Farmer's plight is a damning reflection of how much reform has taken place

Farmer’s suicide is a silent killer being brushed aside as a marginal issue; after all, a few farmers taking their life ‘here and there’ can’t be that serious. Hmm….neither is it ‘few farmers’ (nearly 200,000 in 10 years) nor is it here and there (Karnataka, Andhra Pradesh, Maharashtra, Madhya Pradesh and Chattisgarh are just the big five!). Of course, it is not a marginal issue, stemming out of a simple lack of money to repay a loan – the phenomenon points bloody fingers at the very process of ‘economic reform’ – yes, the same reforms that makes possible the 3G in our hands, and the apple on my desk. A paradox, this….Sridhar Kadam, a farmer who incidentally trained in public health shares this poem. For hindi speakers, please neglect the effort at english translation by Werner and me.

जालियांवाले हत्याकांड आज भी होते है, जरा गौर से देखिये,
गोली के निशान नहीं, जरा मौत की वजह देखिये !

लाश के सरहाने जहर की बोतल देखकर,
सभी ने जान लिया की शायद कोई किसान था!

अब तो कपास भी शरमाता है,
किसान के खेतो में फूलने के लिए!
रोटी तो वो दे नहीं सकता,
मगर कपड़ा भी दे नहीं पाता, बदन ढकने के लिए!

वो सर पर लाद कर सब्जीया बेचती है,
अपने बेटे को पढ़ाने के लिए!
और खुद ‘सरकारी गोली’ खात्ती है,
अपना खून बढाने के लिए!

ऐ लोगो मत कहो ‘खुदखुशी’ किसान की मौत को,
वो खुद की खुशी नहीं, बनाए गए हालात थे!
अगर गौर से देखा जाये तो,
जालियांवाला हत्याकांड में भी कुछ ऐसे ही हालात थे!

इसका रोना नहीं की हमारे पूंजीपती इसके निर्माता है,
और चंद ‘विद्वान’ फिरंगी इसके निर्देशक है!
गम इस बात का है की,
हमारे माटी के पूत ही इसके तमासगीर है!

क्रांती आज भी होगी, जरा आजमा के तो देखिये,
आप हमारे बंधे हाथ, जरा खोल के तो देखिये!

Still today we see bloodbaths not unlike Jalianwala Baagh.

Stop looking for bulletholes.

Watch the cause of death and misery.

See the bodies lying clutching the bottle of poison

To inform us that the cause of death was suicide.

The cotton is embarassed

To flower in the farmer’s field.

May not give bread, this cotton,

Neither will it give the farmer a cloth to cover.

His wife still sells the load of vegetables on her head

So that her son may be lettered.

And she’s still downing sarkari goli

For ironing her blood.

O brother, don’t call this one a death by suicide.

It was not to soothe own failure that he killed himself.

Don’t say destiny created the end of the road.

Cry why!

Did not the massacre at Jalianwala Baagh

Bestow the same destiny for the unarmed?

Don’t shout that Capital was the producer of this drama.

Nor wail that the Bank was the director of this karma.

This pain cuts deeper than a minstrel show.

It took sons of our land to cut so deep.

Radical change is what we need.

Dear brothers, come together

And open up your arms.

Dr. Srinivas had started his career as a doctor trained from Karnataka’s oldest medical colleges, Mysore Medical College. He had joined the state health services early and had worked in remote primary health centres as a doctor and later in hospitals. He had risen up the long ladder stretching form a PHC medical officer to the level of a Project Director of Reproductive and Child Services for the State of Karnataka more recently. After retirement, his rich experience would not be wasted; the state continuing his services as a consultant to help implement the most important initiative these days, the NRHM. Among the lively discussions between the participants and him, was one important aspect of leadership – by example.

Dr. Srinivasa spoke of the fundamental nature of organisations; of adopting the values and principles of the leader. While most people are sincere in their work inherently, many others are fence-sitters, as he called them. They adopt the values of their leader. He also quoted from experience. It is critical for government services to produce such leaders, for in adopting these values of service and dedication, not only would they be transforming the way in which they work, but they would be transforming their entire institution.

