How to create a fever outbreak: Lessons from East Delhi

On Wednesday, Rani Sharma, 40, finally became sick from the deadly viral fever that has gripped the Jhilmil Industrial Area in East Delhi for the past month. Everyone else in her family had already had a spell of it. Over the previous weeks, Sharma had already taken several days of leave from the sticker factory at which she works to tend to her husband and her three grown-up children, aged between 17 and 20.

“My bosses cribbed about my leave and said I take a lot of leave," said Sharma. "But I really cannot go to work. I cannot sit, or stand, or lie down without hurting.”

Rajiv Camp, where Rani lives, is bursting with cases of this viral fever. “Knock any door, and you will find a sick person,” said Neelam Chaudhary, the Accredited Social Health Activist or ASHA for the area. There are about 500 families in the slum with a population of approximately 2,500, she said. She herself has been struck by fever and suffers severe body aches.

A few houses from Sharma lives Mustari Khatoon, 35, who lives with her three children aged 20, 18 and 8. When this correspondent went to their home, they were all lying on a cot and watching a movie on television. Asma, the 20-year old who works at a beauty parlour, said that she could not even sit up without her body aching. All of them had chikungunya-like symptoms.

The viral fever, which has seldom been confirmed as chikungunya among the patients at Rajiv Camp, is debilitating. “I have lived in Delhi for so many decades, but I have not seen a disease like this,” said 70-year-old Jasin Shaikh. His wife Gulshan Khatoon, who also has the fever symptoms, has now resorted to using a walking stick. Three other people in their family are ill.

Unnamed viral fever

The Delhi government and municipal authorities said that the city saw 412 chikungunya cases in the last week of August alone. This was around the time, people in Rajiv Camp started falling sick.

A total of 3,695 cases of chikungunya and 5,982 cases of dengue have been recorded so far in Delhi, the government claimed. Some cases of scrub typhus, a bacterial infection, which also have chikungunya-like symptoms have been recorded in the city. There are also scores of other people diagnosed with chikungunya-like symptoms with high fever for a few days, followed by rash and severe body pain and swelling of joints. There are other people with other kinds of viral fevers doing the rounds in the city, which are equally crippling. People complain of symptoms such as high fever, headache, body ache, cold, cough, among others, which seem to last for over a week sometimes.

“For dengue, we have good diagnostics," said Dr Abhay Chaudhary, the head of the microbiology department at JJ Hospital in Mumbai. "We can detect it even during the illness. However, for chikungunya, the tests are weak and the sensitivity is less.” This would essentially mean that very few fevers would be confirmed chikungunya.

The other viral fevers could be arboviral infections, caused by mosquitoes or ticks. “These viral fevers may not have anything to do with dengue or chikungunya, and could have unique manifestations, including neurological symptoms or encephalitis,” said Chaudhary. He admitted, that often they have no answers for the kind of fevers that are there in the community, especially those which cause sudden deaths.

In August, a fever outbreak in a Noida village killed 10 people. The authorities were not able to explain why those deaths took place, but blamed it on other underlying illnesses. In a similar incident, 12 people in Delhi died after being diagnosed with chikungunya, a disease not known to cause death. What is, however, common to all these outbreaks is the pathetic state of sanitation in areas where people who contracted fevers resided.

Neglect by civic authorities

Residents of the Jhilmil Industrial Area complain of neglect by civic authorities. Their houses are in narrow lines abutting a running open drain. There is a perpetual stench in the area. The big storage drums of water outside each house, apart from coolers, that serve as ideal breeding grounds for mosquitoes.

“Our area was fogged once,"said Murari Singh, referring to the practice of spraying mosquito repellents and larvicide that the Delhi government has undertaken to control mosquito populations this season. "I do not think it has had any impact.”

Chaudhary, the ASHA worker, said that she cleaned out three coolers and drums that were swarming with mosquitoes last week. On Friday, she had been distributing posters about mosquito prevention and treatment of dengue and chikungunya.

In a Facebook post, a women-based political organisation, Mehnatkash Mahila Sangathan, a non-profit that works on labour rights, calls out the ineffective measures taken by government authorities. The post also highlights the plight of health workers, three of whom died after high fever last month.

