Ground report

Eliminating kala azar from four Indian states may just be a quick, concerted push away

After attempting to control the disease several times in the last decade, the state is making efforts to eliminate the disease. Will it work?

“Do you know anyone who had kala azar?” Dr Vikas Aggarwal asked Nandu Singh of Santari village in Muzaffarpur district of Bihar one day in August. Aggarwal is part of the KalaCore consortium, a team of organisations that is now on a mission to control and eliminate the disease in India, Bangladesh, Nepal, Bhutan, and Thailand.

Sixty year-old Singh, who works as a farmer in the village reported that his son had it about two years ago. “We had to stay in the hospital for at least two to three weeks,” he said.

As if expecting this reply, Agarwal said, “No, now it’s only one day. For about three hours straight.”

He added, “Not only is it so easy to cure it, you will also get a cheque of Rs 6,600 for getting treatment.”

Kala azar literally means "black fever" and signifies the greyish discolouration of hands, skin and face. The scientific name for the disease is visceral Leishmaniasis and it is caused by a leishmania parasites transmitted by female sand flies or balu makhi. These sand flies are not even visible to the naked eye. The disease is characterised by irregular bouts of fever, weight loss, enlargement of the spleen and liver that shows up as a pot belly in the patient, and anaemia.

The disease sometimes called the “parasitic HIV” as is destroys its victim’s immune system and is almost always fatal if left untreated. Like HIV, a kala azar patient either dies after catching another infection such as tuberculosis or of severe anaemia.

On February 16, the Bihar chief minister announced this additional Rs 6,600 compensation for each patient cured of kala azar. The central government was already giving Rs 500 as compensation for treatment. This effectively means that a patient walks into the health centre, gets treatment for three hours, and walks out free of kala azar and Rs 7,100 richer.

Singh looked puzzled at Aggarwal's announcement. “We had put in our own money for the treatment of my son,” he said. The scene looked like it was straight out of a government advertisement. But it sums up what has changed in the kala azar control programme.

Poster in a public health centre at Chakia block in East Champaran district, Bihar. Photo: Menaka Rao.
Poster in a public health centre at Chakia block in East Champaran district, Bihar. Photo: Menaka Rao.

With international agencies showing interest in helping eliminate kala azar in India in 2014, the government announced Kala Azar Elimination Programme in four states of the country – Bihar, Jharkhand, West Bengal, and Uttar Pradesh. Elimination for India is defined as reducing the annual incidence of Kala-azar to less than 1 case per 10,000 population at the sub-district level. Bihar has the more than 70% of the disease burden with kala azar endemic in 33 of 38 districts.

The number of kala azar cases shot up from 18,088 in 2003 and reached a peak of 45,508 in 2007. Since then, the cases have been on a decline and have come down to 8500 last year.

The incidence in Bihar, 19 kala azar endemic districts in West Bengal, and four kala azar endemic districts in Jharkhand was more than three cases per 10,000 population in 2014-'15. Uttar Pradesh has six endemic districts which has kala azar cases but had already reached elimination stage by 2015.

"If we calculate the incidence in Bihar state, it is less than one per 10,000 population," said Dr MP Sharma, Bihar state programme officer who handles kala azar and other vector-borne diseases such as malaria. "But we need to achieve that at the PHC level. Some pockets of the state still have more than 1 per 10,000 population."

From about 11 deaths due to reported in the country in 2014, it dropped to five in 2015. This year no deaths have been reported in the country so far.

Members of KalaCore, which includes international non-profits like Drugs for Neglected Diseases Initiative, London School of Hygiene and Tropical Medicine, Medecins Sans Frontieres, and consultancy firm Matt Macdonald, were on a tour of Bihar in August.They were checking on public communication activities to detect more cases, on indoor residual spraying in villages, and on the cold chain – transport, storage and handling – of Liposomal Amphotericin B in public health facilities.

The drug has enabled treatment for kala azar to be cut down from a four-week long cycle to just one day. All the district hospitals of the state provide treatment as do several public health centres at block level.

Mission elimination

Mukesh Singh is on the road all day on his motorbike. Singh is the Samastipur district programme manager of New Concept that handles the public health communications programme for KalaCore. Typically, a communication programme would take place before the village is fixed for indoor residual spray. The staff of New Concept would conduct a behavioural change communication in a village involving a short film, slides, and a question-answer session from the villagers.

