By Dr George Jacob
Kochi, Nov 22, 2021: The southern state of Kerala is supposedly the healthiest among the Indian states. This reputation comprises one of the reasons why Kerala is monikered “God’s own country.”
This is based on certain health indices which places Kerala on par with Scandinavian nations.
These indices are given below, with the rest of India figures in the brackets.
Maternal Mortality Rate 53.49/500,000 live births (178.35)
Infant Mortality Rate 7/1,000 live births (29.07)
Under-5 Mortality Rate 10/1,000 live births (36)
Average Life Expectancy at birth 77.28(70.77)
Birth Rate 14.1/1,000 population (17.64)
Death Rate 7.47/1,000 population (7.26)
Life Expectancy at birth for females 79.98(72.09)
However, not all is hunky dory for Kerala in recent times. Kerala has emerged a hotbed for communicable diseases leaving an indelible botch on her enviable health record.
At the time of writing, 13 students of Veterinary and Animal Sciences at Pookode in Kerala’s Wayanad district were infected with a lesser known Norovirus. They might have contracted the virus which causes diarrhea, vomiting, abdominal pain and fever while handling infected animals during their course. Norovirus spreads through contaminated food and water, person-to-person contact and fomites.
Keralites had also been at the receiving end of Nipah Viral infection spread by fruit-eating bats. The first outbreak in 2018 localized to Kozhikode and Malappuram districts claimed 17 lives. After that outbreak was effectively contained, a 23-year-old student was diagnosed with Nipah in Kochi on June 4, 2019. Though 300 people were placed under observation no further case was reported in that instant.
Recently, Nipah was reported in Kerala in September in Kozhikode, when a 12-year-old boy succumbed to it. Luckily 17 contacts of the boy tested negative. This outbreak was declared controlled after 140 close contacts tested negative and no more patients reported with Nipah.
Kerala’s share of communicable diseases does not end there.
Leptospirosis or rat fever is a zoonotic disease (that transmitted by animals) caused by a bacteria of the genus Leptospira, and transmitted through contact of abraded skin and mucous membrane with water or mud contaminated with urine of infected rodents.
Rat fever has been a major threat to Kerala with more than 1,000 cases reported annually, causing highest number of deaths among all communicable diseases in Kerala. The number of cases of rat fever and deaths caused by it in Kerala were 1821 and 104(5.7 percent), 1359 and 229(16.9 percent) in 2006 and 2007 respectively. Rat fever has seen steady increase in incidence and mortality from then on in Kerala.
Another villain in the list of Kerala’s share of communicable diseases is Dengue fever.
This is caused by a virus belonging to the Flaviviridae family, and is principally transmitted by Aedes Aegypti mosquito, that breeds in stagnant water. Kerala recorded highest number of dengue-related deaths (165) and the second highest number of cases in the country (21,993) after Tamil Nadu in 2017. This was the highest ever dengue-related fatality and cases reported in Kerala.
Kerala’s experience with Covid-19 proved to be an enigma to epidemiologists. The state’s tryst with Covid-19 commenced on January 30 2020, which was the first ever case in India.
Fresh from her spectacular success in taming Nipah, Kerala showcased stellar results initially on the Covid front too.
Kerala’s initial success was made possible by imaginative ‘Break the Chain’ campaign, stringent adherence to the SMS protocol, lockdown and quarantine. Kerala’s dream run with Covid-19 ended when she opened her borders to Non-Resident Keralites residing in other Indian states and Persian Gulf countries.
Kerala’s cases of Covid-19 skyrocketed to an extent where Kerala alone contributed more than 50 percent of India’s daily cases for 28 consecutive days between August 23 and September 19. As of September 19, 13 percent of Kerala’s 35 million population contracted the disease, the highest in any Indian state. Yet, Kerala’s Covid-19-related mortality rate at 0.5 deaths/100 confirmed cases was the least in India. This dreaded infection caused by the virus SARS-CoV2 spreads principally from person-to-person and through fomites.
Kerala turning a veritable hotbed for communicable diseases despite her overall superlative health standards is multifactorial:
• Kerala’s total area of 38,863 sq.km harbors a population of 31,838,619, with a population density of 819 persons/square kilometers, which is thrice the national average. Dense population favors spread of airborne communicable diseases such as Covid-19, Tuberculosis and influenza.
• Kerala’s lowland regions accounting for 10 percent of her total area runs along the coastline and embodies beaches, swamps and lagoons, besides backwaters, paddy fields and coconut plantations. Her abundant water bodies provide breeding ground for mosquitoes, which spread diseases like dengue, malaria, and Chikungunya.
• Among various crops grown in Kerala, cocoa and pineapple provide ideal breeding environs for Aedes Aegypti.
• Plastic is the most telling villain, confirming to global trends contributing to spread of communicable diseases. Kerala generates 480 tonnes of plastic waste/ day, with a family contributing 60 grams. Plastic waste includes carry bags, plastic bottles and caps, ice-cream cups and plastic-coated disposable utensils. Plastic, a bio non-degradable material form major chunk of waste strewn and littered most thoughtlessly in public places, empty plots and roadsides. Plastic form non-destructible crucibles that hold water, especially after rains and floods. Mosquitoes breed in these micro environs, adding to spread of mosquito-borne diseases. Plastic also clogs drains and canals adding to water stagnation and flooding, both favoring widespread breeding of mosquitoes.
• Inept waste management is another factor contributing significantly to communicable diseases. Waste remains uncollected well into the day in public places. Disposable plastic plates with food stuck to them attract rodents, which in turn lead to rodent-transmitted diseases like rat fever. Such waste also attract stray dogs and cats which lead to zoonotic diseases like rabies, as incidents of stray dogs attacking humans inflicting mortal wounds were commonplace at a time in Kerala.
• Kerala’s weather has turned vagarious in recent times. The state witnessed back-to-back floods in 2018, 2019 and 2021. Kerala’s two monsoons, the Southwest and Northeast recently have shown a tendency to bring in excess rain causing floods and inundation, which in turn lead to spurt in water-borne diseases viz; Cholera, dysentery, typhoid and hepatitis, along with mosquito-borne ones viz; malaria, dengue, chikungunya and other zoonotic ones like leptospirosis.
(Doctor George Jacob is a donsultant surgical gastroenterologist at Lakeshore hospital, Kochi.)