By M.M. Janapriya –
It was most disturbing to watch over television news that two school children of the same family in Galle have died of Dengue fever recently. The report also showed the public angered by the incident demonstrating against the government’s inaction on their pleas to act on a nearby building site breeding the killer mosquito. The angry mob set fire to tyres and blocked roads for several hours. I am by no means condoning the response of the public but am deeply empathetic towards their cause.
I know what it is like to raise kids in a dengue stricken area like Galle. People may say I am or was paranoid as I was one of the first if not the first person to completely mosquito proof my house (35/1, Maitipe 1st Lane Karapitiya Hospital Quarters) 32 years ago. My son was barely 7 years then and the elder daughter was just under 3 years of age. I became an active member of the Old Boys Association of Mahinda College and managed to launch a program to clean the premises regularly including the rainwater gutters. I did the same sort of thing with the Joyce Gunasaekara Montessori house of children in Fort Galle, which my elder girl attended. My children were painted with citronella oil before they left home to school every morning or any time they went outdoors to play or indeed attended a birthday party or any such event. The windows and doors closed around 1630 hours. I almost became a nuisance to my own children but I wasn’t deterred by that. My daughter whom I protected so well is now a MOH herself in a far flung place beyond Moneragala fighting tooth and nail to keep Dengue, communicable diseases and non-communicable diseases at bay. She is doing a sterling job and I am very proud to be her father.
Every time the news of a little child dying of Dengue reached my ears, my paranoia increased in geometric progression. I remember as if it was yesterday my classmate and my friend who was a bank manager at Tissamaharama calling me about his loving daughter. He said “Doctor, my daughter has got fever and abdominal pain and a GP has said she probably has got Appendicitis. Can you please see her, I am on my way to Galle.” I said “of course………… please ask your good lady to bring the kid along and I will do the needful”. They did come and the kid did not have appendicitis. (Incidentally they did not live that far away from the place where these two kids died a few days ago ). She was constantly keeping her head on my consultation table signifying the presence of a significant headache. Her tummy was completely soft and not painful on pressing the appendix area. Her white blood cell count (WCC) was normal with a relatively high lymphocyte count and a slightly low platelet count. I told my friend “……………your kid hasn’t got appendicitis. It is very likely that she has got a viral fever and I would like to refer her to a physician as she may well have got Dengue” Unfortunately the physician of his choice was on leave and I had to refer her to a younger, less experienced albeit a fully qualified physician. Lo and behold the doctors lack of experience took it’s toll on this poor kid. A few days after my referring her to the physician her dad called on me in a consultation room of the same hospital where his daughter was an inpatient. He looked ashen grey and with trembling hands and quivering lips he spoke to me. It was a chilling experience. He said “doctor, my daughter is dying. They want to transfer her to Colombo. Is it OK to take her?”. I sprang to my feet and made a bee line to where she was. She was relatively stable and was not on any life support. Hence I said she could be transferred as long as someone who could intubate her and ventilate her lungs (in case she needed it) accompanied her. She was transferred to a well-known private hospital in Colombo and was admitted to the ICU of this hospital. They paid the hospital around Rupees 50,000/day but the kid succumbed to her illness in about 72 hours. This is the sad story of a young girl who bade good bye to us in 1988 if I remember right. The story is not much different in 2019.
In 2017, Sri Lanka saw a record number of dengue fever cases with a total of 184,442, a total more than three times higher than 2016. More than 320 deaths were also reported. The dengue peak was observed during the summer months with more than 41,000 cases reported during July alone.Jan 3, 2018. A total of 48,303 dengue cases and 52 dengue deaths had been reported countrywide up to December 2018. Epidemiology Unit sources said. According to sources, the highest number of dengue cases, 9,551 had been reported from the Colombo district while the second highest number, 5,408 had been reported from the Gampaha district. The third highest number of dengue cases, 4,727 had been reported from the Batticaloa district.