Such is the case of the district hospital in Tumkur. The district hospital in Tumkur is an ancient one. It is one of the older large hospitals in the state of Karnataka, having been established a year after independence in 1948. By a strange quirk of fate, the then Maharaja of Mysore, Sri Jayachamarajendra Wodeyar, who was to inaugurate the hospital abruptly left the venue, for the day the hospital was inaugurated was the day that Mahatma Gandhi was assassinated. The inauguration stone that marked the occasion today lies within the walls outside the office of the District Surgeon. The hospital caters to over 2 million people in Tumkur district, and what a responsibility to manage a hospital of such a size given such a task….

Dr. Pratap Surya is the District Surgeon, the man who is at the helm of affairs at the hospital. He has indeed a mammoth task on his hands. Being the head of a large 250-bedded hospital that sees over 1000 people a day is no joke. A random sample of the patients reveals the enormous service that the hospital renders – one of the patients from Midagesi, a distant town in the taluka of Pavagada had come in search of the ENT surgeon for the chronic infection afflicting his adolescent son. He was a landless labourer from there, nowhere else to go for him; the bus charge from his place to Tumkur and back, and the wage loss resulting from a loss of one day’s work together added to quite a burden. There was another person from the town of Madhugiri, an old man who had come hoping to improve his vision by getting rid of the haze that had recently developed in his eye, a cataract. The hospital in Tumkur has an ophthalmologist and an ENT surgeon to cater to both of them. I ran into the gynaecologist, Dr. Diwakar in the corridor. He had just finished a caesarean surgery to save the life of a mother and the newborn. In this case, the newborn was positioned transversely in the mother’s uterus, thus not being able to be delivered normally; a classic indication for a caesarean section. If the mother had not reached the hospital in time from the distant village beyond Madhugiri town, the physiological process of childbirth could have been fatal for both the mother and the child. In her case, thankfully, the newly launched service of 108 had promptly brought her in time for the procedure. The woman being from a family that is below poverty line, like almost all of the patients that obtain service at the hospital had undergone the procedure completely free of cost.

The old man from Madhugiri will have his vision soon. The ophthalmologist scheduled his surgery for the upcoming batch. The ENT surgeon, who single-handedly manages the entire department will soon see the adolescent boy from Midigesi, in time for him and his father to catch the evening bus back home; he cant miss another day of daily wage. The taluka of Madhugiri could rest easy, avoiding its tryst with yet another maternal mortality, thanks to 108 and the gynaecologist at Tumkur. This was yet another routine day in the government hospital in Tumkur.

Yet, it is not automatically so. A lot of effort has gone into managing the hospital. It is but easy to target government hospitals for their poor quality of care and negligence. Easier still to say “privatise”. But, when one sees the segment of people who these hospitals cater to, we understand the importance of strengthening them; and it is not for lack of effort by the local staff that these ills plague the government system. People like the present District Surgeon, Dr. Pratap Surya are the foot soldiers of health care to the masses. Neglect and carelessness in the leader could easily have a cascading effect on the staff. But, Dr. Pratap Surya, by sending the right signals of integrity, service-mindedness and discipline – he leads by example.

Of course, there are problems. Why do poor people have to travel for such a long distance for an ENT consultation? Why wasnt the mother with a transverse lie diagnosed well in advance, so that she need not have come at the nick of time to the district hospital? Moreover, why aren’t such services available at the sub-district level itself? Why is the district hospital so overcrowded?

Thankfully, the launching of the NRHM holds promise. The priority accorded to maternal and child health and the resulting strengthening of referral units to prevent infant and maternal mortality, upgradation of neo-natal ICU’s in Tumkur district hospital, and of course the leadership by example provided by people like Dr. Pratap Surya, one can see encouraging signs of improvement. Let us hope that the efforts of several people within the system like the district surgeon or Dr. Srinivas and many others among the Tumkur district health team will result in better quality service to the poor.

It is no measure of health to be well adjusted to a profoundly sick society.

- Jiddu Krishnamurti

Gubbi, a Taluka headquaters in Tumkur district

Gubbi is a small town in Tumkur district in Southern Karnataka. Gubbi Veeranna, one of the well-known theatre personalities from Karnataka who started the first Kannada theatre hailed from here. Historically, the town was well-known for its local markets for cotton and areca nut. As early as in 1871, Gubbi was a municipality of its own. The Imperial Gazetteer of India in 1871 talks of the monthly ‘jaatres’ or fairs which were well known for the sale of cotton cloth, blankets, rice and other articles from as far as Malnad (the mountainous monsoon-fed wetlands to the west) to the dry areas of Rayalaseema and the low hills of Arcot to the east and South. Today, Gubbi is a taluka headquarters in Tumkur district and is one of the ten talukas in the district.

