Primary lesson

Published : Sep 11, 2009 00:00 IST

A MILD flu epidemic is actually good for public health, declared a friend who is a health administrator. I protested, pointing out that the recent sweep of swine flu had spread panic, caused some deaths and severely stressed the health services in places such as Pune. Have you considered the fact that the media and the public paid far more attention to health issues and discussed the state of our health services more than ever before? he countered. When else has the whole Union Cabinet met to discuss a public health problem and when did Chief Ministers of States convene such high-profile, inter-sectoral meetings to discuss implementation of public health measures?

While I am still reluctant to accept that somewhat cynical position, since even one avoidable death is a death too many, I am inclined to agree that an occasional touch of flu may be good for the media. Initially many sections of the media overreacted, indulged in competitive scaremongering, fuelled fear and triggered panic across the nation. Later, chastened by the backlash, they started providing a huge volume of useful health information on swine flu. They also started posing some pertinent questions about the state of our health services, although they did not always come up with the right answers.

The swine flu outbreak even managed to keep laffaire Shah Rukh Khan on the margins of the front pages of most newspapers and off the lead story in the visual media a rare feat for the tabloidised media, which usually prefer Bollywood gossip and Hollywood trivia to serious issues such as public health. Even better, Barkha Dutts We The People on NDTV featured middle-class and affluent patients from Pune and Delhi who told us that the government hospitals provided competent, conscientious and caring service. They earnestly declared, with touching conviction, that they would place their trust in government hospitals in the future, in preference to private hospitals. Such a long-overdue endorsement of the underrated government hospitals was very welcome, even as some in the media were demanding to know why the private sector was not called to the rescue.

However, as the dust begins to settle in the panic-ridden streets and sobriety slowly seeps into the media, several serious issues still demand our attention, both on the swine flu pandemic itself and on the general state of health in India. If there is any good to come of this epidemic, it would be from serious reflection on these issues and further commitment to sustainable solutions.

Let us begin with the origins of swine flu. It is in the nature of flu viruses to mutate, mix and morph into new strains. The pig is a particularly hospitable host to many viruses, offering not merely a welcoming shelter but also a dating parlour where visiting viruses can consort and produce new reassorted forms. The H1N1 virus is one such, presenting a mix of antigens from human, pig and bird viruses. When it sprang forth as a human illness for the first time in Mexico, it evoked surprise, uncertainty and fear. The world watched with anxiety and braced for the worst.

The World Health Organisations (WHO) declaration that the H1N1 virus had attained pandemic status stoked these fears further and spurred the media to speculate on apocalyptic scenarios. The WHOs classification, however, is based only on the occurrence of an epidemic simultaneously in at least two continents. It does not take into account the severity or virulence of the virus. Laurie Garrett, a U.S. flu expert, points out that we need a new classification which takes into account both the spread (transmissibility) and severity (virulence) of a virus and suggests that the red flag should be raised only when both criteria suggest a major threat.

Given the state of global alarm, it is not surprising that many in our country reacted with panic, even though it was clear by the time the pandemic touched down in India that the virus was of a much milder disposition than the dreaded H5N1 (avian flu) virus. Indeed the H1N1 is in the same league as the usual seasonal fluviruses. There is, of course, some apprehension that the virus may mutate (antigenic drift) or reassort further into a new strain (antigenic shift), either of which may be more dangerous than the present form. This warrants vigilance through continued virological surveillance.

In the initial stages, containment through case detection, isolation and contact tracing was appropriate. However, in the case of a virus which spreads rapidly, community spread was inevitable. At that point, mitigation became the only relevant strategy. Routine health services had to be depended upon to care for the infected, with intensive hospitalised care reserved for the severely affected. It was at this cross-over point of the two management strategies that there was confusion in the media and the public mind about who needed to be tested, who needed to be treated with anti-viral drugs and who needed to be hospitalised. The guidelines issued by the Union Health Ministry on August 14 helped to clarify the confusion.

It is very clear from the present epidemic that risk communication to the public is as important as the ramping up of health services at all levels. It is essential to provide adequate and accurate information promptly to the people, with clarity and credibility. Otherwise speculation, misinformation and dire predictions rush to occupy the void in the public mind and fear spreads faster than the virus itself. Government agencies and scientists are not always the best communicators. It is important to bring technical experts, policymakers, health system managers and communication specialists together quickly and regularly, during such times, to articulate well-constructed messages and disseminate them widely.

The health services, of course, need the most attention. While rural health services are clearly deficient and are sometimes the subject of discussion at the policy level, it is rather naively assumed that urban areas have enough doctors to take care of all the health needs. While the National Rural Health Mission (NRHM) is guided by the vision of providing comprehensive health care, the yet-to-be launched National Urban Health Mission remains mainly an insurance scheme for the poor. Radical reconfiguration of urban health services has yet to be proposed.

