CESAR CHELALA
Disease from Nepal casts global dark cloud
KATHMANDU, Nepal
Although 90 percent of cases occur in Bangladesh, India, Nepal and Sudan, it has also been reported in 12 veterans of the Gulf War, who apparently contracted the disease while in Saudi Arabia. It has also been reported in Nicaragua, Honduras and El Salvador. Cases of leishmaniasis have also been reported in Texas. Kala azar is produced by infection with a parasite transmitted by the sandfly which both in India and Nepal has man as its reservoir. Kala azar is not uniformly distributed in the affected areas. It is normally present in areas of drought, famine, and densely populated villages with poor or no sanitation. Kala azar had been reported in India in 1824, from where it spread to Bangladesh and Nepal. In Nepal it was first reported in 1980. The DDT used in India by the National Malaria Eradication Program in the 1940s ravaged the sandfly population and interrupted the transmission of Kala azar. By the mid-1950s no new cases of Kala azar had been recorded in India, and in the middle 1960s Kala azar had become an almost forgotten disease in that country. However, when the national malaria campaign was interrupted, Kala azar reappeared in 1970 in the Indian village of Vaishali, in Bihar State. In the late 1970s, Kala azar crossed the river and appeared in Bangladesh, and shortly afterwards entered the Terai, the agricultural area in Nepal bordering Bihar State. Dr. Panduka Wijeyaratne, the resident adviser for the Environmental Health Project in Nepal (funded by USAID) is an expert on Kala azar. For the past several years, this project has carried out a series of actions aimed at reducing the threat of this disease. When I recently met him in Kathmandu, he said, "What we have already seen is only the tip of the iceberg, because below are many asymptomatic cases, some of which will become symptomatic, particularly among the poor." Kala azar is a good example of a bad situation, a disease that affects those of low socio-economic level in households where hygiene and sanitation are poor, circumstances that favor the spreading and multiplication of the sandfly that carries the disease. The treatment of the disease cannot ignore that globalization and trade, combined with increasing socio-economic disparities has led to increased international migration. India, Nepal, and Bangladesh are examples of countries with a porous border and frequent migration of population. Migrants are particularly vulnerable populations, and their movement across borders entails risks for the propagation of communicable diseases and infections such as HIV/AIDS, tuberculosis, malaria and Kala azar. An oral drug, miltefosine, currently being tested at the B.P. Koirala Institute of Health Sciences in Dharan, Nepal, offers hope to replace the painful injectable treatments that have been used so far. I asked Dr. Vijay Kumar Singh, a senior physician at Janakpur Zonal Hospital, if Kala azar could be controlled and eventually eliminated. "Yes, it can," he said to me, "But we have to think about a long term, 10-year effort. "What is necessary is a complementary set of activities including early detection at community level, prompt treatment, regular follow-up and completion of treatment, synchronization of activities between India and Nepal, and continuing political will."
Dr. Cesar Chelala is a public health consultant and a writer on human rights issues. © Copyright 2004 Globe Newspaper Company.
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