Health hazards

In a garbage-infested village outside Delhi, fevers have been claiming lives this monsoon

But the district health administration refutes claims of a 'mystery virus'. The causes of death were different in each case, they say.

Just 10 minutes of rain in Sarfabad village caused floods in its bylanes. The village is in Noida, a township in Uttar Pradesh that is part of the National Capital Region and just outside Delhi. Children in Sarfabad who decided that it was time to play ended up wading in blackish sewage water in the streets. The roads are lined with mounds of garbage. On Friday, civic authorities had removed silt from the gutters that were then piled up in black heaps near the gutters. That silt was washed away again by the next round of rain.

In this village, there have been ten deaths just in the month of August. Residents claim that most of the deceased had suffered fever and body pain for a few days before they died. Public health authorities in Noida investigating the deaths have said that the the causes of death were different in each case including. Some died of heart attacks, they said. There was no outbreak of any disease, they claimed.

Despite this, television reports have started talking about a mystery virus afflicting the area's residents.

Villagers walk through water that has accumulated after about 10 minutes of rain. Photo: Menaka Rao
Villagers walk through water that has accumulated after about 10 minutes of rain. Photo: Menaka Rao

Ten deaths with no pattern 

Twenty two-year-old Vipin Sharma was preparing for a test in a law college on August 15, when he said he was feeling feverish. The next morning at around 7, he complained that he was cold. He was shivering. His family took him to the nearby District Government Hospital at Noida's Sector 30, but say they were sent back. Sharma died at home at around 8.30 am.

“Only two youths have died, among the 10," said Dr VD Verma, the chief medical officer, Gautam Buddha Nagar district which covers Noida. "Another youth who died had a problem of convulsions. Most others were either between 50-60 years of age.”

Verma listed a litany of medical complaints that affected the victims.

“One died of heart attack, one of paralysis, one had acute liver failure, one had pancreatitis, one had chronic obstructive pulmonary disease,” he said. "All of them have died of different reasons."

Sukhpal Yadav, 60, was “perfectly healthy” before he was struck with fever, according to his family. “He was in hospital for ten days," said his son Moolchand, who works as a driver. "We got all the tests done, but nothing came out positive.”

Sarfabad village is contained within a three-kilometer radius and has about 10,000 to 15,000 inhabitants. “If there are 10 deaths in two weeks time associated with fever there is clearly an outbreak,"said Dr Rajib Dasgupta, from the community medicine department of Jawaharlal Nehru University, Delhi. "It is most certainly an unusual event though we cannot comment on what has really happened.”

The district administration did about five rapid malaria tests, and tested a few people for dengue, all of which have turned up negative. While admitting to the lack of sanitation in the area, the administration has denied finding any disease-carrying organisms like the dengue-causing Aedes mosquito.

No primary health centre nearby

Nevertheless, the district administration has also held a medical camp in the area to treat patients who have fever. The camp has been running since August 25, and will continue for some time, said Verma.

Even though temporary, this is the first government facility within the village that Sarfabad residents are getting access to. There is no primary health care centre nearby. It is little wonder that patients were excited about the free medicines available in the camp.

The villagers usually rely on jholachap or quacks in the area, or doctors with Ayurveda degrees. There is not a single MBBS doctor in the village.

Veer Singh, who has a Ayurveda medicine degree, with his patients. Photo: Menaka Rao
Veer Singh, who has a Ayurveda medicine degree, with his patients. Photo: Menaka Rao

Scroll.in visited two doctors who claimed to a have degree in Ayurvedic medicine. Both were receiving many patients with symptoms of fever, cold and cough.

“Many of my patients complain of pain in the leg and fever," said Dr Veer Singh, whose desk was strewn with different formulations of injections. "Some of their blood tests are showing that they have a drop in platelets. We get about 200-250 patients a day, mostly with fever.”

As he spoke, Singh was tending to to a man complaining of knee pain. The doctored administered and injection to the patient through his shirt, without exposing the skin of his arm – a method that could possible infect the site of the injection.

