K.A.V.R Krishnamachari

A self-taught "medical detective," Dr. Krishnamachari is leading India's fight against the disease fluorosis by training organizations to address medical, environmental, and communal aspects of clean drinking water.

Dr. Krishnamachari is using his experience in community health to help NGOs protect Indian villagers from fluorosis, which is caused by high fluoride levels in drinking water. Earlier attempts to save the rural population from this disease have typically relied heavily on technology and have been driven by the state. They provided no space for the community to partake in decisions and projects. These programs were experimental, entailing little subsequent action by the state or the private sector. By teaching people about the scientific causes of fluorosis, pressing local government to take relevant and effective action, and demonstrating the importance of relating public health to environment, Dr. Krishnamachari is demonstrating that the disease, which has afflicted Indian villages for generations, can be beaten.He involves communities at every stage of the battle by educating the people and eliciting their participation. He is now working with the communities to install household defluoridation units and to create an integrated watershed management program. He is ensuring access to safe drinking water by promoting concrete-lined rainwater collection tanks, by exploring the feasibility of small-scale purifiers, and accessing untainted freshwater via new canals. Although Dr. Krishnamachari is starting in the worst-hit district, Nalconda, his approach has potential in other areas affected by natural toxins and man-made pollutants.

A naturally occurring chemical, fluoride is beneficial to human life in small amounts but toxic in high concentration. While in some countries fluoride is added to drinking water, in others high levels of naturally-occurring fluoride can lead to fluorosis, which causes a crippling bone disease. Like China, Kenya, Tanzania, South Africa, and Algeria, in recent years India has become more aware of the dangers posed by fluoride. Fluoride levels seem to be increasing as people settle new towns and villages and disturb sensitive ecosystems. The states of Andhra Pradesh, Karnataka, Tamil Nadu, Uttar Pradesh, Punjab, Rajasthan and Gujarat have reported the effects of high fluoride levels since 1937, when fluorosis was first discovered in the Nalconda district in Andhra Pradesh. Fluorosis is endemic to more than 300 villages in Nalconda. To combat the disease, a large defluoridation plant was built, deep wells were dug, and household defluoridation units were installed. All these attempts failed to provide safe drinking water because communities were never consulted and never took part in planning and implementation. The cause of bone deformity is still a mystery to the people of Nalconda, and therefore they don't know how to protect their water from contamination.

Dr. Krishnamachari is certain that earlier government efforts failed because they did not educate communities and did not relate fluorosis, viewed as a public health issue, to the environment. Without making these connections, various development projects undermined each other. For example, many organizations promote rainwater collecting to solve the water shortage. Unless they test water quality and recognize the importance of concrete-lined tanks, which prevent contamination by natural toxins, fluorosis will persist even if a community drinks rainwater instead of well water. By starting in the most affected area, Dr. Krishnamachari hopes to demonstrate what can and should be done elsewhere. The citizen organizations in Nalconda already have the mandate and resources for rainwater conservation; by also attacking fluorosis they can solve two problems at once.He combines prevention and treatment in a threefold strategy:His "primary prevention" is to provide access to fluoride-free water from the Nagarjuna Sagar reservoir to the villages affected by fluorosis, in collaboration with the state government and the local administration. He will be facilitating collaboration between the government-sponsored watershed management program and the local community. He will encourage households to install defluoridation units by working with local organizations. Then he will help them manufacture the units locally. The Society for Integrated Development of Urban and Rural Areas (SIDUR), where Dr. Krishnamachari is currently health adviser, coordinates 133 organizations, including thirteen organizations in Nalconda that will be trained to understand and explain the nature of fluorosis to the villagers with whom they already work. Now villagers usually fail to see the causal relationship between the water they drink and the deformities that afflict their communities. The training centers will function in the endemic areas with logistical support from SIDUR. The centers will be the focal point for those involved in the strategy. The "secondary prevention" will focus on early diagnosis and treatment of fluorosis through advocacy and community participation, with the ultimate goal of establishing special facilities for fluorosis– affected patients at the district hospital.And finally, "tertiary prevention" will build rehabilitation programs by creating a network of orthopedic surgeons and by sponsoring surgery on bone deformities.

Dr. Krishnamachari has been working in Nalconda for nearly three decades. A native of Andhra Pradesh, he is one of twelve brothers and sisters whose parents were schoolteachers. He was a brilliant medical student who went to work for the state after completing his MD at the University of Andhra Pradesh. Rather than committing himself to conventional allopathic treatment, Dr. Krishnamachari became a "medical detective"–an unconventional, self-taught epidemiologist with no formal qualification in community medicine. He identified symptoms, traced their root causes, and discovered the origins of diseases by working with people. His interest in fluorosis dates back to the mid-seventies, when he met a young boy with a bone deformity in the government hospital in Hyderabad. Dr. Krishnamachari quizzed the boy about his problem and, in the days and years to come, discovered the cause by visiting the boy's village as well as the other fluorosis-affected villages in the district. He was the first doctor to link fluorosis to the condition, which he named endemic genu valgum. In the thirty years since then he has consistently used his talents, resources, and position to deal with fluorosis not only in Andhra Pradesh, but across India.