It is true that dengue has advanced itself from a benign sporadic case of occasional high fever with body aches and pains to a killer febrile illness epidemics of which blow across the country year on year making thousands of people very ill and killing a few hundred of them on it’s way. Last year the total number of reported cases was 48,303 with 52 deaths. I am rather skeptical about these figures as there is a possibility that these figures have been conveniently made inaccurate to save the skin of the preventive health force and others who are expected to help them successfully launch the campaign. After all they say “it is lies, damn lies and statistics”. I say this because in 2004 or so when I was Senior Consultant Surgeon, NHSL Colombo, there was a Dengue epidemic rampaging across the city of Colombo and across the country. The newspapers and the government called it a “Flu epidemic”. I interviewed all the Physicians personally and asked them specific questions geared towards establishing or refuting that this epidemic of `flu’ could indeed be Dengue. They eventually agreed it was probably a Dengue epidemic.
I then wrote to the newspapers in my own inimitable style that this was indeed a Dengue epidemic masquerading as a “Flu epidemic” and not to be complacent about it at all. My article failed to hit the necessary area of the broadsheet but there was a fairly hard hitting editorial embodying the substance of my article. Based on this I was appointed to a dengue control board by Mrs.Renuka Herath, the then Minister of Health. I was the only surgeon ever to be appointed to such a board. We started well and in earnest within a fortnight of the first meeting our pilot was a part of Maharagama where we placed skips for the residents to dump their refuse in order to obviate the need for littering them everywhere. Unfortunately, I had to leave the country and could not see the outcome of our first exercise. Thirteen years and six months on, I am back in Sri Lanka and the Dengue control programs seem as weak as it was then.
The preventive health authorities and other pundits would adduce many reasons for the failure to curb dengue for so long. Virulence of the virus increasing, presence of 4 strains of the virus, urbanization are three of the commonest reasons they would adduce but the bitter truth is that Sri Lanka does not have a well thought of, well executed rational program to curb dengue fever. The authorities have a dispassionate and seemingly defeatist attitude towards Dengue eradication.
I am not very sure if they have indeed studied the history of Dengue control at all. We are often told to learn from the past to model our future. In the 1950s and the 60s Dengue was not a problem in Sri Lanka known as Ceylon then. It was a benign febrile illness that did not produce epidemics as the patient numbers and the mosquito numbers were small.
The vector was known to be Aedes Egypti mosquito with zebra like stripes on the body and the legs. This mosquito bred in holes on trees and other stagnant water collections in the jungles of Africa. When we were having it easy, the tropical countries of the western hemisphere suffered a lot from yellow fever which was also disseminated by the same mosquito. It was the US and the Cuban armies together that managed to eradicate the mosquito from all 27 countries of the Americas in 1947. Unfortunately the mosquito was back in these countries with a vengeance by the 1960s for which urbanization was blamed as the main contributer and they have been struggling since. Cuba however managed to officially declare itself dengue free in the year 2002. Cubans, have a well-structured, scientific and a repetitive program that is being deployed in military style.
The current Dengue control program of Sri Lanka lays a heavy emphasis on the people of the country doing their bit to control Dengue with a lot of accent on punitive measures. So much so it looks like either your do your bit or suffer the consequences. Unfortunately the consequences hit not only the people who negligently let the mosquito breed but everybody who has been unfortunate enough to live within a 200-500 metre radius from there as the Killer mosquito could under normal circumstances fly this distance before infecting humans on route. Punitive measures have never worked on common issues of this nature ever. They will be effective on individual issues such as traffic offences, tax evasion etc. In Vietnam many decades ago they introduced an incentive program instead of punitive measures to rid the country of plastics which was a well-known breeding ground for Aedes Egypti mosquito. They offered a small financial reward for every single yoghurt cup or polythene bag brought to a central collecting centre. It was a resounding success. While the system provided the do-gooders with some extra cash to spend, the waste that could not be collected before, was seen reaching the desired destination swiftly and for sure.
