In the beginning of the first week of June, Shima called me unexpectedly from Egypt when I was waiting for bus to Malappuram in a deserted Kozhikode KSRTC bus stand.
‘Dr. Santhosh, how do you do?’
“Hello Shima, how do you do?”
'Everything is going well.’
Shima is a research fellow who studies on Indian theater at Kerala Kalamandalam. Her research guide and my friend Dr. Raja Warrier called me one day in March.
‘Santhosh, one of my students is down with fever in Egypt. She got it when she was in Kerala. Her doctor needs to talk to a physician here. Please arrange someone,’ he said.
I sent the phone number of a physician of Thiruvananthapuram General Hospital to Egypt. Both the doctors communicated. But Shima’s fever settled down without giving a clue to both the doctors. Shima happened to know about the new happenings in Kerala when she was about to come back here after vacation.
‘Dr. Santhosh, aren’t you living near the place where Nipah virus outbreak occurred?’
I felt curious about the coincidence of that question. I was on my way back from Perambra Taluk Hospital, Changaroth primary health centre, Sooppikkada and Kadiyangad of Changaroth panchayat where the Nipah outbreak occurred. The place is situated 45 km away from Kozhikode city.
Shima called me while I was jotting down some important points I noticed during the journey. I wondered about the world that was shrunk much smaller than we imagined. How much near Kozhikode and Egypt could be? If a tree fell down, its sound could be heard in Egypt and vice versa.
“Yes Shima. But it’s not near, I’m in that place,” I said remembering the fact that 3 out of the 4 patients affected with Nipah virus in Malappuram had died.
Malappuram District Medical Officer Dr. Sakkeena and District Surveillance Officer Dr. Muhammed Ismail have been running around in the district. PG students of community medicine department in Manjery Medical College prepared the list of those who had contact with the Nipah patients and quarantined them.
‘Dr. Santhosh, I feel scared.’
“A doctor’s duty is to find a peaceful place amidst fear.”
In response, I received in WhatsApp a picture of a smiling Buddha with an aura behind his head.
‘Doctors are working in an extremely risky condition. I read about it.’
“Not only doctors, but also nurses, paramedical staff, nursing assistants, cleaning staff, field workers… and many such people.”
‘Tell me the truth. I’m asking seriously. What is the situation now?’
“Shima, the health department has shut the paths of the virus. No new positive cases are reported after May 30. Nobody has died after May 31. Two patients are recovering. The disease is withdrawing.”
‘Really? But 2000 persons are under observation. It means that they are affected with the virus, right?’
“No, it only means that they have contact with the Nipah patients. It does not mean that the virus has affected them. In the present situation, they are less likely to become patients.”
‘Why?’
“Nipah is a short-lived terror. It has no power to spread quickly. If it has to spread to another person, either we have to come face to face with the patient at an arm’s length in the peak stage of the disease, or particles of saliva or vomit of the patient should fall on us or we have to touch blood or body fluids of the patient. Everyone except for the first patient were detected well before this stage. And also they were admitted to the ICU. So, the virus is less likely to spread to more people…”
‘So, you are saying that Nipah is not airborne like influenza?’
“Yes.”
‘I read something opposite.’
“Where did you read it?”
‘Here in Egypt. Through online. They say that we should not travel to Kerala.’
“It’s wrong.”
‘So, I can come there?’
“Of course you can, Shima. You can go anywhere you like. To Kozhikode and Perambra. Even to Sooppikkada where the house of Sabith, Salih, Moosa and Mariyam is situated. Sabith’s mother and younger brother are living there. And also Mariyam’s children. You can talk to them.”
Shima thanked me and ended the conversation.
I felt doubtful if I too have simplified a serious matter. I looked in the diary. No, it was not wrong. Virus is just like human beings. They will behave differently according to the situation. The source of Nipah is bats anywhere. But it does not spread in Bangladesh in the same way it did in Malaysia. The case in Kerala also differs. Because, transmission of disease is an issue of survival for both the virus and human beings. It opts for the most suitable method for each place.
