Delhi’s burden

The Centre’s tight control over revenue restricts Delhi’s spending on public health. The advisories to “intensify” measures to check the breeding of mosquitoes are meaningless if they are not backed by financial and executive restructuring.

Garbage dumped in Raghubir Nagar in West Delhi. There is maldistribution of municipal services within Delhi.

DELHI HAS REPORTED SOME 4,000 DENGUE cases until end September, and the number is bound to go up before the dengue season ends in November.

It is not just Delhi that has seen a rise in the number of dengue patients. According to the National Vector Borne Disease Control Programme (NVBDCP), Karnataka and Kerala have reported 3,000 cases each, Tamil Nadu 2,400, Andhra Pradesh 1,600, and Odisha and Chhattisgarh 500 each. Gurgaon in Haryana, which borders Delhi, has reported 2,000 cases.

Dengue strikes when temperatures come down, humidity is above average, and the monsoon rains are in retreat. These conditions are ideal for the growth of the Aedes Aegypti mosquito, the vector that spreads dengue. Since A. Aegypti breeds in fresh water, the World Health Organisation (WHO) holds the practice of storing water in containers for domestic purposes responsible for the growth of the mosquito. The WHO says: “Low literacy associated with poor economic status leads to constraints in practising personal protection measures.”

It is not just the poor residents of Delhi who are victims of the outbreak. Twenty dengue cases were reported in the high-profile diplomatic community, raising concerns in the media to “panic” level.

The WHO also specifies that there is “no treatment available” for dengue. All that is possible are supportive measures once the disease strikes: antipyretics along with sponging to bring the fever down; analgesics to assuage muscle and joint pains; bed rest with plenty of oral fluids and electrolytes to prevent dehydration; and, where there is bleeding, blood or platelet replacement eventually followed by oxygen therapy if the body goes into shock with low blood pressure. Clearly, that is why hospitals are needed—not to “cure” but to test and provide the necessary support while the body attempts to heal itself.

That is also where a lot of money can be made. In the case of Gurgaon, where most of the patients are in private hospitals, the State Health Minister had to ordain that private hospitals could not declare a patient as having dengue until blood tests by a government hospital confirmed it. Apparently, there were reports that a few private hospitals were spreading a scare and making even patients suffering from simple viral fever undergo tests and charging at least Rs.70,000 a patient for platelet treatment. Similar instances were reported from other States, forcing the Cabinet Secretary to direct all States to set up a 24×7 separate unit in each hospital manned by a senior doctor and to use spare ambulances as mobile clinics.

In view of the shortage of beds and testing facilities, the Delhi government decided to purchase more than 2,000 beds for State-run hospitals and open 55 dengue clinics (with two or three beds each), five in each of the 11 districts. However, the hospitals are facing space and staff shortages, and the clinics have no testing facilities. The Delhi government has under its control 38 hospitals, with a bed strength of 10,000. As these hospitals are already struggling to provide care for the existing patients, they will be hard put to accommodate additional beds and care for patients in distress. The Centre has 25 hospitals in Delhi under its jurisdiction with 9,000 beds. This works out to 1.4 times more beds per hospital than that in the Delhi government’s hospitals (about 260 beds per hospital). Although private hospitals, numbering 755, outnumber government-run hospitals, they have an average of 24 beds per hospital.

Delhi is reported to have 95 hospitals and 1,389 dispensaries and a total of 50,000 beds, whereas, according to the Municipal Corporation of Delhi’s (MCD) Master Plan, the National Capital Region (NCR) should have by 2021 more than twice the number of beds and twice the number of dispensaries. Curiously enough, the least populated districts (New Delhi and Central) have a higher concentration of dispensaries than the more populated ones (North-West and West). Nothing has been done to correct this shortage and maldistribution of health facilities in spite of the fact that in 2010 the city recorded 6,259 dengue cases. At that time, the outbreak was attributed to the water stagnation caused by the massive construction activities that were under way for the Commonwealth Games hosted by the city.

