A surgeonís point of view


by Dr M. M. Janapriya
Senior Consultant Surgeon
National Hospital of Sri Lanka

Sri Lanka has seen the emergence and spontaneous dying down of many an epidemic of Dengue fever over the last few years. In the process it has taken its toll of young lives and rocked the economy of the country too. The present outbreak has not been declared officially as an epidemic. Though I am not a physician actively treating Dengue, as a person who witnesses what is happening in the hospitals both state and private, I am more than convinced that we are in the middle of a bad epidemic. I do not know whether the authorities concerned are acting under orders/instructions but one thing that is as clear to me as daylight is that they are playing the epidemic down. Why do I say this? As a citizen very much concerned about what is happening around me I wanted to establish or refute the fact that there is an epidemic and what steps if any taken by the authorities concerned. I interviewed five out of the 7 Consultant Physicians of the National Hospital of Sri Lanka on this matter. The two questions put to them were

1) Is there a dengue epidemic here in our country?

2) Are you aware of any major steps the health authorities have taken to curb the epidemic?

I was startled by the revelations. The first question was answered in the affirmative by all five. They testified that they see a total of about 50 suspected cases of Dengue per day in all the hospitals they visit. I cannot imagine even the smartest of the medical statisticians being able to show that these figures do not signify an epidemic. My colleagues also confessed that the notification of these cases was very poor due to lack of staff dedicated for the purpose. Isnít it the duty of the physicians who are in thick of this outbreak, to meet with the authorities concerned and explain to them the seriousness of the situation.

The answer to the second question was no different. Most of them were aware of the health education programmes launched by the health authorities and a few even spoke of home visits by the local authorities to educate the public of the mosquito menace and to monitor the eradication measures taken by the community in this regard. None of the physicians were aware of any major steps the government has taken centrally to curb the outbreak. As a matter of fact the health authorities have not considered it important to launch a programme to arrest the spread of the disease. On one of my evening rounds I met a smart physician who recently retired from the public sector. He gave a very rational explanation to this all. He said, that once an outbreak is declared an epidemic major and drastic control measures have to be launched quickly. Hence as long as this is not officially declared there is no need for the central health authorities of the epidemiological department to do any thing active despite the remorseless progression of the epidemic. It may well be because these measures cost money to the government.

I shall now explain why there is this scant regard for human suffering and loss of young lives. According to the 1993 World Bankís World Development Report (World Bank is a major funding agent for most developing countries) control of Dengue occupies a low priority position. Two reasons are adduced for this. a) Annual deaths due to Dengue are 1000 fold less than those due to diarrhoea and Malaria

b) In the opinion of the World Bank, Dengue control methods are both unproven and expensive

The reason (b) will be tackled by me on a later occasion.

Let me enlarge on the first reason adduced by the World Bank. Firstly these figures are over all figures holding water only considered globally. Our death rate due to diarrhoea diseases is very little. This too is related to the economic status of the family. Secondly Malaria is a thing of the past in Sri Lanka. Thirdly treatment of a large number of fever cases, I mean uncomplicated dengue fever, entails a considerable expenditure. The investigations like IgG, IgM antibodies etc are costly too. These have to be done on all cases of suspected dengue fever. Fourthly Dengue Haemorrhagic Fever and Dengue shock syndrome necessarily have to be treated in intensive care units for weeks incurring enormous expenditure to the government. Also, both directly and indirectly a large number of useful man hours are lost as a result of this illness afflicting self or children. Hence an epidemic of dengue will cost large sums of money to the government unless it chooses to adopt the policy of deadly silence it has been adopting year after year.

Cost of Dengue should not be measured in Rupees and Cents only. Dengue conveys a sense of disorder not measured in rupees. It is the health equivalent of street crime or graffiti. These disorders create visually and emotionally contaminated environments in which people feel unsafe and lose their enjoyment of life. Dengue as a house borne disease makes many people unsafe. Millions of parents in Dengue endemic countries lose sleep worrying about the safety of their children. This is the conclusion emphasized by Sornmani and colleagues in their unique study on the social and economic impact of Dengue Haemorrhagic fever in Thailand. Fear and worry are the largely unmeasured burdens of Dengue.