 "The dengue sting needs an out-of-the-box cure")
As it draws closer to midnight, the queue in the dengue ward of Delhi's Lok Nayak Jayprakash Hospital grows longer. In the two hours that I have been here, a new patient has arrived almost every minute. Thanks to the steady trickle of patients, the hospital staff, which has been on its toes all evening, is ready to snap.
The recently created dengue ward is a long hall. It has six beds, each shared by four people. Even at midnight, the room is crowded. Both medical resources and manpower are short here. For one, there is no senior doctor present in the ward; instead three doctors - all in their mid-20s - sit at the entrance.
During the two hours, they rarely move to attend to the patients. Instead, they expect the patients to walk to them. Their reply to queries is often brusque. When one patient asks where he will find the medicines, one of the three doctors replies, "Meri jeb mein (in my pocket)." After the patient leaves, he abuses him for asking a silly question.
The Delhi government's claim of ensuring adequate medical care does not reflect on the ground. It has taken some struggle for two Rajasthan Armed Constabulary men to find even a dose of intravenous paracetamol - the nurse on duty had initially told them she didn't have any. There is no isolation of confirmed dengue cases from the suspected ones.
Going by the number of patients arriving at LNJP, one of Delhi's large government hospitals, it leaves little doubt that the city, severely in the grip of the dengue virus, is at its wit's end.
The long queues of patients, at LNJP as well as other hospitals, suggest there is gross underreporting in the number of dengue cases. According to the National Vector Borne Disease Control Programme (NVBDCP), 3,791 dengue cases and 17 deaths were reported in Delhi until September 20. Nationally, 27,600 cases have been found and 60 deaths have been reported.
Where it began
Dengue is a mosquito-borne viral disease. It is relatively young in India. According to a 2012 research paper titled "50 years of Dengue in India", published in the Transactions of the Royal Society of Tropical Medicine and Hygiene, though cases of dengue have been reported for the last two centuries, the first large epidemic occurred in 1963 in Kolkata, from where it spread to the rest of the country, causing around 200 deaths. However, right up to the 1990s, though dengue cases and related deaths continued to rise, the government did not put in place any surveillance system.
It was only in the mid-90s that some kind of a monitoring system was devised after two major epidemics - in 1993 and 1996 - caused a large number of deaths. The 1996 epidemic was particularly deadly for Delhi; it led to 423 deaths. A surveillance system was put in place to report on suspect dengue cases and the NVBDCP prepared guidelines.
However, doctors say the government has still not challenged this disease as it has in the case of smallpox, polio and AIDS. In contrast, Singapore, which too faces threat from dengue, found a more institutionalised way of defeating the disease.
The island nation developed a four-pronged strategy to take on dengue. It included preventive surveillance and control, public education and community involvement, enforcement, and research. Its National Environment Agency conducts daily surveillance in areas that have high mosquito population. There are 850 officers who are dedicated to only this task.
Since 2001, the Singapore government has also made it mandatory for construction sites to employ an environment control officer whose job is to control pests and mosquitoes. There is also an Inter-agency Dengue Task Force, which comprises 27 government agencies and private associations.
Dengue is transmitted primarily by a female mosquito, Aedes aegypti, and to some extent by A albopictus. The human infections is acquired by the bite of an infected mosquitoes (which is picked up while biting a dengue infected person) and sustained by human-mosquito-human transmission. There are four serotypes of the virus that cause dengue: DEN-1, DEN-2, DEN-3, and DEN-4. A patient who has recovered from one serotype remains immune against it, but is vulnerable to attack from the other three. Infection by other serotype increases the risk of developing severe dengue.
In Delhi, all the four serotypes of the virus are said to be present. This complicates the challenge faced by doctors. Doctors say in almost all the cases, the patients recover without the need for any hospitalisation. And in 95 per cent of the cases, platelet transfusion is not required.
Health experts cite three prominent reasons for the failure to arrest the dengue virus' spread: One is the lack of coordination between the Municipal Corporation of Delhi (MCD) and the Delhi government to stop mosquito breeding, which is the primary responsibility of the MCD. The MCD defends itself by stating that the Delhi government did not provide it with sufficient funds.