“Looking at the serious condition in the capital as well as in the whole country, it can be said that it is not going to subside only by calling for 'Protect yourself from mosquito bites', a few weeks every year,” said the post.

The organisation made representations seeking to improve the state of sanitation, and healthcare in the area to the state government, the civic body and the local MLA.

Inaccessible healthcare facilities

There are two tertiary level hospitals near Rajiv camp – the Guru Tegh Bahadur Hospital and a polyclinic – as well as a mohalla clinic in the area. All these are at least two km to four km away from the colony. Not many people about the polyclinic or the mohalla clinic. The latter runs only between 9 am and 1 pm, which is inadequate to serve the needs of the large number of daily labourers who are free to visit a doctor only in the evening.

Healthcare facilities are visibly better at the nearby Dilshad Gardens, a more upmarket neighbourhood.

The lack of primary health care facilities has left very few options for Rajiv Camp residents. Many have visited quack doctors just to get pain relief. “I went to a jholachap nearby," said Sukhbai Devi, who was limping. "The government doctors do not listen to you. The medicine is very weak.”

Most government hospitals give patients complaining of fever a few doses of paracetamol. Though it is the recommended treatment protocol, it does little to relieve the pains of the Rajiv Camp residents, who stand to lose their daily wages if they do not go to work. That the government doctors did not listen, as people complained, doesn’t help.

Loss of wages

While the fact that ideal treatment is simply taking paracetamol thrice or four times a day, what does a person who wants to go back to work do?

“My sons simply pop pain killers and go to work. We cannot afford to sit at home,” said Shabana Khatoon, whose entire family of six was down with fever.

One of the labourers who attempted to go back to work with severe body pain met with an accident. “My husband who works as a mason fell from the first floor while working,” said Rita Devi. "Now he has stitches."

Devi's entire family of seven people, including her four daughters, and a son, had the same illness. She works in a factory and lost seven days' worth of wages as a result of the sickness.

Each visit to the doctors, including travel, costs at least Rs 200 to Rs 300. Most families have spent about Rs 2,000 to Rs 3,000 on the recent bout illness.

The government, public health experts feel, needs to do more to reduce the panic among residents.

“We need to be able to tell people that a large number of these cases are not serious, and there is no reason to panic,” said Dr Ritu Priya Mehrotra, from the department of Community Medicine at Jawaharlal Nehru University in Delhi. “Only vulnerable people like the elderly, pregnant women, and children need to be careful. They need to be told that its best to take paracetamol and not any painkillers.”

Mehrotra said that the government may need to do more than spreading messages via radio, television and posters.

“The government needs to have people on the ground who can talk about the epidemic directly to the community," said Mehrotra. "They need to talk about what they are doing about it. The people will then feel that it is tallying with their experience. That will help keep the panic down,” she added.

Epidemic control

Although the government is disseminating information on mosquito control, action may not be feasible. “Once there is an outbreak, the options to control it are limited," said Amit Sengupta from the public health non-profit organisation Jan Swasthya Abhiyaan. "There is not much anyone can do apart from treating patients.”

Health surveillance helps predict an outbreak of this sort. “There has to be disease outbreak sentinel which will identify areas where people need to be screened. This can help anticipate outbreaks of this kind and help control them,” said Sengupta

As this Indian Journal of Medical Ethics article written in response to the 2006-2007 chikungunya epidemic in South India, says, "Health depends, at the barest minimum, on access to adequate food, sufficient safe water, housing and sanitation. The provision of these basic requirements dramatically brought down the occurrence of communicable diseases in the West, long before modern vaccines or antibiotics were discovered. We should address these foundations of public health while we create public health foundations. “

In the context of disease outbreak, urban planning again stands out for its failure. “Delhi is a bad example of city planning. All the poor in the city have been moved out into ghettoes,” said Sengupta. Indeed, just a few kilometers away from Jhilmil Industrial Area are gated communities with paved streets and good sanitation facilities.

“In such a situation, there is no one left to speak up for the poor," said Sengupta. "It is a case of out of sight, out of mind.”