The sanitation problem

Whether this round of sickness in Sarfabad is connected to its filth or not, it's evident that the village has a huge sanitation problem, the root of which lies in politics.

Last year, the Uttar Pradesh government decided against having panchayat elections in the villages of Gautam Buddha Nagar. The farmers had then complained that in the absence of an elected body, no one could be held responsible for the development of rural areas and protection of the rights of the villagers, the Times of India reported at the time.

Now, everyone in Sarfabad complains bitterly that the Noida Authority has not taken care of the village's sanitation.

A derelict structure used as a garbage dump at Sarfabad village. Photo: Menaka Rao
A derelict structure used as a garbage dump at Sarfabad village. Photo: Menaka Rao

“Earlier, we had a pradhan [elected sarpanch] who would ensure that the village is kept clean," said Sukhvir Pehelwan, a social worker in the area. "It was running better then. Dabav rehta hai." There are pressures in living in the same society.

Residents complained that municipal workers now come only twice a week.

This is the first monsoon without a panchayat system. The authority has started a cleanliness drive in Sarfabad, a few more villages nearby till September 15.

Risks in peri-urban landscapes

Villages like Sarfabad are peculiar in nature. These peri-urban habitations on the fringes of cities are just one turn off a four-lane highway on a lanes that lead to hamlet-like enlosures where people still live in havelis or kothis.

“In developing countries they are often called ‘peri-urban interfaces’," said Dasgupta. "It is a zone of interaction between urban and rural socioeconomic systems, a transition zone between fully urbanized land in cities and areas in predominantly agricultural use. It is characterised as zone of rapid economic and social structural change. These have implications for urban governance.”

Many people in Sarfabad, like Moolchand, have sold their ancestral land. Just outside the core of the village, where the original village dwellers live, there are buildings and farm houses that are have come up. Some are using their land to build small cemented hutments in which the construction workers live.

There are people who are involved in the construction business, like Bhirampal Yadav, who supplies land mowers. His 62-year old father, Bhimpal Yadav, died of after fever on April 24. The district administration maintains he suffered from pancreatitis.

There is also an influx of migrant populations who work in Noida and rent in Sarfabad village, the villagers said.

“Urban health systems are weak in India, deficient in core public health functions. Peri urban typically falls between two stools, lacking in services provided by either the rural health services or excluded by the municipal system,” said Dasgupta. This, he added, increases the risk of such infections.

The villagers, in the meanwhile, feel the administration is only trying to push things under the carpet. By all the different account the number of deaths in Sarfabad in August varies between 13 and 35. Residents maintain that one or two people have been dying every day for the past three weeks.

Prajwala Sharma, the mother of the 22-year-old Sharma wants the village to be cleaned better. “ I do not want any other mother in this village to cry over a dead son,” she said.

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Removing the layers of complexity that weigh down mental health in rural India

Patients in rural areas of the country face several obstacles to get to treatment.

Two individuals, with sombre faces, are immersed in conversation in a sunlit classroom. This image is the theme across WHO’s 2017 campaign ‘Depression: let’s talk’ that aims to encourage people suffering from depression or anxiety to seek help and get assistance. The fact that depression is the theme of World Health Day 2017 indicates the growing global awareness of mental health. This intensification of the discourse on mental health unfortunately coincides with the global rise in mental illness. According to the latest estimates from WHO, more than 300 million people across the globe are suffering from depression, an increase of 18% between 2005 and 2015.

In India, the National Mental Health Survey of India, 2015-16, conducted by the National Institute of Mental Health and Neurosciences (NIMHANS) revealed the prevalence of mental disorders in 13.7% of the surveyed population. The survey also highlighted that common mental disorders including depression, anxiety disorders and substance use disorders affect nearly 10% of the population, with 1 in 20 people in India suffering from depression. Perhaps the most crucial finding from this survey is the disclosure of a huge treatment gap that remains very high in our country and even worse in rural areas.