But in this case, Nipah virus has not been able to impose its power completely on human beings. Its striking power is lethal. However, it cannot exist in human beings for long. As I told Shima, the virus cannot spread rapidly. It does not know to travel with the wind, to wait by the roadside or to hide inside a bus.
Even though I’m a doctor I would not have understood this, if I did not accompany the health inspectors of Changaroth primary health centre to the house of the deceased or talk to Mariyam’s children or meet the employees of Perambra Taluk Hospital. Nor could I have told Shima this information confidently.
I went from Kozhikode to Kadiyangad on a rainy day. I travelled in a taxi arranged by Divya who is a consultant at Kozhikode office of Arogyakeralam. The rain intensified on the way. But there was no tension on driver Vishnu’s face. ‘Sir, I’m driving so peacefully in this route for the first time,’ he said.
That was right. The road was empty. Shops were closed. Nobody was coming to Kozhikode city. Buses ran with empty seats. Many services were stopped. Perambra town was like a medieval street struck by plague. My only familiarity with the place is a phone communication with Rajan, the health inspector of Changaroth primary health centre. Also I had heard about medical officer Dr. Bijeesh Bhaskar.
The hospital is present on the right turn before Kadiyangad bridge. A tall tree is present in front of the hospital. The colours had gone in the heavy rain. As I ran to the hospital holding my umbrella, there stood Chandran whom I knew for years. He was a Kozhikode native health inspector. He was appointed there to help with the Nipah prevention activities.
I was glad to see him. But there was someone else who was happier than me. It was Unnikrishnan, owner of hotel ‘Friends’ near the hospital. He was meeting a Thiruvananthapuram native doctor for the first time.
There was a duty doctor in the OP. ‘There were at least 300 patients in the OP earlier. But it has come down to 50 now,’ she said. People are slowly getting used to the new situation.
Meanwhile, I understood that Unni’s happiness was genuine. Two plates full of boiled tapioca and sardine curry was sent in the hospital in a short time.
‘How’s this tapioca, sir?’
“Very soft.”
‘This tapioca is from our compound.’
“Such good quality tapioca is not available in Thiruvananthapuram. So is the case with this tasty sardines.”
‘Sir, will you eat freshwater fish?’
“Why not!”
A fried freshwater fish with tempting aroma was humbly served on my plate.
‘This fish was saved for us to eat.’ The sound of serving the fish on the plate repeated.
Unni also showed me the picture of freshwater fish caught from Kadiyangad river. He started talking while having tapioca.
‘Sir, we don’t have any issues here. The heath activists have given awareness. Those who come here are scared. Buses don’t stop here. Even if we board the bus, people would get up once they happen to know that we are from this place. The conductor would not come near us to give the ticket. Nobody wants to see the facts directly. They all put their faith on WhatsApp.’
After food, chief doctor Bineesh, Rajan and public health nurses arrived. All were in the field. The daily duties including immunization were performed without fail amidst the Nipah resistance activities. ‘We are in the middle of people since the day Nipah was confirmed,’ Dr. Bineesh said.
People wore masks both inside and outside their houses based on the information received through media. Many of them thought that the virus was airborne. They fastened the doors and windows. Neighbours of Sabith left the place in fear. Everybody thought all were going to die together. Even the health workers were afraid of the situation.
When Dr. Bhaskaran of ICMR (Indian Council of Medical Research) arrived to talk about the Nipah prevention to the field level health workers assembled in Perambra Taluk Hospital, he saw everyone wearing masks and holding their breath.
“Does anyone of you have fever?” Dr. Bhaskaran asked.
‘No.’
“Did anyone of you treat Nipah patients?”
‘No.’
“Did you take care of them?”
‘No.’
“Had close contact with them?”
‘No.’
“Then why are you all closing your mouth like this?”
All of them untied the masks at once.
The prevention campaign had started even before Nipah outbreak was officially declared.
On 18, a field survey was conducted to find out the patients affected with fever.
On 19, a medical camp was organized. Ministers T. P. Ramakrishnan, A. K. Balan, Health services director Dr. Saritha, Public Health Additional Director Dr. Reena, central team members from Delhi and Kozhikode DMO Dr. Jayasree arrived there.
