A Leader’s Fight Against Malaria in Kolkata, India

The municipal corporation of an unplanned overcrowded city can achieve a lot in terms of prevention and control of malaria provided there is a strong political will. Atin Ghosh, Member of the Mayorin-Council (Health) of Kolkata Municipal Corporation (KMC), has, by way of getting himself constantly involved in planning and implementing various strategies needed to wage a real war against this very mosquito-borne ailment, proved this impeccable. My personal feeling is that many political leaders around the country, who have traditionally been keeping themselves aloof from looking after any mosquito-borne disease control programme in their constituencies, will learn a lesson from this leader of Kolkata and change their mindset.


Introduction
The municipal corporation of an unplanned overcrowded city can achieve a lot in terms of prevention and control of malaria provided there is a strong political will. Atin Ghosh, Member of the Mayorin-Council (Health) of Kolkata Municipal Corporation (KMC), has, by way of getting himself constantly involved in planning and implementing various strategies needed to wage a real war against this very mosquito-borne ailment, proved this impeccable. My personal feeling is that many political leaders around the country, who have traditionally been keeping themselves aloof from looking after any mosquito-borne disease control programme in their constituencies, will learn a lesson from this leader of Kolkata and change their mindset.
In a country like India, where mosquito control is still considered a lowly task, Atin Ghosh, otherwise a proactive popular leader of Trinamool Congress party, has stood against the detrimental flow and taken various initiatives on his own to change the dispiriting malaria scenario of Kolkata. This man, to me, is a trend-setter. A noble job, which was supposed to be done by the medical fraternity of KMC, has been done by a non-medical political leader. Initiatives taken by him during 2010 to 2012 and the quantum of success achieved by KMC in terms of prevention of malaria are reported in this communication.

Study Area
The city of Kolkata is the cultural capital of India. It is situated by the side of the River Hooghly. The city spreads over an area of 206.2 sq km and is inhabited by 45, 67,535 people, as per the Census of 2011. The KMC area is divided into 15 boroughs comprising 144 wards. The city's daily floating population is around 6 million. Quantity of potable water supplied by the KMC per day is 300 Million Gallons (MG). Raw water to the tune of 80 MG is also supplied by KMC per day. Potable water to the tune of 20 MG is supplied by tube-well daily. Frequency of water supply is 8 hours a day for a week (on an average). The city's total daily consumption of water is 296 MG. There are 1236 registered slums and nearly 34% of the city's population live in slum areas. Water storage practice among people in some places is rampant as the water supply in these areas is far from adequate. Housing complexes, apartments, high rises, shopping malls and other business establishments are coming up at an alarming pace. And the city is fast expanding vertically. Free primary health care facilities to the city-dwellers are provided by the health department of KMC through its 132 ward health units. Malaria is an age-old public health problem in this metropolis.

Climate of Kolkata
Three meteorologically distinct seasons-the summer, rainy and winter-characterise the climate of Kolkata City. The summer season here generally begins early in March and extends at least to the end of May or the beginning of June. There are occasional showers of rain during this period. The rainy season starts in June or July and ends by the middle of October. During this time, water is most plentiful. The winter season commences in November and lasts till February. There is very little or no rain during this period. The average monthly temperature here varies from 19.8°C in January to 30.9°C in May. The variation of the average monthly relative humidity is from 68.1% in January to 83.6% in August. Annual rainfall is 1400-2300 mm.

Antimalaria Initiatives Taken by Atin Ghosh in 2010-2012
After taking over the charge of the health department of KMC as an MMIC in June 2010 at the behest of Ms Mamata Banerjee, Hon'ble Chief Minister of West Bengal, Atin Ghosh took the following unprecedented initiatives to prevent and control malaria and worked with clockwork efficiency to implement them taking assistance of some proactive officials of his department.

Listing of high-risk areas
Based on the previous 3 year's data, a list of 52 wards requiring greater antimalaria activities in 2010 was prepared following the advice of Atin Ghosh.

Joint drive for source reduction
A weekly joint drive involving the personnel of health department and some other departments of KMC such as Water Supply, Building, Drainage & Sewerage, Solid Waste Management and Lighting was mounted in each and every KMC ward every year during the period of high malaria transmission between July and November. The progress of such drive was reviewed by Atin Ghosh himself at weekly intervals. The drive proved extremely effective in destroying mosquito breeding sites at various places around the city, including under-construction buildings and hospitals.

