. In other words, people were forced to shuttle between formal and informal systems of medical care which exacerbated their problems.

Human contacts with potential vectors especially animals and plants are changing and these could be also due to changing behaviour of human beings. The Nipah virus infection in Kerala with an extremely high fatality rate which is transmitted through fruit-eating bats, pigs and contaminated foods could be contained somehow although predicted as a future public health crisis. It is now a complex post-COVID scenario, with the threat of chikungunya, dengue fever, leptospirosis, H1N1, cholera and hepatitis looming large which the COVID-strained health infrastructure has to handle.

Another serious problem which may crop-up during post-COVID days is that of wastes. Already huge quantity of wastes are piling up in common places in addition to households. Already, the pre-monsoon heavy rains have given an indication that such piling up can lead to water logging and inundation in urban areas apart from serving as breeding sites.

We interviewed a few ASHA workers in three districts and found that the over-stressed system may find it difficult to handle this complexity. The workers think that their credibility has become extremely low.

“When we go for prevention and awareness-generation activities, people spit on us. They ask us who are you to interfere in their freedom. They think that we are low level staff and people view us with disdain and contempt. We do not get any minimum protection that the health workers get. On the top of it we get all the blame. Our life is in a balance. No dignity or respect. After all we are not professionals. High-level officials think that this kind of work is only our responsibility”.

The workers think that lack of coordination between different departments can reduce the effectiveness of their pre-monsoon activities.

“Sudden opening of dams happen because of such a problem and most of the rivers are choked with wastes. And these areas are also the den of drug mafia and we are not feeling safe to go to such areas. Now we are there to take all blame”.

Workers in a coastal district also think that the pre-monsoon activities are not efficiently carried out.

“There was an activity called ‘Aedes Vida’ which means to destroy the breeding sites of Aedes mosquitos. It is to be done along with health workers. But due to this Corona infection, this is not being carried out. We are all the time involved in monitoring quarantine of the suspected. Because of lack of any income, we do not get any support of other voluntary workers or members of the sanitation committee. When we go for ensuring quarantine, people abuse us. They ask us as if we are nobody to ask them to comply with regulations. Because of too much workload ward-wise, none of our work could be carried  out effectively and the motivation is also low because of low wages”.

Another worker from a hilly district also think that increase in workload has affected their efficiency.

“We are carrying out a program as a pre-monsoon activity. Now because of the pandemic, we are not able to carry this out effectively although some awareness generation activities have been carried out. The main problem is workload as everything is dumped on us and this reduces the effectiveness.  Earlier, the pre-monsoon activities were carried out jointly with other health workers and this is not possible now. Dengue can be expected because of road works and the resulting water logging. It can also increase due to the forest areas and especially bamboo forests where mosquito breeding is more”.

The post-COVID scenario is going to be challenging as COVID is here to stay like the other infections which also can crop up periodically and most probably even as epidemics. The constant monitoring and vigil are important. Primary health care activities have to be stepped up and the reporting system has to be strengthened. ASHA workers are voluntary workers and the current trend of dumping everything onto them may be counter productive unless the primary health care as visualised by the National Health Mission can be effectively carried out in letter and spirit. The current pandemic has affected the rhythm of primary health care activities but it is important to refocus on the pre-monsoon preventive activities to ease the challenge.

(Professor K Rajasekharan Nayar is affiliated to Global Institute of Public Health and Santhigiri Research Foundation, Thiruvananthapuram, Kerala; Dr. Bindhya Vijayan is affiliated to Global Institute of Public Health, Thiruvananthapuram, Kerala; Dr. Muhammed Shaffi is affiliated to the Boston University School of Public Health, USA)



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One Comment

  1. Raghurkn says:

    It is time that we organise teams at different levels with specific task instead of entrusting asha workers with everything.Pre monsoon cleaning involves so many activities like drainage cleaning and
    removing cleared waste, disinfecting and fumigating the backyards garbage collection etc