On 20, Dr. Arun Kumar from Manipal Virology Institute visited the houses of the deceased. The blood samples of those who had contact with the deceased patients were collected. Awareness about disease transmission was held.
On 21, health minister K. K. Shailaja visited Changaroth. Panchayat-level meetings of various departments were organized under the leadership of excise minister T. P. Ramakrishnan.
On 22, the list of those who had contact with the patients was completed.
On 23, health discussions and classes were held by Kerala Sasthra Sahithya Parishad and Medical College team. Dr. K. P. Aravindan and Dr. Khadeeja Mumthas talked to people.
“The major task was to eliminate the fear of people under observation. Some of them were admitted in hospital due to hypertension. We visited them every day and talked to them. Another issue was the estrangement of the relatives of the deceased. We went to their houses without the masks. We had already understood the way of transmission of the virus. We did not wear masks for even a day,” Rajan said.
All these activities derived good results. Those who tied masks in fear while walking in public removed it and set themselves free. The fear they untied and abandoned on that day are still seen here and there on the streets.
The next day after the first patient Sabith died, Dr. Bineesh and health inspectors visited Moosa’s house though it was Sunday. They thought that the cause of death was Japanese flu. The death certificate issued from Kozhikode Medical College had stated the cause of death of Sabith as viral encephalitis.
Considering the public health, Japanese encephalitis is most important among them. So, they continued preventive activities to stop spreading of Japanese encephalitis till May 9. It was only later they recognized that Nipah virus was the actual cause of death.
Sooppikkada is only 2 km away from Kadiyangad bridge. When we reached the junction, take the left turn and go straight and then take the small path on the left to reach Moosa’s house. His sister Mariyam’s house is opposite to the path, on the right side of the road. Moosa was 60 when he died, Mariyam was 56, Salih was 28 and Sabith 26 years old.
When we reached there, the tarpaulin tied in front of the house for funeral ceremony was lying down like a veil. The house had witnessed three deaths one after another. Their neighbours had left the place. Even the tree leaves were standing still there.
The virus first affected Sabith, Moosa’s second son. He was affected with fever on May 2 and it intensified by 4. Also he had vomiting. Sabith had been suffering from ulcer for long. He was working as an electrician in Gulf and returned due to the disease. He cannot have all type of foods and sometimes he used to vomit too. So, his family thought that he was vomiting because of ulcer.
But in the meantime, Nipah virus transmitted to his brother Salih, father Moosa and Moosa’s sister Mariyam. As Sabith’s mother used to wear a veil on face, the virus cannot spread to her. Sabith was taken care by Faizal and Jabir. Faizal used to have nausea while seeing someone vomiting. So, he turned his face whenever Sabith vomited. So the virus did not affect him too.
The fate of Mariyam’s son Jabir can only be called a wonder. It was Jabir who carried Sabith to Perambra Taluk Hospital and then to Kozhikode Medical College. As per Jabir’s narration, he carried Sabith on his shoulder to the car. He also switched off the A/C to improve the car’s speed and also lowered the side windows.
Thus due to the strong wind that blew backward, the virus failed to reach Jabir who was in the front seat. Jabir took not only Sabith but also Salih, Moosa and later Mariyam to Baby Memorial Hospital in the same way. Each time, the strong wind prevented the virus from reaching Jabir.
On May 4, Sabith was admitted to Perambra Taluk Hospital with symptoms like fever, headache, breathing trouble and vomiting. The lab technician of the hospital still remembers Sabith who was seated in the wheel chair with his head leaning to one side. Mariyam’s daughter remembers that a common symptom found on all four of the patients was body pain, especially pain of legs.
On 4, Sabith was admitted in the male ward of Perambra Taluk Hospital at night. There were 11 patients and their bystanders in the ward at that time. The virus transmitted from Sabith to four others, including a patient, a nurse and two bystanders, that night.
Among the patients, only Ismail was affected with the virus because he was an advocate of brotherhood. Ismail wants to help others. So, he left his bed and approached other patients. Thus he might have reached near Sabith. Janaki was the bystander of 90-year-old Kuppa. She ran to Sabith whenever he vomited to help him clean. Thus the virus was transmitted to her.