He follows a microplan for indoor residual spraying of each house and cowshed in the villages in his district that had one kala azar patient in the last three years.

DDT, which has long known to be ineffective in vector control, is no longer used as an insecticide. It has been used since the 1970s and most parasites, including mosquitoes and sandflies, are believed to have developed resistance against the chemical. In 2014, after the announcement of the elimination programme, the government switched to synthetic pyrethroid and also changed the pump that was used to spray the insecticide

“We earlier had a stirrup pump which required two people to operate,” said Sharma.

Singh has to co-ordinate with the ASHA worker to mobilise the community, the indoor residual spray squad, and the kala azar treatment supervisor who work at the block level to detect cases of the disease. Singh co-ordinates with these different groups of workers via Whatsapp.

“Typically we would go to a Musahar tola or a tola of a backward community to generate a demand for various services from the government including indoor residual spray,” said Vidya Raghavan, assistant director at New Concept. If residents in the village point out to possible kala azar affected people after the awareness programme, the team also coordinates to refer them to a PHC, and checks on the treatment taken.

On the road, hopping from village to village, the KalaCore team checked on the availability of AmBisome – the Liposomal Amphotericin B drug – in the designated hospitals, including checking for the temperature of the freezer, indoor residual spray, active case finding, and the behavioral change communication activities in communities. The various activities related to elimination must all simultaneously run in tandem for this mission to work.

Vulnerability by caste

Village in Bihar are divided into tolas, each of which houses people from on particular caste. The most marginalised communities, such as the Musuhar community, among others are the most vulnerable to the disease. Many of the people living in the backward caste Bhagat tola do not own land and work as labourers for the higher caste residents. Their houses are made of mud where they also keep cows or chickens. Mud houses that preserve moisture are ideal conditions for breeding of the sand fly.

Joginder Bhagat was treated for Kala Azar this April and received compensation of Rs 6,600. Photo: Menaka Rao.
Joginder Bhagat was treated for Kala Azar this April and received compensation of Rs 6,600. Photo: Menaka Rao.

Early this year, 60-year-old Joginder Bhagat often fell sick. His stomach swelled up and he had fevers. He went to see a local doctor but got no relief. In April, he went to the Motipur Public Health Centre, a designated kala azar treatment centre, but was referred again to Muzaffarpur city’s Shree Krishna Medical College.

“There was no blood in my body," he said, referring to his severe anaemia. "They also gave me 15 bottles of saline, along with blood transfusion.” At the end of the treatment, he got a cheque of Rs 7,100, which included the Chief Minister’s compensation of Rs 6600 and the Centre’s compensation of Rs 500. This money is supposed to compensate for the wages lost.

Bhagat’s son, Sanjay, 28, had fever for more than three months. In June, he was diagnosed with kala azar at the Motipur primary health centre but the drug AmBisome was not available. “I went three times to the Motipur primary health centre to get treatment for kala azar after being diagnosed,” complained the younger Bhagat. “I had to take a vehicle each time.

The KalaCore team had checked the Motipur primary health centre and had seen that it had stocks of the drug. Noting the earlier stock out, they urged the villagers to go to the government centre where the treatment would be free of cost and the cost and they could avail of the chief minister's compensation.

“But the staff in Motipur spoke so badly,” complained Chinta Devi who had taken her son there a few years ago.

Many of Bhagat's neighbours prefer to go to Rambaug’s famous Kala Azar Research Institute but those who sought medical aid there said that they have not received their compensations. Only 64% of the patients who availed of the treatment have received the compensation so far. The rest are being processed, said Sharma.

The younger Bhagat, who got tired of traveling up and down from Motipur, also went to Rambaug and received Rs 500 as compensation only. But, he is now free of kala azar. "They treated me in a day,” he said.

We welcome your comments at letters@scroll.in.
Sponsored Content BY 

How sustainable farming practices can secure India's food for the future

India is home to 15% of the world’s undernourished population.

Food security is a pressing problem in India and in the world. According to the Food and Agriculture Organization of the UN (FAO), it is estimated that over 190 million people go hungry every day in the country.

Evidence for India’s food challenge can be found in the fact that the yield per hectare of rice, one of India’s principal crops, is 2177 kgs per hectare, lagging behind countries such as China and Brazil that have yield rates of 4263 kgs/hectare and 3265 kgs/hectare respectively. The cereal yield per hectare in the country is also 2,981 kgs per hectare, lagging far behind countries such as China, Japan and the US.

