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Reducing Malaria Using Environment-Friendly Approach: A Gandhian Way of Life

2019; Medknow; Volume: 149; Issue: Suppl 1 Linguagem: Inglês

10.4103/0971-5916.251665

0971-5916

Neena Valecha, Ramesh C. Dhiman,

Viral Infections and Outbreaks Research

The growth and development of a nation depend upon the stature of its leaders who are think tanks and can guide the country. Mohandas Karamchand Gandhi, born on October 2, 1869 at Porbandar (Gujarat) in India, was such a dynamic and charismatic leader. His contributions to humanity are very well known globally. He is popularly known as Bapu or Mahatma Gandhi. Gandhiji was a leader of masses who practiced ahimsa to achieve the Independence of India in 1947. Apart from this, Gandhiji was also a crusader of cleanliness and hygiene at the village level. Based on his life's experiences, he wrote a book Key to Health in 1948 wherein he touched upon various aspects of life dealing with sun, food, water and air, etc. In his book, while at Aga Khan Palace, Yerwada, Pune, 27.8.42, he wrote in the preface, “I am giving a new name: Key to Health. Anyone who observes the rules of health mentioned in this book will find that he has got in it a real key to unlock the gates leading him to health. He will not need to knock at the doors of doctors or vaidyas from day to day.” Being a highly revered leader, the sayings and path shown by Gandhiji are being followed by many Indians and are still relevant in combating many vector-borne diseases, including malaria, which are related with sanitation and better hygiene. In order to commemorate his 150th birthday, an attempt has been made to look back into the progress made in the field of malaria disease since his birth in 1869. Malaria, or a disease resembling malaria, has been known in history for more than 4,000 years. As we know, malaria is the Third World's most dreaded killer. In The Compendium of Sushruta, a Sanskrit medical treatise, the symptoms of malarial fever were described and attributed to the bites of certain insects. A number of Roman writers attributed malarial diseases to the swamps. The word ‘malaria’ originates from Medieval Italian word mal (bad) aria (air). Malaria has been a major public health problem in India. A known malaria epidemic dates back to 1852 in West Bengal. The spread of malaria was associated with the development of Indian railways and irrigation systems. Major epidemics occurred in Bombay and Punjab under the British administration. The construction of railway embankments provided innumerable breeding sites for the malaria vectors, and movement of labourers from different parts of the country probably introduced different strains of the parasite to the areas in which they worked. High morbidity and mortality was reported in Punjab and Bengal during the malaria epidemics in the 1920s. As per the Malaria Institute of India in 1935, about 100 million people suffered from malaria in India and approximately one million deaths occurred annually in endemic areas. During the Second World War, a rise in malaria deaths was observed. In 1943, over 680,000 deaths and in 1944 about 763,220 deaths due to the disease were recorded in Bengal.Annual malaria incidence in India, 1961–2018. Source: National Vector Borne Disease Control Programme.Malaria Elimination Target: 2030 Implementation Body: National Vector Borne Diseases Control Programme (NVBDCP) Current Situation: 1.08 million cases with 331 deaths (2016) Global Technical Strategy for Malaria: 2030 Reduce case incidence by 90% Reduce morbidity by 90% Eliminate malaria in at least 35 countries Preventing resurgence in malaria-free countries Fighting malaria: From grass root level to Mission Mode Malaria Treatment Progress: Cinchona→Quinine→Chloroquine→ACT Insecticide Usage: DDT→BHC→Malathion→Pyrethroids Bed Net→Insecticide Treated Net→Long Lasting Insecticidal Net Bio-environmental Control Rapid Diagnostic Kits Malaria Vaccine: A future hope from achieving eradication MERA India (Malaria Elimination Research Alliance) – to be rolled out At the time of independence in 1947, of a population of 330 million, about 75 million people were estimated to be suffering from malaria annually, and the mortality rate was estimated at 0.8 million per annum. To combat this menace, the Government of India launched the National Malaria Control Programme in April 1953. The programme proved highly successful and the number of malaria cases significantly declined to about 2 million by 1958. Encouraged by this, the programme was changed to a more ambitious National Malaria Eradication Programme in 1958. By 1961, the incidence dropped further to a mere 49,151 cases, with no deaths. The success was short-lived and malaria resurged during 1970s. In 1976, the cases again reached to over 6 million but since then the burden is reducing. Since the beginning of the 21st century, India has been demonstrating significant achievements in malaria control with progressive decline in total cases and deaths. Further, in