Healthy forests and healthy people – A problem of First among equals

Aphu was a young man in his twenties when he passed away. In the hinterland of India’s largest tiger reserve, few people keep track of their age, for nobody here registers them for social welfare, nor do they have a doctor who asks them their age to fill up a column on a case sheet. Aphu’s home was in Gandhigram, a remote tribal village in the state of Arunachal Pradesh in North-east India, where he lived a little more than 20 years. His village is surrounded on one side by one of India’s largest tiger reserves, Namdapha Tiger Reserve, and on the other are vast stretches of Myanmar’s Hukawng Valley Tiger Reserve, perhaps the world’s largest protected area spanning close to 6000 square kilometers.

Late last year, Aphu died. A healthy young man, he was among the people hired to carry luggage and supplies for a group of people. We were visiting the village to see how we could address their health care needs. Cystic fibrosis did not dry up his lungs. Neither was it any of those eponymous autosomal diseases that strike the young, of which we learn so much in medical school. These diseases were very interesting, with articles about them in journals describing correlations to genes with numbers like the latest version of MS Windows. They all had their “Disability adjusted Life Years”(DALYs) that were screaming out their importance to be taken up in any of the new programs that the State might decide to launch. But, these rare and publishable afflictions were not among those that Aphu was ever afflicted with. He died, quite simply, of malaria. Quite ironic, that a country with nuclear power still has anaemic mothers and malaria deaths!

I have been to Aphu’s village a few times with the wildlife scientists who work here. His village happens to be surrounded by one of the northernmost primary rainforests in the world. The place teems with biodiversity and the forests of Arunachal Pradesh have witnessed descriptions of a new species of bird and even a new primate, all in the past few years. Although, it is the tiger that has given this area its protected status, it is not for the tiger that this national park and many of the forests in Arunachal Pradesh are known. They are famous for their rich biodiversity including several endemic insects, butterflies, birds and plants. Such rainforests play a central role in wildlife conservation and climate change. However, climate change and global warming are distant issues for the Lisu and other tribal people living in and around these forests. Strangely, tigers aren’t.

In India today, there is a public debate on tiger deaths. Tigers and tribal people are being pitted against each other in conferences and in hallowed policy-making chambers. Co-existence of tigers and tribals is being questioned. In an environment where health care is financed literally out of people’s pockets, a tiger’s fate and people’s health can get intertwined easily. And hunting becomes a means of averting any unplanned and sudden catastrophic expenditure. It is invariably health costs that crop up in the category of unforeseen expenses. With poor access to primary health care or even to community health workers, people in such remote regions often find that hunting can finance their long journeys to towns. And it does not help matters that private providers with expensive secondary level care and irrational practices become the first line health providers for these people. The Lisus travel through about 150 km of thick forests interspersed with rivers often in spate, to reach ‘civilization’. From here, they take a 6 hour bus journey to reach a town where they invariably see a private provider. Roads, understandably are a bigger concern than chloroquine.

I work in an NGO in South India, with another indigenous tribal people, called the Soligas. The forests have shrunken around the Soligas, leaving a 540 sq. km area, still remaining, due to its legal protection by the State. The Soligas were semi-nomadic people, until they were forced to settle due in part to the shrinking forests and the legal protection accorded to their forests. They couldn’t hunt anymore. However, a doctor who settled in these hills 25 years ago, began to provide health care to them. He went further to education and livelihood, as just providing health care was helping their health! This NGO today provides health care, education and livelihood to these tribal people. Today, the elderly Soligas talk about how climate has changed. They do not question it and do not need evidence. They know it and also see how their forests are getting choked from the outside.

These two glaring examples from South India and Arunachal Pradesh in North-east India typify the problems faced by people living in and around forests in India. However, the key is in access to basic health care and livelihoods. Wildlife scientists today see this connection between people’s basic needs and their conservation ethic. In fact, it was a group of wildlife biologists that started a community health care program and an education initiative among the Lisus. I went there to train a group of tribal youth in basic health care. Among other things, I wanted these youth to be able to identify and institute treatment against malaria. It was indeed a satisfying experience for me, to see how wildlife biologists had looked beyond their paradigm of biodiversity conservation, and had looked for solutions outside ‘their box’. We, in health care, sadly are yet to make this connection. A glance at our curricula reveals the level of medicalisation that we undergo. A glance at our policy shows how fragmented and restricted it is.

