Public health in peril

The dengue outbreak in Delhi exposes the total absence of a functional public health care system with an efficient disease surveillance mechanism and highlights the dangers of leaving public health to the private sector.

At the outpatient department of Guru Gobind Singh Hospital on September 16 as signs of a dengue outbreak caused panic in Delhi.

In the wee hours of September 8, Babita and Laxmichandra Rout, a migrant couple from Odisha, did the unthinkable. They tied their hands together with a stole and jumped off a government school building at Lado Sarai, an urban village in New Delhi, where they had been living for many years. When their bodies were found the next morning, the stole still held their hands together. “It is nobody’s fault. It is our decision,” a suicide note in Odiya they left behind read.

The life of the middle-class couple turned upside down in a single day. Hours before taking the extreme step, the couple had buried their seven-year-old son Avinash, who succumbed to dengue fever. Laxmichandra was employed in a private company and Babita managed the house. "When Avinash contracted fever a few days before his death, nobody thought it was something serious. Avinash was lively as ever despite the fever,” one of the couple's neighbours said.

On the morning of September 8, a local doctor who treated Avinash for fever advised Babita to get him admitted in a hospital. As Avinash was vivacious even then, the couple did not think it was a case of life-threatening medical emergency. But Avinash’s condition started to deteriorate in the evening and he complained of severe headache and body ache. Worried, the couple went from one hospital to another, but the hospitals refused to admit the boy "as they did not have enough beds for dengue patients", said Gyanendra Debasish, Laxmichandra’s neighbour. Around 11 p.m., Avinash was admitted to Batra Hospital in South Delhi but it was too late. Around midnight, he stopped breathing because of “dengue shock syndrome with septic shock”, a state in which an extreme deficiency of platelets caused by dengue fever leads to innumerable blood clots, triggering a multiple organ failure.

“According to their custom, the body of a child is buried [and not cremated]. Avinash was buried at around 1 a.m. We returned home together at around 2 a.m. We could not believe our eyes when we found the bodies of Avinash's parents in the morning. In one single day, a happy family was gone,” said Debasish, who is yet to come to terms with the shocking incident.

AN upsurge in the number of cases of dengue infection by itself should not have caused the kind of hyped-up visual media coverage and the consequent panic that one has seen in Delhi since the beginning of September. Dengue is a self-limiting viral disease, caused by the day-biting Aedes Aegypti mosquito that breeds in clean and stagnant water and transmits the virus among humans. It is not life-threatening and is rarely fatal and over 99 per cent of the cases get cured if the infection is identified by proper and timely diagnosis. The disease, which in its non-severe form is characterised largely only by fever, headache and severe body ache, can be managed and its progression checked by simple home treatment or treatment at the level of a general physician.

The disease is endemic in most parts of the country and occurs practically every year, particularly during the rainy season when stagnant clean water is available all around. The seasonal upsurge turns into an outbreak with the number of cases peaking periodically, every two to three years or so. But checking the spread of the disease requires a functional public health care system and civic bodies of towns and cities of the country and, not the least, a responsible society that works towards a clean environment.

While the Delhi-centric visual media hardly ever concerns itself with much more fatal diseases, such as cerebral malaria, diarrhoeal diseases among children and acute respiratory infections, which occur round the year and cause deaths to thousands of poor around the country, an outbreak of dengue temporarily shakes up the largely urban middle- and upper-middle class sensibilities. As it happens, dengue is largely an urban disease as the high urban population density aided by convenient breeding grounds for the Aedes mosquito. Roads with potholes, abandoned cars, discarded tyres, home desert coolers, overhead tanks and other means to store water for daily use, flower pots and containers of various kinds used in home gardens constitute an enabling environment for rapid transmission of the disease.

