Epidemic proportions

S Remadevi /Kochi

Spread of viral and other infectious diseases in the wake of monsoon every year has triggered health care crisis in Kerala. The government's efforts to curb the menace have fallen flat.

Inflation, Every year as the monsoon lashes Kerala, there is a surge in cases of infectious diseases, especially dengue fever. Hospitals and healthcare facilities have been grappling with the recent phenomenon for some time.

The health department's efforts to curb the spread of diseases have fallen flat as every year the number of cases shows a steady increase. Viral fever patients swell hospital wards and observation rooms in almost all Government hospitals across the State. While much of the fever cases crowding the hospitals have been seasonal viral fever, often accompanied by a secondary bacterial infection affecting the chest, there is no denying the fact that dengue fever numbers are growing larger every year.

"Dengue has become so well-established in the State now that in every outbreak, at least three panchayats are involved. This is a recent phenomenon that we have had to reckon with and quite worrying because it indicates fast local transmission of the infection," a senior public health personnel said.

Official figures cite that there have been 1,021 confirmed cases of dengue fever in the State this year (till June 27), with five confirmed deaths. But these are the cases which have been confirmed in laboratories and reported to the Health department.

Which means that clinically dengue-suspected and unconfirmed cases could be even double or treble this figure. Also, the figure quoted by the department does not reflect the dengue cases which are attended to by private hospitals as reportage from the private sector continues to be very poor.

Reports from the districts suggest that after an upsurge of viral fever cases in June, with the monsoon remaining erratic, cases have been showing a downward trend. However, with the monsoon becoming active again, it is possible that the fever cases, including dengue could go up too.

The State has been bearing the brunt of Chikungunya outbreaks consecutively for the past four years during which time almost all districts were affected. This year, though there are scattered cases from all districts, outbreaks should be expected from Wayanad and Malappuram, which have so far remained relatively unaffected, Health officials said.

This year, the huge burden of mortality related to the Influenza A (H1N1 ) infection is something else that the State had to deal with. The H1N1 virus, in its second spell since May this year, has claimed 58 lives so far and nearly 1,100 cases of the infection have been confirmed

Dengue cases are currently showing an upward trend in Thiruvananthapuram, Pathanamthitta, Idukki, Kottayam, Wayanad, Kannur and Kasargode districts . Over 600 cases are from Thiruvananthapuram, Kottayam has 300-odd cases, about 144 cases have been confirmed from Idukki. Wayanad has fewer dengue cases - about 14 - and more of Chikungunya cases this year (44 confirmed). Leptospirosis continues to be a major problem in all districts, with high mortality rate also. Thiruvananthapuram has around 180 cases, Wayanad, 25 cases and seven deaths, Idukki has also reported some 20 cases. In 2009, official figures state that the State had 1,156 cases with 126 deaths.

"The actual figures from districts will never tally with the official figure. There is gross under-reporting and often, data from the OP clinics in the periphery are collected only till 1 p.m. to avoid showing the actual number of cases, a doctor working in the periphery said.

"All plantation districts and the rubber belt have loads of dengue cases. Ernakulam is another district, where increasing urbanisation and environmental degradation has led to an explosion in dengue cases. But with most people approaching the private hospitals for treatment, the official figures do not reflect the actual situation there at all," he added.

The high number of dengue cases in the plantation districts never reflect in the official figures because all dengue testing facilities are concentrated in urban areas, a public health expert pointed out. Thiruvananthapuram has more testing facilities, better surveillance and documentation, which naturally reflects in the high figures also.

"We are getting complacent about the annual dengue outbreak and seek comfort in the fact that our dengue mortality is still low. But this is no reflection of our better control measures; it just indicates that the doctors in the State are old hands at managing dengue now!", he pointed out.

Dengue and the vector primarily responsible for transmitting this disease, the Aedes species of mosquitoes, have become well-established in the State in the past decade and as soon as the rains begin, there is a surge in dengue cases also. Cases which start to trickle in by May-end with pre-monsoon showers peaks during July-August and ebbs around September-October.

