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Insurgency makes health care dangerous

In the state with the highest prevalence of HIV in the country, insurgency has added to the difficulties of people accessing health care. Health teams cannot operate freely in areas where the insurgents’ writ runs large, and bombs, bandhs and curfews prevent people from getting timely medication. Chitra Ahanthem reports from Manipur

Manipur, one of the seven states that make up the North East region of India, has the highest prevalence of HIV among the high prevalence states in India. About 1.13% of the state’s adult population is HIV-positive.  

This figure, from the National Family Health Survey 3 (2005-6), is five times higher than the national adult prevalence of 0.28 %.  

The National Family Health Survey (NFHS-3), 2005-06 provides the latest figures on health and healthcare in the state. However, these figures give a picture of health at the state level. In Manipur, as in other states in the region, there are marked differences from one district to another in terms of political, economic, social, cultural, health, development and education norms and standards. The urban-rural divide has little relevance here either, because the state is home to various tribes with their own aspirations of governance and identity. 

One of the biggest problems the healthcare system faces is staff absenteeism. There are many reasons for this. Doctors, paramedical staff, teachers and most government officials posted to districts other than the main Imphal East and Imphal West districts, do not remain there.  

“The living quarters are not fit to be lived in,” said a doctor posted in a district hospital in the hill districts. “I decided that I would stay two nights there every week, but I was told that no one has ever done even that much.” A compounder belonging to a village in the district doubles up as diagnostician and traditional healthcare provider in the doctor’s absence.  

For people like K T Shangrein, secretary of the Chandel Network of Positive People, the irregular attendance of doctors at the district hospital means that when she goes to get her monthly stock of anti-retroviral (ART) medicines, she cannot always get a health check-up at the same time.  

“I always end up coming to Imphal to go to the main hospitals or have my check-up done by the doctors who give time to the Manipur Network of Positive People,” she says. “The doctors posted at the district hospital are from other districts and do not turn up regularly. This is true for most departments but for people living with HIV/AIDS who have opportunistic infections that need to be treated immediately, it means that we have to take out time and spend money to go to Imphal.” 

Doctors may be deterred by more than just the condition of the living quarters in this conflict-ridden state. Various armed groups decide what happens within their areas of influence and there have been many incidents of healthcare workers being denied entry into a district. It is not uncommon to come across news reports of government officials being refused entry into an area, beaten up and even killed.  

The latest incident was in August 2009. Three staff members of the central government’s ministry of health and family welfare, who were conducting an awareness campaign at Khoupoum village in Tamenglong district, were subjected to brutal torture by cadres of the underground National Socialist Council of Nagaland-Isak-Muivah (NSCN-IM). The team was on a central government tour to spread awareness against tobacco. They were charged with the crime of not taking prior permission from the NSCN-IM to conduct the health programme.  

The conflict in the state affects healthcare institutions at all levels. The Regional Medical Institute of Medical Science (RIMS) is supposed to be one of 10 regional centres of excellence established to provide state of the art services for people living with HIV/AIDS, and be knowledge hubs, resource centres and centres for training of other doctors on HIV/AIDS.  

RIMS is a joint venture of all the north eastern states funded by the Government of India through the North Eastern Council and the six beneficiary states. Yet it regularly shuts down its operation theatres, outpatient departments and various other departments in response to demands made by armed groups. Over the course of any given year RIMS, as well as private clinics and hospitals operating in the state, are held to ransom by various armed groups demanding large sums of money. At present, no vehicles are allowed entry inside the RIMS campus following an official notification on September 10.  

Dr Y Mohen, medical superintendent of RIMS, told the media, “The Institute has become vulnerable to… violence, and in view of the security of the hospital and to prevent any untoward incident in the RIMS campus, the authorities have recently decided to prevent entry or parking of private vehicles inside the RIMS campus on security grounds.”  

