Why are children in Kerala’s Muslim-dominated Kozhikode and Malappuram districts dying of diphtheria? Propaganda by orthodox Muslim community leaders and alternative medicine practitioners that vaccination is un-Islamic is the main cause, reports Rajeev G.R.

Her years of clinical experience had not prepared her for that damp, rainy night when death lingered in the air inside the operation theatre. As Mohammad Afzaz (14) desperately gasped for air, he told her, “You do the surgery fast, just let me breathe.” The Class IX student, afflicted with diphtheria, died within hours after the surgery on the morning of June 23.

That he would have been alive if administered with a simple vaccine is not lost on Beena Oommen, Associate Professor, ENT, Government Medical College, Kozhikode, who performed the surgery. She knew she needed to hurry if Afzaz were to have any chance of survival, rushing to perform the operation without all the protective gear for fear of losing time. “I performed the surgery in a few minutes. His airway was clear. And he looked at me with thankful eyes. But the toxins in the body killed the poor boy in six hours,” says Dr. Oommen, recollecting that night, and turning emotional, “Who is responsible for his death? The ignorant parents or those who talk against immunisation?”

The young doctor who was tasked with certifying Afzaz’s death, Mohammed Niyas, Senior Resident at the hospital, was just as disturbed. In a Facebook post, he wrote angrily: “I cursed all the vaccine hate-mongers in Kerala a thousand times in my mind as I was looking at him, my helplessness hid behind my face mask. I thought of blaming the parents for not vaccinating their child, but soon realised that it was not their fault. We have failed as a society, to educate people about vaccines and expose the anti-vaccine mafia in our State.”

A whisper campaign at work

In >Kerala’s Muslim-majority districts of Kozhikode and Malappuram, there are a number of other cases like that of Afzaz. And there is enough anecdotal evidence to suggest that such cases are on the rise, >thanks to propaganda that vaccines — which may contain microbes, chemicals, and animal-derived products — are essentially haram, or forbidden by Islamic law. There is a widely shared video clip with a cleric-like figure speaking about the potential harm of vaccines at a public meeting organised by a Muslim organisation for girls in Malappuram in February 2015. “A human being gets all the protection he or she needs in the womb before birth,” he thunders, “Vaccination is simply not required.”

The view that vaccination as a form of preventive medicine is not compliant with Shariat, the Islamic canonical law, is rarely expressed openly but spoken in whispers. Often, extreme religious orthodoxy dovetails with efforts to promote forms of alternative medicine such as Unani and naturopathy. “Many of the fake Unani and naturopathy practitioners dissuade less-educated people from vaccination. The quacks spread the lie that vaccination destroys the original immunity of the body and once you take modern medicine, homoeopathy and nature cure will not work,” says Ummer Farook V., District Medical Officer, Malappuram.

Days before Afzaz’s death, Mohammed Ameen from Tanur, Malappuram, had also died of diphtheria in the Government Medical College Hospital, Kozhikode. The acute and highly contagious bacterial disease, one that can be largely curbed by immunisation, >started spreading in Malappuram around September last year when two children from a poor family at Vettathur died of it in the hospital. Following the deaths, health officials found in a survey that 1,70,000 children in the 0-16 age group had not been immunised in Malappuram.

Thomas Bina, head of the Community Medicine Department at the medical college, says cases with symptoms of diphtheria have been coming to the hospital since 2011. Data compiled by the department show that while there were five cases each in 2014 and 2015, the number is 12 and climbing in 2016.

The short-term objective is to prevent more children from catching diphtheria. But the longer-term concern, say many doctors, is to prevent the propaganda against vaccines from spreading further. It could have implications for a slew of diseases ranging from tetanus to polio to rubella, they fear.

K.C. Soman, Superintendent of the Government Medical College Hospital in Kozhikode, has just received word from the laboratory that Majidha Farzana (15) is also down with the disease. The doctor says that Afzaz and the boy who died before him had not been given any vaccine shots. Those who were infected and survived had been partially immunised.

The hospital has been stocking its medicine chest with anti-toxins against diphtheria after long years. A Delhi-based firm produces it only on order, and the process using horse serum has juddered to a start. The doctors in the hospital break the vials, priced at about Rs.1,200 apiece, at the slightest hint of a sore throat turning into something worse.

From Dr. Soman’s office to Ward No. 43, where patients with infectious diseases are admitted, is a walk past several corridors and a flight of stairs. Ms. Farzana has arrived now and been given a bed in the isolation unit, a long enclosure of aluminium fabrication and glass, inside the ward. The girl’s mother, Oderil Sheeja (40), says she does not know what vaccines have been administered to her daughter. “We are poor. My husband is no more,” she says.

Outside the cubicle is a line of grimy white iron cots packed close together. On one of them is Mohammed Fayiz, his mother Vahida by his side. He is just out of the isolation unit, after being admitted a day after Afzaz died. From behind his green mask, the only thing infectious about the young boy is his laughter. At 21, Mr. Fayiz, who is awaiting his B.Com. results, is a rare diphtheria patient because the disease usually strikes those aged below the age of 16.

