Malaria: The view from India

DELHI — Twenty-six people died of malaria in a single hospital in the northeastern Indian state of Assam this winter. But as far as the government is concerned, they might as well never have existed. The district administration reported no deaths, and nobody except members of a local NGO took any notice.

India has always underreported its malaria cases, government officials admit off the record. But the scope of the hidden problem has become astounding. While the official figures state that in 2008 India had 1.5 million malaria cases, resulting in 924 deaths, the real number of deaths is higher by several orders of magnitude.

"These numbers are a joke,” said Sunil Kaul, a doctor who works for a volunteer organization called the Ant that treats villagers. “In Assam alone we had at least 1,500 deaths last year.”

The real number of malaria-related deaths in India was closer to 40,000 in 2008, according to various non-governmental sources and some government officials who didn't want to be named.

"Unless you know the level of the disease burden how can you plan to prevent or treat it?" Kaul asked.

Indeed, the underreporting of malaria cases is one of the main reasons that India has been unable to prevent malaria or treat malaria cases. It has led to an astounding absence of knowledge — even among supposedly qualified private and government health workers. Few know, for instance, that malaria occurs in different topographies for different reasons and must be prevented differently in each area.

These problems are further complicated by foreign agencies such as the World Health Organization (WHO), which — under the influence of global lending agencies like the World Bank and big pharmaceutical companies — have pushed India to adopt prevention methods that don't suit the local conditions and to initiate huge, ill-considered projects rather than targeted ones.

For example, under the National Vector Borne Disease Control Program, the umbrella program for prevention and control of malaria, the Indian government has introduced new “rapid diagnostic tests,” put a legion of India's version of barefoot doctors in the field and rushed to convert to expensive Artemisinin-based Combination Therapy (ACT). None of these tools is sufficient, according to the grassroots health workers who are fighting this disease in the jungles.

Rapid diagnostic kits only tell you if the disease is present, not how severe or advanced it is, so they are not a substitute for microscope diagnosis, said Yogesh Jain of Jan Swasthya Sahyog, a volunteer organization in Chhattisgarh state. And perhaps more importantly, the kits only last six months to a year — compared with a quarter-century for a good microscope — and they don't eliminate the need for qualified personnel. Even if the kits do make it to India's remote villages, Kaul asked, “Who will use them?”

The disease control program's answer to that question is another program that sounds good, but isn't working. The government has trained workers to make diagnoses and administer malaria treatment. But most of them actually know precious little about malaria — and because they are also responsible for prenatal care, the immunization of children and other schemes, they are often unavailable to dispense anti-malarial medication.

The sudden rush to convert to ACT treatment has also raised hackles. "In the Mekong delta already 20 percent have developed a resistance to ACT that is otherwise considered invincible," Jain said. The reason: "If you handle it poorly you will develop resistance. The drug (ACT) has to be given for a minimum of four days with two doses a day," he explained. When chloroquinine — a cure for certain kinds of malaria that has been around for decades — is not being administered properly, it is almost certain that ACT will be misused.

Jain doesn't hesitate to blame the WHO for the ACT push. "At some level (India's) malaria department is better than other departments, but daddies like the WHO and World Bank are able to influence the department in such a way that the interest of the poor is not finding its way into decision making," he said.

And even as India continues to pretend it doesn't have a malaria crisis, the problem is set to worsen with climate change and increased development.

"With over 650 million depending on climate-sensitive sectors for their livelihood, over 973 million people are exposed to malarial parasites," said Sumana Bhattacharya, a consultant to India's environment ministry. Also, because developmental activities such as hydro-electric dams and irrigation canal systems widen the breeding grounds for malaria, malaria exposure will likely increase unless precautions are taken. Jain said that the town of Jabalpur in Madhya Pradesh state had almost no malaria cases until the 1980s. But since the construction of the Bargi dam on the Narmada river, there has been a 25-fold increase in malaria cases.

Read more about malaria:

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The situation in Indonesia

The situation in Mozambique

The situation in South Africa

The science of prevention

The science of vaccines

One NGO worker's quest

A vaccine in Ireland?