Though this year, the Health department did try to plan ahead and had launched a comprehensive pre-monsoon, pre-epidemic disease-control programme -- the Four Plus Strategy-to tackle all mosquito-borne diseases and leptospirosis, the mosquitoes seem to have had the winning edge in this battle.

An explosion in the mosquito population and the manner in which the Aedes species seem to have adapted its breeding habits to the State's climatic and geographic conditions are playing havoc with the vector management strategies adopted by the State, which has been focussing mostly on source-reduction or destruction of mosquito-breeding sites.

Vector management is a problem rid with much difficulty in the plantation districts, where control strategies are limited because more than man-made breeding sources, it is Nature which plays host to the vector.

If in the urban areas, it is the Aedes aegypti which is the primary vector which transmits dengue, in the hilly terrains, it is the tiger mosquito or the A. albopictus which is the incriminating vector. A.albopictus is a less efficient vector, but it makes up for this by its huge numbers.

Entomologists pointed out that there can be no blanket strategy for controlling the Aedes species and that strategies would have to be devised depending on the geographical terrain, climatic patterns and the nature of human and mosquito contact. In plantations, source reduction alone does not work because the mosquitoes are found breeding in tree hollows, on the wet, leafy mass on ground and even inside the tiny rubber fruit pods scattered on the ground.

Last year, at Kanjirappally in Kottayam district, A. albopictus was the primary vector responsible for the outbreak there. Though this vector is believed to breed in natural environs, in Kanjiarappally, entomologists found that this species had adapted itself to indoor breeding and that it was breeding in flower vases and refrigerator trays. Multi-pronged strategies, including intensive fogging, use of pesticides etc would have to be adopted along with source reduction in plantation areas.

Vector management is thus rid with new challenges and this is one area where in the long-term, State would have to invest heavily in research and development, it is pointed out. More entomological research - the adaptability of mosquitoes, the local climatic and geographic conditions, environmental issues -- would be crucial for the State in evolving new vector control strategies.

In the 2008 March issue of Public Library of Science journal, in the article, `Defining Challenges and Proposing Solutions for Control of the Virus Vector Aedes Aegypti', scientists have pointed out that the universal reliance over the last 50 years on source reduction may appear logical given the vector's domestic habitat, but obviously, it has not been working in societies at risk.

Unless there is blanket coverage of source reduction activities, conscientious execution over a sustained period and a determined leadership to monitor the execution of the programme, source reduction cannot be successful, the article said. Unless all members of the community participate in the activities, one could still be at risk from a neighbour who does not bother about source reduction.

Which is why, the article suggested, that perhaps it is time that strategies for Aedes destruction were revised, to give more attention to adult mosquitoes as in malaria prevention programmes. More focussed surveillance and improved strategies for killing mosquitoes, use of improved and less toxic pesticides for indoor residual spraying should be tried, it says.

Geographic mapping of dengue or suspected cases of dengue are important for outbreak assessment as well as for launching control measures. Risk stratification is a strategy that the island nation of Singapore has been using successfully to tackle its huge dengue burden.

While the dengue situation in Singapore is quite different from the State's scenario, last year, the Health department despatched its entomologists to Singapore to assess if there were lessons from the island nation's war against mosquitoes that Kerala could adopt.

In Singapore, it is mandatory that doctors report all dengue cases to the Health Ministry, which in turn alerts the National Environment Agency. The NEA prepares a dengue spot map and any area where two cases of dengue occur within 14 days of each other in about 150 m radius is treated as a hot spot , because it indicates local transmission. Intensive source reduction and vector control measures like spraying and fogging are then launched in these hot spots.

This strategy could be adopted here too for checking outbreaks and for preventing flare-ups.

Even allowing for all the limitations that dengue management might pose for the State's health task force, public health experts are quite disappointed over the health system's poor response to the newer challenges that the State has to face year after year.