Shrinking forests are an important reason for climate change, and so are empty forests; forests devoid of their biodiversity. While hunting empties forests in some places, it is firewood needs and fires in other places. It is after all people, who are to blame for this. People living in and around forest areas depend on them for their livelihood and daily needs. And when there are financial pressures for any of their needs, they turn to their resources – forests. Thus, they find themselves being the villains accelerating deforestation and emptying the forests. Isn’t this the same thing that our forefathers did, that we find ourselves in this position today? Can we blame them for being late in destroying their forests, just because, we thought of legal protection for it now, and we have climate change now! As population pressures and urbanization increase in India, rural and tribal India face a different problem; one of access – both physical and financial. It is time for health planners to consider the special needs and contextual factors affecting tribal
people and those living or affected by forests. It would be presumptuous to imagine that national programs for any of the diseases will change the situation with these people. Lisus or Soligas and for that matter any individual is not asking for malaria control programs or early cancer detection programs. They are asking for plain health care – financial and physical access to a person who can cure them of their illness and can help them live a healthier life. A malaria program for them is even lower in priority than a road or a source of livelihood, simply because, they have accepted malaria deaths as their destiny. It is perhaps time to think beyond programs and address health as a need in itself rather than health as a consequence of our programs.

Aphu died of malaria in his early 20s only because he was born in a place where climate change and the biodiversity mattered more than his life. In many areas the world over, where man-wildlife conflicts occur, the situation is similar. How are we going to prioritize between biodiversity conservation and people’s needs? Are our politicians and policy-makers even seeing this problem of ‘First among equals’? The global health research agenda needs to gear up to answer these difficult questions; questions that matter to people dying of malaria in this age, when in many countries, research is addressing carpal tunnel syndrome.

Bird flu – Birds edition

It’s an interesting puzzle, this bird flu. On one side, while birdwatchers are all disturbed about even the suggestion of wild bird culling as a control measure to prevent spread of bird flu by migratory birds, on the other hand, for the public health professionals, it is just among various available ‘vector-control’ measure…..kinda like control mosquitoes to prevent malaria. Who would listen if for whatever reason, ‘mosquito-rights’ activists want to prevent any such measure!!

Anyways, neither are there any mosquito-rights activists, nor are things as simple as taking a leaf from malaria vector control and applying it in bird flu. Understandably, things are much more complex than that. In two posts to two different groups, I have shared my opinions with both interest groups – birdwatchers and public health professionals…….here is the birds edition, and soon to come the public health edition.

Just a few comments of mine especially in view of several discussions that I have been witness to in course of my study here. I just share below some of my thoughts for the general reader and may be writing on topics way out of the purview of our discussion group in hope that many birdwatchers would be interested in topics related to bird flu – an interesting situation that calls for a lot of inter-disciplinary work and understanding of concepts in biology, epidemiology, public health and veterinary science.

Sudheendra’s mail and Krishna’s and Deepa’s subsequent replies about Avian flu bring up many issues on avian flu that are hardly being considered. Sudheendra rightly points out the serious economic consequences of mass culling being undertaken in response to ‘declared’ cases of the flu in Orissa and Bengal. Many of the people involved here are small poultry owners for whom livelihood is a much more proximate concern than an unheard ‘flu’.

Flu is definitely not something to be taken lightly. As Krishna points out, if the virus does ‘cross-over’ to humans, the chances are only among the animal handlers, and that is exactly where the public health authorities must focus. It is also to be noted that until recently bird-human infection was not yet reported and it was only spreading among birds. But, the worldwide panic is because IF there is such a mutation that enables the flu to spread among people, it could take up the pandemic proportions that the world has seen before.

The thing about flu is that it is clinically….well…so insignificant! Fever, feeling of weakness, body pain, red eyes are symptoms that dont get reported. MOre so in the health system landscape that India has with a zillion private clinics, quacks, traditional healers and disgruntled and frustrated public health system. The reports we are getting now are the ones we could detect.

Flu viruses have the uncanny ability of sweeping across the world bringing about widespread deaths and then, suddenly disappearing. This has happened many times before. The classical example quoted is that of the Swine Flu epidemic in the US which is supposed to have killed over 20 million people over 4 months just in the US! Of course, the pandemic was worldwide, but you
can get numbers only for the US, UK and some other countries which did have such systems. Over 200,000 people are supposed to have died in this pandemic in UK. It took more lives than in the First world war. And then, suddenly Swine Flu vanished into thin air. Poof! I say this to emphasize the point that flu is a very real danger. The reason why it flares up so suddenly is
attributed to mutations.

