Wake-up call

The outbreak of the Ebola virus disease (EVD) in some West African nations and the subsequent possibility of the virus spreading to countries in South Asia, including India, have raised legitimate concerns not only about the state of preparedness but also about the general state of public health infrastructure in the country. While it is true that the government took the threat of the epidemic seriously following the global panic when an American doctor and an aid worker got infected, the thrust of the effort and governmental intervention seem to be symptomatic rather than systemic. The high mortality rate of the disease, at 90 per cent, is attributed to the underdeveloped immune response to the virus. And with pharmaceutical companies reluctant to invest in producing vaccines for the disease as Ebola cases have affected mostly the poorest countries of the world, the need to step up public expenditure on health is of utmost importance. However, the National Democratic Alliance (NDA) government, despite its promises of bringing a new health policy with stepped-up public expenditure on health and universal access to health services, is relying on the public-private partnership (PPP) model to deliver services. If the experience of the Ebola disease outbreak is anything to go by, there is a crying need for more government spending and research on health.

Resurgence of communicable diseases

It is widely acknowledged that there has been a resurgence of communicable diseases in the past decade, with their outbreak and spread confined not just to developing countries. Following the Ebola disease outbreak, on May 2, the National Institute of Communicable Diseases (NICD) issued an advisory to all health-care providers, including State surveillance officers, to keep a constant vigil and to raise their level of awareness and knowledge of standard precautions to be taken during the care and treatment of suspected Ebola patients. The advisory includes instructions on sample collection techniques and packaging conditions. It also cautions that samples from patients are an “extreme biological risk and that testing should be conducted under maximum biological containment conditions”. The World Health Organisation’s (WHO) Twelfth General Programme of Work has stated the reduction of “mortality, morbidity and societal disruption resulting from epidemics... through prevention, preparedness, response and recovery activities” as one its five strategic imperatives. In the editorial titled “Are we prepared?” in Journal of the Association of Physicians of India (September 2014, Volume 62), its authors, Falguni Parekh and Shweta Shah, state that India needs to walk an extra mile as far as “preparedness, response and recovery activities” are concerned. According to them, an estimated 47,000 Indians in Ebola-affected countries were being contacted by diplomatic missions and supplied with educational material about the disease. And from August 9 onwards, passengers coming from these countries have been asked to fill in a form detailing the places visited and symptoms, if any, before landing. This is essentially a screening procedure for the standard symptoms of the virus. These steps, though welcome, are not adequate, given the potential of the virus to spread.

“It is impossible to screen everyone having some symptoms. Given the overcrowding at our airports, by the time the affected person is identified and quarantined, hundreds of people would have been infected,” said a health specialist with expertise in dealing with epidemics. The government has restricted flights coming from Ebola-affected areas to two international airports, Delhi and Mumbai. The guidelines of the Ministry of Health & Family Welfare state that samples should be collected from any person who has or has had fever with acute clinical symptoms and signs of haemorrhage, such as bleeding of gums, nose bleeds, conjunctival infection, and red spots on the body. But experts say the isolation of such cases coming into the country, given the sheer numbers, will be difficult unless those symptoms are reported by people themselves.

High cost of PPE and therapy

Dr K.P. Kushwaha, head of BRD Medical College at Gorakhpur, Uttar Pradesh, has dealt with all kinds of diseases caused by deadly viruses, including the scourge of Japanese encephalitis that affects the district and surrounding areas each year. He told Frontline that the Ebola virus, which is an RNA (ribonucleic acid) virus, was a deadly one. The guidelines issued by the Centres for Disease Control and Prevention (CDC) were not followed by the United States government. The personal protection equipment (PPE) comprising gowns that covered the entire body, he said, was manufactured by private companies and was too expensive. “The health worker who has been in contact with an infected person has to be cleaned thoroughly; even while removing the glove, care has to be taken that it does not touch any body part. The guidelines by the WHO and other agencies are very strict about precautionary measures. To what extent they are followed or violated is a big question as the risks are great,” he explained.