Two, MCD lacks the power to take action against those whose premises are found to contain mosquito breeding sites. At present, the maximum MCD can do is impose a fine of around Rs 400, which is hardly an effective deterrent.
Three, there is a lack of information among people about the disease. An example of this was visible during the initial days of the outbreak, when some of the patients opted for unscientific remedies such as drinking goat's milk (prices shot up from Rs 40 a litre to Rs 2,000 a litre) and eating papaya leaves (Rs 500 a leaf) in the hope that it would boost their platelet count.
Finding solutions
More institutional reforms are needed. For instance, according to Census 2011, nearly 20 per cent of Delhi households do not have access to piped water. These people, who often live below the poverty line, collect water in open vessels, which are the ideal breeding ground for the dengue virus.
"The (Delhi) government has taken a number of steps. It has increased the number of beds, created fever clinics just for dengue patients, and cancelled the leave of doctors. But the situation in Delhi was allowed to go out of control because of lack of action when it was needed," says a senior Delhi government doctor. "The first cases of dengue were reported in May. The government should have taken aggressive steps then, especially pushing MCD to ensure cleanliness."
S P Byotra of Sir Ganga Ram Hospital agrees: "Doctors are a soft target for everyone. The reality is we (the government and municipalities) did not do our homework and allowed the mosquitoes to breed." MCD, like most other municipalities in the country, has also not looked beyond fumigation drives (whose effectiveness is questioned) and insecticide sprays to destroy mosquito breeding grounds. "The fumigation does not have much effect. But people think we are working," admits the mayor of one of the three municipalities of Delhi.
As a vaccine for dengue still remains in the work, countries such as Cambodia and Lao People's Democratic Republic are experimenting with larvae-eating fish to combat the spread of dengue. Brazil is experimenting with a genetically modified variant of Aedes Aegypti that mates with native mosquito population to produce offspring which die before reaching maturity. China has, meanwhile, set up the "world's largest mosquito factory" in Guangzhou from where it release one million sterilised mosquitoes every week to replace them with those that carry the dengue disease.
The situation calls for such out-of-the-box solutions.
The recently created dengue ward is a long hall. It has six beds, each shared by four people. Even at midnight, the room is crowded. Both medical resources and manpower are short here. For one, there is no senior doctor present in the ward; instead three doctors - all in their mid-20s - sit at the entrance.
During the two hours, they rarely move to attend to the patients. Instead, they expect the patients to walk to them. Their reply to queries is often brusque. When one patient asks where he will find the medicines, one of the three doctors replies, "Meri jeb mein (in my pocket)." After the patient leaves, he abuses him for asking a silly question.
The Delhi government's claim of ensuring adequate medical care does not reflect on the ground. It has taken some struggle for two Rajasthan Armed Constabulary men to find even a dose of intravenous paracetamol - the nurse on duty had initially told them she didn't have any. There is no isolation of confirmed dengue cases from the suspected ones.
Going by the number of patients arriving at LNJP, one of Delhi's large government hospitals, it leaves little doubt that the city, severely in the grip of the dengue virus, is at its wit's end.
The long queues of patients, at LNJP as well as other hospitals, suggest there is gross underreporting in the number of dengue cases. According to the National Vector Borne Disease Control Programme (NVBDCP), 3,791 dengue cases and 17 deaths were reported in Delhi until September 20. Nationally, 27,600 cases have been found and 60 deaths have been reported.
Where it began
Dengue is a mosquito-borne viral disease. It is relatively young in India. According to a 2012 research paper titled "50 years of Dengue in India", published in the Transactions of the Royal Society of Tropical Medicine and Hygiene, though cases of dengue have been reported for the last two centuries, the first large epidemic occurred in 1963 in Kolkata, from where it spread to the rest of the country, causing around 200 deaths. However, right up to the 1990s, though dengue cases and related deaths continued to rise, the government did not put in place any surveillance system.