The current uncoordinated response to the outbreak, as indicated by both the Supreme Court and the Delhi High Court, may be ascribed to poor governance. It is often pointed out that there is a tussle going on between the Centre, the State government and the municipalities, essentially because these institutions are governed by different political parties. But this was not the case in 2010. The Master Plan, while acknowledging that there is a shortage, only prescribes that the capacity of the existing health units be increased by enhancing the floor area ratio, or FAR, and rebuilding, while passing the buck by stating that “complementary health facilities at par should be developed in the NCR to reduce the burden on Delhi”.

The failures are not only in the context of building enough hospitals and dispensaries, as are normatively required; they are obvious in the measures required to prevent the mosquito from breeding. The Cabinet Secretary’s instruction to the States that “a renewed focus should be imparted to preventive measures” and the Union Health Ministry’s advisory to the Delhi government to “intensify” measures to check the breeding of mosquitoes are meaningless if they are not backed by financial and executive restructuring.

For instance, the municipalities are blaming the Delhi government for not releasing funds. The Delhi government is, in turn, accusing the Centre of parting with only a fraction of the Rs.1.25 lakh crore it claims to have paid by way of taxes every three months. These figures may be part of the ploy to score political points, but it is acknowledged that Delhi’s State gross domestic product (GDP) is Rs.4.5 lakh crore at current prices but its budget is heavily contingent on what the Centre releases from the Central revenues. Unless the Centre loosens its tight control that restricts spending on public health to about 1 per cent of GDP, there is little that the States can do to improve the health sector’s performance.

If the “surroundings are [to be] kept clean”, both manpower and money are needed. Delhi has about 47,000 safai karamcharis as per the 1973 norm of 2.8 sanitation workers per 1,000 population. But in the past four decades, not only has the per capita waste generation almost doubled but the per hectare density of population has also increased threefold. Yet the norm remains obstinately fixed in time and space. In the past three months, the safai karamcharis struck work twice demanding wages, release of child education allowance, and access to cashless medical facilities.

As in the case of health facilities, there is maldistribution of municipal services within Delhi. Thus, while in Lutyen’s New Delhi Municipal Council area a municipal employee serves only 23 persons, in the MCD areas a single employee is supposed to serve 108 persons. This is despite the fact that 97 per cent of Delhi’s population resides in the MCD area. The same is true for the supply of potable water. According to the Jal Board, Delhi has an average availability of 225 litres per capita per day, or lpcd (that is, about 15 buckets of water per person a day). But some areas get 24-hour water supply, while others hardly get water for one or two hours every day. Official claims, of course, are that there is a shortage in supply. But if the norm of 225 lpcd is enforced, the current population would need 840 million gallons a day, while the current capacity of the city is 855 million gallons a day. No official answers are forthcoming about what is being done to correct the maldistribution, which contributes to the disease load of the city.

In fact, it is often the poor who are blamed for disease, as is evident from the WHO’s views on the spread of dengue. The Master Plan states without any evidence whatsoever: “The blockage of the natural channel is mainly because of the encroachment by slum dwellers along the drains.” This has been the argument given by many cities apart from Delhi to demolish slums and move the inhabitants from the centre of the city to faraway places.

The data suggest that in slums, the provision of toilet seats, for instance, is about 95 persons per seat, as against the norm of 20 to one seat. Even the 33.39 lakh ration cards that used to be available to the poor in 2011 have been drastically reduced to 17.68 lakh smart cards on the pretext that their numbers have shrunk. And the number of buses that used to cater to the needs of the poor has dropped dramatically from 41,500 in 2001 to 6,500 in 2014. How can a city deal with crises such as the one posed by dengue—with swine flu likely to follow soon —when public services for health, water, hygiene, nutrition and transport are being systematically dismantled as part of policy?

Dunu Roy is Senior Fellow at CPACT, Shiv Nadar University.