Manipur: Epidemics May Break Out in Relief Camps if Urgent Measures Not Taken, Warn Doctors

Routine immunisation for children has stopped, surgeries and dialysis put on hold, referral to higher health facilities has become a thing of the past. Shortage of medicines and restrictions on doctors' movements paralyse healthcare in the state.

New Delhi: The people living in camps in Manipur may face outbreaks of dengue and other infectious diseases if preventive measures are not taken up soon, doctors have warned. The cramped spaces where people are living, and not-so-good water and sanitation facilities, may aid these outbreaks, they said.

Talking to The Wire from Imphal, Dr M. Nara Singh, who is also a former health minister of the state, said, “I am worried – epidemics may break out – especially dengue and Japanese encephalitis, because the season is such and there are hardly any preventive measures being taken up,” he said. Dr Nara Singh is also a member of an association called Indian Doctors for Peace and Development (IDPD). IDPD members from outside Manipur also visited the state on September 1 and 2.

“There are more than 60,000 people in the camps without much proper arrangement and therefore they are susceptible to all these infections, ” Dr Nara Singh said, adding that already there are some reports of malaria cases coming up.

The violence in the state entered its fifth month in September.

Dr Manglem Singh, another IDPD member based in Imphal, said that only a handful of the camps have piped water supply. The rest have to rely on potable water which is supplied through tankers. Not only can the supply be erratic due to blockades, but it is difficult to ensure the quality of drinking water being supplied like this. Dr Manglem Singh is a retired medical officer of the state.

Routine immunisation of children has also almost stopped in the state, said Dr Shakeel Ur Rahman, one of the IDPD members who visited the state recently. The state government will need to launch catch-up campaigns for children who have missed out on immunisation.

Dr Rahman was also worried about the quality of food being made available to the children, especially, in the camps, as the bulk of responsibility of running those camps is on the community or civil society groups.

“One camp manager in a Meitei area told us that his team is able to give an egg once a week to the child. In a Kuki area, the team told us it is happening only once in fortnight,” he told The Wire.

Whenever the situation returns to normalcy, then the government will have to give children Vitamin A orally to make up for the loss, Dr Rahman said. Severe Vitamin A deficiency can cause eye damage and a higher risk of dying from measles and diarrhoeal disease. Also, a measles immunisation drive is urgently needed for children in camps, he added.

Green, leafy vegetables have also almost gone missing for four months now, the IDPD team found. And this could directly impact some of the health indicators of the state’s children. According to the National Family Health Survey (NFHS)-5, as many as 43% children aged between 6-59 months are already suffering from anaemia in the state. The overall anaemia in children went up to 43% in 2019-21 (NFHS-5 period) from 23% in 2015-16 (NFHS-4 period).

The NFHS-5 had already flagged the problem of undernutrition in the state. And the ongoing ethnic clashes, which have forced people to live in camps and have led to halting of various government programmes for children, might only end up increasing the scale of the problem.

The deficiency of various micronutrients are responsible for aggravating childhood morbidity and mortality. According to the NFHS-5, the percentage of children who are stunted in the state decreased slightly from 29% to 23% in the 4 years between NFHS-4 and NFHS-5.

“However, the continuing high levels of undernutrition are still a major problem in Manipur,” NFHS-5 had noted.

Representative image. A camp housing those displaced by the Manipur violence in Imphal East camp. Photo: Yaqut Ali/The Wire

The United Nations Humanitarian Commissioner for Relief (UNHCR) has a set of guidelines called ‘Sphere standards’ for people living in relief camps. “Either most of these guidelines were not being followed or only done so partially,” Dr Rahman observed about the camps the IDPD visited. The Sphere standards pertain to minimum services that the people living in camps must get in four  areas: water supply, sanitation and hygiene; food security and nutrition; shelter and settlement; and general health.

Immediate problems

While these long-term problems could potentially impact the people, especially children, living in the camps, the IDPD doctors also alluded to the immediate health problems that the four-month-long shutdown in the state has led to.

Healthcare delivery services have near paralysed in the peripheral areas. As The Wire reported earlier, the split along the community lines – Meitei and Kuki – among doctors and other healthcare providers, just like other professionals, is nearly complete. This ensured that doctors belonging to a particular community would not go to their healthcare facilities if they fell in the areas that were dominated by the other community, and vice-versa. This has resulted in a shortage of doctors across the state.