the last 10 years, total malaria cases declined by 42 per cent from 1,915,363 in 2004 to 1,102,205 in 2014, combined with a 41 per cent decline in malaria-related deaths from 949 to 562. Since 2015, the annual cases of malaria have been in and around or less than one million.Breeding sites of mosquitoes.MALARIA AS A PUBLIC HEALTH PROBLEM IN INDIA Malaria is caused by a protozoan parasite, Plasmodium, and transmitted by the vector anopheline mosquitoes. The disease affects mainly rural and tribal population in the country where there are variety of places where water gets stagnated during the rainy season, e.g., ponds, ditches, marshy areas, seepage water as temporary breeding grounds for mosquitoes as well as some permanent water bodies like rivers, river beds, pools, rice fields, lakes and agricultural channels. Among the major diseases transmitted by mosquitoes, malaria brings the greatest economic burden. Malaria has been termed an economic misfortune, having an impact on physical and intellectual standards, and hampers prosperity and economic progress in every way. The major burden of malaria in India is borne by the most backward, poor and remote parts of the country, with >90–95 per cent cases reported from rural areas and <5–10 per cent from urban areas; however, the low malaria incidence in urban areas may be due to almost non-existing surveillance. The state of Orissa, with a population of 36.7 million (3.5 per cent), contributes about 25 per cent of the total annual malaria cases, more than 40 per cent of P. falciparum malaria cases and nearly 20 to 30 per cent of deaths caused by malaria in India (where poverty is quite prevalent), followed by Meghalaya, Mizoram, Maharashtra, Rajasthan, Gujarat, Karnataka, Goa, southern Madhya Pradesh, Chhattisgarh and Jharkhand also reporting significant number of malaria cases and deaths. Gandhiji believed in serving the poor and established the philosophy that efforts should reach the last person of the society. Since malaria predominates the rural population more, preventing and controlling this disease in a Gandhian way can provide significant outcomes.Filling of pits by soil and levelling so as to make it unsuitable for breeding of mosquitoes (Source: IDVC profile).EFFORTS TO COMBAT MALARIA IN GANDHIAN WAY THROUGH HOLISTIC COMMUNITY-BASED APPROACHES Bioenvironmental control approach Focal outbreaks of malaria were reported during the 1980s and new malaria paradigms were witnessed. The basic reasons were vector resistance to insecticide(s); pronounced exophilic vector behaviour; extensive vector breeding grounds created principally by the water resource development projects, urbanization and industrialization; change in parasite formula in favour of P. falciparum; resistance in P. falciparum to chloroquine and other anti-malarial drugs; and human resistance to chemical control of vectors. This led to the development of a new approach, i.e., bioenvironmental control strategy. Involvement of communities at village level for improving their lives was close to the heart of Mahatma Gandhi. In 1983, the Malaria Research Centre (renamed as National Institute of Malaria Research in 2005), launched a study on the bioenvironmental control of malaria in Nadiad taluka in Kheda district, Gujarat, involving communities at village level, environmental management, biological control, health education and intersectoral coordination, etc. The successful control of larval stages of mosquitoes, reduction in the adult vector populations, coupled with early diagnosis, prompt treatment and creating awareness among the society showed significant impact on the curtailment of malaria transmission in large rural areas. When compared with the residual spraying of insecticides under the National Malaria Eradication Programme, the alternate strategy was found feasible, socially acceptable, cost effective and brought about environmental improvement and awareness in the rural areas. Based on the experience of community involvement for reducing mosquito menace as well as malaria in Kheda (Gujarat), the Integrated Disease Vector Control Project for control of mosquito vectors of malaria filariasis, etc., was launched in 1986 and this strategy was successfully replicated in different eco-epidemiological zones of the country like Haridwar, Shahjahanpur, Haldwani, Car Nicobar, Rourkela, Sonapur, Bangalore, Shankargah (Allahabad), Mandla (Madhya Pradesh) and Chennai by improving the environment as well as reducing the burden of malaria. The strategy involves the following elements: Source reduction: Filling and levelling stagnant water collections was undertaken at various field stations of MRC, which reduced the menace of mosquitoes and malaria. Use of EPS beads for preventing mosquito breeding: The easiest, cheapest and most environment-friendly method to control malaria is by preventing the mosquito from laying eggs. Expanded polystyrene (EPS) beads, available as hard transparent glass beads of thermocol with diameter 0.6 to 2.5 mm, were used in abandoned/unused wells or septic