DENGUE – A FAILURE OF MEDICAL LEADERSHIP
by Gabriel

I refer to the news that Malaysia is seeing a higher death toll from dengue fever this year. Health Ministry’s Director of Disease Control, Hasan Abdul Rahman said 44 people had died in the first four months of 2007 from 16,214 cases reported, compared to 21 deaths and 10,244 cases in the same period last year.

Even more disturbing is the statement that the disease has seen a rise of 16 per cent in cases every year since 2003 with fatalities reaching record levels in 2004, when 102 people died.

The Ministry’s Deputy Director-General, Ramlee Rahmat further appears to have even identified the cause for the rise attributing it to unkempt construction sites, indifferent contractors and land owners, public complacency and ideal weather conditions for breeding the Aedes mosquito.

Primary health care officials, having already identified the problems, may need to do more if this plague is to be dealt with more effectively.

The time is appropriate for them to speak to the DPM and ask for emergency powers for they may have no clout if some of these problems fall into the domain of the Environmental Ministry or local councils who may take a lackadaisical attitude to this endemic plague which can very well rapidly escalate to be an epidemic if these erratic weather conditions continue to facilitate the exponential breeding of the Aedes aegypti.

How indeed memories are short for authorities do not appear to remember the other great mosquito scourge that swamped this country in its early years — malaria.

Malaria was first successfully shown to be controlled in Malaya by a government surgeon, Sir Malcolm Watson in 1901 who, faced with an epidemic of malaria, brought it under control by a program of jungle clearing and drainage in the town of Klang. This was one of the world’s first examples of successful malaria control by anti-larval measures.

But a far greater problem awaited Watson in Port Swettenham, opened in September 1901, where by the end of that year 118 out of the 176 government servants working in the port had gone down with malaria causing the port to cease functioning. On Watson’s advice – bunds, which stand till this day, were built around the area to keep out the tide and the area inside the bunds was drained and oiled. Malaria was soon brought under control and the port working again.

These two successful measures by Watson were the harbinger for the application of similar drainage methods including subsoil drainage in estates — so vital for the economy at that time, where malaria proved fatal to many of its Indian laborers.

Watson’s efforts were complemented by G.F Leicester, an entomologist at IMR, who helped him identify the different species of mosquitoes and this they did by actually going together into the jungle round Klang sometime in 1903 and catching Anopheles umbrosus, the mosquito vector responsible on flat land.

In 1911, the Malaria Advisory Board was formed with Watson as one of its members. The Board had a free hand and wide powers which included powers to coordinate, order and execute control measures.

Watson with his skillful methods of combining subsoil drainage and a suitable blend of oil was able to significantly reduce the incidence and subsequent mortality of malaria.

By careful observations and experimentation, he was able to recognize the vectors of the tidal zone, the coastal plains, the inland plains, and the hills and apply specific control measures adapted to their habits.

Many in Port Klang would remember its main trunk road which was named for him, Jalan Watson, now renamed Persiaran Raja Muda Musa.

The rise of dengue in our current ecological circumstances is not dissimilar to Sir Malcolm Watson’s analysis of the relationship between economic activity, landscape change, insect density and malaria in Central Africa in 1953.

Constant attention to the ecology of the local mosquito species in relation to control measures is critical if we are to curtail this rise in incidence and bring about its consequent reduction in mortality which is more related to reinfection rather then primary infection.

Our primary health care leaders need to demonstrate greater leadership qualities adopting more aggressive and proactive measures.

They must be further equipped with adequate powers to rope in other departments such as the DID, JKR, local councils, the police and the Environmental Ministry to effect the necessary environmental changes so required to eradicate the vector.

Fogging and fines are akin to treating the symptom unlike Watson and Leicester who went down to the field to treat the disease.

This country has a powerful tradition in overcoming many tropical illnesses basically because of its strong initial foundations since pre-independence days. Sadly we appear to have let slip this advantage and reading in the papers about children, golfers and lecturers dying of dengue is I am certain not something our forefathers would have been proud of.

The main reason dengue still kills is because we do not possess the medical leadership so critically required in surmounting it.