The art of fighting the dengue outbreak

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.