Distribution of multicoloured multilingual leaflets
In the field of mass awareness-raising campaigns through leaflets, Atin Ghosh brought in a phenomenal change. Prior to his joining KMC as the MMIC, the health department used to print unattractive leaflets (all in black and white) every year to disseminate information about the do's and don'ts for prevention of malaria. Mosquito control staff of the department used to distribute those leaflets among the people at random. People whose mother tongue was English could not read the leaflets printed in Bengali. Similarly, Bengali-knowing people could not read the leaflet printed in English. Atin Ghosh thought about it very seriously and asked his department to prepare multicoloured leaflets each containing the same messages printed in four different languages-English, Bengali, Hindi and Urdu. This helped people from every sector understand the KMC's messages quite easily. And needless to mention, the initiative was immensely appreciated by numerous people around the city. In all 15, 00,000 leaflets were distributed in 2010-2012 @ 5, 00,000 leaflets per year. Through the leaflets, these three important antimalaria messages, each printed in the chronological order of Bengali, Hindi, Urdu and English languages under the caption "Mosquito is bearer of diseases. Three tips for survival", were disseminated to the people: 1. If you suddenly catch fever, get your blood tested immediately. Malaria clinics of KMC are located very near to your residence. 2. Don't store water in any open container. 3. Use mosquito nets.

Propaganda through TV and Radios
To launch a high-voltage mass awareness campaign against mosquitoes and malaria, a beautiful first-of-its kind Bengali song was written by a noted lyricist of the city (Chandril Bhattacharya) and its music was composed by a well-known music director (Joy Sarkar). Sung by four renowned singers of Kolkata (Lopamudra, Raghav, Rupankar and Shubhamita), the song was recorded in August 2010. A music audio CD and a video CD of the song were released by the Hon'ble Chairman of KMC in September 2010. These CDs were then distributed among different ward councillors of KMC, journalists, local clubs, MPs, MLAs and many other distinguished persons. Secretaries of different puja committees across the city too were given these CDs for playing in their puja pandals during all the four days of the Durga Puja (Hindu festival).
The music audio CD containing the aforesaid song (of 80-second duration) was played on-air for 8 times a day for 1-2 months in every year during 2010 to 2012 through 9 FM channels. Similarly, a video CD of the song was played on 9-11 popular TV channels for one month in every year during 2010 to 2012, spending a total of $US534, 188. The health department of KMC had never ever done such a campaign before.

Organising health camps for the poor
To cater to the people's need for an early diagnosis and prompt treatment of malaria, treatment of common minor ailments and their awareness about malaria, Health Camps (12-19) adjacent to slum areas of the city were organised every year in September-October.

Publicity through auto-branding
Flex boards specifying do's and don'ts for prevention of malaria were put up on 4000-5000 hired auto-rickshaws and they plied on different routes covering all the wards of KMC in September-October every year during 2010 to 2012. Messages sent out through autobranding included these: 1. Get your blood tested immediately if you catch a bout of sudden fever. 2. Don't store water in any open container. 3. Don't take aspirin/ibuprofen type of medicine to get rid of the fever. 4. Sleep under a mosquito net. These messages were propagated in three languages-Bengali, Hindi and Urdu. The campaign proved effective.

Campaign using audio and video mobile vans
A two-month long campaign using 6 audio and video mobile vans was mounted in October 2010. The vans covered all the 52 high-risk malarious wards of the city and the CDs (both audio and video) were played to make people aware of the do's and don'ts for prevention of the disease. The campaign continued till November. Such campaign could not be launched in 2011 and 2012 due to funds crunch.

Distribution of multicoloured booklets among schoolchildren
Schoolchildren constitute the most sensitive part of our society. Hence their awareness about mosquito-borne diseases is very essential. Having realised this, Mr Ghosh caused to publish 3,25,000 multicoloured booklets in four different languages-1,50,000 Bengali, 1,00,000 English, 50,000 Hindi and 25,000 Urdu-at a cost of $US164,529.9 and distributed them among the students of 701 schools across the city. Neither had any civic body nor any state health authority ever brought out such booklets for school children in India.

Making mosquito control staff to render extra-hour service
Leaves of all mosquito control staff were cancelled. They worked on all holidays, including Durga Puja holidays and Sundays, for a period of three consecutive months-September, October and November. Such arrangement was made only in 2010 since the problem of malaria was grave. The initiative yielded notable impact.