Gubbi is about 20 km from Tumkur and is situated along the highway to Honnavar from Bangalore, that passes through Tumkur. The taluka hospital of Gubbi is along the highway passing through the town. The Administrative Medical Officer, the doctor in the hospital tasked with managing this hospital is Dr. NL Dani. The hospital was a Community Health Centre earlier with 30 beds being upgraded now to a 100 bedded hospital.

Dani is one of the participants of the capacity-building programme organised by IPH and its partners in Tumkur. Dani is a paediatrician by training with three decades of experience. He is today managing a 100 bedded Taluka hospital. His hospital sees over 200 patients in a day, is severely understaffed and morbidly overloaded. In these days of panchayati raj, he is answerable not only to his superiors in the hallowed chambers of the directorate in Bangalore, but also to the representatives of the people in the narrow chambers of the Gubbi Taluk Panchayat.

Gubbi Taluka Map

The hospital provides out-patient services to nearly 300 people in a day. At a time when there is a beeline towards corporate hospitals and having busy evening practices, it is heartening to see Dani and his colleagues in Gubbi hospital providing services within the constraints they face; and these are many. Dani conducted a study in his hospital to understand patient satisfaction, as it bothered him that most of the people obtaining the services at Gubbi hospital were reporting that they were not happy with the services. Was there truth to this?

Dani approached it very scientifically. He did not take this for granted. Nor did he cursorily conclude on the reasons for patient dissatisfaction. He conducted a study consisting of exit interviews of through a structured questionnaire. Patients were recruited into the study randomly. He considered the following aspects in his questionnaire:

1. Staff availability of patients
2. Basic amenities like toilets, drinking water, ambulance services and drug availability
3. Patient safety in hospital – infection control, physical safety of women and children
4. Perceptions of cost
5. Administrative and procedural problems

The questionnaire confirmed his hunch about dissatisfaction. Presenting the results in Tumkur, Dani also shared the possible reasons for this. On an average, each doctor in his hospital sees over 70 patients in a day. Many of these, of course are specialists who are supposed to be giving a lot more time than they can to these patients that are referred from primary health centres. However, these patients needing specialist care are clouded by many others who come here for routine health problems. There is no referral system in place.

Dani in his study prepared hospital performance indicators for all departments – in-patients, specialities, CSSD etc. He identified issues in human resources, infrastructure and a few other issues as key reasons for the patient dissatisfaction. He found that staff motivation was poor. Also, he was working in a severely understaffed hospital. Recruitment to the hospital happen in Bangalore. While it is easy to upgrade the beds from 30 to 100, finding the requisite support staff and motivated doctors to work here is another story. The district is helpless to fulfill existing vacancies. In addition, he found that supervision was poor. The doctors and other senior staff could hardly devote time to supervise and hand-hold their non-clinical team. Where is the time for management of the hospital?

In addition to doctors not being available in good numbers, the amenities provided were also poor. Residential quarters were not available for all the staff. The hospital lacked good water and sanitation facilities. A reception counter itself was not there.

This was of course a small study done in a small taluka hospital, one among over a hundred taluka hospitals in the country. However, the issue Dani identified for his study, ‘patient dissatisfaction’ is a universal phenomenon in public health services in the country today. In India today, irrational health practices and expensive health care is becoming a feature rather than a problem. Government-provided health services is the lifeline for millions of poor, who depend on these, and for whom health expenditure is often catastrophic. The reasons Dani identifies through his study are also quite representative of hundreds of other taluka hospitals.

Doctors in government services work with many constraints. Staff are demotivated. There is always pressure from elected representatives, sometimes justified, and other times not. Teamwork is lacking and the work environment is not always cheerful or fulfilling. Yet, there are people such as Dani in many of the small hospitals in the country, whose toils go unheard, and whose stories go unsaid. Yet, we often see the glamour and glory that many a corporate hospital catering to a much smaller proportion of people get.