Eradication of the disease is not rocket science. It is clear that one has to either get rid of the mosquito or the virus. As it is easier to tackle the mosquito most countries have resorted eradicating the adult and the larval stages by a variety of methods. The countries which succeeded had the will, the necessary personnel, equipment, a plan and courage and motivation to deploy the plan to a finish. This is basically what we need. Sri Lanka is a small island and it not impossible to achieve this. Most important tools of any such program are a sense of moral indignation at unnecessary suffering and for the leadership to mobilize human will power and resources to take on the task.
The very basic process should be an all out attack on the adult mosquito and the larval stages at one and the same time all across the country. The rationale is that some of these mosquitoes can fly up to 1000 meters and hence if one does a piece meal attack, there is a good chance that the mosquito can escape to the next area that is going to be attacked on a later date. The country is only about 65,000 sq. km in extent and has over 14,000 Grama Niladhari Divisions (GND). Arithmetically, each GND is only around 4.5 square km and can be cleaned up by the authorities (including drains gutters etc) and volunteers very easily in a day. If 200 people take part in the exercise each person will have to clean only 20 sq. metres. All the waste collected will later be removed to the central collecting area for disposal.
Heavily infested areas should be first fumigated before cleaning. This process should be repeated in 3 weeks as the life cycle is 10-12 days and the adult lives up to a month.
1. Public will be educated about the importance and the details of the program
2. Public will also be educated about what exactly would be done
3. The Grama Niladhari, the PHI, a representative from all government departments and local private enterprises will form the steering committee
4. The above will `recruit’ about 200 volunteers for the job
5. MOH will oversee the overall process specially spraying and fumigating if required
6. Equipment needed, viz mammoties, spades, crow bars, knives, axes, cane baskets etc could be locally purchased and inventoried by the steering committee. On production of receipts the Divisional Secretary will reimburse the expenditure
7. The day of launch will be declared a public holiday so that all interested can take part
8. This process will be repeated every 3 months for the first year, and thereafter every 6 months till the mosquito numbers are below the threshold level.
9. The DDG(PHS), Drectors, Assistant Directors, Regional Epidemiologists, local Epidemiologists, and the MOHH will be responsible to draw up the program and ensure it’s first deployment and the repeats
10. Even so, keeping the local GND clean and devoid of mosquitoes will be the responsibility of the Grama Niladhari, upwards to the DS
11. This process by no means obviates the need for individuals to keep their premises clean
This program has to start soon after the rains stop as this is the period during which conditions would be optimal for the egg laying and the larval and pupal stages of the mosquito to develop.
The other mosquito control means like, individual source control, fine netting over water collecting tanks, management of bird baths, mosquito traps, chemical control, bioinsecticides, other biological control methods should go on as deployed by the preventive health authorities independent of the above military style cleaning. Also means of reducing the chances of exposure to mosquitoes like, using nets, long clothing, insecticide impregnated nets and curtains, and the use of repellants is good practice for the people to carry on with.
A forgotten area is `protecting the mosquito from the patient’. All suspected Dengue patients should be nursed inside a mosquito net ideally insecticide impregnated. This will ensure that the mosquitoes will not have a chance to suck blood infected with the virus to inoculate to others. This should happen in all public and private hospitals and indeed in households too.
We may not be able to bring the mosquito numbers to zero but if it is below a certain level then epidemics will not happen and we should achieve this level if we religiously deploy the above system. Thereafter we have to make sure that these numbers stay small by repeating the process of cleaning at regular intervals with or without spraying and fumigation and observing to the last letter, all source control methods at individual, departmental and community levels. Clearly our official and expert numbers in the Dengue control program are very small. Therefore a genuine effort should be made to increase these numbers to realistic figures commensurate with the magnitude of the problem.