Formation of rapid action teams
As in other big cities of India, in Kolkata too, Anopheles stephensi is the main transmitter of malaria [1] and this mosquito breeds mostly in fresh water collections in and around human-dwellings [2] Unless breeding sources of this malaria-bearing species are detected and destroyed, preventing the spread of the disease among the city-dwellers of Kolkata is literally not possible. Regrettably, controlling officials of the health department of KMC had never understood these basic facts. Let me correct myself-these officers had rather never wanted to understand these basic facts. And hence they were highly reluctant to run vector control activities under the control of entomologists. Mr Ghosh made a breakthrough. Vector control was his priority. So, he gave free hand to entomologists (4 in all) and constituted 4 Rapid Action Teams (RATs) in December 2010 for detection and destruction of mosquito breeding sources by deploying 50 trained field workers through an agency against payment of $US1,038.4 per year to each worker.
The idea of building an in-house monitoring system for vector control by constituting RATs was absolutely new in India and this initiative was profusely appreciated by the Directorate of the National Vector Borne Disease Control Programme (NVBDCP), the only agency of the Government of India that formulates and monitors vector-borne disease control strategies in different states of the country. These RATs worked in all high-risk malarious wards of KMC under the technical guidance of entomologists. From December 2010 to December 2012, the 4 RATs made house-to-house checks for mosquito larvae in all high-risk wards of the city once a month, @100-200 houses per ward, to estimate the prevalence of the breeding sources of An. stephensi. Collection of information was carried on as per the format prescribed by the entomologists. Container index of An. stephensi (% of containers positive for An. stephensi larvae) was used as a tool for estimating the magnitude of the larval prevalence of this mosquito in the wards brought under scanner.

Establishment of a mosquito research laboratory
Unlike all his predecessors, Mr Ghosh realised the need for studying vector mosquitoes in Kolkata for planning scientific strategies so needed to win the battle against them. Hence he decided to create facilities for entomologist to undertake research on mosquitoes. He discussed the issue with the Mayor, got a go-ahead from him and set up a small research laboratory in August 2010, incurring funds to the tune of $US 6410.2 from the exchequer of KMC. This is a first-of-its kind laboratory in eastern India. Needless to say, a new era of mosquito control activities ushered in following the establishment of this laboratory. As an entomologist, I feel delighted and honoured when doctors and mosquito control workers from non-KMC organisations come to our laboratory to learn about mosquito identification [3]. Even the harsh critics will not refrain from appreciating the entomologists of KMC who, in the past 3 years, have published their research papers in 3 medical journals of international repute-Transactions of the Royal Society of Tropical Medicine and Hygiene, Dengue Bulletin of the World Health Organisation [4] and the Journal of Vector-borne Diseases [5].

Early diagnosis and complete treatment (EDCT)
EDCT is one of the key strategies of the National Malaria Control Programme. To implement this policy, the health department of KMC has so far established 140 malaria clinics in different places across the city. Blood samples of all clinically suspected cases of malaria were examined at these clinics, mainly by microscopy, and the confirmed cases of malaria were treated in accordance with the National Drug Policy on Malaria. Since Plasmodium falciparum in Kolkata has grown resistant to chloroquine, all patients of falciparum malaria were treated exclusively with ACT (Artimisinine Combined Therapy) and primaquine after being diagnosed at the clinics of KMC.

Source elimination drive right from January
In Kolkata, uncovered overhead water tanks, seepage water, water tanks built for soaking bricks at construction sites, deserted fountains, basement water tanks and other such sites act as the main breeding sources of An. stephensi during the winter season. These sources are called the mother foci of An. stephensi. The best way of controlling An. stephensi population in Kolkata is the elimination of its mother foci from the city's environment. After having a series of talks with experts, Mr Ghosh asked his department to undertake a city-wide drive for destruction of the breeding sources of this mosquito right from the beginning of the year against the earlier practice of mounting source elimination drive during the rainy season and the times thereafter. And so did the department from January 2011.

Larvicidal spray
There are 1350 Field Workers in the health department of KMC.

Fever surveillance
Active fever surveillance was undertaken in all high-risk wards during the peak season of malaria transmission (July-November) every year in 2010-2012. As many as 850 honorary health workers did the job as per the order of the MMIC (Health).