Here is a doctor who in the middle of taluka meetings, trainings, reviews and visits by superiors, also manages a busy clinic as a paediatrician and is expected to manage a 100-bedded hospital for a taluka. In the midst of this, he keeps his spirit alive and did a study to understand and document patient dissatisfaction. We hope that Gubbi finds more specialists and most importantly, committed people like Dani.

Crossposted on IPH India Blog

I have a dream….

If Martin Luther King were born in the forests of BR Hills in Southern Karnataka during the nineties, apart from perhaps running into Veerappan, he could’nt have expected more adventure. Nonetheless, I am sure he would still have had a dream.

His dream would have to do much more with owning a television and watching an action film. It may have been about having a bulb at home and a tap with water. It may have been about seeing the insides of a car or wearing colourful clothes. These are some dreams that a ML King look-alike, Ketha has in BR Hills.

Ketha from Gombegallu

Ketha is a Soliga tribal boy far removed from the realities that some of us take for granted. He does not have a facebook profile and the only tweets he hears are that of a a bird which shares his name, the Kethanakki, named after a tribal god’s coming that this bird announces promptly. He lives in a small hamlet within a wildlife sanctuary.

His life is a part of several debates in which he has no voice. There is for example the school of thought on development that wonders why indigenous tribal people are being ‘developed’. What about erosion of their culture? Another argues passionately that the fruits of development (Facebook and twitter included!) cannot be denied to them. The State refers to him as marginalised and has scheduled him.He is one of the 400-odd tribes in India constituting 8 per cent of our population.

Another group of people strongly believe that he and his kind living in protected areas are in fact the obstacle to the conservation of our forests. Wherever, man and wildlife have tried co-existance, some say has ended in a diasaster. Inviolate areas for wildlife are touted as a prerequisite for any conservation strategy. Others weave a more utopian reality for Ketha, suggesting that conservation of wildlife and human livelihoods can go together. Others nuance it further saying that this has definitely happened in some areas. Ketha, of course is blissfully unaware of such realities.

Where would he read these debates? In the textbooks….

Hardly….In the textbooks, Ketha finds references to events, he cannot understand even….such as September 9/11 terror attacks on the US. While, this chapter in the 9th Standard English textbook of Karnataka State Board makes a good effort at trying to convey to Ketha what a watershed these attacks were for global politics, it perhaps misses the boat on connecting with him on issues closer home such as tigers, tribal people or traditional knowledge.

What about the internet? Hardly. Ketha has no access to the internet. Having a local NGO run a school itself is such a privilege for him, when compared to his other tribal brothers in other areas.Perhaps, on the internet, Ketha could have participated in these debates that adorn journals and blogs.

Ketha and Pareto come to my mind as I read the recent guarantee of broadband internet access to every Finn as a fundemental right. I still remember joking about how I am waiting for the day when the Indian State will guarantee 2 Mbps per citizen with unlimited download as a fundemental right. Less than a year from my joke, a country that Ketha has never perhaps heard of, has guaranteed it. Recently, when Michael Moore made that wonderful ‘reality show’ called Sicko, he apparently removed scenes shot about the Norwegian health care system, because, nobody would believe it!

Anyways, my point is that there is today within Ketha’s lifetime, a country where broadband internet access has been granted as a fundemental right, while in Ketha’s country, we are still wondering how to give him and his kind a good primary education.

Late last year, Aphu died. A healthy young man, he was among the people hired to carry luggage and supplies for a group of people. We were visiting the village to see how we could address their health care needs. Cystic fibrosis did not dry up his lungs. Neither was it any of those eponymous autosomal diseases that strike the young, of which we learn so much in medical school. These diseases were very interesting, with articles about them in journals describing correlations to genes with numbers like the latest version of MS Windows. They all had their “Disability adjusted Life Years”(DALYs) that were screaming out their importance to be taken up in any of the new programs that the State might decide to launch. But, these rare and publishable afflictions were not among those that Aphu was ever afflicted with. He died, quite simply, of malaria. Quite ironic, that a country with nuclear power still has anaemic mothers and malaria deaths!