In the public health arena, it is the doctor in the local health care institution who should play a pivotal role in leading the health care activities in a locality. But the doctors here are focussing only on the curative aspect and none has any orientation in public health, it is pointed out. Doctors mostly handle the OP clinics and the paper work and leave and there are none to supervise and monitor public health activities in the field.

"What we need is a dedicated public health cadre, with adequate training, skills and experience in public health and epidemiology at the Centre and State-level. We need personnel who are experienced in case-based and real-time disease surveillance; detection of early signals of outbreaks and immediate interventional response and coordinated control and monitoring of trends of all endemic infectious diseases which will vary from region. Most of all we need a good infectious disease surveillance system, which closely interfaced with health care in the public and private sector," T. Jacob John, a prominent public health activist in the country and the former Head of the department of Clinical Virology, CMC Vellore, said.

Bihar: High growth fails to reduce poverty

Sopan Correspondent/New Delhi

Nitish govt is riding on growth wave but a reality check shows not much change in the ground situation

The word "Bihar" has always been conjured an image of poverty, backwardness, violence and failed governance. All along media has been portraying the miseries of people for last two decades. With the change of government in 2005, hopes had risen that things would change in the state and lot of people would improve in the next five to seven years. But have things fallen in line since then, it seems the time has come to evaluate the state of affairs in Bihar.
No doubt in the last seven years, the new government has shown some character and the sense of insecurity in the minds of people is now a fact of bygone era. The state has been growing with a double-digit rate for last four years. In the four successive years since 2008-09 state's GSDP registered 14.58 percent, 10.42 percent, 14.77 percent and 13.13 percent respectively. But even after registering one of the highest growths in the country for four consecutive years, have things actually changed on the ground and improved the lot of people at large? The answer appears to be in a big no, as data release by planning commission show that half of the state still live below poverty line (BPL).
Keeping in view the alarming figures on poverty in Bihar, one of the members of planning commission Abhijit Sen had recently said, "It is a matter of serious concern that there is no decline in poverty in Bihar despite a high growth rate and development."
Dr Sen, also a well-known economist, said that while Bihar had been maintaining good growth rates, it had failed to reduce the rate of poverty. "Bihar has impressed many with its high growth rate. That is good. But at the same time, the state has not seen a decline in the rate of poverty. It is still at the bottom of the pile and has a lot of catching up to do," he said.
During the 11th plan period (2007-12), Bihar has added 50 lakh people to the number of its poor, by far the largest number of any Indian state in this period. A look at Planning Commission numbers for 2009-10 and 2004-05 shows that poverty has declined at a negligible rate in Bihar, so much so that the absolute number of people living in poverty has actually increased. In 2009-10, 55.3 percent of Bihar was under the poverty line as compared to 53.5% in 2004-5.
To add to this the population of the state has also shown a decadal growth more than the national average, which also added more people under BPL in absolute number. Bihar had a decadal growth population by 28.6 percent in the 2011 census, where as the national average stood at 17.6 percent.
