Triple jeopardy

Since May 2020, Suresh Sarkar’s family of seven in West Bengal has seen a decline in nutrition intake. First, cyclone Amphan devastated their village, Bamonpukur, in the Sundarbans. Their house, a semi-permanent dwelling made of bamboo and mud, was damaged and all the fish in their pond died, as a nearby embankment had breached and released polluted, saline sea water. This dealt a major blow to Shankar, Suresh’s nephew and the sole earner of the family, who used to earn Rs 15,000 a month from fishery in the pond. The next year, cyclone Yaas made landfall exactly at the time of high tide. Fields were inundated with saline water, destroying crops in a region where most people survive on subsistence agriculture and fishery.

Now, Shankar drives a cycle van to transport goods and finds jobs as a construction worker, for just Rs 7,000 a month. The family has also incurred debt after building a small pucca house post Amphan. This economic disparity has changed food habits; rice and wheat are now staples, and leafy vegetables grown in the wild have replaced eggs, fish and chicken.

The change is especially risky for 50-year-old Suresh, due to his history with leprosy, a bacterial disease that affects motor and sensory nerves causing numbness and deformities in the limbs. The infection targets people with protein-energy malnutrition, lack of sanitation and hygiene, and inadequate housing. Suresh was diagnosed twice, in 2003 and in 2011. Although cured, he still faces muscle weakness and chronic fatigue. He fears developing ulcers on his numb hands and feet and cannot even work as a contractual labourer. His 16-year-old son and 18-year-old daughter, genetically susceptible to leprosy, eat barely one nutritious meal a day.

Such stories are found across the Sundarbans, the cyclone capital of India. But this region is not the only one. Several districts face the triple burden of high leprosy prevalence, climate extremes and socio-economic vulnerabilities.

Risk patterns

India has the highest leprosy prevalence in the world, contributing about 55 per cent of the global cases reported each year. Historically, seven states—Bihar, Chhattisgarh, Jharkhand, Maharashtra, Odisha, Uttar Pradesh and West Bengal—contribute 70-80 per cent of the cases, as per data with the Directorate General of Health Services (DGHS) under the Union Ministry of Health and Family Welfare.

“Climate Vulnerability Assessment for Adaptation Planning in India Using a Common Framework”, a report released by the Department of Science and Technology in 2021, identifies states highly vulnerable to climate change. An analysis of the report by The Leprosy Mission Trust of India finds that these same states have a high endemicity of leprosy and other neglected tropical diseases (NTDs) such as lymphatic filariasis, a vector-borne infection that causes swelling in the legs, arms and genitalia.

Further, a study of NITI Aayog’s “India National Multidimensional Poverty Index 2021”, which measures the parameters of health, education and living standards, shows that the same districts that fare poorly in nutrition intake and other indicators are also co-endemic for leprosy and other NTDs.

Take Bihar, for example. On average, the state reports about 15 per cent of the new leprosy cases in India each year, as per the Central Leprosy Division. More than half (51.9 per cent) of its population is multidimensionally poor. In its three northern districts, Sitamarhi, Supaul and Kishanganj, the leprosy prevalence rate is up to 2.32 per 10,000 population, as against the national average of 0.57. Some 63-65 per cent of people in these districts live in multidimensional poverty.

In some districts of the state, up to 75 per cent of leprosy cases are multibacillary (MB), in which the patient has high bacterial load and can lead to more transmission. They are also at greater risk of developing reactions and consequent nerve damage. MB leprosy cases develop in patients with reduced or impaired cell-mediated immune reaction, caused due to protein-energy malnutrition, says a 2017 study by researchers from Brazil and the US, published in PLOS Neglected Tropical Diseases.

This calls attention to Bihar’s food security landscape. Some 31 of its 38 districts are among the top 25 per cent most climate-vulnerable districts. Around 6.8 million hectares (76 per cent of north and 73 per cent of south Bihar) of the state’s 9.4 million hectares is flood-prone. Extended dry spells in summer, erratic monsoon rainfall, and abnormal rise and fall in temperature during the rabi sowing season in winter causes high variability in foodgrain yield, especially in diverse and nutritious crops, which can affect intake of essential nutrients.

Bihar’s neighbour Uttar Pradesh shows a similar cause-and-effect relationship. In 2020, the state reported 15,484 new leprosy cases, the third highest in the country. In Shravasti and Bahraich districts, where it is highly prevalent, over 70 per cent of the population lives in multidimensional poverty. The districts also report other NTDs.

About 31.2 per cent of the population in the state does not have adequate sanitation facilities, according to the fifth National Family Health Survey for 2019-21. Out-of-pocket expenditure accounts for 72.6 per cent of the state’s total health expenditure—much higher than the national average of 48.8 per cent—forcing households to compromise on food security.

In terms of climate vulnerability, 69 per cent of districts in Uttar Pradesh are exposed to events like floods and droughts, according to a 2021 report by the Council of Energy, Environment and Water. Over the past two decades, it has seen an increase in incidence of extremely high temperatures and torrential rain. Its agricultural productivity is predicted to decline by up to 25 per cent in irrigated areas and up to 50 per cent in rain-fed areas, as per the “Uttar Pradesh State Action Plan on Climate Change”, 2017.

Similar patterns emerge in Chhattisgarh, Odisha and Maharashtra. Districts with high endemicity of leprosy and high proportion of tribal populations shuttle between droughts and floods. This impacts agriculture and allied sectors, leaving marginal farmers and tribal people who rely on rain-fed monocrop agriculture or forest produce, the most vulnerable to the impact of climate change.

Focus on health

The National Leprosy Eradication Programme has two specific targets for 2027: interruption of transmission at district level, or zero occurrence of new child cases for at least five consecutive years; and elimination of leprosy as a disease, or no new cases reported for at least three consecutive years. For this, we need interventions on supply and demand sides of health systems.

It is important for the at-risk population to be able to prioritise health. This is not possible when exposure to climate anomalies raises concerns over food insecurity, homelessness and debts. There is a need to move away from national and focus on block-level vulnerability assessment through hyperlocal epidemiological and meteorological data.

On the supply side, frontline health workers must be sensitised on the linkages between climate and health and build their capacity to identify risks and plan preventive interventions. Implementing a holistic One Health approach towards leprosy elimination, which goes beyond only the clinical aspects of the disease and focuses on intersectoral coordination between the departments of health, tribal affairs, agriculture and environment is needed.

Subhojit Goswami is senior programme manager and Nikita Sarah is head of advocacy and communications at The Leprosy Mission Trust India

This was first published in the 16-31 March, 2024 print edition of Down To Earth