It was only in the mid-90s that some kind of a monitoring system was devised after two major epidemics - in 1993 and 1996 - caused a large number of deaths. The 1996 epidemic was particularly deadly for Delhi; it led to 423 deaths. A surveillance system was put in place to report on suspect dengue cases and the NVBDCP prepared guidelines.
However, doctors say the government has still not challenged this disease as it has in the case of smallpox, polio and AIDS. In contrast, Singapore, which too faces threat from dengue, found a more institutionalised way of defeating the disease.
The island nation developed a four-pronged strategy to take on dengue. It included preventive surveillance and control, public education and community involvement, enforcement, and research. Its National Environment Agency conducts daily surveillance in areas that have high mosquito population. There are 850 officers who are dedicated to only this task.
Since 2001, the Singapore government has also made it mandatory for construction sites to employ an environment control officer whose job is to control pests and mosquitoes. There is also an Inter-agency Dengue Task Force, which comprises 27 government agencies and private associations.
Dengue is transmitted primarily by a female mosquito, Aedes aegypti, and to some extent by A albopictus. The human infections is acquired by the bite of an infected mosquitoes (which is picked up while biting a dengue infected person) and sustained by human-mosquito-human transmission. There are four serotypes of the virus that cause dengue: DEN-1, DEN-2, DEN-3, and DEN-4. A patient who has recovered from one serotype remains immune against it, but is vulnerable to attack from the other three. Infection by other serotype increases the risk of developing severe dengue.
In Delhi, all the four serotypes of the virus are said to be present. This complicates the challenge faced by doctors. Doctors say in almost all the cases, the patients recover without the need for any hospitalisation. And in 95 per cent of the cases, platelet transfusion is not required.
Health experts cite three prominent reasons for the failure to arrest the dengue virus' spread: One is the lack of coordination between the Municipal Corporation of Delhi (MCD) and the Delhi government to stop mosquito breeding, which is the primary responsibility of the MCD. The MCD defends itself by stating that the Delhi government did not provide it with sufficient funds.
Two, MCD lacks the power to take action against those whose premises are found to contain mosquito breeding sites. At present, the maximum MCD can do is impose a fine of around Rs 400, which is hardly an effective deterrent.
Three, there is a lack of information among people about the disease. An example of this was visible during the initial days of the outbreak, when some of the patients opted for unscientific remedies such as drinking goat's milk (prices shot up from Rs 40 a litre to Rs 2,000 a litre) and eating papaya leaves (Rs 500 a leaf) in the hope that it would boost their platelet count.
Finding solutions
More institutional reforms are needed. For instance, according to Census 2011, nearly 20 per cent of Delhi households do not have access to piped water. These people, who often live below the poverty line, collect water in open vessels, which are the ideal breeding ground for the dengue virus.
"The (Delhi) government has taken a number of steps. It has increased the number of beds, created fever clinics just for dengue patients, and cancelled the leave of doctors. But the situation in Delhi was allowed to go out of control because of lack of action when it was needed," says a senior Delhi government doctor. "The first cases of dengue were reported in May. The government should have taken aggressive steps then, especially pushing MCD to ensure cleanliness."
S P Byotra of Sir Ganga Ram Hospital agrees: "Doctors are a soft target for everyone. The reality is we (the government and municipalities) did not do our homework and allowed the mosquitoes to breed." MCD, like most other municipalities in the country, has also not looked beyond fumigation drives (whose effectiveness is questioned) and insecticide sprays to destroy mosquito breeding grounds. "The fumigation does not have much effect. But people think we are working," admits the mayor of one of the three municipalities of Delhi.
As a vaccine for dengue still remains in the work, countries such as Cambodia and Lao People's Democratic Republic are experimenting with larvae-eating fish to combat the spread of dengue. Brazil is experimenting with a genetically modified variant of Aedes Aegypti that mates with native mosquito population to produce offspring which die before reaching maturity. China has, meanwhile, set up the "world's largest mosquito factory" in Guangzhou from where it release one million sterilised mosquitoes every week to replace them with those that carry the dengue disease.
The situation calls for such out-of-the-box solutions.