What Will It Take To End The Malaria Mayhem In Mewat?

It's a sign of crisis that the very first resident we meet on entering Ujina in Haryana's Nuh (formerly Mewat) district, turns out to be a Malaria patient.

Mohan Singh, 43, started shivering after a continuous spell of rain for three days. He soon found himself in the grip of high fever. With the weather clearing on Tuesday (24 July 2018), Mohan sat outside his house soaking in the sun, but was too weak to talk. His neighbour Madan Singh said, "Ghar-ghar mein bukhaar hai. Har saal wahi kahaani (Every family has members suffering from fever. Every monsoon, it's the same story.)."

Ujina is the worst-affected area in a district that bears two-third of Haryana's Malaria burden. It is home to 9 per cent of Nuh's 13 lakh population, but contributes about 75 per cent of Malaria cases in the district.

Last year, the government primary health centre (PHC) at Ujina recorded 2,468 out of a total 3,643 cases of Malaria in Nuh, which has 13 PHCs. Even this year, the PHC at Ujina has reported the most, 350, of a total 492 cases in Nuh (until mid-July).

The actual number of Malaria patients is many times higher as most residents go to private practitioners, says Madan Singh.

Residents say they dread the evenings. "I bet you can't survive even one night here. There are just too many mosquitoes," says Arif Mohammad, a resident of adjoining Ranika village.

What ails Ujina and the whole of Nuh?

The outbreak in Ujina, as in Nuh, is the result of a combination of factors, but it is the filthy, stagnant water in Ujina drain that makes the area particularly vulnerable to mosquito-borne diseases. The drain flows from Faridabad to Punahana, passing through two dozen villages. Around monsoon, the health department adds Gambusia fish, which eats mosquito larvae, into the drain. The department also adds kala tel (black oil from machines) obtained from PepsiCo plant. But it is just not enough.

"The drain is dirty all year round. They don't do much about it the rest of the year," said Arif.

Dayanand Kumar, health inspector at Ujina PHC that caters to 38 villages, said Nuh's clay-like soil aggravates the problem. "There are always lingering puddles on its soil after heavy rains. Adult mosquitoes use this stagnant water to deposit their eggs," he said.

When Swarajya visited the area on Tuesday (24 July 2018), pools of stagnant water could be seen all around. Ironically, an uncovered drain bordering the PHC itself looked like a Malaria hotspot.

Residents say the pools are never cleared; officials say it is beyond the purview of the health department. Dayanand Kumar said they have deployed five 'breeding checkers' in the area but admitted that they need many more.

While most residents are into agriculture, a substantial number is into fish farming which, again, adds to stagnant water that serves as breeding spots for mosquitoes carrying Malaria-causing larvae.

The health department primarily depends on insecticide sprays (called Indoor Residual Spray or IRS) and fogging to control an outbreak, both expensive measures. "IRS is done once in 90 days. We did it in April and are preparing for a second round," informed Kumar. Residents, however, complain this provides relief only for a few weeks.

In its defence, the health department cites government data that suggest a steady decline in Malaria cases over the years. As per PHC records, from 6,638 cases in 2015 to 5,075 cases in 2016, Malaria cases have been coming down in the Nuh district and dropped to 3,646 last year. The data also claims zero deaths due to Malaria in the district in the last four years, with 2015 as an exception when three people lost their lives to the disease.

“We have largely controlled the incidence of deadly PF,” said Kumar. PF (Plasmodium Falciparum) and PV (Plasmodium Vivax) are two species of the parasite that cause Malaria. PF is a severe form that has a cerebral manifestation while PV is milder. Both, however, are curable. When Nuh was hit by its worst Malaria outbreak in 1996 with 1,300 deaths, half the cases diagnosed were of the PF type. Last year, only 545 cases tested positive for PF.

But a Nuh-based journalist working for a Hindi daily for two decades told Swarajya that there is gross under-reporting. "It is a matter of great shame for the administration if even one person dies of Malaria. So they suppress the figures. If deaths happen, they blame it on other factors," he said.

Sher Singh, a resident of Ujina village, said "deaths happen all the time", but critical patients usually leave the PHC before getting discharged, so their deaths go unnoticed in government records.

Manpower, the biggest hurdle

Vimlesh Narayan Tiwari, district epidermiologist for Nuh, told Swarajya that the most effective measure to reduce the burden of Malaria is prompt diagnosis and treatment. This is brought about by health workers going door-to-door to check on fever patients, using rapid diagnostic test kits, which provide results in 15-20 minutes, and starting the treatment.

But Nuh is criminally short of manpower. The district has about 30,000 kits, but few hands to use them. Of the 19 sanctioned posts of multipurpose health supervisors or MPHS, who hold master's degrees in public health, 13 are vacant. Of the 94 sanctioned posts of multipurpose health workers or MPHWs, who are grassroots workers, 88 are vacant. The health department says it actually needs more than 250 MPHWs. It also needs to fill senior positions such as district Malaria officer and assistant Malaria officer.

A senior official in the department, who did not wish to be named, told Swarajya that skilled manpower avoid the highly underdeveloped Nuh district like the plague.

Indeed, Nuh figured at the bottom of NITI Aayog's recent list of most backward districts in India. A crying shame, given that it is just a two-hour drive from New Delhi and is part of the National Capital Region.

A combination of factors such as abysmal literacy rates (as low as 6 per cent in some areas), unavailability of water for drinking and irrigation purpose (as ground water here is highly saline), and education and health being in shambles, makes Nuh a "punishment posting", the official said.

Mewat, home to Meo Muslims, was carved as a cultural region out of erstwhile Punjab in 1966 after the reorganisation of states, with half its area extending to Rajasthan. In 2005, the area in Haryana was declared as a district, with 75 per cent Meo Muslim population. In 2016, it was rechristened as Nuh.

Government apathy and social exclusion have ensured Mewat remains a failure; today, it is mostly known for notorious gangs and even terror links.

The backward nature of the district also mars many of the government's health efforts. For instance, vaccines are opposed for fear of sterilisation, and even fogging and insecticide spraying are viewed with suspicion. Birth control is frowned upon.

"Most families are poor but have six to seven children. Their bare bodies catch infection easily. They also have poor immunity as malnutrition is high. Anemia is rampant," said Tiwari, sharing that 80 per cent of Malaria patients are children.

Power cuts in Nuh are long and frequent, which forces residents to sleep in the open. The administration recently distributed 1.7 lakh mosquito nets, but it says it needs at least three lakh more. There is also acute water shortage, forcing residents to store water. Nadeem Khan, a Ranika resident, said his wife travels 2km to fetch drinking water daily. The residents also habitually leave rain-filled buckets outside.

It's quite clear that to control the annual outbreak of Malaria, the district needs to develop on multiple fronts. Chief Minister Manohar Lal Khattar recently announced Rs 3,427 crore for the district, including Rs 1,185 crore for a much-needed water pipeline project.

It is to be seen when the government delivers on its promises. Till then, the district must fight the Malaria mayhem with a fraction of the needed manpower.