The country's public health system appears to be fighting a losing battle against measles, suspected measles and dengue. The situation is especially disconcerting because health and family welfare minister last April had expressed the hope that the measles outbreak would come under control soon once nationwide vaccination was expanded. More than four months later, however, confirmed and suspected measles cases, hospitalisations and deaths show no sign of abating. Rather, after some decline in June and July, the trend turned upward again in August. According to the Directorate General of Health Services (DGHS), the combined death toll from confirmed measles and measles-like symptoms reached 983 on September 2, of which only 99 were laboratory-confirmed measles deaths. Over 160,000 suspected and less than 19,500 confirmed cases had been recorded since mid-March. Obviously, something has gone wrong between the government's vaccination targets, actual coverage and the measures necessary to contain transmission.

In fact, the weakness in the vaccination programme came to light when it was found that 3.9 million more children were covered by the nationwide Vitamin A Plus campaign than were by the measles-rubella vaccination drive. The difference is too large to be dismissed as a statistical aberration. The government later admitted that its vaccination target had been underestimated and went for mop-up vaccination. Even so, cases and deaths rose again in August. Why? Was the problem simply one of missed children, or were there gaps in vaccine delivery, cold-chain management, case isolation and surveillance? The health authorities cannot keep answering such questions with another vaccination drive alone. What is required now is an epidemiological study by an expert group to analyse the geographical and age-related pattern of infections, vaccination status of patients and reasons behind deaths. The findings should be made public so people may know why a vaccine-preventable disease is continuing to claim so many lives despite the ongoing campaign.

There is yet another issue that requires immediate clarification. What exactly does the DGHS mean by 'suspected measles'? In public-health surveillance, a suspected case may mean a patient having fever and characteristic rash or one whom a health worker suspects of having measles before laboratory confirmation. But when around 90 per cent of the reported deaths are classified as suspected measles deaths, the matter can no longer remain confined to a technical definition. If these deaths were caused by measles, why could those not be confirmed? And if a significant number were not measles, what disease or diseases presenting measles-like symptoms caused those fatalities? The health authorities and experts should explain how many suspected cases are tested, what proportion ultimately prove to be measles and what other diagnoses are found. Without such information, neither the true magnitude of the epidemic nor effectiveness of measures taken can be assessed. Public confidence cannot be expected to grow when most reported deaths remain under the label of 'suspected'.

Meanwhile, dengue has returned to complicate the health situation further. Five more dengue deaths and over 1,100 hospitalisations were reported in 24 hours on September 2, taking this year's dengue death toll to 107 and hospital admissions to more than 38,000. With monsoon conditions continuing to provide breeding grounds for Aedes mosquito, infections may rise further even as thousands of measles patients require hospital care. So, how is the health ministry going to manage two epidemics simultaneously with the same overstretched hospitals, doctors, nurses, laboratories and disease-control machinery? The response cannot be one of separate programmes working in bureaucratic compartments. There has to be a unified command bringing together the health ministry, DGHS, local government bodies, epidemiologists, laboratories and hospitals to fight the present national health emergency. Faced with measles that refuses to go away and dengue that is again gathering force, the government should take commensurate measures to combat both.