Health Infrastructure

Deficient system

Print edition : April 10, 2020

A doctor in a protective suit outside an isolation ward for COVID-19 patients at a hospital in Hyderabad on March 15. Photo: AP/Mahesh Kumar A.

India’s ill-prepared public health system faces its toughest test yet as the number of coronavirus cases continue to increase, putting pressure on the government’s limited resources.

One of the things that is being lauded in India is that in a population of 1.3 billion, the number of reported coronavirus cases has been very low. The national address of Prime Minister Narendra Modi on March 19 asking people to observe a self-imposed curfew on March 22, to clap and ring bells from their balconies to appreciate the work of doctors and health workers, and to not hoard, do not give an indication of the state of health preparedness across the country.

While the efforts of the government in issuing travel advisories, installing screening mechanisms at airports and advising people to take precautions have been acknowledged, public health experts have cautioned about gross under-reporting of infected cases and emphasised that the total number of tests conducted by the Indian Council of Medical Research (ICMR) based on a small sample was not enough to arrive at the conclusion that community transmission was not occurring.

There also were reports of people diagnosed with COVID-19 interacting and moving freely in the community. The revised strategy of testing issued on March 21 by the ICMR underscores the approach that cases of COVID-19 in India relate only to travel and local transmission from “imported cases to their immediate contacts”. The notification says that “community transmission of the disease has not been documented till now. Once community transmission is documented, the above testing strategy will undergo changes to evolve into stage-appropriate testing strategy.”

The current testing strategy says that all asymptomatic individuals who have undertaken international travel in the last 14 days should stay in home quarantine for 14 days; that they should be tested only if they become symptomatic (fever, cough, difficulty in breathing) and all family members with a confirmed case should be home-quarantined. All symptomatic contacts of laboratory-confirmed cases, all symptomatic health-care workers, all hospitalised patients with Severe Acute Respiratory Illness fever (fever, cough and breathlessness) as well as asymptomatic high-risk contacts of a confirmed case must be tested between Day 5 and Day 14 of coming into contact with a confirmed case. This marks a slight shift from its earlier position of not testing all hospitalised patients with severe acute respiratory illnesses and fever.

‘Test, treat and trace’

“Countries must isolate, test, treat and trace,” says the latest message from the World Health Organisation (WHO), a dictum the Indian government does not seem to be following.

These concerns have arisen against the backdrop of India’s poor health care system and abysmally low public health expenditures as a percentage of GDP. The rise in the incidence of COVID-19 cases in the Western economies despite their advanced health systems and services has caused consternation in India regarding the preparedness of its own health services and systems. The overemphasis on self-management, isolation and “physical distancing”, as opposed to ensuring more district-level testing facilities and more economic and social support for those who are vulnerable has been criticised. Questions have also been raised about the effectiveness of the Integrated Disease Surveillance Project (IDSP) set up in 2004 in order to detect and respond to epidemic outbreaks.

Yogesh Jain, a public health physician in rural Chhattisgarh who has written on the coronavirus outbreak, told Frontline that absence of evidence does not mean evidence of absence. India, he said, was showing fewer cases because of restricted testing. “There isn’t a different epidemiology in India and therefore community transmission is already happening. There should be larger testing criteria and the data must be shared with the people. The ICMR says it has sentinel sites from which it has picked up the samples. But even if 10 hospitals are selected and the cases of pneumonia are investigated, one will get an idea. Just because we are one to two weeks behind the European escalation curve doesn’t mean it won’t happen here,” he said. The strategy that the government would act only if there was community transmission was “nonsense”, he added. The WHO had indicated indirectly that some countries needed to move faster.

A shortage of testing kits was cited as a reason by an ICMR official for the low rate of testing, but public health experts felt that it should have been addressed much earlier. There are an estimated 168 flu testing sites under the IDSP. In fact, given the frequent outbreak of viral agents, the Department of Health Research set up the Viral Research and Diagnostic Labs under the aegis of the ICMR to identify and diagnose early viral infections of importance. There are around 85 such laboratories functioning, but whether they are testing for COVID-19 is not known. “If there is an air of secrecy, people will come to all kinds of conclusions,” said Jain.

China was successful in the lockdown of Wuhan, but to emulate physical distancing in India is not practical given the high population concentration and diversified demography. “Even when people were diagnosed as positive, they didn’t care and mingled in the community,” said Jain. The Chinese government ensured that everyone in Wuhan was taken care of in their homes so that they did not have to step out. At least 10 per cent of those diagnosed with COVID-19 would need to be put in an ICU and on ventilator as well, he said. But the shortage of ventilators and fully equipped ICUs was a huge challenge.

In Chhattisgarh, there were 156 ventilators for a population of 32 million, that is, one ventilator for every two lakh people, said Jain. “Even if the prevalence is one per cent, it means a thousand persons will get infected and a hundred will need ventilator support but only one person will get it,” he said.

In recent years, global health agencies had shifted focus to non-communicable diseases and lifestyle-related diseases such as cancer, diabetes and chronic obstructive pulmonary disease. The re-emergence of communicable diseases in the form of epidemic viral outbreaks poses a new challenge altogether. According to the Department of Health Research, India had witnessed such outbreaks and faced threats of potential infiltration of Nipah (2001, 2007 and 2018), Avian Influenza H5N1 (2006), Chikungunya (2006), pandemic influenza (2009), Ebola (2013) and Zika (2016).

The government has set many targets for itself, including increasing the number of paramedics and doctors as per the Indian Public Health Standards (IPHS) norms in high-priority districts by 2020 and decreasing the proportion of households facing catastrophic health expenditure by 25 per cent from the current levels by 2025. The government also plans to increase its health expenditure as a proportion of GDP from the present 1.15 per cent to 2.5 per cent by 2025.