Influenza is caused by a virus which are comparable to “a bad xerox machine inside a protein cover”, the xerox machine in this case referring to its genetic material. I call it bad because it lacks a particular ‘proof-reading’ mechanism that other living things have and hence there are
no ‘errors’ when for example our own skin cells multiply in a healing wound. If our cells did not have a good way of keeping our genetic material intact during division, then we would all be doomed! But, for the virus this is quite an advantage, and hence through mechanisms called drifts and shifts, the virus keeps changing its protein clothing, which is what enables our immune system to identify them. So, how does the human immune system grapple with a virus that keeps changing its appearance……It cant!…which is why, HIV and many other such viruses pose a great threat for vaccines. We would have to keep making vaccines for every new dominant appearance (strain) of the virus. IN simple language what I spoke about here is recognized as Genetic drifts and Genetic shifts. Drifts are minor changes occuring in the protein coat of the virus that leads to failure of vaccines and sometimes, major catastrophes, such as the Spanish Influenza Pandemic in the spring of 1918 which is supposed to have killed anywhwere between 40-100 million people! Get ready for this one – The Spanish Flu strain was supposed to have been an avian virus that underwent a shift!

Coming back to avian flu, the present strain finds it very difficult to get transmitted from human to human. Still, over 300 worldwide deaths that have been reported today are mostly bird-human transmissions with a few rare ‘within family’ transmissions reported mostly again, within the family of the animal/poultry handlers. The virus strain causing the flu is called H5N1
which is the standard name for naming influenza viruses. H stands for one of the surface proteins on the virus that enables entry into cells, and N stands for an enzyme that enables the new virus particles to break out of the dying cell. Now, 4 sub-types of the avian flu virus are recognized. All
of them are deadly to birds, and can cause disease and death among humans. It is important to remember here that the virus presently is an AVIAN FLU virus and is being incidentally passed on to humans because of the way in which we have organized our poultry system! Wild birds, especially waterfowl are natural carriers of the virus, although, they are not as susceptible to
the disease as are the domestic birds. For eg. Russian vets are supposed to have drawn over 4000 samples of blood in Siberia with around 50 showing antibodies, which indicates active infection or past infection.

It is quite evident that migrant birds can carry these strains. But, it is important to note the following:

1) Birds carry several kinds of flu viruses and they have been doing so for zillions of years.

2) Wild birds themselves pose NO THREAT to any person directly. The only way is for them to pass on their infection to poultry birds, where the flu could spread like wildfire.

What we need to focus on is the situation within our poultry industry, handling of dead birds and a surveillance system that reports bird deaths in poultry houses. Moreover, awareness on this for animal handlers is extremely important. I find it quite ridiculous that may international bodies are calling for culling of wild birds. Such measures are not only scientifically untenable, they are also quite a schoolboy solution, I must say….a bit like trying to kill all mosquitoes to eradicate malaria!

What we must concentrate on is surveillance systems, awareness on animal handling and vaccine research. Prototypes of the vaccines are being reported. If the virus does acquire mutations that enable human-human transmission, it could definitely be catastrophic, else, it could just go away into the thin air like a million other strains of flu that we in the third world could never ever find document, let alone naming them after their surface proteins. India must’ve seen so many other previous outbreaks that were never documented.

Just a final word, Avian Flu is a disease that presents a lot of research opportunities. There could be many PhDs created. It creates good business opportunities, many patents, awards, paper presentations, conferences and well, sales of the vaccine will rake in millions…….it’s not the same
situation for diseases like Malaria, Kala-azar, Tuberculosis etc. which continue to kill millions of people across millennia….these are the neglected diseases that no one ever bothers about. There are no new vaccines being tried, and no new drug being developed for these diseases….there is
simply no ‘market’!!! An irony that avian flu gets so much attention.

Wonder how many of you got this far into my long rant at the end of a busy week here in cold, birdless Antwerp….most of the birds around my house are around where most of you are sitting. Who knows, maybe some of them carried the flu!!! I started the mail saying “…just a few comments”……

Some references for those who are interested:

Johnson, NP; Mueller, J (2002 Spring). “Updating the accounts: global
mortality of the 1918-1920 “Spanish” influenza pandemic.

J. D. Earn, J. Dushoff, S. A. Levin (2002). “Ecology and Evolution of the
Flu”. *Trends in Ecology and Evolution* 17: 334-340.

Bill Bryson (2003) A Short History of Nearly Everything. pp. 386-388

BR Hills – My home away from home….

