Long before the British colonised India, malaria was a serious problem for the country, imposing enormous economic costs and a great deal of human misery. Malaria epidemics occurred throughout India with varying intensity. In 1852, one malaria epidemic wiped out the entire village of Ula and then spread across the Bhagirathi River to Hooghly and continued to devastate populations for many years in Burdwan. The development of the Indian railways under the British administration contributed to the spread of malaria. While the construction of railway embankments provided a number of breeding sites for the malaria vectors, the labourers probably introduced different strains of the parasite to the areas in which they worked. The city of Bombay suffered greatly from malaria epidemics. The construction of railroads or bridges were often associated with increases in malaria, probably due to imported labour from malarious areas. There were significant outbreaks of malaria during the construction of the Colaba causeway between 1821 and 1841 and during the construction of Alexander Dock and Hughes Dry Dock. Malaria epidemics in the Punjab and Bengal both show a startlingly high morbidity and mortality. In the early 1920s, Bengal suffered a severe malaria epidemic which resulted in over 730 000 deaths in 1921 alone. Thereafter, the number of deaths from malaria slowly decreased to within 300 to 400 000 per annum. During the Second World War however malaria deaths rose again, particularly in 1943, when Bengal recorded over 680 000 deaths and in 1944 when there were an appalling 763 220 deaths from the disease. Although quinine was available at the time, its supply was probably inadequate and patients did not seek treatment on time.
On the other, some of the great successes in controlling the disease were also achieved in India. Formal malaria control programmes were started under British colonial rule and continued after Indian Independence in 1946. Early malaria control efforts invloved removal of breeding sites and later used chemicals such as the larvicides Paris green and kerosene. One of the first formal operations to control the disease was at at Mian Mir, near the city of Lahore (now in Pakistan). Mian Mir had an intricate system of irrigation canals which provided excellent breeding grounds for the vectors. The malariologists Drs. J.W.W. Stephens and S.R. Christophers, who had worked with Sir Ronald Ross in Freetown, Sierra Leone earlier, arrived at Mian Mir in 1901 with ambitious plans to remove all the breeding sites, evacuate the infected people and administer quinine as both a curative and preventative measure. Their programme developed into a massive effort, with between four and five hundred soldiers set to work full time at filling in the irrigation canals. The programme of constantly filling in ditches and removing puddles and any other potential breeding site continued until 1909. During 1909 there was a serious malaria epidemic, as there was in 1908 throughout the Punjab, and the courageous, but ultimately useless control programme was abandoned.
Indian Medical Service (IMS) and Malaria
The diseases endemic to India provided a rich field for research and the work of some of the IMS officers led to landmark discoveries. The foundation was laid by Surgeon-Major Dempster in 1845 with his work on the spleen rate as a reliable guide to the incidence of malaria. Major general Ronald Ross carried forward this work with distinction. He identified the mosquito as carrier of the malarial parasite in 1897-99. He was awarded the Nobel Prize in 1902 and knighted in 1911 in recognition of his outstanding contribution. Sir Samuel Rickard Christophers, who directed the Central Malarial Bureau from 1919 to 1924, supplemented Ross’s work. Further work was done by John Alexander Sinton, when he was the Director of Malarial Survey of India from 1927-38. In 1948, Henry Edward Shortt demonstrated the tissue phases of P. vivax malarial parasite for the first time.
Larviciding operations were also conducted at Bombay, Jhansi, Poona, Meerut, Secunderabad and all other military posts. In 1917, the Bengal Nagpur Railway and the East India Railways formed a separate malaria control organisation, specifically to control the disease in and around stations. National Railways managed to dramatically reduce the incidence of malaria among its staff though a comprehensive larviciding programme. Similar larviciding and breeding pool removal programmes were undertaken during the 1920s in the tea plantations of Assam and in Mysore by the Rockefeller Foundation. In 1927 the Central Malaria Bureau was expanded and renamed as the Malaria Survey of India. The first reported aerial spraying of Paris Green was in 1937. In 1938, pyrethrum was first used in malaria control in Delhi. The Rockefeller Foundation began using pyrethrum sprays experimentally in India to great success. The use of pyrethrum was then expanded to Assam by Dr. D. K. Viswanathan in 1942. However, all these interventions were unable to sustain the control of the disease. Vast breeding , colossal numbers of malaria vectors, limited effectiveness of pyrethrum sprays in houses and cattle sheds against the An. culicifacies vector, but not against An. fluviatilis and An. minimus were some of the causes for this setback.
DDT was first used in India by the armed forces in 1944 for the control of malaria and other vector borne diseases. In 1945, DDT was made available for civilian use in Bombay to control malaria and produced some remarkable results within a very short period. On 1st July 1945, the first civilian home was sprayed in India with a 5% solution of DDT mixed in kerosene. In 1946, pilot schemes using DDT were set up in several areas, including Karnataka, Maharashtra, West Bengal and Assam. Between 1948 and 1952 the WHO set up DDT demonstration teams in Uttar Pradesh, Rayagada, Wynad and Malnad. Use of DDT not only helped in the control of mosquitoes and malaria, but also improved the life expectancy. After the spraying in the Kanara district, the population began to grow because of a decrease in the death rate. Prior to DDT being used, the district reported an average of 50,000 malaria cases every year, which was reduced by around 97% to only 1,500 cases after DDT was introduced. The project was also blessed by Mahatma Gandhi.