The United States and the United Kingdom have been facing shortages of ventilators and other ICU facilities in the context of the COVID-19 outbreak. These are also the countries which have a high level of universal health coverage in terms of essential services. Prime Minister Boris Johnson of the U.K. told the media that the government would not track and trace the contacts of suspected cases and that only those admitted to hospitals would be tested. But as the numbers burgeoned in Europe, especially Italy, he changed his position.

Challenge of Communicable diseases

In India, according to the National Health Profile 2019, the average population served by government allopathic doctors was 10,926 persons per doctor. There were around 8.6 lakh auxiliary nurse midwives and some 20 lakh registered nurses. For a population of 1.3 billion, there are only 25,778 government hospitals and 7,13,986 beds. The budget for managing epidemics and natural calamities had never exceeded Rs.100 crore in any year. In fact, the actual expenditure ranged between Rs.50 crore and Rs.60 crore from 2016 onwards. The budget for health sector disaster preparedness and management, including emergency medical relief and emergency medical services was halved in the Budget Estimates (BE) of 2018-19 from what was allocated in 2016-17 (Rs.30 crore in BE 2016-17; Rs 16.85 crore in BE 2018-19).

According to Census 2011, only 8.3 per cent of the population is above 60 years, while 64.7 per cent is in the 15-59 age group. The assumption that the virus would attack only the elderly is not true given that in the U.S., nearly 30 per cent of the cases was in the 20-44 age group, though deaths have been in the older age cohorts. The government might be taking solace from the fact that the disease burden for communicable, maternal, neo-natal and nutritional diseases dropped from 61 per cent to 33 per cent between 1990 and 2016, and for non-communicable diseases (NCDs) it grew from 30 per cent to 55 per cent. But the epidemiological variations between States ranged from 48 per cent to 75 per cent for NCDs and 14 per cent to 43 per cent for infectious and associated diseases.

But according to the National Health Profile 2019, acute respiratory infections accounted for nearly 69.47 per cent of the total morbidity because of communicable diseases. Mortality because of pneumonia and acute respiratory infections accounted for 57.86 per cent of all mortality because of communicable diseases. The third highest cause of mortality was acute diarrhoea, which accounted for 10.5 per cent. There were 9.2 lakh cases of pneumonia alone in 2018, compared with 7.5 lakh cases the previous year. Similarly, viral hepatitis, viral meningitis, swine flu, acute diarrhoea and acute respiratory infections went up in 2018 over the previous year.

Curfew as cure

Yet, in India, denial that there might be more cases than what has been reported continues to be the position despite public health experts cautioning the government not to be complacent. The government seems to be following the dictum that “prevention is better than cure” at a time when the virus may have already entered the community. The emphasis on prevention and the onus for keeping the contagion at bay has been disproportionately placed solely on people with the understanding that following certain behavioural and sanitation norms, such as washing hands regularly with soap, using alcohol-based sanitisers and avoiding physical contact, can prevent the spread.

In the Indian context, it is next to impossible to quarantine huge sections of the population, especially those who have to commute for wage work. In Wuhan, the Chinese authorities ensured that people received food at their doorstep and were thereby successful in containing the spread by way of physical and social contact. No such effort is on in India.

The repeated exhortation by the Union Health Ministry to citizens to wash their hands with soap and use sanitisers needs to be seen in the context of the overall access to clean water for drinking and bathing and other sanitation needs. Only 43.5 per cent of households in the country according to the National Health Profile 2018, had access to tap water, of which only in 32 per cent the water was from a treated source. Some 33.5 per cent of households relied on hand pumps, while 11 per cent depended on well water, of which 9 per cent used uncovered wells. Some 8.5 per cent depended on tube wells. Only 46.6 per cent of households had access to drinking water within their premises, while 35.8 per cent had it near the premises and 17.6 per cent away from the premises.

There was a wide variation observed between the States as well. While 77.7 per cent of households in Kerala had clean drinking water within the premises, the corresponding figure for Chhattisgarh was only 26.5 per cent. There were 10,379 rural habitations without safe drinking water and with a problem of excess fluoride levels. Some 16,279 habitations had the presence of arsenic in their drinking water supply. Latrine facilities were present only in 46.9 per cent of households, while 53.1 per cent did not have latrines inside the premises. Some 48.9 per cent of households had no drainage; only 42 per cent had bathrooms; 55.8 per cent had kitchens, while 31.5 per cent had no separate kitchen.

Therefore, with the limited guarantee of clean running water, frequent “hand washing” with soap or sanitiser is a luxury in the Indian context. With the scare of COVID-19 going up, the sale of face masks and sanitisers shot up among middle and upper middle-class sections and retailers had begun charging exorbitant amounts from panic-stricken consumers. Fears of a lockdown prompted several people to hoard food and medicines, leading to acute shortages in stores. The prices of vegetables, too, soared. On March 21, the Ministry of Consumer Affairs, Food and Public Distribution, belatedly realising that some people were exploiting the crisis, issued an order under the Essential Commodities Act, 1950, regulating the price of masks and sanitisers. Retailers, the order said, would not be allowed to charge more than Rs.8 and Rs.10 for the two specified categories of masks and Rs.100 for a 200 ml bottle of sanitiser. This notification will be effective until June 30. Yet, even at the reduced cost, sanitiser is not affordable for many. There has been no commitment from the government to provide these things free for those who cannot afford to buy them.

With each passing day, the number of COVID-19 cases in India is going up. A spurt is predicted in the coming weeks, for which the Indian health care system, a highly privatised one, does not seem to be prepared. The outbreak is an opportunity for the government to take a hard look at public health, reduce its dependence on the private sector and strengthen and reinvest in the public sector pharmaceutical industry in the interests of the people.