The slow growth of agricultural production in India can be attributed to an inefficient rural transport system, lack of awareness about the treatment of crops, limited access to modern farming technology and the shrinking agricultural land due to urbanization. Add to that, an irregular monsoon and the fact that 63% of agricultural land is dependent on rainfall further increase the difficulties we face.

Despite these odds, there is huge potential for India to increase its agricultural productivity to meet the food requirements of its growing population.

The good news is that experience in India and other countries shows that the adoption of sustainable farming practices can increase both productivity and reduce ecological harm.

Sustainable agriculture techniques enable higher resource efficiency – they help produce greater agricultural output while using lesser land, water and energy, ensuring profitability for the farmer. These essentially include methods that, among other things, protect and enhance the crops and the soil, improve water absorption and use efficient seed treatments. While Indian farmers have traditionally followed these principles, new technology now makes them more effective.

For example, for soil enhancement, certified biodegradable mulch films are now available. A mulch film is a layer of protective material applied to soil to conserve moisture and fertility. Most mulch films used in agriculture today are made of polyethylene (PE), which has the unwanted overhead of disposal. It is a labour intensive and time-consuming process to remove the PE mulch film after usage. If not done, it affects soil quality and hence, crop yield. An independently certified biodegradable mulch film, on the other hand, is directly absorbed by the microorganisms in the soil. It conserves the soil properties, eliminates soil contamination, and saves the labor cost that comes with PE mulch films.

The other perpetual challenge for India’s farms is the availability of water. Many food crops like rice and sugarcane have a high-water requirement. In a country like India, where majority of the agricultural land is rain-fed, low rainfall years can wreak havoc for crops and cause a slew of other problems - a surge in crop prices and a reduction in access to essential food items. Again, Indian farmers have long experience in water conservation that can now be enhanced through technology.

Seeds can now be treated with enhancements that help them improve their root systems. This leads to more efficient water absorption.

In addition to soil and water management, the third big factor, better seed treatment, can also significantly improve crop health and boost productivity. These solutions include application of fungicides and insecticides that protect the seed from unwanted fungi and parasites that can damage crops or hinder growth, and increase productivity.

While sustainable agriculture through soil, water and seed management can increase crop yields, an efficient warehousing and distribution system is also necessary to ensure that the output reaches the consumers. According to a study by CIPHET, Indian government’s harvest-research body, up to 67 million tons of food get wasted every year — a quantity equivalent to that consumed by the entire state of Bihar in a year. Perishables, such as fruits and vegetables, end up rotting in store houses or during transportation due to pests, erratic weather and the lack of modern storage facilities. In fact, simply bringing down food wastage and increasing the efficiency in distribution alone can significantly help improve food security. Innovations such as special tarpaulins, that keep perishables cool during transit, and more efficient insulation solutions can reduce rotting and reduce energy usage in cold storage.

Thus, all three aspects — production, storage, and distribution — need to be optimized if India is to feed its ever-growing population.

One company working to drive increased sustainability down the entire agriculture value chain is BASF. For example, the company offers cutting edge seed treatments that protect crops from disease and provide plant health benefits such as enhanced vitality and better tolerance for stress and cold. In addition, BASF has developed a biodegradable mulch film from its ecovio® bioplastic that is certified compostable – meaning farmers can reap the benefits of better soil without risk of contamination or increased labor costs. These and more of the company’s innovations are helping farmers in India achieve higher and more sustainable yields.

Of course, products are only one part of the solution. The company also recognizes the importance of training farmers in sustainable farming practices and in the safe use of its products. To this end, BASF engaged in a widespread farmer outreach program called Samruddhi from 2007 to 2014. Their ‘Suraksha Hamesha’ (safety always) program reached over 23,000 farmers and 4,000 spray men across India in 2016 alone. In addition to training, the company also offers a ‘Sanrakshan® Kit’ to farmers that includes personal protection tools and equipment. All these efforts serve to spread awareness about the sustainable and responsible use of crop protection products – ensuring that farmers stay safe while producing good quality food.

Interested in learning more about BASF’s work in sustainable agriculture? See here.

This article was produced by the Scroll marketing team on behalf of BASF and not by the Scroll editorial team.