Given the large number of cases in Delhi this year (3,791 cases with 17 deaths as of September 20), compared with 995 cases in 2014, one would probably call it an outbreak because the dengue season will stretch up to November and the number of cases is likely to increase. In 2013, the capital recorded 5,574 cases with six deaths, and the outbreak before that was in 2010 when there were 6,259 cases with eight deaths. Of course, the fatality rate seems somewhat higher this year. Given that the dengue virus, of which there are four types, is a fast-mutating one, this would require a coordinated scientific investigation into mutation of the circulating virus type (said to be Type-2 and Type-4 but predominantly Type-2, which is the most virulent) and characterising its virulence by virus isolation, its sequencing, and post-outbreak epidemiological studies.

This time around, the dengue outbreak has occurred not only in Delhi but in several other States as well, as is evident from the data of the National Vector Borne Disease Control Programme (NVBDCP). But what brought the issue to the media centre stage is the death of two young boys, infected with dengue, in two similar incidents about a week apart. The large high-profile private hospitals that their families approached for treatment had turned them away, citing shortage of beds.

The boys would not have died had the doctors and/or the authorities of these hospitals had a sense of medical ethics and ensured that the boys were out of danger by stabilising their condition first and then referring them to another hospital. Stabilisation requires only administration of fluids to prevent dehydration and not any critical medical intervention, unless it is a serious case of dengue haemorrhagic fever (DHF) or dengue shock syndrome (DSS), which happens in a very small fraction of cases.

The hospitals’ conduct towards patients seeking immediate medical assistance raises the issue of regulating the private sector hospitals, particularly with regard to the issue of medical ethics. But, more importantly, the dengue episodes highlight the much larger issue of the total absence of a functional public health care system to provide timely medical assistance. A dengue case need not be immediately rushed to a large tertiary hospital. All that is required is a primary health centre (PHC) or a dispensary nearby that can take immediate measures such as ensuring sufficient fluid intake and stabilising the patient.

Interestingly, data from the Union Ministry of Health and Family Welfare show that Delhi State has a shortfall of 67 per cent of health sub-centres, 62 per cent of PHCs and 100 per cent of community health centres (CHCs) set up under the National Rural Health Mission (NRHM). However, Delhi, being a metropolitan city and the capital to boot, is served by multiple agencies, including the Union Health Ministry, the Delhi government’s Directorate of Health Services (DHS) and the Directorate of Family Welfare (DFW), and three local government bodies—the Municipal Corporation of Delhi (MCD), the New Delhi Municipal Council (NDMC) and the Delhi Cantonment Board (DCB).

Besides PHCs, there are the urban PHCs or dispensaries, the Central Government Health Scheme (CGHS) dispensaries, and the Delhi government dispensaries that are run by different agencies. In all, there are about 1,000 such centres, including 430 primary urban health centres (PUHCs), set up under the NRHM (the NRHM is now a sub-mission of the overarching National Health Mission). Besides the NRHM data on PHCs (which probably serve the semi-urban/rural areas around the city), there is no other set of data available to determine how many of these are functional and how many have qualified doctors to attend to patients.

According to the Jan Swasthya Abhiyan (JSA, or People’s Health Movement), there is practically no coordination between these agencies. In the run-up to the Delhi Assembly elections, the JSA had demanded a functioning public health system with an apex coordinating mechanism to help patients move seamlessly between facilities. Added to these, Delhi Chief Minister Arvind Kejriwal has called for the setting up of mohalla (neighbourhood) clinics.

What is surprising—a fact that needs to be stressed—is that the families of the two boys who succumbed to dengue could not (or because of distrust deliberately did not) access any of these health centres; they went in search of a tertiary-level private hospital. Either way, it is indicative of a dysfunctional public health system. The JSA had demanded that “all these centres should be upgraded to meet the norms of a PUHC with basic laboratory facilities, offering a range of services (curative, preventive and promotive) and referral services to secondary and tertiary facilities”. If that can be achieved, there would be one such facility for every 15,000 population.