My friend Sunil, once remarked that nostalgia is a sign of old age, and if that is what I am suffering from, may it be so……As I sit in my ill-lit room in Antwerp, eating microwave heated, yesterday cooked, lemon rice, I think about those wonderful days in the hills…..and my heard dances with BR Hills (No Daffodils there… 🙂

As you enter the sanctuary, you start with scrub jungle with regular sightings of Baybacked Shrikes and Peafowl. As you then pass the first waterhole on your right, if you dont see ‘party dudes’ from Mysore listening to Backstreet Boys, you will see sometimes Dholes. If the summer gets real bad, Elephants too, for this is quite a good lake.

As you ascend, you see the towns of Yelandur and nearby villages onyour right from the watchpost, as the road curves to the left. Now theforest slowly turns greener, and trees replace the shrubs. The Laughing Dove turns into the Spotted one. This is where you will see that the trees are all of the same height and one-storeyed almost like a plantation. But, this only indicates the result of ‘protection’, for this is the area of extension of the sanctuary and most of the trees here came up together once the hills got legal protection.

You continue walking up, and you will definitely see Gaurs if it is fairly late in the day. Most of the days, as I returned from my clinics at the foothills, I could see Garus, and on ‘good’ days, bears. Monitors are also seen sometimes. As you go up, you reach the Purani area, which is where the ‘Purani tiger’ frequently hangs around. Curiously, he is sighted more frequently by busloads of uninterested pilgrims, rather than our kinds! This guy can get quite nasty a little later in the year, post-december, when he starts lifting a cattle or two. In fact, one late evening, I saw this guy resting on a rock on a valley across, quite not bothering about us watching him!

You ascend up and you can really feel the air cooling down…..heres’ where the Drongos become smaller and shinier…we start seeing the Bronzed Drongo. The first of the Wagtails you start seeing, especially the Grey Wagtail, in the winters, all along the road! In fact, it is quite a pattern…once the Greys arrive, the Whites seem to go downstairs! And so, do the White-bellied Drongos which go further down..

After this of course, is the town of BR Hills with its own charm and beauty! If you continue down the road, as I see you have, the Drongos become racquet-tailed, the minivets turn scarlet and the Pigeons become green, emerald and imperial! I can go on and on..but, gotta stop somewhere, here goes…STOP……hmm…..getting old is fun!

Diclofenac and Vulture deaths – From naivity to reality

Diclofenac is one of the most commonly used Non-steroidal anti-inflammatories. Just to give you an idea of the magnitude, I take the human example. Although, I really dont know to what extend ‘human diclo cycle’ touches birds, as an example, it would be good. There are about 1600 odd government health centres in Karnataka – just one state. A govt. PHC on an average dispenses 30 tablets of diclo daily. That amounts to about 50000 tablets daily in Karnataka on ONE DAY!

The wonder of this drug is that it is much sought after for the various kinds of pains, most often, arthritic pain. Moreover, recent precription practices of doctors show a remarkable bias towards diclo as compared to traditional painkillers. But, most importantly, it is quite inexpensive when compared to many others.

Changing prescription practices among doctors is a sisyphean task! Trust me, public health professionals have been trying for ages to bring in rational and evidence-based drug use, but to no avail. Unless, safer, and more importantly, more economical alternatives to vets is proposed and ACTIVELY pushed the ground situation is not likely to change at all. And this pushing has to happen, NOT THROUGH conservation groups but through medical reps! Catch any medical
professional listening to conservation groups!

Of course, all this is assuming that Diclo truely is the reason for the ‘vulture decline’. I really dont know if it is safe to assume that banning diclo would be of any help in Africa at all! Is there evidence for this?

If the future of vulture in India rests in fact on the effectiveness of the ban on diclofenac, then God save the Vulture! If at all, the vultures do manage to fight back a few years after the ban, we can rest assured that diclofenac never was the reason anyways! Cos, rarely have we ever achieved any ban in reality. ( Go to the nearest pharmacy to purchase any of the following ‘banned drugs’ – Analgin, Cisapride, Droperidol, Furazolidone, Piperazine etc…)

The artist clarifies!

In the winter of 2004, from my abode in BR Hills, where I was dwelling then, I had all the time in the world to philosophize! I was writing about the artist-scientist ‘polarities’ and one of my senior colleagues in BR Hills, responded to my turmoil by throwing some light. Stephen Jay Gould is a wonderful companion through such confusions on lonely nights…….I am myself quite surprised on what I have just said, but if you ever go to a place like Belgium, after living for a few years in a forest in the Western Ghats, you will know what I am saying!