I have been to Aphu’s village a few times with the wildlife scientists who work here. His village happens to be surrounded by one of the northernmost primary rainforests in the world. The place teems with biodiversity and the forests of Arunachal Pradesh have witnessed descriptions of a new species of bird and even a new primate, all in the past few years. Although, it is the tiger that has given this area its protected status, it is not for the tiger that this national park and many of the forests in Arunachal Pradesh are known. They are famous for their rich biodiversity including several endemic insects, butterflies, birds and plants. Such rainforests play a central role in wildlife conservation and climate change. However, climate change and global warming are distant issues for the Lisu and other tribal people living in and around these forests. Strangely, tigers aren’t.

In India today, there is a public debate on tiger deaths. Tigers and tribal people are being pitted against each other in conferences and in hallowed policy-making chambers. Co-existence of tigers and tribals is being questioned. In an environment where health care is financed literally out of people’s pockets, a tiger’s fate and people’s health can get intertwined easily. And hunting becomes a means of averting any unplanned and sudden catastrophic expenditure. It is invariably health costs that crop up in the category of unforeseen expenses. With poor access to primary health care or even to community health workers, people in such remote regions often find that hunting can finance their long journeys to towns. And it does not help matters that private providers with expensive secondary level care and irrational practices become the first line health providers for these people. The Lisus travel through about 150 km of thick forests interspersed with rivers often in spate, to reach ‘civilization’. From here, they take a 6 hour bus journey to reach a town where they invariably see a private provider. Roads, understandably are a bigger concern than chloroquine.

I work in an NGO in South India, with another indigenous tribal people, called the Soligas. The forests have shrunken around the Soligas, leaving a 540 sq. km area, still remaining, due to its legal protection by the State. The Soligas were semi-nomadic people, until they were forced to settle due in part to the shrinking forests and the legal protection accorded to their forests. They couldn’t hunt anymore. However, a doctor who settled in these hills 25 years ago, began to provide health care to them. He went further to education and livelihood, as just providing health care was helping their health! This NGO today provides health care, education and livelihood to these tribal people. Today, the elderly Soligas talk about how climate has changed. They do not question it and do not need evidence. They know it and also see how their forests are getting choked from the outside.

These two glaring examples from South India and Arunachal Pradesh in North-east India typify the problems faced by people living in and around forests in India. However, the key is in access to basic health care and livelihoods. Wildlife scientists today see this connection between people’s basic needs and their conservation ethic. In fact, it was a group of wildlife biologists that started a community health care program and an education initiative among the Lisus. I went there to train a group of tribal youth in basic health care. Among other things, I wanted these youth to be able to identify and institute treatment against malaria. It was indeed a satisfying experience for me, to see how wildlife biologists had looked beyond their paradigm of biodiversity conservation, and had looked for solutions outside ‘their box’. We, in health care, sadly are yet to make this connection. A glance at our curricula reveals the level of medicalisation that we undergo. A glance at our policy shows how fragmented and restricted it is.

Shrinking forests are an important reason for climate change, and so are empty forests; forests devoid of their biodiversity. While hunting empties forests in some places, it is firewood needs and fires in other places. It is after all people, who are to blame for this. People living in and around forest areas depend on them for their livelihood and daily needs. And when there are financial pressures for any of their needs, they turn to their resources – forests. Thus, they find themselves being the villains accelerating deforestation and emptying the forests. Isn’t this the same thing that our forefathers did, that we find ourselves in this position today? Can we blame them for being late in destroying their forests, just because, we thought of legal protection for it now, and we have climate change now! As population pressures and urbanization increase in India, rural and tribal India face a different problem; one of access – both physical and financial. It is time for health planners to consider the special needs and contextual factors affecting tribal
people and those living or affected by forests. It would be presumptuous to imagine that national programs for any of the diseases will change the situation with these people. Lisus or Soligas and for that matter any individual is not asking for malaria control programs or early cancer detection programs. They are asking for plain health care – financial and physical access to a person who can cure them of their illness and can help them live a healthier life. A malaria program for them is even lower in priority than a road or a source of livelihood, simply because, they have accepted malaria deaths as their destiny. It is perhaps time to think beyond programs and address health as a need in itself rather than health as a consequence of our programs.