From a public health perspective, it is equally important to have an efficient and operative disease surveillance and monitoring mechanism, the data from which can help health professionals carry out epidemiological studies and disease forecasting. If these things had been in place, the current dengue outbreak could perhaps have been anticipated and appropriate measures instituted. Even the fumigation exercise by the city’s civic agency, which should have started in April/May itself, began much after the rainy season had begun. While the Integrated Disease Surveillance Programme of the Health Ministry claims to have a disease surveillance and monitoring mechanism in place, clearly it was ineffective. The situation points to the total absence of coordination among government agencies, health centres and hospitals (both public and private), civic bodies and local community organisations.

It is important to prepare the public by creating awareness before the outbreak of dengue or any other seasonal disease so that people can approach the health facilities for timely treatment. The Ministry has claimed that the public awareness campaign, through newspaper advertisements and messages on television, was started in February itself. If that is true, it was clearly not effective enough.

Otherwise, why would a situation have arisen when people lose faith in the health care system and start believing in irrational remedies such as drinking goat’s milk (sold at as much as Rs.2,000 a litre) or eating boiled papaya leaves. Apparently, a whole papaya tree was uprooted from the campus of the All India Institute of Medical Sciences (AIIMS).

The role of civic agencies is important in ensuring better sanitation and community-level hygiene. With the shortage of water, most urban poor, particularly in slums and jhuggi-jhopri clusters, collect water from roadside taps or trucks of water supply agencies. This leads to waterlogging, which creates a breeding ground for mosquitoes. In much of urban India, especially small towns, civic agencies tasked with ensuring an effective sewage and garbage removal system exist largely on paper. Public health cannot be seen in isolation; it is not health centres and medicines alone. It is intimately tied to civic issues. But the health agencies hardly communicate with other agencies to ensure that these related systems work effectively.

Even as the dengue outbreak is on, data collection seems to be quite disorganised and uncoordinated. In Delhi, the task of compiling disease data is entrusted with the MCD. But there are multiple agencies that collect data: the NVBDCP and the MCD, Central research hospitals such as the AIIMS (which is one of the 15 Apex Referral Laboratories under the NVBDCP and does not come under the MCD), and the completely unregulated private sector. According to P. Ravindran, who heads the Emergency Medical Relief (EMR) cell at the Health Ministry, this lack of coordination is evident from the fact that even the proformas designed to submit data are not harmonised. He said the MCD’s proforma did not even have a provision to indicate the fatality rate.

But more significantly, many private hospitals, according to M.K. Kabra of the Department of Medicine, AIIMS, do not even share the data on the dengue cases they handle. As of September 22, only 20 of the 44 private hospitals in the city shared their data.

In principle, this should be enforceable under the Clinical Establishments (Registration and Regulation) Act, 2010, said Lalit Dar, Professor of Microbiology at the AIIMS. But, health being a State subject, each State has to enact its own law, and Delhi has not done so.

The fatality rate of the current outbreak can be deduced only from the data provided by the AIIMS. According to Dar, of the 700 cases that the AIIMS has handled, there have been four deaths, which gives us a fatality rate of about 0.06, a slightly higher scale compared with the previous outbreaks. Also, the Type-4 virus had been isolated only from among the AIIMS cases. All the other cases referred to the AIIMS were of Type-2, he said. But even this Type-2 variant did not cause cases of DHF, but some cases of DSS were seen, he added. The Type-4 variant is apparently less virulent and has not caused any death so far. “But our experience with past outbreaks suggests that our own samples plus those referred to us are fairly representative of the virus types in circulation,” Dar said.

If this is what prevails in a non-epidemic situation of a disease that is relatively benign with a much lower fatality rate than many other diseases and that too in an urban setting in the capital region, one can well imagine the state of affairs in an epidemic situation of a high-fatality disease, particularly in rural and remote areas where health infrastructure is practically non-existent. A robust and effective public health care system with much better finances, larger human resource in terms of skilled professionals, and a mechanism like the NRHM designed to function in rural settings but better equipped and endowed is the need of the hour. Unfortunately, even envisioning such a system is not on the government’s agenda let alone working towards creating one. The policies and strategies that are being evolved are slowly dismantling even the existing system and handing health care to the private sector, whose performance in the current dengue outbreak is there for all to see.