For longer term success we have to be mindful of the following. The kind of control programs we are dealing with in general do not have top level medical entomologists leading the way. When their brethren in other fields of Medicine are well off financially medical entomologists will have to be happy with only the salary to make a living. Therefore it is important to attract bright and motivated people for the job decorating it with attractive perks. Public Health Inspectors and other similar level staff steer programs drawn up to modify human behaviour which is indeed the bedrock of any effective dengue control program. This has to change. Those of us working in the field with graduate degrees in Medicine and other Biological Sciences till recently, have obtained their post graduate training and qualifications abroad, and hence did not have enough knowledge and experience in the field. This has been changing slowly but frightful apathy on the part of the state and the authorities is a matter of concern.
For a successful and a sustainable Dengue Eradication Program, the preventive health department’s capability has to be augmented by the other departments and ministries as follows,
1. MOHH in big cities should occupy very central position in the program as most of the mosquito population lives in the cities as are the sources available for the former to lay eggs. Unlike between the highways department and Telecom and other `digging’ departments, program of big cities and the national program should be well coordinated.
2. Minister and the ministry of Defence and Environment should ensure
Proper solid refuse disposal (at the moment dumped in far flung places in a way `out of sight out of mind’),
Management of rainwater and other non-sewage waste water (gray water) drainage,
Regulation of construction sites (if this was done deaths in Galle would not have happened)
Management of drainage in general eg. Prevention of water logging
3. Ministry of Urban Development should, in the towns and cities, lead the way in,
Preventing of indiscriminate reclamation of low lying areas (usually done by politicians and goons)
Design and construction of buildings with minimal sites for mosquito breeding,
Regulation of construction sites and
Coordinating of the above
4. Ministry of Justice has to make sure that necessary legislation is put in place to punish authorities who fail to bring wrong doers to justice. Source reduction needs social behavioral change which in turn entails incentives, disincentives and punitive actions. Laws are already in place but very few have been taken to court for not abiding by them because of a variety of reasons the main one being political interference
5. Ministry of Education has a very important role to play in Dengue control.
From year 1 to ECE(AL) children should be educated in basic entomology of Aedes Egypti, personal responsibility at keeping environment clean thereby facilitating source reduction.
Universities will have courses directed towards supplying qualified people in all the branches of Dengue control including behavioral sciences, virology of Dengue, Entomology including vector bionomics, environmental science etc.
6. Media should play a more active role in controlling Dengue. Instead of just reporting deaths due to Dengue fever and any public reaction to these as happened recently, they should invest in programs that drive home the seriousness albeit the preventability of Dengue in a dramatized manner. This may be in the form of slides, panel discussions, addresses to the nation by experts, and serial movies like `Ella Langa Walawwa’.
7. Private sector has been left behind by successive Governments either by oversight or blissful unawareness of it’s resources and in some enterprises their generosity. A completely capitalist economy might even have handed over the entire program to the private sector which would have eliminated Dengue long time ago but at a cost. Instead the state can use their expertise technology and personnel by exploiting their generosity.
It is common practice in the western society to launch organized protest campaigns against government inaction to curb injurious agents constantly haunting the public leading to serious harm to health or loss of life. I have never seen a single politician or any other prominent public figure including senior doctors organizing such a campaign in Sri Lanka. Population at large believes that these are natural disasters about which governments can do little. They are ill-educated about their rights. It is ironical that some parts of the population are unaware even about their right to life let alone their right to health. I am not trying to create a people’s wave against the establishment or indeed the government but I learnt by working and living in a developed country for long years that knowledge is power and absolute knowledge is a power that any authority would fear. My endeavor to educate the public is solely with the intention of generating this power and seeing an end to Dengue fever for ever.
*Dr. M.M. Janapriya MB.BS(Cey), LRCP(Lon), MRCS(Eng),FRCS FRCSEd, Retired Senior Consultant Surgeon, NHSL, Colombo – Past President GMOA (1983 through to 1987)