Rajan, the bystander of Balan, who was under treatment for breathing trouble, also was affected with Nipah virus in the same way. Lini was the night duty nurse in the hospital that day. When the duty doctor entered the ward, he saw Lini carrying the basin for Sabith to vomit. The virus might have entered her body during this act.
Mariyam was more affectionate towards her nephews than her own children. The night when Sabith was admitted to Perambra Taluk Hospital, Mariyam visited him there. She put the medicinal powder for fever on his head, hugged and kissed him. Maybe, the virus transmitted to her thus.
Sabith’s condition turned worse on May 5. Doctor referred him to Kozhikode Medical College. Sabith died that evening at 5.45 pm. Meanwhile, the virus was transmitted to 10 more persons from him. Malappuram Moorkkanad native Velayudhan was affected with the virus from the casualty of medical college. He also was an advocate of brotherhood and never hesitated to help others.
When Velayudhan accompanied a patient from Malappuram to Kozhikode Medical College, Sabith was there. The virus spread to his body before he returned. Velayudhan was a diabetic patient and also had a minor kidney disease. He got a carbuncle which is usually seen on diabetic patients. Dr. Saji Mathew, the surgeon of Perinthalmanna District Hospital, admitted Velayudhan there and controlled his diabetes and dressed the carbuncle.
On the day before discharging, a slight fever caught Velayudhan and he started talking gibberish. The doctor concluded that it was because of the brain disorder resulted from imbalance of electrolytes in the body as he was a diabetic and nephro patient. He was referred to Kozhikode Medical College where he later died.
Velayudhan’s blood samples were sent for tests as the Nipah outbreak was confirmed and he had difference in behavior. But the test results came only after Velayudhan’s funeral was carried out. He was tested positive with Nipah virus. His relatives and those who attended the funeral panicked on knowing this.
About 40 patients were admitted in the same ward with Velayudhan at Perinthalmanna hospital. all of them were discharged from hospital. The hospital authorities prepared a list of all and convened a meeting of field level health workers. Everyone who were in the ward should be found out immediately and should be kept under surveillance for 3 weeks.
In the meantime, two more deaths were reported in Malappuram. One was Munniyoor native Sindhu and the other Thennala native Shajitha. The virus spread to Sindhu when Sabith was present at the casualty of medical college, just as in case of Velayudhan. Shajitha was affected in front of the narrow CT scan room. Sabith had to spend a lot of time in front of the CT scan room.
The virus was transmitted from Sabith to other seven patients - Kozhikode Naripatta native Kalyani, Chekkiyad native Ashokan, Palazhi natives Madhusoodanan and Abin, Kodiyathoor native Akhil, nursing student Ajanya and Shajitha’s husband Ubeesh – at the narrow corridor leading to scan room, waiting centre in front of scan room, casualty and ICU of the hospital.
When I went with Malappuram deputy DMO Dr. Ahammed Afsal to attend a meeting of field level health workers at Perinthalmanna, they seemed to be quite anxious.
The silent attack of this virus was first identified on May 16. It was on that day, Sabith’s brother Salih was admitted to Baby Memorial Hospital with similar symptoms. His brother Sabith’s death on May 5 was an important clue. The doctors identified the presence of an animal-borne epidemic. Salih was immediately admitted to the ICU. The doctors talked to his relatives and they offered complete cooperation.
Salih was too exhausted to take the samples of blood and body fluids by the time. As the doctors had already understood the nature of the disease, they inquired if anyone else in their house had fever. On May 13, when Salih went to Kuttiady Taluk Hospital in the beginning of fever, Moosa also had consulted the doctor for body pain.
The doctors asked the relatives to bring Moosa to hospital. Moosa had just returned after visiting Salih in the hospital, broke his fasting and attended prayer in the mosque. ‘You people are dragging to the hospital for no reason,’ Moosa complained to his relatives. But by the time he waited for taking blood samples, he was caught with severe fever.
Mariyam’s case also was similar, said her daughter. Though she was slightly feverish, no external symptoms were found in Mariyam when she was brought to the hospital.