There is some sort of light at the end of the tunnel. I have pasted below the reply of the ‘artist’ I referred to in my earlier mail. The artist here is the doctor I work with, and he has been ‘seeing’ birds for a coupla‘ decades now. I presume his mail will more appropriately confuse Sudhee! As Guru adds, the mind-body problem is what I had in my mind (!) when I penned my reply. The seat of the mind has been quite a mystery for years. The realm of the answer has been classically left to philosophers and artists. However, it is those scientists who have stood at the shores of ‘science’ and looked beyond the oceans of art, that have seen the answer to everything.
I was just pondering on how science is relevant to the ‘artist birdwatcher’? Is it just enough then if we enjoy the whistle of a thrush and the cackle of a bulbul while not wondering on the hows, whys and whithers?

Consider an artist. A 20 year old man with a lot of ambition, and skilled as well (defining ‘skill’ is altogether another discussion!). He wants to take up landscape painting. Having been in Bangalore all his life, he does not get too much of the natural landscapes he likes. He initially wants some ‘mountain with sunset’ kind of subject to paint. A friend suggests BR hills and he goes there. He spends a day there and goes back to Bangalore with a painting. Which painting would be a true work of art (as they say!)…

1) Mountains with trees, and sun setting: Mountains are portrayed with a diffuse growth of trees and a huge expanse of forest is shown. While the painting itself is beautiful showing a vast expanse of forest, a magnifying glass would only show ‘trees with green leaves’!

2) The same mountains and trees and the expanse but, with an attention to detail…the Lianas hanging, the racquet-tailed drongos flying, the spot of the road (a nightjar for a trained eye!), the shadow of the cloud over the canopy, string of trees on the mountains with a plusher green(where the streams flow!), trees with bare bark near the water body (debarked by elephants!), a huge group of swifts overhead (strong monsoon winds are blowing!). This artist may not at all know what I have indicated in brackets, but his ‘work of art’ incorporates it. It is here that science meets art!

The artist here is like the tern we see or the cow that the doctor saw (refer the article below!) Where the cow or the tern never involve themselves in any ‘bheja fry’ like us, the true scientist-artist would. (Like it or not, we have a neo-cortex); And it is here that we see the meaning of birdwatching. Such should be our observations. In trying to see the angered tern or a ‘single racqueteddrongo, all of us have to look for a satisfying explanation. It is only that for some, this explanation lies in art and for others in science! And of course, the tern or the cow never really bothered, because they were the problem itself! (It is not the problem, but the solution that bothers us)

NB: I looked to S J Gould for some clarity. (Art Meets Science in The Heart of the Andes: Church Paints, Humboldt Dies, Darwin writes, and Nature Blinks in the Fateful Year of 1859 Pp 90-109 from “I Have Landed – The End of a Beginning in Natural History”, Stephan Jay Gould, 2002)

Dr. Sridhar’s reply:

Dear Prashanth,

//snip…Now let me add to the confusion. The word emotion is derived from its Latin ancestor ‘emovere‘ which means ‘to be disturbed’. So literally speaking, the bird was disturbed. To be disturbed is one of the essential qualities of “life”. In addition, emotion is the body’s response to life situations, preparing it to be “responsible”! Again, Responsibility literally means Ability to Respond adequately and appropriately from moment to moment. Coming back to emotions, it is a much earlier manifestation in evolutionary scheme, as the chemicals are released from the primitive reptalian brain and not from the much junior neo cortex. What the birds probably don’t do is to name the various emotions as we do . Our neo cortex constantly tries to name, find meaning where there they are probably not needed.We seem to complicate things in trying to find meaning.( philosophical ? uh?) So “life is constant Disturbance” and the beauty lies in constant Responsibility to the never ending Disturbance !!

I would like to tell you about a certain event that happened a few years ago, which has left a deep impression in my mind. When I was in the clinic, a herd of cows came into the campus. Soon they were being driven away. One of them while trying to get out, got entangled in the barbed wire fence and came down with a thud. I wanted to help it extricate its leg . When I went
near it , it started struggling more vigorously and the leg started bleeding. Hence I withdrew. The cow lay there helplessly, frothing from the mouth and the eyes were upturned and pitiable. Soon, another cow on the other side of the fence came near the ‘fallen’ cow, sniffed it and started
licking. Within a few seconds, the cow came alive and got up smoothly extricating its trapped leg and went away. Probably , I noticed a wide cascade of emotional expressions in the cows, raging from fear, helplessness and love and thankfulness. The animals did not take the trouble to name the emotions, nor did they care to thank! Who knows, after a while they might have locked horns over an inviting bull!

I can only marvel at nature and I think I will be a terrible failure to explain everything . I would rather be an artist!