Is dengue fever today a man-made disaster? An ethical dilemma

I faced a serious ethical dilemma while attending a couple of cases of dengue fever at a ward in the Kolkata Municipal Corporation (KMC) area during September 2013. Two patients had tested positive for dengue IgM antibody by MAC ELISA. Adjacent to their house was a vacant plot of around 1500 sq feet and this was heaped with domestic waste from the neighbouring houses. The waste comprised plastic cups, thermocol plates, plastic bags and boxes of biscuits, cakes, chips and other foodstuff, coconut shells, bicycle tyres and earthen pots. These served as a permanent breeding ground for Aedes mosquitoes, the vector for the dengue virus. The owner of the land lived elsewhere and the local people had been dumping their domestic waste here indiscriminately, without the owner’s permission. They had converted the area into an unauthorised garbage dump, despite the fact that the conservancy workers of the KMC visited the place for house collection of wastes every day.

Later, I came to know that two more NS1-reactive dengue cases had been reported from the same locality the following week. I informed the KMC health department about the matter, as dengue is a notifiable disease here. Health workers from the KMC visited the area and discovered several plastic cups, earthen pots, coconut shells and the like, which contained stagnant water. Larval and pupal stages of the Aedes species were found on the rooftops of most houses in the locality. Van-fogging of the area with adulticides was performed, as well as source reduction, followed by chemical (Temephos 50% EC) spraying in the moist areas and other possible breeding sites that could not be destroyed. Last year, there had been a dengue outbreak in the area and three deaths due to dengue shock syndrome were reported. The KMC authorities have been sending surveillance workers with information, education and communication (IEC) materials, such as handbills, to this area on a weekly basis for the past six months. They have even hired an auto-rickshaw and fitted it with a microphone to conduct IEC activities in the area twice a week. Their field workers and surveillance workers have been carrying out anti-larval activities, such as source destruction and chemical spraying, and conducting active surveillance for new cases of fever throughout the year. Further, IEC activities are being carried out through television, FM radio, newspapers, electricity bills, handbills, and so on.

Despite the above measures, people continue to dispose of waste indiscriminately, resulting in the accumulation of stagnant water. Therefore, it was evident that mere IEC and chemical spraying would not suffice; the civic authorities would need to take decisive action to improve the environment.

Despite the outbreak of dengue in the area the previous year, the residents failed to reduce the sources conducive to the breeding of mosquitoes in their own premises. Even after the enormous efforts of the KMC health department, they failed to realise how they themselves had promoted the breeding of Aedes mosquitoes. Should people have the liberty not to keep their premises clean when this can make others ill and even result in their deaths? Should the authorities, in the interest of beneficence and justice for the larger community, have the right to forcibly take action to clean up people’s premises? Should people have the right to convert others’ premises into an unauthorised dumping ground, endangering the life of others in the community? Should the authorities, in the interest of non-maleficence and justice for the owner, as well as beneficence for the community, have the right to take legal action against such transgressions? The dilemma remains unanswered.