The IDPD doctors told The Wire that even if security is promised to healthcare workers along the routes of their travel, they won’t agree to go for two reasons – doctors of one community now can’t seem to work with their colleagues from the other community; and they don’t trust security forces because people have been killed in their presence.

The absence of doctors has led to inordinate delays in conducting many elective but necessary surgeries across the state, among many other problems.

“Surgery is teamwork. If there is one member of the team present, s/he can’t do anything if others are not there,” said Dr Nara Singh. “And, if the team comprises doctors belonging to both the communities, then it is impossible that the full team would be at work on any given day [in the current circumstances],” he added.

Manipur has four medical college-hospitals. Out of them, three are located in Imphal. The hills, where the Kuki population lives, has only one medical college-hospital which is in Churachandpur. This district got the medical college recently as its district hospital was converted into it.

According to the last edition of the Rural Health Statistics (RHS), there is a major scarcity of specialist doctors – obstetrics and gynaecology, surgeons, paediatricians and physicians – in the community health centres (CHCs) of the state. The state has 17 CHCs. According to the RHS, against the requirement of 17 doctors specialising in each of the various disciplines, only a handful are available at the state’s CHCs: surgery (2), Oostetrics and gynaecology (8), physicians (2), paediatricians (3) and eye surgeon (1).

This shortage reveals how heavily the people living in peripheral areas would depend on the tertiary care centres of Imphal. As such, most people from the hills would rush to Imphal should specialist care be needed in the period when things were functioning normally in the state.

Now, because of the ongoing violence, the movement of people living in the hills to the valley is completely restricted, thus bringing the referral to higher centres to a grinding halt. Therefore, now people are either travelling more than 100 km to reach Dimapur in Nagaland or Aizawl in Mizoram from the respective borders of the state. While a person with resources might be able to afford this, it will not be possible for everyone.

Dr Rahman came across a patient in a Kangpopki camp who was suffering from scrub typhus, an infectious disease. For diagnosis he had gone to Nagaland’s Kohima but it was impossible for him to go there again, for a follow-up. And he was living in the camp, without access to any treatment as such. He was reported as having breathing issues among other problems.

Dr Rahman also found cases where patients who require routine dialysis were not able to get it done – which would worsen kidney disease. The IDPD team, which met two state government officials, recommended starting at least peritoneal dialysis – a less sophisticated process than hemodialysis which is usually preferred – but considering the current scenario, even the former would come handy. peritoneal dialysis doesn’t require the presence of a specialist.

At a Kangpopki primary health centre, where the team visited, it found there was not even a blood storage unit, forget a blood bank. So if a C-section patient required blood post the procedure, she would have no option because the route to Imphal was shut and there was no facility to get blood locally.

Even telemedicine, a service which receives special attention from policymakers, had turned out to be non-existent, thanks to the internet ban. “If patients are not able to go physically and consult specialists in Imphal, telemedicine at least would have provided them some sort of an alternative,” Dr Rahman said.

“Making prefabricated operation theatres and arranging mobile health facilities is, we hear, on the cards. But it defies common sense why it took so long for the government to think about them,” Dr Manglem Singh said. He also added that the Union government could have easily deputed doctors from outside the state in various parts of the state, as they would not have a Meitei or a Kuki affiliation, and would have been easily worked in hospitals across the state.

All the doctors that The Wire spoke to said a lot needed to be done to ensure adequate supply of medicines to people living in relief camps. The ones who suffer from diseases like hypertension, diabetes and cardiac problems need a constant flow of drugs which have turned elusive from them. This could lead to worsening of diseases, or even death.

“A senior official of the state government told us that there was no shortage of medicine per se. But the distribution chain, which got broken due to the blockades and violence, has resulted in an artificial shortage,” Dr Rahman said. For four months now, somehow, the government has not been able to find ways to ensure through dialogue or whatever means, that the ones creating blockades should at least allow the movement of drugs and vaccines.

According to the RHS, the state has 416 health subcentres, 86 primary health centres, 17 community health centres, six district hospitals and three (now four) medical colleges-hospitals. Reports suggest from right from subcentres to medical colleges, all health facilities are grappling with medicines shortages.