A Handful of Stories

Reportage on health, science and politics. And some meditations on film

A Rich Tradition of Under-reporting Disease

In a country where doctors can get suspended for Facebook posts on health crises, ‘mystery fever’ is the preferred term to dodge government paranoia

In the 1990 film Ganashatru, director Satyajit Ray tells the story of a doctor who finds himself unemployed and ostracised when he speaks about the contaminated water supply in his town. The doctor traces the growing cases of jaundice and hepatitis in the town to the poison in the water. He gets blowback from the municipality, though the chairman is also the good doctor’s brother. The story was adapted from Henrik Ibsen’s play Enemy of the People set in a Norwegian resort, but Ray told The New York Times that it was relevant to India too. “It deals with topical problems,” he said.

It would seem especially topical in Ray’s state of Bengal today, where reports of dengue deaths in the news have put the government in a state of denial. On November 10, a doctor in a government hospital in Barasat district was suspended for writing a Facebook post on the crisis. “In the days when the number of patients admitted [in a day] was around 100, I knew it was a war,” wrote Dr Arunachal Choudhury in a long post titled “Hospital Journal” on November 8. “But today, when the number of patients admitted is near 500, I know the war is lost. The floodwaters have entered, there is no option but to be carried away with the water.

“On the death certificates, I write ‘not dengue’. There is no dengue in this state. Clever me … on the unfortunate dead man’s death certificate, I write fever with thrombocytopenia as the cause of death.”

Dengue, a mosquito-borne viral disease, causes a flu-like illness that, left untreated, can have a fatality rate as high as 50 per cent. The WHO says that the prevalence of dengue has soared in recent years; India records the highest number of cases globally, according to a report from broadcaster Deutsche Welle.

In the suspension letter from the Department of Health and Family Welfare, the grounds for his suspension were cited as “misinterpretation to the public as well as derogatory [remarks] to the hospital administration as well as general health administration”. “I shall now write only romantic poetry for my wife,” Choudhury said over the phone. “My [hospital journal] post is still up but that’s it. My family has said this much is OK, no more. My mother is 89, and my father 92. He is a cancer survivor. My time with him is stolen from destiny. I can’t afford to do anything to cut short this time.”

The trailer of Ganashatru (Enemy of the People), directed by Satyajit Ray. The film is available for viewing on Mubi India.

Choudhury’s Facebook post was a rare moment when a doctor or public health official spoke publicly about the dengue situation. The government’s figures are not only suspiciously low, but have also varied from day to day and from person to person. On October 12, West Bengal Chief Minister Mamata Banerjee said 30 people had died of dengue in the state in the “past seven to eight months”. At a meeting with her party on October 25, she said there have been 34 deaths due to dengue this year in Bengal. Then on October 30, at a press conference, she said it was confirmed that 13 people died of dengue, while 27 others are reported to have died of the fever in private health facilities.

In response to several public interest litigations in Calcutta High Court, however, the state government on November 18 submitted that 38 people had died of dengue so far. On November 24, the Calcutta High Court rebuked the West Bengal government, and asked it to take more measures to check for dengue. The chief minister also appeared to criticise private health care facilities. “We have also received a report of 27 deaths which were caused by malaria, dengue or swine flu … we are yet to verify the reports,” she said.

There is some truth to this, said public health researcher Olivier Telle. “The disease [dengue] shares many symptoms with other diseases. So taking only confirmed cases is not always a bad idea.” However, he added that the problem of “under-reporting is an important issue”.

Under-reporting figures on dengue, and communicable diseases in general is a national tradition. A study in the American Journal of Tropical Medicine and Hygiene found that India under-reported dengue by a factor of 282 times, compared to other countries that under-report 10-30 times the actual number.

Such is the authorities’ fear that even the rich and influential, who presumably avail of the best health care, are not spared. Bollywood mogul Yash Chopra was reported to have died of dengue in 2013, and the Mumbai municipal corporation reviewed his case after death to check if this was correct. An Al Jazeera investigation published in 2016 uncovered evidence that malaria figures were manipulated in Orissa state and Andhra Pradesh.

A study in the American Journal of Tropical Medicine and Hygiene found that India under-reported dengue by a factor of 282 times, compared to other countries that under-report 10-30 times the actual number.

American Journal of Tropical Medicine and Hygiene

This is not a recent phenomenon either. A report in The Telegraph in September 2005 said the Calcutta government had acknowledged dengue belatedly after it was “shoved under the carpet as either viral fever or sometimes as mystery fever”.

Like Choudhury, Dr Zarir Udwadia – one of the world’s foremost experts in tuberculosis (TB) – also experienced the Indian health bureaucracy’s paranoia first-hand. Udwadia has published 115 research papers in scientific journals, and his paper “Totally Drug Resistant Tuberculosis in India” co-authored with three others was published in the journal Clinical Infectious Diseases in 2012. It was based on his treatment of, and research on four patients in Mumbai who did not respond to any of the first or second line TB drugs available. Hence, the use of the term totally drug resistant (TDR).
“The response from the Indian government was immediate,” said Udwadia. “There was a ‘raid’ on our lab [in Hinduja Hospital] and they seized the four cultures we had developed to study the strain of tuberculosis. There was pressure on me to retract the paper.”

The paper, however, still stands and has had a major impact in the scientific community.

When Ray made his film Ganashatru, it received poor reviews, mostly for its play-like feel. It was a more innocent time then; there was less journalism on the under-reporting of public health crises and there was no social media. Also, academic research on such subjects was less accessible because there was no internet.
Perhaps, the conflict between state and medical professionals felt abstract at the time. Today, when doctors are suspended and raided for writing the truth, it feels prescient and relevant. A warning that came years before we knew what was going on.

This story was originally published in the South China Morning Post