THIRUVANANTHAPURAM: Public health expert Dr T Jacob John warns that in the absence of a dedicated public health agency in Kerala, outbreak of diseases could go undetected. As someone who was involved in setting up a public health agency in Kerala almost two decades ago, the former head of the ICMR virology research centre tells TNIE that ‘strong, unseen forces’ are preventing the establishment of a dedicated agency to track and respond to outbreaks.
Is Kerala especially vulnerable to infectious diseases? Do you recall a similar situation elsewhere?
When we recall that Kerala had a reputation for excellent health metrics, in the 1970s through to the 1990s, the main pieces of evidence were: Lowest birth rate; lowest infant mortality rate (IMR); and, longest life expectancy at birth among Indian states. It’s wrong to attribute these to successful health management. If one dies at the age of one and another at 99, the mean duration of life is 50 years. My point is that the biggest influence on life expectancy is IMR, not the health of adults. IMR is closely associated with birth rate. Thus, the singularly important factor for longer life expectancy was low birth rate, which led to low IMR and high life expectancy. Perhaps partly due to this reputation, infectious diseases were neglected and diagnostic services were inadequate. In 1986 or 87, dengue was first diagnosed in Kerala from blood samples collected near Kottayam. In 1987, leptospirosis was reported in Kolenchery, but the health department refused to acknowledge it. When Japanese encephalitis broke out in Alappuzha, the state needed virologists from Madurai to diagnose it. During the polio-eradication years, stool samples of children had to be shipped to Coonoor for virus isolation. Kerala neglected good microbiology facilities until the 1990s/2000s. Due to the high population density, larger proportion of senior citizens, heavy rainfall, returning diaspora, large tourist arrivals, besides forests running the entire length of the state, we are vulnerable to a variety of infectious diseases.
Why is Nipah recurring in Kozhikode and its surrounding areas?
Vertebrate to human transmitted diseases (zoonoses) require ecological niches. Now we know that Kozhikode and its neighbourhood have a niche for the Nipah virus. Everyone had suspected it since 2018, when NIV discovered infected bats in northern Kerala.
If other places are equally vulnerable what should be the approach?
In countries genuinely interested in human health, health management consists of systematic mitigation of environmental and sociobehavioural risk factors (determinants) of communicable diseases and systematic responses to episodes. The first system is called public health and the second health care. Kerala made some attempts to establish public health but they were shot down every time by unseen forces. The E K Nayanar ministry initiated the process of setting up a public health system, but the A K Antony ministry that came next dismantled it. I was not privy to the reasons. Imagine the present Nipah outbreak was not investigated. One person dies in a hospital. Another dies in another hospital 10 or 11 days later. The links could easily have been missed unless that was a large outbreak. Public health would demand a verifiable cause for every death -- especially of young or middleaged adults, in whom mortality rate is very low.
We are yet to find a link to the Nipah infection in humans. There were attempts in 2018. But they could not reach any meaningful conclusion. How do we connect the dots?
It’s easy to say that ‘links should be investigated’, but can you identify the agency entrusted with and empowered to investigate ecological backgrounds post outbreak? Health care or medical education personnel have their jobs and jurisdictions -- they do not cover the ecology of microbial pathogens, environmental determinants of pathogen transmission and even sociocultural behavioural determinants. These areas are, the world over, the responsibility of public health. You can’t blame a non-existent system for failing its duty.
The presentation of Nipah is similar to Japanese encephalitis (JE). Government hospitals could not identify Nipah. (This year there were 40 JE deaths in the state.) It is clear that protocols are not always followed, especially in fever season. What can be done in such a situation?
Very important point. In health care, we look for patterns to narrow down the diagnostic range. In public health, we look for dissimilarities for discriminating disease diagnosis. I have offered my services to teach the differences in pattern recognition versus detection of pattern anomalies to diagnose diseases. It is for the government to decide if this is a necessary exercise.
Does Nipah warrant Covidlike containment measures?
The Covid agent was everywhere and lockdown was overdone. Two weeks should have sufficed but beyond that the solution was worse than the problem. For Nipah, the curtailment of movement will be time- and space-limited. However, whether or not such lockdowns are effective should be determined by public health. In its absence, the response is guesswork. Tourism on