“Mariyam, how many days it’s been since your fever started?” The doctor asked.
‘Three months.’
‘No, doctor. It’s three days,’ her daughter corrected.
Then Mariyam started talking gibberish. Both Moosa and Mariyam were admitted. Samples for testing was first collected from Moosa and then from Salih. It was their relatives themselves carried the samples to Manipal Virology Institute on May 17. We all owe to them for that. The result came next day. Everyone know what happened from the next day onwards through the media.
Salih died on May 18 when Nipah outbreak was confirmed. Mariyam died on May 19, Ismail on 20th, Nurse Lini and Janaki on 21st, Rajan on 22nd, Moosa on 24th and others between May 20 and 31. Total 17 persons including Sabith died.
The cause of death of a bystander of a patient who was lying in the bed next to Sabith in Perambra Taluk Hospital, another patient, two others including a staff nurse of Kozhikode Medical College is not yet confirmed to be the Nipah virus. Officially, the death toll is 17.
Sister Lini was diagnosed with the symptoms on May 17. Her fever continued to intensify along with breathing trouble. Head nurse of the hospital let her lie on her lap and consoled, ‘Nothing will happen to you, dear.’ When Lini was about to go to medical college from taluk hospital, she told her mother, ‘Something is there within me. You should not come near me.’ Mariyam also stopped her children from coming near her while going to the hospital.
After Lini’s death, Perambra taluk hospital was estranged from the rest of the world. No patient went there. Shops and hotels around the hospital closed down. Auto drivers hesitated to take the hospital staff for ride. Hospital cleaning staff Balamani’s husband is a painter. His friends asked him to stay away from work. ‘Everyone abandoned us. We have only each other,’ said head nurse Janaki.
But the doctors, nurses and other staff of the hospital did not leave the hospital. They did not take eave for even a day. All who had contact with Lini were in quarantine. They all stay together and pour in strength to each other.
The only question remaining is how did a virus that existed only in Malaysia, Bangladesh and Bengal travelled all the way to reach Changaroth Sooppikkada…!
Many theories have already been propagated. The epidemiology department of ICMR may find a scientific answer for that. However, a common man in the village may wish to say this. The world is shrinking faster than we thought. A small wave in a place may appear to be a large flood in another location. The globalization has strengthened this phenomenon.
Just as human beings, birds, animals, and micro-organisms also fight to the new political, social and environmental conditions to survive. Unlike any ages in the past, climate change and environmental impact have turned to be factors which determine the health of human beings.
This phenomenon has compelled the micro-organisms to come out of their natural habitats. They keep trying to cope up with the new environments. They are on an evolutionary battle to move from birds to animals and then to humans. We experience this as an attack of new epidemics.
The changing global situations make way for new diseases. This is not only a health problem, but also a political, economic and environmental issue. We can understand this, if we closely watch the Nipah prevention activities in Kozhikode.
The brilliant clinical judgement of doctors helped identify the disease in a short time. But it was an excellent political leadership that helped to arrange preventive measures rapidly and contain the disease. The integration of local self-governments and health systems is a key factor in this excellence. It helped to combine various agencies from international to local level swiftly and also to ensure public participation.
We witnessed an expert popular health alternative that comprises of specialist doctors, ministers, officials, panchayat presidents, ward councillors, veterinary doctors, researchers, epidemiologists, journalists, anthropologists, bat specialists, sociologists, medical officers, field health workers and common people.
It has an alternative politics content in it. The new health issues can be effectively resolved in this way only. But if we could not lead this alternative to environmental awareness, these attempts will be in vain. At least a person could be able to walk through Kozhikode city without covering his nose. Because, the biggest morbidity is the ecological morbidity.
Three factors are named as the reason for the origination of new epidemics and comeback of the eradicated ones.
- Changes in the human habitat
- Superfast inter-continental journeys, transportation of goods, migration
- Environmental impact
Dengue fever was an epidemic that used to spread in only 6-7 countries in southeast Asia. But now it has spread across more than 100 countries. It is one of the most crucial health problem in Kerala. About 80 million people are affected with dengue fever every year. One of the main reason for the spread of dengue fever is said to be the increase in the breeding of Aedes mosquitoes which can resist high temperature according to the escalating global warming.