tanks for preventing mosquito breeding. These beads are inert and non-toxic, non-wettable and resistant to water. They were extensively used in a variety of places. They act as a physical barrier and prevent mosquitoes to lay eggs. Further, the immature stages under the layer of beads die of suffocation in few days and nearly no mosquitoes emerge from the habitat. Biological larvicides (Biocides): One of the safest and interesting methods in mosquito control is the use of biological agents that eat or destroy the larvae. Bacteria such as Bacillus sphaericus and Bacillus thuringiensis var israelensis were found effective larvicides in multicentric field trials undertaken by NIMR. However, they need to be reintroduced every 15 days at the rate of 250 gm/10 litre and sprayed at the rate of one litre for 50 linear metres. This approach is suitable for larval control in urban settings. Larvivorous fishes: Mosquito fish, or Gambusia affinis, was introduced in India in 1928. The fish eats mosquito larvae without causing harm to the environment. Gambusia fish are suitable for clean aquatic habitats like ponds, tanks and well, while another fish, Poecilia reticulata, commonly known as guppy fish, is suitable for polluted water. Aphanius dispar, a fish which can survive in salt water in areas of Kutchh, has also been found effective for control of larvae in domestic tanks. NIMR has demonstrated the control of mosquito population and malaria using larvivorous fish in various eco-epidemiological zones in the country, particularly in Karnataka and Gujarat. The size of aforesaid fish is small and can be introduced into all collections of water like wells, tanks, ponds and lakes, particularly in rural and peri-urban areas and in freshwater bodies in rural areas, and they can survive wide range of temperatures and salinity. This approach has been adopted by several states in the country including Assam.Application of expanded polystyrene beads in abandoned wells and Septic tanks (Source: IDVC profile).IGR compounds: Insect growth regulators are applied in aquatic habitats so as to prevent larvae and pupae of mosquitoes to develop completely, thus inhibiting the emergence of adult mosquitoes. At present, diflurobenzuron and pyreproxifen are being used as larvicides in urban areas by the National Vector Borne Disease Control Programme in the country. Better housing conditions Some kinds of houses also play an important role in providing suitable shelter for mosquitoes to rest. In rural areas, most of the houses are of mud/mud-plastered or thatched, which are preferred by the mosquitoes as they provide suitable temperature and humidity.(a) Type of houses prevalent in Tribal areas (suitable for resting of mosquitoes); (b) Cement plastered house not preferable for resting of mosquitoes.Houses in the 1800s were made of mud, known as ‘kuccha houses’, the drainage system was poor, open water flow and its aggregation was common. Houses were generally built near ponds and lakes, where mosquito breeding was profound and host availability was easy for the mosquitoes taking a blood meal. These were some of the major reasons for increased malaria cases in that era. Gandhiji at that time emphasized on cleanliness and proper water storage and its use, describing which he said, “In Bengal almost every house has a kaccha tank attached to it. As a rule, the water of these tanks is unfit for drinking purpose,” as all these places were ideal for mosquito breeding. He stated in his book Key to Health about houses, “The choice of the country does not always lie in our hands but the choice of a suitable house in a suitable locality does rest with us till some extent. The general rule should be to live in a locality which is not too congested and insist upon the house being well lighted and well ventilated.” There is lot of improvement in the country from the point of view of houses, as in rural areas also they are being constructed on the pattern of the urban, thus reducing the suitable resting places of anopheline mosquitoes. India has been undergoing rapid urbanization since independence. Now houses are made of cement, known as ‘pucca houses’. Linking environmental management with livelihood of communities In order to link the vector control with sources of livelihood as a sustainable model, MRC (now NIMR) also demonstrated composite fish culture, i.e., culturing edible fishes (Rohu, catla, Mrigal) along with larvivorous fish (like Gambusia, Guppy), so that along with vector control through Guppy & Gambusia, the communities will get income by culturing edible fishes. Similarly, after filling and levelling the breeding grounds of mosquitoes, the levelled land was used for raising a nursery (as demonstrated by MRC in Haldwani (Nainital district, Uttarakhand), Bangalore (Karnataka) and Nadiad (Gujarat). “I will not congratulate you, if you tell me that you have distributed thousand quinine pills, go there with spades and shovels, fill up stagnant pools, see to the drainage, see that their wells are properly dredged and their