Dr. Ummer Farook V. says organisations such as the Jamaat-e-Islami have faced accusations of opposing vaccinations in the past. But Sheikh Mohammed Karakkunnu, assistant amir, Jamaat-e-Islami, Kerala, says there is nothing un-Islamic about vaccination. He blames differences between doctors of various systems of medicine for the slack vaccination in many pockets of Malappuram. Homoeopathy and naturopathy doctors are unleashing a campaign against vaccination, he alleges.

At a press conference in Kozhikode on June 30, the Ethical Medical Forum, the health wing of the Jamaat-e-Islami, demanded that Muslim leaders make clear their stand on diphtheria vaccination. The forum said vested interests were misusing the names of religious leaders to turn the faithful against vaccination. Immunisation is mandatory in all Arab countries, it added.

Sipping tea after iftar in his house near the Chaliyam ferry, some 30 km from Kozhikode city, T.P. Abdullakoya Madhani, president of the Kerala Nadvathul Mujahideen, an organisation that propagates Islamic beliefs, debunks various theories floated by fundamentalist elements globally, such as vaccination being a Western conspiracy to make Muslims infertile and vaccines being a prime cause of autism. He says Kerala’s Muslims, aware and educated, would never deny their children vaccines. “Anything the government does is viewed with suspicion. When Aadhaar was introduced, many said it was an attempt at profiling. But now almost every Muslim household in the State has Aadhaar cards,” he says.

In damage-control mode

Following Afzaz’s death, his parents Abdul Salam and Najimunnissa left Pulikal — 25 km from Kozhikode city — for Beypore, unable to live with the memories of their son in the village where he grew up. From their Pulikal house, against the backdrop of a hill from which rocks have been gouged out, a road leads to the village centre. At the gram panchayat office, panchayat president Shejini V.P., vice-president P.V.A. Jaleel and other members are in a meeting. Three more diphtheria cases were detected in the village on July 3, including of 21-year-old Sajina (21). The panchayat is now organising vaccination camps on a war footing.

It seems to be working: Afzaz’s classmates, and all students in the school subsequently, have been vaccinated. Mr. Jaleel says a 90-year-old man turned up for a vaccine shot, and a panchayat member who had not vaccinated his three children has done so now — but there are holdouts such as a man who has not vaccinated his children out of his belief that his elder brother’s son turned mentally challenged after being given the shot.

Soon after the September deaths, a 500-strong group of so-called alternative healers, led by Jacob Wadakkancherry, had marched from the District Collector’s bungalow through Malappuram town, speaking out against vaccination. A few days later, they organised a family meeting of those who have abjured vaccinations. The District Medical Office videotaped both events for taking action, but the “order from the top” was to maintain silence, says Dr. Farook.

His deputy, Mohammad Ismail, wonders how people in Malappuram, no den of the unlettered with a literacy rate of almost the same as the State average of 94 per cent, can believe in magical cures and alternative therapy in this age. Both doctors are now busy organising immunisation camps. It is not easy work; the district’s population stands at nearly 4.5 million, Kerala’s largest, the area is an expansive 3,550 sq. km, and its immunisation rate as of now is 84 per cent, one percentage point lower than the State average. From September to June, nearly 40,000 people above the age of six had been given the TD (tetanus-diphtheria) vaccine (the diphtheria-pertussis-tetanus vaccine or DPT can be given only up to the age of six). With 1,30,000 children in the 0-16 age group remaining to be vaccinated, fear has built up over the spread of infections.

The June deaths have amplified the campaign, with Mission Mukthi and Total Immunisation Malappuram being launched. Accompanying the campaign teams are video vans to screen reruns of the late Panakkad Syed Mohammadali Shihab Thangal, who headed the political party Indian Union Muslim League for many years, administering polio drops to children.

Sunni scholar Khalilul Bukhari Thangal inaugurated a mass immunisation campaign recently. “Community leaders have not taken ownership of immunisation campaigns so far. It’s time they did so. Teachers, activists, everyone should join in,” says Dr. Ismail.

The stellar role played in it by Muslim religious leaders in Uttar Pradesh has, in a major way, helped India achieve polio-free status. In 2002, when 1,242 of the 1,600 polio cases in the country were from the State, UNICEF took the help of 2,800 religious leaders, 500 madrasas, 2,000 madrasa teachers and principals and 5,788 hajis to dispel misconceptions and myths about the polio vaccine, all of which eventually made U.P. polio-free.

Geeta M., Additional Professor, Institute of Maternal and Child Health, Kozhikode, says the vaccination rate would go up if women are made decision-makers in families.

On July 4, Dr. Geeta, as the duty medical officer, was in charge of six diphtheria-affected children. The lab has confirmed three of the cases. The institute, adjoining the medical college, has attended to 12 cases since June.

The college hospital is perhaps the only one which receives many tetanus patients, another fallout of low immunisation, she says. When un-immunised adults and children reach a critical number, the risk of contagious diseases rises. That perhaps explains why adults are getting diphtheria. That perhaps explains why 90-year-olds are turning up for vaccination shots. Or why even madrassa leaders such as Ustad Hamsa Faizi of Masjid-ul-Huda of Vettathur have taken the vaccine. That is a shot of hope.