After the 1980’s, about 30 new deadly viruses have spread among the human beings. Where were they before? They were living in the bodies of birds and animals inside the deeper parts of forests where humans never entered. As the human beings trespassed into forests, they paved way for the viruses to come into their society.
Gradually, the microbes gained power to survive in the new circumstances. Thus new communicable diseases originated. The deforestation in Sumatra led to Nipah outbreak in Malaysia. The bats went to Malaysia after they lost their habitats. When the viruses realized they are not safe in the bats any more, they also started searching for new places to live. Thus they get transmitted to pigs and from pigs to human beings.
When a forest in Brazil is destroyed, a person in Thiruvananthapuram may die of West Nile fever. When the Vembanad lake in Kottayam is levelled, bird flu may strike Sri Lanka. Take a look at the bird flu reported in Kuttanad recently.
The migratory birds have been visiting there for many years. They used to live in the mangroves in the middle of backwaters and return later. Those birds never had any contact with the indigenous birds. But as the backwaters were levelled, the migratory birds started mingling with the local ones and the viruses reached the land.
Nipah may not remain as a less communicable disease forever as it is now. The World Health Organization (WHO) is considering Nipah as a virus like Ebola that is capable of globally transmitting the disease. We should keep in mind that just as we study about the viruses whenever a disease outbreak occurs, the virus also understands the human body.
The virus is practicing to live in the human body for a long time. There is no point in blaming the virus because it is the new circumstances that compel the virus to do so. It is not the virus, but we are responsible for our destruction. The best way to avoid this is having exclusive spaces for microbes and human beings in the earth. Each should fit in their slot.
We will definitely find how Nipah virus appeared in Kozhikode. Also we may develop an effective medicine or vaccine against Nipah. But who would resolve the ecological morbidity which led to these situations?
Recently, I had to travel through Vettathoor in Areekode which is the border of Malappuram along with state epidemiologist Dr. Sukumaran as part of dengue fever surveillance. As requested by the locals, we visited a forest region called Kallikkad. When a native man entered the forest and clapped loudly, the sound of thousands of bats flapping their wings was heard.
The people said that the number of bats escalated in the place within the last 2 years. Before that, their number was considerably low. There was Kadalundi river beyond Kallikkad and Kozhikode district away from that. When we went to Sooppikkada in Perambra of Kozhikode, the locals there also said, ‘We knew only now that this much of bats live here.’
Is there any changes that occurred in the habitat of bats in Malabar? If the locals were right, a huge number of bats have come here from somewhere. They are more likely to have contact with human beings. Then could Nipah outbreak be an indication of the immense changes taken place in the environment of Kerala?
Maybe. Because, we have been telling the same thing for more than 30 years. “Our voices have died. We have no power to repeat it any more. We are mere jokers. Nobody wants to hear us,’ said poet Sugatha Kumari teacher when we met recently.
Just as I told Shima, disease transmission is completely under control. The disease is withdrawing. For sure, it is a great achievement. We have to feel proud of the talent of our doctors. We have to heartily congratulate our government, health minister and secretary of health department. They deserve it. Ajanya and Ubeesh who were diagnosed with Nipah have been cured and have come back to life unbelievably.
People have started coming to Kozhikode city. The vehicles are no more hesitant to stop at Changaroth bus stop. Neighbours of Moosa are coming back. After a long break, a patient was admitted in Perambra Taluk Hospital. The virus did not transmit to anyone from Sister Lini. Acquaintances of Velayudhan also are remaining calm.
Shima is preparing to come back to Kozhikode from Egypt. The ambulances that run along the roads of Kozhikode city will be replaced with school buses running with laughter of happiness. Everything will be normal as in the past. Everyone will come back here, except for those 17 persons.
We should not forget the deceased. They used to believe in brotherhood. They were bundles of love who ran to console others. They took up the sins humans committed to the nature. They sacrificed their lives… They are martyrs.
Translated by Aswini KP
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