tank is not contaminated… you must teach them sanitation and hygiene, which alone can prevent malaria…” – M.K. Gandhi Improving the quality of life The tribal communities living in forest and inaccessible areas bear the major burden of malaria in India. Due to lack of proper houses, they cannot protect themselves from the bites of mosquitoes. With research and development, Insecticide Treated Bed Nets and even Long Lasting Insecticidal Nets are being provided free to the communities in high malaria-endemic areas like Jharkhand, Chhattisgarh, Odisha and north-eastern states in the country since 1995. With the distribution of mosquito nets, not only did the community get protection from the bites of mosquitoes and a reduction in malaria burden, but also the quality of life has improved by getting relief from the nuisance of mosquitoes without harming the environment.(a) Release of larvivorous fishes in breeding sites; (b) Edible fishes being cultured as source of livelihood (Source: IDVC profile); (c) Plantation in Bangalore after filling and leveling marshy land (Source: IDVC profile).Herbal products as antimalarials or repellents The bark of the cinchona tree was used by Indian tribes since the 17th century; it is now known as quinine, an antimalarial drug. Even Gandhiji, once when down with malaria, took quinine and recovered. In China, during the 2nd century BC, the Qinghao plant (Artemisia annua) was described in the medical treatise. The active ingredient of Qinghao, known as artemisinin, was isolated by Chinese scientists in 1971. Derivatives of this extract, known collectively as artemisinins, are being used today as artemisinin-based combination therapy, which is the frontline anti-malarial drug these days. Pyrethrum extract (2 per cent) derived from the flowers of Chrysanthemum cinerariaefolium is an effective knock-down repellent being used by communities for the prevention of bites from mosquitoes. Health education/awakening masses/healthy practices: “Mankind is notoriously too dense to read the signs that God sends from time to time. We require drums to be beaten into our ears, before we would wake from our trance and hear the warning and see that to lose oneself in all is the only way to find oneself.” – M.K. Gandhi. Prevention is always better than cure. Health education is an important tool for creating awareness within society for inculcating good habits as well as to disseminate the findings of the outcome of research that may help in empowering communities to take care of themselves for the prevention of mosquito bites. Health camps, demonstrations, door-to-door visits, group discussions and involvement of students were part of the campaign. Youth clubs, women groups and others were also included in MRC activities. MRC (now NIMR) imparted health education to communities (students, nurses, farmers and engineers, etc.) about preventive measures like source reduction of mosquito-breeding, preventing mosquito-breeding in houses by cleaning/changing water weekly of the mud pots, tanks, overhead tanks, coolers, flower pots, etc., or put fishes, use mosquito nets to prevent bites, etc., at various locations in the country so as to implement bioenvironmental control of malaria. Messages of cleanliness were written on houses in the villages, so that they did not let the water stagnate for mosquito breeding. Key to Health, written by Gandhiji, may be a useful guide, particularly in rural areas, for adopting the simplest means for better health.Distribution of insecticide treated nets to community in Tribal area of Odisha.Imparting health education including cleanliness to community by MRC staff (Source: IDVC profile).ICMR-National Institute of Malaria Research, New Delhi.Gandhiji said, “The future depends on what you do today.” The foremost task to be done is to prevent the proliferation of the vectors by curbing their breeding sites. From the learning of the past it can be concluded that nipping the evil in the bud is the best solution even for the control of malaria or other mosquito-borne diseases like filariasis, dengue and chikungunya. Bioenvironmental approach of malaria control follows the Gandhian way of life and improves the life of communities at the village level with their active involvement. Even the basic tenets of the present-day Swachh Bharat Abhiyan, was translated into action by MRC (NIMR) way back in 1983. Artemisinin and quinine, which are the potent antimalarial drugs being used, are basically derived from plants. Our reliance on chemical insecticides should be very minimal. Cleanliness in and around houses, reducing the breeding habitats of mosquitoes, making the environment clean and healthy, preventing mosquito bites by using Long-Lasting Nets, linking income-generating schemes associated with mosquito control, viz. fish culture, raising nurseries with active involvement of communities are sustainable approaches to control malaria and will be a tribute to our father of the nation, Mahatma Gandhi. FINANCIAL SUPPORT & SPONSORSHIP: None CONFLICTS OF INTEREST: None