Worse killers

IN the second week of August, even as the Union Ministry of Health and Family Welfare was at pains to stress that the H1N1 virus attack was under control, the head of the paediatrics department in a government hospital in Gorakhpur, eastern Uttar Pradesh, made an anguished statement. He voiced his concern at the unparalleled importance given to the new flu outbreak when existing communicable diseases had claimed more lives in recent years. But his views did not grab the headlines.

This was not the first time that Dr K.P. Kushwaha has spoken out against the malaise that has affected the public health system. He said it was not confined to any particular district such as Gorakhpur, but was typical of any nondescript part of the country.

Talking to Frontline over phone from Gorakhpur, Kushwaha said the crisis plaguing the district was no less serious than what was caused by the H1N1 virus in the country. Viral encephalitis, he said, had become synonymous with Gorakhpur. It draws attention only when huge numbers of people die. This has not affected policymakers in terms of providing better infrastructure or ensuring better management of the disease, he said.

Uttar Pradesh accounts for the largest number of deaths from Japanese encephalitis in the country, Gorakhpur being its epicentre. As many as 1,682 people died of Japanese encephalitis in India in 2005, 658 in 2006, 963 in 2007 and 662 in 2008.

He said people with symptoms of encephalitis were admitted to the BRD Medical College and Hospital every day. Most of them came from as far as 100 kilometres away because the primary health centres (PHCs) or the community health centres there simply did not have adequate facilities to cope with the crisis. Health care has to be at the doorstep, he said.

Twenty-five people tested positive for the encephalitis virus in the hospital in two weeks from the last week of July. Some died within two hours of admission. The hospital was grossly understaffed. The ward where Kushwaha worked had more than 250 children, for whom there were three staff nurses, one doctor and a sweeper. In contrast, Kushwaha noted, government hospitals in Delhi had a team of 100 doctors and 200 nurses for the same number of children.

When special wards were created in government hospitals in the aftermath of every international outbreak of disease, whether it is severe acute respiratory syndrome (SARS), avian flu or H1N1 flu, there were no special wards to cater to an endemic virus such as encephalitis, he said.

There is a special ward at the Ram Manohar Lohia Hospital in Lucknow. But people are dying here [in Gorakhpur]. They cannot be taken to Lucknow, said an anguished Kushwaha, adding that 27 of every 100 patients admitted with encephalitis died. The figures are of those who are admitted in government hospitals; there are virtually no records of those who seek treatment, successful or otherwise, from private medical practitioners. Last year, 22 per cent of the 2,500 patients who tested positive for encephalitis died. In 2005, the death rate was higher and so were the number of patients admitted.

The doctor said the average patient was poor, lived in a village, and was undernourished and in the age group of one to 15. The five to 10 age group was the most vulnerable. This was when water contamination was at its peak, compounded with stagnant water in the paddy fields. As these things do not happen elsewhere, for example in Delhi, these do not receive attention, he said.

Encephalitis is not the only disease the hospital has to grapple with. Morbidity and mortality because of pneumonia, hepatitis, tetanus and diphtheria are common.

Other medical practitioners Frontline spoke to, including private practitioners at Gorakhpur, also said the Central government was in denial of the prevalence of encephalitis, mainly to avoid scaring the people. According to the fact sheet listed on the website of the National Institute of Communicable Diseases (NICD) recently renamed the National Centre for Disease Control by Union Health Minister Ghulam Nabi Azad Japanese encephalitis is a potentially severe viral disease spread by mosquitoes in the agricultural regions of Asia. It can affect the central nervous system and cause severe complications leading to death. There is no specific treatment for Japanese encephalitis. But for some strange reason, the website on investigation reports relating to the outbreaks of the disease has data only until 2002.

It is ironical that the largest number of deaths from H1N1 flu occurred in a city where the National Institute of Virology is located. Health experts say Pune has no proper epidemiological surveillance system. All the screening was done at Naidu Hospital, said Abhay Shukla, joint convener of the Jan Swasthya Abhiyan, from Pune. Epidemic surveillance, he said, could not be conducted only at government hospitals and over-centralisation was symptomatic of a weak epidemiological surveillance system.

According to him, there is no system by which new diseases or outbreaks can be notified and there is a complete absence of PHC-level service in the majority of urban centres. In a few cities like Mumbai a system of community health workers exists, but there is nothing equivalent to it in other cities. More importantly, he said, nearly 80 per cent of the urban population approached the private health sector for treatment.

Former Union Health Minister Anbumani Ramadoss made many declarations about the launching of a National Urban Health Mission (NUHM), which was to be patterned on the lines of the National Rural Health Mission (NRHM). The first time he announced it was in February 2008 when he told the media that the NUHM would be launched in three months. In April that year, the government said it would be launched in five months. On January 6, 2009, Anbumani Ramadoss once again promised to launch the NUHM within two months, covering 400 cities with a population of over one lakh.

