INDIAN YAWS ERADICATION PROGRAMME NEEDS ...

Indian Journal of Community Medicine Vol. XXVIII, No.1, Jan.-Mar., 2003

Continuing Medical Education: INDIAN YAWS ERADICATION PROGRAMME NEEDS REINFORCEMENT V.B. Saxena*

Yaws is not an epidemic disease but is an endemic problem with which the tribals are obliged to live and sustain. Yaws does not raise any local sensational sentiments as seen in killing epidemics like plague, cholera, falciparum-malaria etc. Ulcers with scab and other skin manifestations etc. are usually not reported to health workers entering these areas from outside. Field workers make their time table as per their convenience and not as per convenience of tribal people who leave the village before sunrise for their routine and forest activities. Therefore, as observed during last 5-6 years, health workers visiting tribal villages from health centres and sub-centres have not proved useful in yaws campaigns. Thus, for example, endemicity of yaws in Dang district of Gujarat is known at national and international level since 1982, but it was really pathetic to observe that, number of cases recorded in year 2000 and 2001 were only one case per year. This detection of only one yaws case per year, inspite of various training and motivation etc. needs serious thinking. It is, therefore, now recommended that, special efforts should be made to promote in each village (a group of 100-250 population in tough tribal terrains) a local health-worker or volunteer who knows the people and their activities and is a part and parcel of tribal life.

Yaws Eradication Programme (YEP) is the most important felt need of both, the tribal people living in yaws endemic areas as well as the administration in general. People demand YEP because, multipotent drugs used in the programme result into a miraculous disappearance of their nocturnal bone and joint pains (the commonest manifestation of yaws) as well as some other common diseases prevalent in the area. The administrators being well versed with the present tribal militancy in many tough terrains, now realize that this programme is one of the best way to enter tribal community and gain their confidence. There are no financial problems for the programme, and many national (e.g. tribal welfare departments) and international agencies are willing to help if needed. However, the biggest obstacle that the programme is facing for its implementation is from the health department. When the concept of the programme was initiated in 1995, the health department was geared up to achieve the target “Health for ALL by year 2000”. It was presumed that yaws will also disappear by year 2000, and, after that 3-4 year surveillance will be needed to get certification of eradication. However, now with the postponement of target time from year 2000 to 2010, the health activities at peripheral areas in tribal terrains need substantive reinforcements at various levels, to achieve the desired target.

For planning to have a suitable local worker or volunteer, it must be clearly understood that, as per strategy formulated in 1996-97, yaws eradication programme is not a uniproblem activity, but it includes most of the skin diseases (e.g. scabies etc.), leprosy, louse infestation, worminfestations, diarrhoea and even pneumonia etc. The multipotent drug used in yaws eradication is accompanied by group of drugs and ointments etc. to meet all the

Reinforcement at Peripheral Level:

With the dismissal of Community Health Volunteers in most states, a peculiar situation has now been created and this needs to be comprehended properly, specially with regards to tough tribal terrains where, as per WHO Newsletter (1955), tigers are in the time-table of field workers.

*The author worked as National Consultant for initiating National Yaws Eradication Programme in 1995-96. This paper is based on various observations made by him during independant appraisal of the programme in year 2000 and year 2002, and also during planning of Yaws - search in Abujmad in Jagdalpur division in year 2000.

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Indian Journal of Community Medicine Vol. XXVIII, No.1, Jan.-Mar., 2003

felt-needs of the people, and the programme is bound to raise the confidence of the people on health administration and general administration. It would, therefore, be very useful to consider reinforcement of yaws activities by involving and training a local health volunteer in each village (or a group of 100-250 population) in tribal areas having yaws endemicity. A link-person has already been established in malaria programme. If such a link-person is given some general

training on yaws and allied problems and motivated by some incentive by Government or local Panchayat, then, he or she will provide a better information (Table I) about the people and their problems and will greatly facilitate a proper management of those problems under the umbrella of local Panchayats. With this reinforcement for people’s participation, yaws will certainly be eradicated in a few (4 or 5) years.

Table I: Yaws Detection Centre.

