Kala-azar: a disease from the “Darkness”

Balram Halwai the antihero of the novel The White Tiger, a page-turner from Aravind Adiga, leaves his poor rural village in Bihar to work as a driver in Delhi. Thousands of Biharis do the same trip every year escaping the “Darkness” as Balram describes this northern region in India. It is in this “Darkness” where a major part of the population in Bihar lives, with raw sewage flowing through town, no access to fresh drinking water, and endemic kala-azar.

Kala-azar means black fever in Hindi. It is a parasitic disease transmitted by sand flies. Known as visceral leishmaniasis, it stands for a dull title: the second parasitic killer in the world after malaria. More than 90% of global kala-azar cases occur in six countries: India, Bangladesh, Sudan, South Sudan, Ethiopia and Brazil. Kala-azar is especially prevalent in the most vulnerable communities in Bihar, where 90% of the cases reported in India are registered. The burden does not only fall disproportionately on the poorest of the poor, but also on the socially excluded, that is the lowest castes.

Adiga uses Balram’s adventures to provide a darkly comic perspective of modern India society, outstanding the big differences between socio-economic classes and castes. Indeed, in rural Bihar socio-cultural factors play a significant role in limiting access to diagnosis and treatment of kala-azar and other diseases. In Balram’s rural village everybody would have heard about kala-azar, since it is a curse not easy to escape from. Kala-azar kills you if you are not treated. But if you reach the hospital and are treated on time, the cost of treatment will certainly bankrupt your family. Balram escapes the “Darkness” after his father, a rickshaw puller, succumbs to tuberculosis in a hospital in which there is no doctor to attend him. Had he suffered from kala-azar, the outcome would have been the same.

As Margaret Chan, the Director-General of the World Health Organization, noted during the launch of the World Health Report 2013, there have been major advances in drugs and diagnostics to fight kala-azar in recent years. Research has shown that a new and cheaper drug combination for the treatment of kala-azar is just as effective as the existing treatment. It requires a shorter treatment time, has a good safety profile, and carries a lower risk of drug resistance. However, these new tools do not always reach the most vulnerable communities. Efforts need to be renewed to ensure complete, safe, efficacious, and free treatment is provided to all kala-azar patients in Bihar. Efforts should be renewed to bring light into the “Darkness”.