The political ecology of the resurgence of malaria in India
The resurgence of malaria in India epitomises the current problem of emerging infectious diseases in the South. Taking as their case study the situation in the Indian State of Rajasthan, the writers argue that this resurgence, in what was previously a non-endemic area is primarily due to the ecological and socio-economic consequences of the policies advocated by the Bretton Woods institutions.
by Dr Mira Shiva & Dr Vandana Shiva
IN recent years there has been a tremendous resurgence of malaria epidemics and emergence of the disease in non-endemic areas in India. This resurgence can be linked to the environmental and socio-economic changes in India induced by the global financial system.
On the one hand, financing from agencies like the World Bank has promoted projects such as the Indira Gandhi Canal which have major ecological impacts and have become a breeding ground for mosquitoes and the centre of malaria epidemics. On the other hand, cuts in the health budget under structural adjustment programmes have contributed to the breakdown of the public health system and weakened the preventive and curative capacity of the system. The cuts have also increased the vulnerability of the poor through increased food prices, higher costs of health care, decreases in real wages and increased unemployment. In addition, the conventional malaria eradication techniques such as insecticidal spraying have also started to fail after initial success due to the emergence of vector resistance. The combination of these ecological and economic factors have contributed to the conditions for the resurgence of malaria.
At the time of Indian independence in 1947, it was estimated that 75 million people suffered from malaria in India with about 800,000 deaths a year. After the first seven years of the National Malaria Eradication Programme (NEP), the number of cases of malaria was reduced to a merely 100,000 in the year 1965 with no deaths. It then appeared possible that malaria would soon be totally eradicated.
However, malaria has once again emerged as a major public health problem. The re-emergence of malaria and its spread to new regions is a reminder that health cannot be reduced to a market service. It is linked to ecology and the economy and health solutions need strong public systems for preventing disruption of ecological processes, for preventive measures, and for ensuring that the poorest have access to curative measures such as medicines and drugs.
Ecological basis of resurgence
The emergence of malaria in the desert regions of Rajasthan is a particularly disturbing trend since Rajasthan is not an endemic malaria region. In the Rajasthan epidemic of 1994, 60-70% of total malaria cases were identified as fatal Falciparum cases in spite of the fact that Rajasthan is not a Falciparum-predominant area.
Major ecological changes have contributed to malaria resurgence. The spread of irrigation projects has been recognised as a major cause for the spread and increase of malaria epidemics. In addition, the expansion of water-intensive crops has created conditions conducive to the spread of malaria. Irrigation was increased from 26.8 mh in 1951 to 76.6 mh in 1991. Deforestation has reduced forest cover from 40.48 mh in 1950 to 22.30 mh in 1991, rice paddy cultivation has increased from 30.81 mh in 1950 to 42.18 mh in 1991 and sugarcane acreage has increased from 1.71 mh in 1950 to 3.41 mh in 1991. This has created tremendous opportunities for the mosquito vectors to breed uninterruptedly and invade new regions, thus increasing the area of their distribution and also the duration of transmission.
Rajasthan is a good case study on the links between international finance, ecological imbalance and health problems.
The Great Indian Thar Desert lies between 24-30% latitude M and 68- 78 Longitude East. It covers 75,000 sq. km or 62% of the state of Rajasthan and has 12.8 million or 39% of the states population. On the east it is bounded by the Aravalli range of mountains.
The western part of Rajasthan is covered by a major canal system. This is also the region where the malaria epidemic has been concentrated.
The Indira Gandhi Canal Project is a World Bank-funded project in the Thar Desert of Rajasthan which changed the ecological profile of the desert region through water logging. The 8,000-km canal system consisting of Gang Canal, Bhakra Sirhind Canal and Indira Gandhi Canal have led to seepage, and areas in their vicinity have become marshy and a 'veritable paradise for perennial breeding of certain vector species'. The Anopheles Culcifacies and the Plasmodium Falciparum have invaded the desert recently.
The Thar Desert has now become a wet, water-logged region in the Indira Gandhi Canal command areas. According to an estimate, a total of 8,600 ha of land is permanently inundated under the Indira Gandhi Canal Stage I while a 1,000 ha area is converted into marshy land due to water logging and excessive seepage from the canal in Stage II.
This is the zone that was responsible for the Plasmodium Falciparum infection in the desert.