Therefore, now no one would be constraint to claim that in Bihar riche became richer and poor became poorer and this can be further endorsed by an empirical analysis of an event, which this author had seen during his visit to a West Champaran district village named Kesariya to attend a family function.
An elaborate puja (rituals) was performed by one of the relative families of the author. It was a 12-hour exercise and after the completion of all the rituals, there was a dinner scheduled to be served to all present in and around the area.
However, since morning, children of poor families of the village were seen flocking around the house of the author's relative in the hope of getting something to eat. But since their presence was disturbing and obstructing the function to go on smoothly, one member of the family drove all the children surrounding the house away by threatening to beat them with a stick. Sensing the risk of being beaten up the children fled away. But the same exercise got repeated again and again throughout the day, as children used to come back to wait to get something to eat. Most of the children were necked or half necked portraying the true picture poverty in the state.
It to utmost surprise to this author that in the evening, when the rich family was to feed the poor children in the hope of earning God's blessings, the same children were sitting in the row to get food. They were eating the normal "mid-day-meal" stuff as if they have not eaten for sometime. The scene was so appalling and pathetic that one was forced to ask if the Integrated Child Development Scheme (ICDS) is working in the state or not, where the state government has claimed that it has spent on the scheme Rs. 818.20 crore.
However, in the past one decade there is no doubt that the weakest sections of the society has made rapid gains in their material wellbeing, acquiring assets such as cell phones, televisions, two-wheelers and bank accounts. But almost half the population of scheduled castes in the state continue to live by the light of the humble kerosene lamp, much more than the national number of 31 per cent.
The latest data of census 2011 has also shown that asset poverty has declined substantially. In fact the decline in the number of dalits having assets is comparable to the numbers nationally.
In 2001, 42.6 per cent of SC were without any of the 13 assets specified in the houselisting survey of the Census. In 2011, this had come down to 22.6 per cent. Nationally, the percentage of households without any assets came down to 17.8 per cent from 34.5 per cent.
This means nearly 80 per cent of Dalits had one of the specified assets, which includes a bank account, radio, television, bicycle, car, telephone, mobile, computer and internet connectivity. While half the Dalit population has a bank account, 40 per cent have TV sets and another 51 per cent have telephone connectivity. In 2001, just 25 per cent had bank accounts, and 21 per cent had a television, while a phone connection was available with just 3.5 per cent.
The decline in asset poverty of Dalits has been striking in the erstwhile Bimaru states such as Bihar and Uttar Pradesh. While 67.5 per cent of SC in Bihar had no assets in 2001, this has halved to 38.9 per cent now. In UP, where 26 per cent had no assets a decade earlier, the figure has come down to 15 per cent.
In Kerala, where the figure was 47 per cent a decade before, it is now 11 per cent. In Bengal, where 38 per cent had no assets earlier, it is 28.3 per cent. Ownership of motorised vehicles has increased from 5.3 per cent to 11.9 per cent.
However, a majority of SC still have no electricity. In Uttar Pradesh, 74 per cent of SC households depended on kerosene for light. In West Bengal, it is 56.4 per cent, in Odisha, 63 per cent. In Jharkhand, 60 per cent. Nationally, the dependence on kerosene as the sole source of light was only 31 per cent.