The linchpin of the NUHM was to be the Urban Social Health Activist, or USHA, similar to the Accredited Social Health Activist, or ASHA, the backbone of the NRHM. Anbumani Ramadoss also made a candid admission that there were only seven lakh doctors in the country when eight lakh more were needed. Similarly, the present strength of nurses in the country was 10 lakhs and the country needed 15 lakhs more, he said. The NUHM never saw the light of day.

In May 2009, the new Health Minister declared that an NUHM on the lines of the NRHM would be initiated soon. The following figures speak for themselves about the need for such a mission. According to the National Family Health Survey III, the under-five mortality rate among the urban poor is higher than the urban average of 51.9 per cent. More than half the children are underweight and 60 per cent miss total immunisation before completing one year.

The latest flu outbreak has only added itself to the existing list of killer diseases prevalent in the country. According to the National Health Profile, 2008, of the communicable diseases that reported more than a hundred deaths in 2008, pulmonary tuberculosis (64,824) topped the list, followed by acute respiratory infections (4,681), pneumonia (3,765), acute diarrhoeal diseases (2,841), malaria (878), Japanese encephalitis (662), meningococcal meningitis (534), enteric fever (338), rabies (262), tetanus (253), measles (188) and kala azar (141).

Shukla said that around four lakh people in India died each year of tuberculosis, which was roughly the same number at the time of Independence. We have so far been unable to detect and treat various communicable diseases or to look at the connection between malnutrition and tuberculosis, he said. The epidemiological surveillance for tuberculosis has been very poor and detection took place only at a very late stage.

There were 1,707 reported deaths due to malaria alone in the country in 2006 which has seen a decline since then. Shukla said the government under-reported the number of confirmed cases to be around 15 lakhs when there are some 30-40 lakh cases of malaria each year. According to the National Vector Borne Disease Control Programme (NVBDCP), 40 to 50 per cent of the cases were because of Plasmodium falciparum, the chloroquine-resistant strain of malaria. According to the epidemiological profile provided by the NVBDCP, there were 100 deaths from malaria in all urban towns in 2006 and 103 the following year. The rural toll would be much higher. Up to April 2009, 130 deaths were reported from all over India; the figures were 963, 1,707, 1,311 and 935 for the four years form 2005.

Malaria is still a major problem in the north-eastern States. There is some system of surveillance in place, including comprehensive guidelines for treatment. Similar surveillance has been initiated for dengue and chikungunya as well, but health experts feel that a lot of under-reporting takes place.

Following the claims of the government that leprosy had been eradicated, the detection process itself was discontinued, Shukla said. Epidemics actually alert us. They are a symptom of all the cracks in the system, including poverty and poor surveillance. Even in H1N1, there were no clinical criteria of detection earlier. Only two criteria were deployed: those who had returned from the United States and those who had come in contact with such people, he said.

Said Arun Gupta, regional coordinator, International Baby Food Action Network, Asia, and member of the Prime Ministers Council on Indias Nutrition Challenges: It was sad to hear that a seven-month-old child died of swine flu. I wish such meticulous monitoring was there for the health of every infant of this nation. It is all the more relevant in this context as almost three infants die every minute in this country, the most common cause being newborn infections, diarrhoea and pneumonia. If we could find the systemic faults and plug them or at least have a plan to plug them, it would make good sense. More than 70 per cent of infants in our country are inappropriately fed during the first few months. We need to encourage and support women to breastfeed their children.

He said breastfeeding was now being internationally recommended to protect infants from the swine flu outbreak. According to the Academy of Breastfeeding Medicine, breastfeeding can limit the severity of respiratory infections in infants and is particularly important for minimising the risk and effects of infection during an influenza outbreak.

In a separate release, the Centres for Disease Control and Prevention (CDC) issued an updated guidance on H1N1 flu considerations for pregnancy and breastfeeding, stating that: Infants who are not breastfed are particularly vulnerable to infection and hospitalisation for severe respiratory illness. Women who deliver should be encouraged to initiate breastfeeding early and feed frequently.

The latest outbreak should be seen as an opportunity to build a strong, immune society. Babies, Arun Gupta said, got largely infected by diarrhoea because of poor feeding practices and the lack of safe drinking water. If we conclude that these deaths due to diarrhoea are caused by rotavirus infection and require a vaccine as the solution, the long-term solutions which look at diarrhoea as a public health problem will get either ignored or neglected, he added.

According to the latest District Level Household and Facility Survey (DLHS III 2007-08), one of the largest demographic and health surveys carried out in the country, sampling about seven lakh households, only 39.6 per cent had access to piped drinking water, 46.8 had access to a toilet facility, and 57.4 per cent of the women reported that they had any knowledge of diarrhoea and acute respiratory infections. As many as 58.6 per cent of the women reported to have heard of HIV and AIDS.

The writing on the wall is clear. The government can make health a priority if it has the will. Otherwise, for the next 10 years, it can continue firefighting and hold endless deliberations on why things are the way they are. Soon enough, victims of H1N1 flu and Japanese encephalitis at Gorakhpur will be just another statistic in a government report.