Person responsible Village health guide or any suitable health volunteer willing and devoted for the job, and who is trained for ability to identify symptoms of yaws and its complications

Task carried out

Support & supplies needed

1. Case finding by early recognition of suspected yaws cases and their referral for treatment. 2. Searching for source and contact examination and refer the suspected cases to treatment centres. 3. Health education with the support of school teacher or any voluntary agency. 4. Inform health authorities about movement of infectious cases and families to other area for notification.

Reinforcement at Primary Health Centre Level:

In most tribal areas endemic for yaws e.g. in Chhattisgarh, the posts of Medical Officers are lying vacant. To cope up with the situation, the state has started five Medical Colleges in tribal areas to produce graduate doctors in a three years degree course. However, at present, it does not appear feasible to get the services and guidance of medical profession in these tribal health centres for next 3-4 years. During my recent visit to a tribal district in Gujarat, maximum number of yaws cases were seen in a primary health centre where the doctor was not present for last four months. Another doctor from neighbouring health centre used to visit on alternate days (usually 2-3 days a week) but could not pay attention to problems of distant villages. The pharmacist of the health centre was informally informed of

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1. Provided with yaws photographs and other check list or manual of his task and has a spot map of villages and houses in his area. 2. Has access to yaws treatment centre and gets reinforcement of training and guidance whenever needed. 3. Gets support of community and other field workers.

the peculiar situation he is facing. He has received an order in writing that he should not give medicine or treatment to any body without the prescription of a doctor. However, when the doctor is going out of the health centre, he personally asks me to take care of the patients coming to the centre to prevent any public resentment. Even if one doctor is posted in these tribal primary health centres, he will be so busy with medical and other problems coming to PHC that very little time and energy is left to visit and attend to problems in distant villages attached to health centre. Looking to these situations, it was planned that at least 2 doctors be posted in each PHC, so that they may attend to field problems on alternate days. However, such a situation is not seen anywhere in tribal areas. Looking to this obvious deficiency of medical staff in tough tribal terrains, it is recommended that at PHC level, one of the senior health-supervisors be given some incentive

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Indian Journal of Community Medicine Vol. XXVIII, No.1, Jan.-Mar., 2003

(say yaws allowance equivalent to 20% of the salary) to look after yaws activities and yaws-cell at the primary health centre. Reinforcement at District Level:

Looking to the inadequacy of Medical Officers at health centre level and their frequent absence or leaving without information, specially in tough tribal terrains (which are usually endemic for yaws), it is recommended that each yaws endemic tribal district must have a whole time Medical Officer to act as a trainer and co-ordinator of field activities under yaws eradication programme. It must be comprehended that, because of rapidly changing yaws situation, training is not only a one time initial exercise but it is a continuous phenomenon and to implement it, the trainer (at district level) should also act as a supervisor of field activities. Field situations are more realistic lessons than those given in books and hence, the trainer can exploit them during supervision, to reinforce the needed incentive. The co-ordinator of YEP in the district, if attached to district Panchayat, will be successful in involving the Panchayats and other voluntary organisation in the district. However, it would be obligatory that the co-ordinator should be given full control (drawing and disbursing authority) of the funds allotted to him for drugs, laboratory services, training activities, mobility for supervision and coordination and supporting staff (technical asstt., clerical asstt., accountant, driver and field assistant etc.). The incentive provided to link-persons at village level and to the health supervisor at health centre level should also be provided to the co-ordinator for necessary dispersal, preferably through the Panchayat. Reinforcement at State Level:

The responsibility of state level Yaws-cell is not only a passive transfer of messages and resources from the centre to periphery and vice versa. Hence some States (e.g. Chhattisgarh) have already designated one post to act as nodal officer for YEP. Following activities of YEP are to be carried out by the state Nodal Officer for Yaws:(1) Training the trainers (co-ordinators at district level) as per changing epidemiological situation and strategies.