Hope takes root in Kerala

S Remadevi/ Kochi

Water and soil conservation efforts have made agriculture sustainable in Kerala. initiative was supported by NABARD.

Agriculture sector in Kerala is reeling under severe crisis. The plantation sector has witnessed unprecedented cases of farmers' suicides in the last five years.
The state with two third of its net sown area under plantation crops is a major producer of cash crops like pepper, rubber, cashew, cardamom, ginger and coconut, in the country. These crops are mainly grown in the undulating midlands and steep highlands of western ghat region of the State. Area identified as high ranges ie 1000M above MSL, account for 5.15 lakh ha. and are mainly spread over in Wayanad, Palakkad and Idukki districts forming 16 percent of the total area. High land areas i.e. 75 M above MSL are estimated to be about 18.71 lakh ha. The production of major crops like coconut, arecanut, pepper, cardamom, cashew, tea, coffee etc. showed wide variation during the last four decades for a variety of reasons such as drought, diseases etc.
The biophysical resources influencing agricultural productivity are land, soil and water. Denudational nature of the major portion of terrain leads to high soil erosion and surface runoff. Weathered and transported soils have low levels of plant nutrients indicated by low pH and base saturation.
The water availability indicators show water deficiency for most of the crops during mundakan and puncha seasons (August to May).
These constraints result in lowering of production of the crops and also sustainability. The constraints of the biophysical resources can be overcome to a considerable extent by adopting soil and water conservation measures on watershed basis.
Considering the importance of soil and water conservation for bringing about improvements in production and productivity as also for maintaining sustainability of agriculture, National Bank for Watershed Development Programmes in Kerala Agriculture and Rural Development (NABARD) undertook the task of providing financial assistance for soil and water conservation projects under Rural Infrastructure Development (RIDF).
In all 112 projects with RIDF assistance of Rs.28.69 crore have been sanctioned under RIDF, with first three tranche, the details of which are indicated below.
Under RIDF-I, 40 projects were assisted, with a total outlay of Rs.1013.159 lakh and RIDF assistance of Rs.500.97 lakh. The details of sanction are given in.
A techno economic evaluation study of the projects was taken up with objectives of understanding the impediments in implementation and to collect empirical evidences on the impact of the investments.
Of the forty soil and water conservation projects sanctioned, thirty-seven projects have been completed and three projects have been dropped.
The project components include mechanical measures like contour bunds, earthen bunds, terraces, check dam, water harvesting structures and retaining wall as well agronomic measures like agrostological, agro-forestry etc.
Two projects each were selected at random from Kasargod, Idukki and Thiruvananthapuram and one from Wayanad. A total of seven projects were brought under the study. In the absence of data on sedimentation rate, run-off velocity, ground water fluctuation etc. interview with the farmers using structure questionnaire was resorted to capture the impact of soil and water conservation measures.
Twenty respondents were selected at random from each of the watersheds covering 140 respondents. The comparison has been made with the pre and post development situations.
The State Soil Conservation unit under Agriculture Department is the implementing agency for all the projects. The soil conservation works are implemented through field level units of the department, viz., soil conservation unit and overseer unit. The common works like drainage line treatment retaining wall, check dam. WHS etc are implemented by the Beneficiary Committee constituted for the purpose. Works in individual fields are carried out by skilled labour employed either by the beneficiary or by the beneficiary committee.
Adoption of soil and water conservation mearures leads to better use of land, which is measured in terms cropping intensity. Cropping intensity for the various scheme areas before and after implementation of the schemes are indicated. As the cropping system in the area of study are of a mixed nature estimation of cropping intensity has been made based on the area occupied by each crop on the basis of standard crop stand recommended by the package of practice of Kerala Agriculture University.
The cropping intensity has improved during post implementation period in all the scheme areas. The largest improvement in cropping intensity is recorded in Kalvery Mount, followed by Rajamudy at 105 and 98 per cent, respectively. This is due mainly to the fact that the cult arable area in both the watershed were not put to use before taking up conservation measures. Both these schemes are in Idukki district.
The next highest improvement was recorded at Pallickal scheme in Thiruvanthapuram district at 45%.
The major effect of soil and water conservation measures is reflected in improvements to productivity of crops. The changes in productivity of the major crops in the scheme areas was estimated on a per hectare basis as mono cropping does not exist in any of the scheme areas. The productivity change for the major crops.
There have been positive changes in productivity for all crops. The highest improvement in productivity has been recorded by Tea at 121 per cent in Rajamudy followed by cardamom at 107 per cent in Kalvery Mount.
The economic effect of soil and water conservation measures was estimated by valuating the incremental production in the different scheme areas at the farm gate prices indicated by the respondents.
The prices of all the commodities remained more or less the same in the areas. Based on the price realized by the respondents, the net incremental income has been worked out. Incidentally it was noted that the cost of maintenance remained the same during the pre and post development periods.
The highest incremental income per hectare was recorded at Mangalassery scheme, which had predominance of coffee and pepper, which are high value crops. The incremental income from Karivedakam where rubber and coconut occupy substantial area, was found to be the next highest at Rs.20,500. Here it was observed that productivity of most the crops shown substantial gains. The lowest income per hectare was observed in Rajamudy scheme area of Idukki district. The incremental income at Chemmattanchal of Kasargod and Pallickal of Thiruvannathapuram was above Rs.13000. Kalvery Mount Rs.12100 and Arivippuram Rs.19400.
The incremental income generated in all the scheme areas has been substantially high due to better soil and water conservation.
Based on the actual cost of works and the estimates of incremental income generated, the Financial rate of return and the Economic rate of return for the scheme were worked out.
The Financial and economic rates of return for the various schemes taken up for study was above 25 per cent. For four schemes viz. Karivedakam, Mangalassery, Arivippuram and Pallickal it was morethan 100 per cent.