The neglect of primary health care services, along with the absence of clearly defined referral linkages, has been the major weakness of our health services. The NRHM attempts to redress this in rural areas. However, urban primary health care has not even been a design feature of our health system. Persons with primary health care needs in urban areas either seek out an assortment of variably qualified and utterly unregulated individual private health care providers or inappropriately access tertiary care institutions in the government or private sector. Referrals too do not follow rational guidelines or predictable patterns. The anarchy that characterises urban health care has been all too evident during the swine flu epidemic.

Imagine an alternative scenario. If our urban areas had geographically well-distributed urban community health centres, which were designed and equipped to deal with the primary health care needs of the neighbourhood populations, most of the cases of swine flu could have been attended to at those centres, with reassurance and domiciliary treatment.

Only a few would have been referred to larger hospitals, where severe cases would have been admitted, tested and treated. The wild rush to a few select hospitals and the sad spectacle of milling crowds demanding universal testing could have been avoided.

It is only when we provide routine primary health care services which are robust and easily accessible, whether in rural or urban areas, that the health services can cope with both the usual and the unexpected demands of the communitys health care needs. Ad hoc responses to public health emergencies will always be incomplete and inadequate if the regular services are ill-planned or under-resourced.

A question has been correctly raised in many quarters as to why there has been so much attention and resource mobilisation for swine flu when many other health conditions that are more serious do not feature in the media or figure prominently on the agenda of high-level policymakers. Our infant mortality rate is 57 per 1,000 live births. India contributes 2.4 million of the global 10.8 million under-five child deaths annually. Even with considerable recent declines, our maternal mortality ratio is 254 per 100,000 live births. The proportion of fully vaccinated children, in the age group of 12-23 months, was 54 per cent in 2007-2008. According to the WHO, 60-70 per cent of a total of 90-160 million cases of malaria in the South-East Asian region occur in India. We have a third of the worlds cases of tuberculosis. A million Indians die each year from tobacco-related diseases. The list could go on.

A disproportionate response to the swine flu epidemic is, to some extent understandable, given the worldwide alert. The novelty of a new pandemic, coupled with fearful historical references to the 1918 flu pandemic, was enough to ignite the media while the poignancy of the first death, of a 14-year-old girl in Pune, gripped the nations attention. In any case, an acute and unanticipated threat always attracts more attention than problems that have been there for a while.

These facts do not, however, absolve the media, policymakers, health professionals or even the public of the responsibility for exhibiting less concern for the many serious public health threats that exist today. If issues relating to public health of diseases and their determinants, of health systems and health services, of prevention and treatment form a part of regular public discourse, we will not have to lament loudly when our attention is suddenly grabbed by a perceived crisis. Have the media questioned why reliable disease-surveillance systems are still not available across the country? Even though the Integrated Disease Surveillance Programme is expected to provide that information, the proposed district laboratories are yet to be established as a dependable network for the testing of various pathogens. Public health needs regular, reasoned and rational review, not sporadic, shrill and sensational scrutiny.

The weaknesses of our health system from design to delivery, financial to human resources, surveillance to response, drug procurement to distribution, laboratory services to infrastructure of health facilities, regulatory frameworks to referral systems and governance to accountability have to recognised and rectified if we have to deal more effectively with our many health challenges. If we do that, swine flu or a similar pandemic will not induce such a sense of helplessness as the urban middle class experienced in the past few weeks, indeed as poor people do all the year round in all parts of India, with respect to their health problems.

The swine flu history has another profound lesson for sustainable development. It is not by an accident of nature or by the malevolent misanthropic mischief of pigs, cattle and birds that new infectious diseases are now occurring at such frequency. Indeed, the Institute of Medicine (U.S. National Academies) estimates that in recent decades, there has been a new outbreak every year on an average. About 60 per cent of these are zoonotic, that is, acquired from animals. This has to do with large commercial-scale livestock breeding, which places crowded animal populations in close proximity to human populations.

Grain feeding of many of these captive-bred animals in factory farms further leads to deforestation for expanded agriculture. Hitherto contained viruses and vectors from forest life are released into human habitats. A conveyor belt between wildlife, captive veterinary populations and human communities establishes a rapid transmission chain for initiating new epidemics.

Given the threat that such large livestock breeding also poses to the environment, through greenhouse gases, the world needs to curb the animal farms and reduce meat consumption. Why blame the poor pig, if we eat like gluttons and disturb natures equilibrium through our unbridled consumption?

K. Srinath Reddy is president, Public Health Foundation of India.

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