The art of fighting the dengue outbreak

Tantri Yuliandini, The Jakarta Post, Jakarta

Millennia have passed since Sun Tzu wrote his extraordinary treatise The Art of War, yet the wisdom of it is still relevant and can be applied to a different kind of war today, one that is no less devastating in effect -- the effort to control the spread of dengue hemorrhagic fever (DHF).

Every year since 1968, Indonesia has been beset by an onslaught of DHF, with the number of victims rising with the passing of years and with an upward spike every five years or so.

There have been 3,903 reported deaths caused by DHF since 1998, and recent figures show that 19,904 dengue infections with 344 casualties (March 2, 2004) in 25 provinces have occurred thus far in 2004. And there does not seem to be an end in sight.

Whoever is first in the field and waits for the coming of the enemy, will be fresh for the fight; whoever is second in the field and has to hasten to battle, will arrive exhausted.

Experts say that synchronized, comprehensive and continued action to stop dengue is crucial, but year after year government efforts focus on immediate threats rather than long-term sustainability, and meanwhile hundreds die every year.

According to the director for the eradication of animal-borne diseases, Thomas Suroso, the problem lies in the blatant lack of funding for a long-term, large-scale community effort.

"The Mercedes is available and ready to go, but we don't have the fuel to run it," he explained. Thomas was speaking at a monthly discussion organized by non-governmental organization, Coalition for a Healthy Indonesia (KIS).

It is unfortunate that there is this "out of sight, out of mind" mentality by the government bureaucrats as soon as the scourge dies down each year, and they move on to the next fire to extinguish.

The art of war teaches us to rely not on the likelihood of the enemy not coming, but on our own readiness to receive him; not on the chance of his not attacking, but rather on the fact that we have made our position unassailable.

Limited financial and human resources and competing priorities have resulted in a crisis mentality with emphasis on implementing so-called emergency control methods in response to epidemics rather than on developing long-term programs to prevent the epidemic from cropping up each year.

As a result, an epidemic has often reached or passed transmission before it is detected, while longer term efforts to eradicate the disease have become nothing more than ceremonial events.

If you know the enemy and know yourself, you need not fear the result of a hundred battles. If you know yourself but not the enemy, for every victory gained you will also suffer a defeat. If you know neither the enemy nor yourself, you will succumb in every battle.

Dengue is a disease caused by any one of four closely related viruses (DEN-1, DEN-2, DEN-3, and DEN-4) of the genus Flavivirus.

It is transmitted to humans through the bite of an infected mosquito, with the Aedes aegypti mosquito as the primary transmitter, or vector, and the Aedes albopictus and Aedes polynesiensis mosquitoes as secondary and tertiary vectors.

The dengue virus infection may be asymptomatic or may cause undifferentiated fever, classic dengue fever, or DHF and dengue shock syndrome (DSS).

DHF is a potentially lethal complication, and according to the World Health Organization has become the leading cause of hospitalization and death among children in several Asian countries.

According to University of Indonesia professor of clinical microbiology Agus Syahrurachman, recovery from infection by one of the four viruses will give lifelong immunity against that particular serotype, but not against the other three dengue types. So persons living in a dengue-prone areas can have up to four infections during their lifetimes.

"Secondary infections with another type of dengue can be more severe," Agus said, explaining that a vaccine for all four dengue types has yet to be developed.

To fight and conquer in all your battles is not supreme excellence; supreme excellence consists in breaking the enemy's resistance without fighting.

At present, the best method to control and prevent dengue and DHF is to combat the vector mosquito which breeds primarily in man-made containers such as water storage vessels, bottles, cans, metal drums, discarded plastic food containers and other items that collect rainwater.

Prevention efforts should focus on sustainable control of Aedes aegypti, permanently reducing mosquito populations to very low levels. And this means a community effort, or what is called here as kerja bakti (voluntary work), promoting community ownership and participation.

The rationale is that the families who live in the houses where Aedes aegypti mosquitoes breed, and who help create the larval habitats, are the only people who can control it effectively of the long haul.

The problem is, according to Agus, the communal concern, which Indonesians were so proud of a decade ago, has diminished in the reform era as it is associated with the harsh New Order regime.

"People today don't take action unless they personally have been hit by the tragedy. It wouldn't cost much money if people could be made to understand the need and their interest in the effort (to keep all breeding areas in and around their homes clean)," Agus said.

In order to kill the enemy, our men must be aroused to anger so that there may be advantage from defeating the enemy, they must have their rewards.