Private hospitals and clinics are worse off than the government health institutions. “Government hospitals get only extortion letters. We get grenade bombs hurled into the hospital premises,” said Sheila (name changed), a nurse working in a private hospital, 

According to L Deepak, president of the Manipur Network of Positive People, “The law and order situation in the state is not facilitating an all out response in the fight against HIV/AIDS.” He goes on to add, “The frequency of bandhs, strikes and curfews affects access to healthcare among PLHAs and drug users. The intake of fresh needles and syringes drops, which increases the risks of HIV transmission since drug users end up sharing injecting equipment. Sometimes, people who have to collect ART on certain days are not able to come to the ART centre because of a bandh. We ask another person taking the same medication to share the dosage until a fresh supply becomes available.”  

It gets more complex for people who are on ART as well as TB medication since the anti-TB medication must be given to patients under the direct observation of the staff, and the drugs vary according to the duration of treatment. “Many of our members have missed out on TB drug doses during the recent curfew phase that we had in the state since neither the staff at the DOT centres nor the patients could move out of their homes,” added Deepak. 

Clearly, the overall health situation in Manipur is being affected by the ongoing conflict that affects service delivery as well as the health infrastructure. It is not uncommon for pharmacies to be shut for weeks protesting against huge extortion demands or for hospitals to run out of stock of essential emergency items like oxygen cylinders on account of highway blockades.

Manipur: Some statistics 

With a geographical area of 22,327 sq km, the state of Manipur has 22,93,896 inhabitants (according to the 2001 census). They are spread out over five districts in the hills and three districts in the plains.  

According to the National Family Health Survey 3 (2005-2006), which interviewed 4,512 women and 3,951 men across the state, 1.13% of the general adult population has HIV –  0.76 % of women and 1.59 % of men.  

According to NACO’s sentinel surveillance figures, based on blood collected from antenatal clinics, HIV prevalence dropped from 1.25% in 2006 to 0.75% in 2007. HIV prevalence is much higher in certain districts (Ukhrul 6% and Churachandpur 3%), and certain groups (16.4% among men who have sex with men, 17.9% among injecting drug users and 13.1% among female sex workers in 2007 (based on blood collected from centres run by NGOs working with these groups).  

In the latest quarterly report from the management information system of state AIDS control societies, 13.3% of clients at integrated counselling and testing centres (ICTC) in Manipur, referred there by health care providers, and 11.2% of clients who visited the ICTC on their own, tested positive.  

The prevalence of tuberculosis in Manipur - 804/100,000 - is twice the national average, higher than in all other states of India, except Arunachal Pradesh. 

The infant mortality rate in Manipur (30/1,000 children die before the age of 1) is lower than all other states in India except Goa and Kerala.  

Some 36% of children in Manipur under age five are too short for their age, which means that they have been undernourished for a long period. Nine per cent are too thin for their height, which can be because of an acute episode of starvation or a recent illness. Over one-fifth is underweight, which can be because of both chronic and acute under-nutrition. 

Some 36% of women aged 15-49 in Manipur have anaemia, more for pregnant and breastfeeding women, and scheduled caste women. Anaemia is more widespread now among both women and children than it was seven years ago at the time of NFHS-2.  

About four-fifths of households in Manipur get health care from public health centres and hospitals (82% in rural areas and 72% in urban areas).  

Some 87% of pregnant women received some prenatal care and 59% had institutional deliveries, which are a key factor in reducing maternal mortality. About 47% of children received all vaccinations.  

In Manipur 89% of children under six years live in areas covered by an anganwadi centre through which the Integrated Child Development Services programme provides nutrition and health services. However, less than one-third of these children receive services of any kind from a centre.  

Source:
http://www.nfhsindia.org/pdf/MN.pdf
|http://www.nfhsindia.org/Manipur_report.html
http://www.nacoonline.org/upload/

(Chitra Ahanthem writes on issues around HIV/AIDS and drug use, gender and conflict. She is based in Imphal and writes for The Imphal Free Press (Manipur) and the Health and Development Network (HDN, based in Chiang Mai, Thailand) 

InfoChange News & Features, September 2009