The conventional malaria control strategy has been the spraying of insecticides. Spraying of insecticides (DDT, HCH, Malathion) was the mainstay of the malaria control programme. In fact the centre's contribution to the states was in terms of these insecticides. The reliance on large-scale insecticidal spraying prevented development of alternative strategies of malaria control.
Under the continued assault of insecticides, vector mosquitoes have developed resistance, thus undermining the 'insecticidal approach'. During the 1960s, no research was done on the evolution of resistance because of the euphoria of malaria control programmes. This gap in research was filled only after resurgence had occurred. In the case of Anopheles culcifacies resistance to DDT is now common in 18 states and 286 districts, to HCH in 16 states and 233 districts and to malathion in eight states and 71 districts. An stephensi has developed resistance to DDT in 34 districts in seven states and to HCH in 27 districts in six states. Resistance to malathion has been detected in eight districts in three states.
There is, however, a revival of traditional systems of combating malaria through biological control such as the introduction of larvicidal fish in water bodies and the use of bio-larvicides such as Bacillus thuringensis(Bt) and Bacillus Sphaericus. These are particularly effective when combined with neem oil from the neem tree. Studies have shown that neem oil offers tremendous opportunities of providing protection from mosquito bites and neem products can be applied in a variety of ways to control mosquito production. Neem oil also has good larvicidal action as well as good repellent action and has been used traditionally by tribals in malaria endemic areas.
The resurgence of malaria calls for the revival of sustainable bio-environmental methods for controlling it. Two major evaluations are needed to ensure that this change in paradigm from the insecticidal to the ecological approach will be sustainable and accessible to all. The effective and sustainable use of neem has depended on the use of neem oil as a composite of many active principles. Does the isolation and purification of active ingredients carry a risk of the emergence of resistance in the vector along the pattern of resistance to chemicals such as DDT? The free or low-cost access to neem oil has depended on the fact that its production and knowledge was in the public domain. As patenting of neem products and processes begins to enclose the public domain, how will the access of the poor to the bounties of neem be affected?
These questions need to be answered as part of the development of an alternative paradigm for malaria control.
Structural adjustment policies and the undermining of health care
The growing incidence of malaria and the failure of conventional insecticidal approaches demand an expansion of public health financing for public facilities accessible freely to the poor. At a time when the poor need cheap and accessible health care most, structural adjustment programmes are leading to increased costs and decreased access to health care.
The health budget has been steadily declining. Share of health in central outlay was reduced from 0.70 in 1990-92 to 0.62 in 1992-93. Excluding 58 crores for AIDS, the actual health budget was cut to 244 crores. The budget cut was 30%.
In 1992-93 the malaria programme was cut by 43% in nominal terms and since the malaria programme financially supports the multipurpose workers, the impact on health care was significant. The health spending in 1991 was 6% of GDP. Of the total health spending 75% (Rs.240 per capita) is from the pocket of private households i.e. a disproportionate burden of health care falls on the poor who can least afford it. The government spends only 22% (Rs.70 per capita). Of this the contribution of the states is 15% and that of the centre is a mere 6%.
In poorer states where the health status of the people is lower, the public spending on health is the lowest. The ratio of per capita expenditure on public health between the highest and the lowest was 7:1.
The control of many communicable diseases like the National Malaria Eradication Programme which is the largest, require 50:50 ratio centre between state funds. Since the poorer states are unable to raise enough to meet their 50% contribution, they miss out on the centre's contribution of 50%. The states MOST in need of financial resources are those that are LEAST able to mobilise these resources.
There is a distinct possibility that budget cut-backs and the imbalances at the state level due to stabilisation policies are likely to be introduced into a system that in fact needs to be expanded and strengthened.
Stabilisation can affect government health spending through a reduction in central plan scheme allocations, reduction in central 'untied' transfers to states reduced government revenue at state level and autonomous state reduction in actual health spending in response to their general fiscal constraints.
Sizable reductions in health spending have not yet appeared, although where reductions have occurred they have affected poorer states that need the disease control program the most.
Given the inability of the public system in poorer states with poorer people to provide health care, the burden falls on poor households who meet health needs through out-of-pocket expenditure and debt. The cost of increased health problems and the need for extra care thus falls disproportionately on the poor. Private spending is dominant in provision of primary health services accounting for 82% of total spending. The expense on curative care is 92% and only 27% is accounted for by preventive and promotive services. For secondary and tertiary in-patient care, expenditure of private households is 70%. Household ambulatory curative care spending accounts for about 50% of the national health expenditure.