Use of larvivorous fish
Efforts to destroy mosquito larvae by using guppy fish (Poecilia reticulata) were made as and when required, especially in places where larvicidal spray was not feasible. To ensure ready availability of guppy fish, in-house fish production facilities by establishing hatcheries in different areas of the city were developed by the department on Mr Ghosh insistence by the MMIC (Health).

Results
In all 3, 55,293 patients visited the KMC-run malaria clinics with complaints of fever during 2010 get their blood tested for malaria. Blood samples drawn from these patients were examined by microscopy. Of them, 96,693 samples were found positive for malaria ( Table 1)

Discussion
Malaria is a biblical scourge to the people of Kolkata. Nearly 50% of the 1200 companions of Job Charnock, who was until recently considered to be the founder of Kolkata City, reportedly died of malaria in a span of only one year after their landing in the city back in 1690 [6].
Until the mid-1950 s, the ravages caused by malaria were terrible. Then with the implementation of the National Malaria Eradication Programme (NMEP) based on indoor residual spray with DDT, much relief followed. Unfortunately, in the mid-1970s, as in many other parts of the country, in Kolkata too, malaria swayed back into the scenario and its incidence, more particularly the cases of falciparum malaria, started spiralling up. Officially, the average annual incidence of falciparum malaria was 0.09% (1/1404) in the 1970s. It rose to 4.1% in the 1980s (610/14707). And in the 1990s, the figure shot up to a staggering 18.5% (7820/42118) [7].
In 1995, besides 18 other cities of India, Kolkata too was declared as a high-risk malarious city by the Directorate of NVBDCP (erstwhile NMEP), Government of India [8] Fifty-two people died of malaria in this city during 1995. In 1996-1997, chloroquine-resistance of P. falciparum in the city was first reported by the Directorate of NMEP, [9] but the health officials of KMC, state health authorities, practising physicians of the city did not bothered about it. At some malaria clinics of KMC, treatment of Pf cases with quinine tablets was resorted to. In 2009, the health department of KMC tried to obtain ACT (Artimisinine Combined Therapy) from the Directorate of NVBDCP, but failed for some corrigible technical impediments. Finding no other alternative, the health department of KMC procured ACT from the local market and started using it through some of its clinics. But the religious use of ACT in treating cases of falciparum malaria through each and every malaria clinic of KMC began only after Mr Ghosh had become the MMIC (Health). Incidentally, he himself had to stay admitted at a nursing home for a couple of days for treatment after being afflicted with falciparum malaria about 15-16 years back. Perhaps this was why Mr Ghosh put in mammoth efforts to fight against this disease.
For implementing the national guidelines for treatment of falciparum malaria at all city-based hospitals and nursing homes too, Mr Ghosh took a personal initiative. He wrote letters to the health authorities of both the Government of India and the Government of West Bengal urging them to ensure treatment of Pf cases with ACT at each and every hospital, nursing homes and other non-KMC health establishments across the city. His endeavour yielded results. Use of ACT began everywhere.
As evident from Table 1 Situation improved and we all plunged into the realm of inaction. Antivector activities ran haphazardly. As a result, the number of malaria cases again rose to 51,266 in 2008, including 4 deaths.
The anti-malaria plan of KMC, under the guidance of Mr Ghosh, has, to say the least, achieved a sparkling success and lapped up commendable appraisal from the World Health Organization which said in an alert issued to travellers, "Risk of falciparum malaria and drug resistance in Kolkata is relatively lower than the other places of the state of West Bengal." [10].
The Directorate of NVBDCP too eventually lauded the KMC's efforts. In an Urban Malaria Review meeting held on 28-29 June in 2012 at the Directorate of NVBDCP, Govt. of India, the KMC's antimalaria programme undertaken in 2010-2011 was profusely appreciated by all the higher officials of the Directorate and other participants from around the country. Mr Ghosh was invited to the meeting to share his experience of steering antimalaria activities.
Pertinently, mosquito control in West Bengal has traditionally been looked after by doctors who know very little about the subject. Tangible initiative to recruit qualified entomologists so needed to plan and implement strategies for mosquito control is still not in sight. Atin Ghosh has shown a path which the other state health departments of the country ought to opt to walk down to improve the threadbare infrastructure. I would like to mention here that I don't have any intention of having a crack at the medical fraternity of India but the true scenario has to be brought to surface somehow or the other.