According to the National Mental Health Programme, basic psychiatric care is mandated to be provided in every primary health centre – the state run rural healthcare clinics that are the most basic units of India’s public health system. The government provides basic training for all primary health centre doctors, and pays for psychiatric medication to be stocked and available to patients. Despite this mandate, the implementation of mental health services in rural parts of the country continues to be riddled with difficulties:

Attitudinal barriers

In some rural parts of the country, a heavy social stigma exists against mental illness – this has been documented in many studies including the NIMHANS study mentioned earlier. Mental illness is considered to be the “possession of an evil spirit in an individual”. To rid the individual of this evil spirit, patients or family members rely on traditional healers or religious practitioners. Lack of awareness on mental disorders has led to further strengthening of this stigma. Most families refuse to acknowledge the presence of a mental disorder to save themselves from the discrimination in the community.

Lack of healthcare services

The average national deficit of trained psychiatrists in India is estimated to be 77% (0.2 psychiatrists per 1,00,000 population) – this shows the scale of the problem across rural and urban India. The absence of mental healthcare infrastructure compounds the public health problem as many individuals living with mental disorders remain untreated.

Economic burden

The scarcity of healthcare services also means that poor families have to travel great distances to get good mental healthcare. They are often unable to afford the cost of transportation to medical centres that provide treatment.

After focussed efforts towards awareness building on mental health in India, The Live Love Laugh Foundation (TLLLF), founded by Deepika Padukone, is steering its cause towards understanding mental health of rural India. TLLLF has joined forces with The Association of People with Disability (APD), a non-governmental organisation working in the field of disability for the last 57 years to work towards ensuring quality treatment for the rural population living with mental disorders.

APD’s intervention strategy starts with surveys to identify individuals suffering from mental illnesses. The identified individuals and families are then directed to the local Primary Healthcare Centres. In the background, APD capacity building programs work simultaneously to create awareness about mental illnesses amongst community workers (ASHA workers, Village Rehabilitation Workers and General Physicians) in the area. The whole complex process involves creating the social acceptance of mental health conditions and motivating them to approach healthcare specialists.

Participants of the program.
Participants of the program.

When mental health patients are finally free of social barriers and seeking help, APD also mobilises its network to make treatments accessible and affordable. The organisation coordinates psychiatrists’ visits to camps and local healthcare centres and ensures that the necessary medicines are well stocked and free medicines are available to the patients.

We spent a lot of money for treatment and travel. We visited Shivamogha Manasa and Dharwad Hospital for getting treatment. We were not able to continue the treatment for long as we are poor. We suffered economic burden because of the long- distance travel required for the treatment. Now we are getting quality psychiatric service near our village. We are getting free medication in taluk and Primary Healthcare Centres resulting in less economic stress.

— A parent's experience at an APD treatment camp.

In the two years TLLLF has partnered with APD, 892 and individuals with mental health concerns have been treated in the districts of Kolar, Davangere, Chikkaballapur and Bijapur in Karnataka. Over 4620 students participated in awareness building sessions. TLLLF and APD have also secured the participation of 810 community health workers including ASHA workers in the mental health awareness projects - a crucial victory as these workers play an important role in spreading awareness about health. Post treatment, 155 patients have resumed their previous occupations.

To mark World Mental Health Day, 2017, a team from TLLLF lead by Deepika Padukone visited program participants in the Davengere district.

Sessions on World Mental Health Day, 2017.
Sessions on World Mental Health Day, 2017.

In the face of a mental health crisis, it is essential to overcome the treatment gap present across the country, rural and urban. While awareness campaigns attempt to destigmatise mental disorders, policymakers need to make treatment accessible and cost effective. Until then, organisations like TLLLF and APD are doing what they can to create an environment that acknowledges and supports people who live with mental disorders. To know more, see here.

This article was produced by the Scroll marketing team on behalf of The Live Love Laugh Foundation and not by the Scroll editorial team.