Expenditure for the in-patient care in private hospitals is much more costly than that available in public facilities. The costs of private hospitalisation are on an average 1.3 to 9 times higher than public health services. Seventy to eighty per cent of the operation and maintenance budget for hospitals is for salaries.
Funds for operation and maintenance purpose have fallen from 30% to less than 20% of the budget since the mid-1970s. Salaries have grown at the average growth rate of 10% compared to 5% or less for other inputs.
Lack of availability of medicines and other supplies from publicly managed facilities especially in rural areas is a major cause for the low quality of care provided at primary health facilities. This is a major cause for lack of demand of services from primary health centres. It is evident that where public health care is concerned, it receives low priority in the public, private as well as household spending. Even for curative care the spiralling costs of drugs and doctors' fees have made medical care more costly.
All the national health programmes are based on Western medicine and are not involved in the promotion and utilisation of traditional systems of medicine. Since most national health programmes are run as government programmes, neither the practitioners of other systems of medicine nor the members of the community as such recognise and accept these programmes as their own. Hence they are unable to feel that they have a unique role in eradication of disease, especially where communicable diseases are concerned.
The morbidity and mortality related to malaria is undoubtedly increasing. Increased dependence on spraying rather than on environmental sanitation (and that too irregular spraying, improper spraying, inappropriate spraying) has resulted not only in increases in the number of vectors but also the emergence of pesticide resistance.
The increasing dependence on curative care and the failure to recognise the ecological basis of epidemics is leading to inappropriate solutions for a deadly disease. Hopes for freedom from communicable diseases for the poor lie in strengthening public systems of prevention and cure, and treating disease at its ecological roots. This challenge of keeping health care in the public domain becomes even more crucial in the context of the new patent regimes which allow monopolies on essential and life-saving drugs.
Keeping malaria cure in the public domain
A Colombian physician, Dr Manuel Elkin Patarroyo, has developed the world's first malaria vaccine. The new vaccine provides a protection rate of 77% in children under the age of five, and a rate of close to 70% in adolescents and adults. Since 1987, the vaccine has been tested on more than 40,000 people in Latin America. Further clinical trials are now being performed in other parts of the world including Africa, the site of 90% of the 300 million malaria cases worldwide. Dr Patarroyo's development of a synthetic malaria vaccine means that its wide spread utilisation has the potential to save the lives of thousands, perhaps millions of people all over the world.
In spite of multi-million-dollar offers from multinational pharmaceutical companies which sought to gain monopoly control over the vaccine through patents and licences, Dr Patarroyo donated the legal rights to the World Health Organisation on behalf of the Colombian people. He has thus resisted the trend of patents and monopolies and ensured that the vaccine will remain cheap and accessible to millions of malaria sufferers all over the world. At a time when all fundamental rights to food, nutrition and health care are being eroded and being transformed into marketed services controlled through monopoly, ownership, Dr Patarroyo has taken a step to preserve the free space for health for all.
The resurgence of malaria and other communicable diseases as a result of structural adjustment policies and the intrinsic privatisation built into them shows that health care is not possible in a privatised world.
Those who are left disenfranchised as a result of poverty-creating mechanisms of structural adjustment are the most vulnerable to the resurgent epidemics. The eradication of communicable diseases needs a widening of the public base of health policy, rather than its shrinkage. The environmental solutions aimed at preventing the spread of diseases like malaria necessitate collective action and cannot be addressed at the individual level. The curative aspects of treatment of malaria also require that a large public domain be kept alive to ensure that essential life-saving drugs and medicines are accessible to the poor who are the worst victims.
The renewed appearance of epidemics is a reminder that privatisation, monopolisation and individualisation of health care is neither just nor sustainable. We need to make an urgent and radical shift towards making our public systems more resilient and accountable, protecting the public domain in the production of drugs and pharmaceuticals, and strengthening collective public responses at both the preventive and curative levels.
Even for those who think only in terms of dollars and rupees, the resurgence of communicable diseases should cause anxiety. A study of the economic loss due to malaria and its future trends revealed that malaria in India was responsible for economic losses between US$0.5 and 1.0 billion annually. The study also brought out that if ecological destruction continues unabated, the proliferation of disease vectors was inevitable.
These costs outweigh any savings achieved by budget cuts in health care.
Dr Mira Shiva is a physician and a public health activist who has been actively involved in public health care and human rights. Dr Vandana Shiva is a scientist and activist. She is also a contributing editor for Third World Resurgence.