Aphu died of malaria in his early 20s only because he was born in a place where climate change and the biodiversity mattered more than his life. In many areas the world over, where man-wildlife conflicts occur, the situation is similar. How are we going to prioritize between biodiversity conservation and people’s needs? Are our politicians and policy-makers even seeing this problem of ‘First among equals’? The global health research agenda needs to gear up to answer these difficult questions; questions that matter to people dying of malaria in this age, when in many countries, research is addressing carpal tunnel syndrome.

Anyways, neither are there any mosquito-rights activists, nor are things as simple as taking a leaf from malaria vector control and applying it in bird flu. Understandably, things are much more complex than that. In two posts to two different groups, I have shared my opinions with both interest groups – birdwatchers and public health professionals…….here is the birds edition, and soon to come the public health edition.

Just a few comments of mine especially in view of several discussions that I have been witness to in course of my study here. I just share below some of my thoughts for the general reader and may be writing on topics way out of the purview of our discussion group in hope that many birdwatchers would be interested in topics related to bird flu – an interesting situation that calls for a lot of inter-disciplinary work and understanding of concepts in biology, epidemiology, public health and veterinary science.

Sudheendra’s mail and Krishna’s and Deepa’s subsequent replies about Avian flu bring up many issues on avian flu that are hardly being considered. Sudheendra rightly points out the serious economic consequences of mass culling being undertaken in response to ‘declared’ cases of the flu in Orissa and Bengal. Many of the people involved here are small poultry owners for whom livelihood is a much more proximate concern than an unheard ‘flu’.

Flu is definitely not something to be taken lightly. As Krishna points out, if the virus does ‘cross-over’ to humans, the chances are only among the animal handlers, and that is exactly where the public health authorities must focus. It is also to be noted that until recently bird-human infection was not yet reported and it was only spreading among birds. But, the worldwide panic is because IF there is such a mutation that enables the flu to spread among people, it could take up the pandemic proportions that the world has seen before.

The thing about flu is that it is clinically….well…so insignificant! Fever, feeling of weakness, body pain, red eyes are symptoms that dont get reported. MOre so in the health system landscape that India has with a zillion private clinics, quacks, traditional healers and disgruntled and frustrated public health system. The reports we are getting now are the ones we could detect.

Flu viruses have the uncanny ability of sweeping across the world bringing about widespread deaths and then, suddenly disappearing. This has happened many times before. The classical example quoted is that of the Swine Flu epidemic in the US which is supposed to have killed over 20 million people over 4 months just in the US! Of course, the pandemic was worldwide, but you
can get numbers only for the US, UK and some other countries which did have such systems. Over 200,000 people are supposed to have died in this pandemic in UK. It took more lives than in the First world war. And then, suddenly Swine Flu vanished into thin air. Poof! I say this to emphasize the point that flu is a very real danger. The reason why it flares up so suddenly is
attributed to mutations.

Influenza is caused by a virus which are comparable to “a bad xerox machine inside a protein cover”, the xerox machine in this case referring to its genetic material. I call it bad because it lacks a particular ‘proof-reading’ mechanism that other living things have and hence there are
no ‘errors’ when for example our own skin cells multiply in a healing wound. If our cells did not have a good way of keeping our genetic material intact during division, then we would all be doomed! But, for the virus this is quite an advantage, and hence through mechanisms called drifts and shifts, the virus keeps changing its protein clothing, which is what enables our immune system to identify them. So, how does the human immune system grapple with a virus that keeps changing its appearance……It cant!…which is why, HIV and many other such viruses pose a great threat for vaccines. We would have to keep making vaccines for every new dominant appearance (strain) of the virus. IN simple language what I spoke about here is recognized as Genetic drifts and Genetic shifts. Drifts are minor changes occuring in the protein coat of the virus that leads to failure of vaccines and sometimes, major catastrophes, such as the Spanish Influenza Pandemic in the spring of 1918 which is supposed to have killed anywhwere between 40-100 million people! Get ready for this one – The Spanish Flu strain was supposed to have been an avian virus that underwent a shift!