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(2) Organising co-ordinated activities at border line

endemic areas of two districts in the same state. (3) Motivating and implementing co-ordinated surveillance and containment in borderline areas between neighbouring states. (4) Prompt initiation of YEP in any new areas of border district where Yaws has been reported e.g. Nasik and Dhulia district of Maharashtra. Diagnosing special high risk areas (e.g. Abujmad in Chhattisgarh or Sahyadri Hill-tribes in Maharashtra) and planning special co-ordinated exercises for necessary containment of endemicity. (6) Proper maintenance of yaws-consciousness till yaws is declared eradicated. For this objective, more and more input will be needed for exploitation of media. Posters for arousing rural consciousness and prizes or incentives will be needed for reporting cases and motivation to involve other departments (like tribal welfare, social welfare, education etc.) at state-level. (7) To be an active participant of any team-exercise or counselling activities planned by national authorities. It may be emphasized that, the state-level Nodal Officers for Yaws will be key-persons of national importance for ensuring satisfactory achievement of YEP. (5)

Reinforcement at National Level to Meet the Challenge of YEP:

Out of about 200 tribal districts in India, Yaws was known to be present in about fifty districts, but YEP has been launched in only 25 districts. Nothing is at present known about status of yaws endemicity in remaining districts. The administrators in those districts (with past history of yaws) have nearly forgotten about yaws and, there are very few medical persons aware of the problem. The biggest shortcoming in the present programme is lack of epidemiological skill to understand the magnitude of yaws endemicity. At present, besides routine monitoring and guidance to state governments for YEP, National Institute of Communicable Diseases (NICD) is actively involved in supporting field supervision and motivation through its field units at Chhattisgarh, Andhra Pradesh etc. Now it appears

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Indian Journal of Community Medicine Vol. XXVIII, No.1, Jan.-Mar., 2003

obligatory that NICD should be supported to organise few (3-4) Yaws Reconnaissance Teams to provide necessary skill for the following activities:1. Study of suspected (on basis of history of previous endemicity and other migratory factors etc.) tribal areas to know their endemicity status and recommend necessary policy for implementation of YEP. If the areas are found free of yaws, then as per criteria decided in YEP, they may be certified “yaws free”. 2. The Yaws Reconnaissance Team should also organise regular field-training in tribal areas to reinforce the necessary skill and activity among field workers and specially the Medical Officers who have been recently posted. Priority should be given to those areas where yaws problem has been revealed only recently e.g. Nasik, Dhulia and other tribal districts bordering Gujarat. 3. Review of national yaws situation and necessary tuning of activities should be carried out every three months and observations should not remain dead in files but should get due publicity in journals, media and copies be sent to co-ordinators at district level and also to other co-ordinating departments like tribal deptt., social deptt., forest deptt. etc. The Yaws Reconnaissance Team will work under an experienced epidemiologist and, based on epidemiolgoical assessment, will guide expansion or limitation of the programme area.

Reinforcement of International Support for National YEP:

This reinforcement will have to be extended till the year 2010 which has been declared by Govt. of India as the target time to provide “Health for ALL” and, the tough tribal terrains are the most difficult components of “ALL”. Besides providing necessary input for surveillance and containment activities, the international agencies should also help in organising co-ordinated search in Myanmar border where yaws was known in 1980. Conclusion:

Looking to the general socio-political situation in tribal areas, and because of increasing rift between the tribal communities and general administration (leading to even tribal militancy in many districts), it is now very important that, at this critical juncture, the health administrators at various levels (Panchayat, District, State, National and even International) must meet and discuss in depth, a suitable reinforcement for launching this programme successfully to meet the felt needs of the tribes, and generate confidence which will fill up the gap between them and the society in general as well as the administration. References:

1. 2.

WHO: “Tigers on the Time Table” WHO Newsletter Oct. 1955, Geneva. WHO: “Endemic Treponematoses”, Weekly Epidemiol Rec. 1981; 56: 241-8, Geneva.

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22.

23. 24.

Bautista LE. Duration of maternal breastfeeding in the Dominican Republic. Pan Am J Pub Health 1997; 1(2): 104-11. Ahamed MM. Breastfeeding in Bangladesh. Journal of Biosocial Science 1986; 18(4): 425-34. Williamson NE. Breastfeeding trends and patterns. International Journal of Gynaecology and Obstetrics 1989;(Suppl 1): 145-52.

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25. Vestermark V, Hogdall CK, Plenov G, Brich M, Toftager-Larsen K. The duration of breastfeeding: a longitudinal prospective study in Denmark. Scand J Soc Med 1991; 19: 105-9. 26. Grummer-Strawn LM. The effect of changes in population characteristics on breastfeeding: trends in fifteen developing countries. International Journal of Epidemiology 1996; 25(1): 94-102.

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