During 1949, it is estimated that over 6 million people in Bombay were protected from malaria through the use of DDT and that at least half a million cases of malaria were prevented. In the early 1950s India’s population was estimated to be around 360 million and every year around 75 million people suffered from malaria and approximately 800,000 died from the disease.
Usefulness of DDT prompted the launch of the National Malaria Control Programme (NMCP) in 1953. The control programme first set out to control the disease in the endemic and hyperendemic areas with 125 control units. Each of these control units consisted of between 130 and 275 men and was to protect approximately 1 million people each. By 1958, the malaria control programme had been increased to protect at least 165 million people from the disease with 160 control units. The programme saw tremendous impact and the annual number of cases came down to 49151 by 1961. With this success, the programme was renamed as National Malaria Eradication Program (NMEP) in 1958 with a belief that malaria could be eradicated in seven to nine years. On the contrary, malaria began to re-emerge in 1965 to reach well over 1 million in 1971. One of the major problems with the eradication programme was that the supervisors could not manage to inspect all of the buildings that had been sprayed. There was a decline in the morale of the spray men and inspectors. With the declining number of cases, complacency set in among spray workers as well as the general population, as people turned the sprayers away. With the incomplete spraying operations, by 1959, resistance to DDT began to develop in certain areas and added to the problem. Furthermore, malaria cases were not treated properly.
With increase in malaria cases in urban areas, The Urban Malaria Scheme (UMS) was launched in 1971 with the objective of controlling malaria by reducing the vector population in the urban areas through recurrent anti larval measures and detection and treatment of cases through the existing health care services. Passive surveillance (case detection and treatment) and anti-larval measures are the main components of UMS strategy.
The number of malaria cases rose gradually and consistently with a peak of 6.47 million cases in 1976. With this, the focus was again shifted to control of malaria and in 1977 the Modified Plan of Operation (MPO) was launched which also comprised the P. falciparum Containment Programme (PfPC). The objectives of the MPO were
- Effective Control of Malaria to reduce Malaria Morbidity
- Prevent deaths due to Malaria
- Retention of the achievements gained.
Fever Treatment Deport and Drug Distribution Centers were established for distribution of chloroquine. Residual insecticide Spray was limited to areas with an API (Annual Parasite Index) above two. By 1985, the incidence rate stabilized at 2 million cases. However, many focal outbreaks, particularly of P. falciparum malaria and deaths from malaria have occurred throughout India since the 1990’s and large scale epidemics have been reported from eastern India and Western Rajasthan since 1994. Many of these are related to irrigation projects aided by global funding agencies.
The National Anti Malaria Programme (NAMP) was launched in 1995 as a Centrally Sponsored Scheme on 50:50 Cost Sharing Basis between the Centre and the State Govts. As the Central share, the Central Govt. provides drugs, insecticides and larvicides and also technical assistance/guidance as and when required by the State Govts. The State Govts. meet the operational cost including salary of the staff. However, considering the difficulties faced by the seven North-Eastern States namely Arunachal Pradesh, Assam, Manipur, Meghalaya, Mizoram, Nagaland and Tripura, 100% Central Assistance except salary of the staff, which is a Non-Plan activity, is being provided since December, 1994. The Union Territories without Legislatures are also covered under 100% Central Assistance. An Enhanced Malaria Control Project with World Bank support is being implemented since September, 1997 covering a population of around 62.2 million in 1045 PHCs in 100 predominantly P.falciparum malaria endemic and tribal dominated districts in the peninsular States namely Andhra Pradesh, Bihar/Jharkhand, Gujarat, Madhya Pradesh/Chattisgarh, Maharashtra, Orissa and Rajasthan. The project lays emphasis on Early diagnosis and prompt treatment; selective vector control, eco-friendly methods like introduction of medicated mosquito nets (MMNs), larvivorus fishes, bio-larvicides etc.; epidemic planning and rapid response including inter-sectoral coordination and institutional and human resources development through training/reorientation training; strengthening management Information System (MIS), Information, Education and Communication (IEC) and operational research. It also aims to cover the most problematic areas and also has the flexibility to divert resources to any needy areas in the country in case of any outbreak of malaria.
In 2004, the integrated National Vector Borne Disease Control Programme (NVBDCP) for the prevention and control of vector borne diseases i.e. Malaria, Dengue, Lymphatic Filariasis, Kala-azar and Japanese Encephalitis has been launched and it has been changed to Enhanced Vector Borne Disease Control Programme (EVBDCP) with the World Bank support. [See NVBDCP website; See World Bank Site]
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