Coming back to avian flu, the present strain finds it very difficult to get transmitted from human to human. Still, over 300 worldwide deaths that have been reported today are mostly bird-human transmissions with a few rare ‘within family’ transmissions reported mostly again, within the family of the animal/poultry handlers. The virus strain causing the flu is called H5N1
which is the standard name for naming influenza viruses. H stands for one of the surface proteins on the virus that enables entry into cells, and N stands for an enzyme that enables the new virus particles to break out of the dying cell. Now, 4 sub-types of the avian flu virus are recognized. All
of them are deadly to birds, and can cause disease and death among humans. It is important to remember here that the virus presently is an AVIAN FLU virus and is being incidentally passed on to humans because of the way in which we have organized our poultry system! Wild birds, especially waterfowl are natural carriers of the virus, although, they are not as susceptible to
the disease as are the domestic birds. For eg. Russian vets are supposed to have drawn over 4000 samples of blood in Siberia with around 50 showing antibodies, which indicates active infection or past infection.

It is quite evident that migrant birds can carry these strains. But, it is important to note the following:

1) Birds carry several kinds of flu viruses and they have been doing so for zillions of years.

2) Wild birds themselves pose NO THREAT to any person directly. The only way is for them to pass on their infection to poultry birds, where the flu could spread like wildfire.

What we need to focus on is the situation within our poultry industry, handling of dead birds and a surveillance system that reports bird deaths in poultry houses. Moreover, awareness on this for animal handlers is extremely important. I find it quite ridiculous that may international bodies are calling for culling of wild birds. Such measures are not only scientifically untenable, they are also quite a schoolboy solution, I must say….a bit like trying to kill all mosquitoes to eradicate malaria!

What we must concentrate on is surveillance systems, awareness on animal handling and vaccine research. Prototypes of the vaccines are being reported. If the virus does acquire mutations that enable human-human transmission, it could definitely be catastrophic, else, it could just go away into the thin air like a million other strains of flu that we in the third world could never ever find document, let alone naming them after their surface proteins. India must’ve seen so many other previous outbreaks that were never documented.

Just a final word, Avian Flu is a disease that presents a lot of research opportunities. There could be many PhDs created. It creates good business opportunities, many patents, awards, paper presentations, conferences and well, sales of the vaccine will rake in millions…….it’s not the same
situation for diseases like Malaria, Kala-azar, Tuberculosis etc. which continue to kill millions of people across millennia….these are the neglected diseases that no one ever bothers about. There are no new vaccines being tried, and no new drug being developed for these diseases….there is
simply no ‘market’!!! An irony that avian flu gets so much attention.

Wonder how many of you got this far into my long rant at the end of a busy week here in cold, birdless Antwerp….most of the birds around my house are around where most of you are sitting. Who knows, maybe some of them carried the flu!!! I started the mail saying “…just a few comments”……

Some references for those who are interested:

Johnson, NP; Mueller, J (2002 Spring). “Updating the accounts: global
mortality of the 1918-1920 “Spanish” influenza pandemic.

J. D. Earn, J. Dushoff, S. A. Levin (2002). “Ecology and Evolution of the
Flu”. *Trends in Ecology and Evolution* 17: 334-340.

Bill Bryson (2003) A Short History of Nearly Everything. pp. 386-388

The wonder of this drug is that it is much sought after for the various kinds of pains, most often, arthritic pain. Moreover, recent precription practices of doctors show a remarkable bias towards diclo as compared to traditional painkillers. But, most importantly, it is quite inexpensive when compared to many others.

Changing prescription practices among doctors is a sisyphean task! Trust me, public health professionals have been trying for ages to bring in rational and evidence-based drug use, but to no avail. Unless, safer, and more importantly, more economical alternatives to vets is proposed and ACTIVELY pushed the ground situation is not likely to change at all. And this pushing has to happen, NOT THROUGH conservation groups but through medical reps! Catch any medical
professional listening to conservation groups!

Of course, all this is assuming that Diclo truely is the reason for the ‘vulture decline’. I really dont know if it is safe to assume that banning diclo would be of any help in Africa at all! Is there evidence for this?

If the future of vulture in India rests in fact on the effectiveness of the ban on diclofenac, then God save the Vulture! If at all, the vultures do manage to fight back a few years after the ban, we can rest assured that diclofenac never was the reason anyways! Cos, rarely have we ever achieved any ban in reality. ( Go to the nearest pharmacy to purchase any of the following ‘banned drugs’ – Analgin, Cisapride, Droperidol, Furazolidone, Piperazine etc…)