Games in the Time of Dengue

THERE are genuine reasons for the nation to exult as India showcased its capabilities through the truly spectacular opening ceremony of the Commonwealth Games in Delhi. A nation, reeling from the continuous disclosures of ineptitude and corruption in the run up to the Games, breathed a collective sigh of relief. There will be occasion later to make sense of why a country, supposedly poised to take its place among the most developed nations of the world, should have made such a complete mess of the preparations for the Games. Notwithstanding how many accolades the organisation of the Games are able to now garner, the fact remains that the Kalmadis and their ilk have not shamed themselves – they have shamed a proud country and its people. They have, through their acts, allowed the country to be subjected to ridicule, some of which were thinly veiled examples of persisting racist prejudices.

THE CLEANSING OF DELHI

This column, however, is not about the Commonwealth Games. It is about another Delhi – a city where people live, work and die. A city where the working people are expected to be used but not to be either seen or heard. For Delhi is a city where the poor have been banished to the periphery, so that the rich and the affluent are not faced with the moral dilemma of having to constantly contrast their plush lifestyles with those who make Delhi function. Mercifully, Mumbai, Kolkata or Chennai still do not offer them this option – the poor still retain some rights to share the same physical space as the sons and daughters of ‘Shining India’. But Delhi has been almost entirely cleansed of its poor – at least from places where the gaze of the rest of the world is likely to be focused. This started many years before the Games, beginning with the Emergency and then with the move to relocate industries and workers from the centre of the city. The Games has been but another excuse to further sanitise the city.

The grand facades that welcome visitors to the Games do not stand testimony to the efforts of the now completely discredited Organising Committee of the Games – they are a creation of the blood and sweat of tens of thousands of workers who were brought into the city to showcase modern India’s accomplishments. Curiously, it is these people who the Delhi Government is desperate to hide. The attempts at denying that poor working people actually constitute a majority of the city’s population would have been comic were it not for the tragedy that it hides. The past few weeks have witnessed frenzied attempts to drive away the poor in the few remaining pockets in the centre of the city, where they still lived. Newspapers have reported how the police and administration held out threats of dire consequences to force migrant workers – who built the Games infrastructure – to leave the city. Those who could not be driven out are hidden from view behind giant cutouts that welcome visitors to the city. The city seems to be under a virtual siege and bus services used by the working people to commute to the city centre have been withdrawn for reasons difficult to understand.

The poor are much more magnanimous than the rich and famous that they are forced to serve. They do not grudge the fact that a few shall have a place in the sun at their behest. They are proud to be Indians and want to see the nation of 1.2 billion people take its rightful place among the community of nations. They are even willing to overlook the severe disruptions in their daily lives caused by the conduct of the Games – for they do not have the luxury to go on an extended holiday as some of the rich and famous have declared their intentions to. All they however would like, is to be seen, and acknowledged, and heard. For they have stories to tell that completes the picture of the real India.

DENGUE EPIDEMIC IN DELHI

As the cacophony regarding the Games reaches a crescendo, something else — that has affected the life of ordinary citizens in the city — has been quietly buried. Few in the media even care to report any more that Delhi is experiencing one of the severest epidemics in recent decades. Talk to people in Delhi and everybody knows of some friend or relative who’s suffering from dengue fever. While official figures peg the number of cases of Dengue to about three thousand, the real numbers would be anything between 10-100 times that.

Dengue has been a constant companion of the citizens of Delhi. Every year, after the monsoon showers, Delhi welcomes the onset of a Dengue epidemic. We also know that the severe epidemics are seen in cycles of 3-4 years, ie, while every season sees a number of Dengue cases, there is a sharp spike every 3-4 years. There is a reason why this happens, but it has nothing, unfortunately, to do with any public health efforts by the Delhi government. Like all epidemics, the dengue epidemic starts slowing down when a sufficient number of people have been infected by the virus as those affected get immunity to the disease — known as “herd immunity”. After a lapse of 3-4 years the effect of this herd immunity weakens and the epidemic is seen in a more severe form.

Dengue is a viral disease transmitted by mosquitoes. The reason why Dengue epidemics occur just after the rains is twofold. First, rainwater collection promotes mosquito breeding. Further, moderate temperatures in the monsoon season provides optimum conditions for both mosquitoes to breed and survive and for the virus to thrive. This is also why the epidemic starts petering out as winter sets in – Delhi’s harsh winter acting as a deterrent to both mosquito breeding and the transmission of the virus.

While in most people Dengue runs a relatively benign course, with a few days of fever and pains, in a small percent of those affected it can acquire a much more severe and life threatening form. In these patients there is a sudden drop in a kind of blood cells, called platelets that are vital for the clotting of blood. When the number of platelets fall below a certain level,  the person affected can have spontaneous bleeding from different sites of the body. If not treated in a hospital setting such patients can die due to blood loss or other complications. This form of Dengue – called Dengue hemorrhagic fever – affects children and adolescents more than others, but other age groups can also be affected. The reason why Dengue patients have to be treated with extreme care is that there is no way to anticipate which of the infected patients will eventually get Dengue hemorrhagic fever. Consequently, all Dengue patients need to be observed carefully for symptoms of Dengue hemorrhagic to be expressed.

DELHI GOVT’S MASTERLY INACTIVITY

This is why a Dengue epidemic is a major public health problem. Unfortunately, the Delhi government has mastered a unique manner of addressing this problem – every Dengue season the government goes into a state of masterly inactivity! The reason for this lies in the almost total lack of a public health system in the city – not just health facilities but other public health measures such as mosquito control, sanitation, etc. Delhi’s health system, is afflicted with the same malaise that affects the entire country’s public health system. Every year, during the dengue season, we see ritual pronouncements about public health measures being undertaken such as spraying of mosquito repellants, and destruction of breeding sites. Clearly, such measures are far too inadequate. Moreover such measures do not have a major impact once an epidemic is established – they have to be continued throughout the year. Unfortunately every year is a new experience for the Delhi government, having learnt nothing from the experiences of previous years!

When an epidemic does get established, it is natural that a large number would be affected – not a few thousand as the government claims but tens of thousands. Again it is important to understand what the figures the Delhi government really means. There is no legal requirement to notify Dengue cases – so an overwhelming number of cases are never notified. This is especially so for the private sector, where a majority of Delhi’s citizens seek care, given the very poor state of public facilities. Second, Dengue can be conclusively diagnosed only through an expensive test for the antigen of the virus. A very large majority of people, who contract Dengue, are not tested for this antigen. In other words, the reported number of cases are those that by some miracle actually get reported. This failure is a failure of health surveillance – a necessary requirement for any epidemic control mechanism is a public health system.

The story does not end here. The Dengue season is a bonanza for the private health system. Private hospitals rake in huge amounts as people flock to these facilities, in the absence of public health services. Most of these facilities pump unnecessary drugs into Dengue patients though the disease runs its own course and does not respond to antibiotics. In a functioning health system almost all Dengue patients could be cared for at home under the care of a primary care physician. Those that would eventually require hospitalisation (a small fraction of all dengue patients) can be detected in time if they are monitored by the health system. In the absence of such a system incidence of expensive hospitalisation is much greater than what it should be.

Before we finish let us once again return to the Games. It is estimated that the total expenditure on the Games was twice that of the annual public expenditure on health in the entire country. We contrast these two figures, not as an argument for not organising the Games. But it is definitely an argument for balancing the need to showcase “shining India” with the need to address the needs of the real India! The Delhi government’s negligence of the Dengue epidemic is but a small example of the systematic and deliberate neglect of the needs of an overwhelming majority of people in this country.