There was no PPE at the airports, Dr Kushwaha said, and expressed doubts about the manpower and resources for the isolation and screening of people, even at the airports. The personnel deployed were only filling in forms and checking whether individuals had any fever or cough. Quarantining was the biggest challenge, but all that had been happening was in the nature of formalities getting fulfilled, he said.

There is no cure for Ebola, and persons infected with the virus have to be put on oxygen and antibiotics. In the absence of a vaccine, only an experimental medicine or therapy such as ZMapp, which consists of monoclonal antibodies prepared from the plasma of the person infected, can be given. “Conservative treatment and the isolation of the patient are the only possible ways out,” he said. People returning from Liberia, Sierra Leone or Guinea had to be isolated and screened for symptoms, he said. “All persons returning from the affected countries should disembark at one airport,” he suggested. In fact, the costs itself of PPE and the experimental therapy have come under question. Each set of PPE costs as much as $100, and the affected countries are finding it very difficult to pay for the PPE.

Dr Kushwaha said that barring surgery involving HIV patients, PPE was not provided anywhere in government hospitals. The medicine, too, he said, was very costly, at $4,000 a patient a day. The combination had to be taken until the patient was fully cured, he said. Dr Kushwaha also stressed the need for laboratories, biosafety laboratories in particular, in adequate numbers. Given the nature of the virus, special containment facilities were required, which at present were available only at the NICD in Delhi and the National Institute of Virology (NIV) in Pune. Experts are of the opinion that normal pathological laboratories are not suitable for the testing of suspected Ebola samples.

Doctor-patient ratio

Dr Kushwaha also laments the poor doctor-patient ratio in the country. “The number of doctors and health workers has not kept pace with the growth in population. The 40,000-odd doctors and 284 medical colleges are hardly enough to meet this challenge,” he said, adding that every State should ideally have an epidemiological institution. He recommends an epidemiological control authority on the lines of the National Disaster Management Authority to tackle an epidemic situation. The Integrated Disease Surveillance Unit was not working well, he said, as there was no monitoring. He recalled how at the time of the swine flu epidemic, each hospital was sanctioned up to Rs.4 crore to establish swine flu laboratories. None of those laboratories were functional, he said.

The chapter on health in the 12th Plan document notes that the total health infrastructure in the country is much below the stated requirement. While the number of skilled professionals has increased, they are concentrated in urban areas. In rural areas, the numbers of accredited social health activists (ASHAs) has gone up but only half of the additional numbers got advanced or 5th module training. In any case, ASHAs, who draw incentive-based emoluments, are deployed for the purpose of reducing maternal and infant mortality. Moreover, their regularisation and working conditions still remain unaddressed.

The chapter further notes that very few of the facilities at the sub-centre, community health centre (CHC) and primary health centre (PHC) levels meet the requirements laid down in the Indian Public Health Standards. The shortfall in each category is huge: laboratory technicians 80 per cent, specialists 88 per cent, doctors 76 per cent, health workers (male) 75 per cent, nurses 53 per cent, and auxiliary nurses and midwives (ANMs) 52 per cent.

Over-reliance on contractual appointments as the means of increasing service providers is another matter mentioned in the chapter. The difference in pay and perks for the same work between contractual and regular staff is irrational.

More seriously, the health chapter in the 12th Plan, while arguing for a comprehensive approach for health care, observes that public expenditure on health, both Plan and non-Plan and State and Central, was less than 1 per cent of the gross domestic product (GDP) in 2007-08. This went up marginally to 1.05 per cent in 2010-11, which the chapter says, “needed to increase much more”.

But it does not appear that the present government’s thinking on public expenditure is very much different from that of the previous government. Reports of a targeted National Health Assurance Mission with some promises of health insurance and provision of generic variants of essential medicines at affordable rates have appeared, but the government plans to deliver health care through the PPP mode as well.

For a maximalist approach

While the scare of Ebola should legitimately make the authorities focus attention on India’s public health system, some experts say there is no need to go into panic mode as far as mortality and infectivity are concerned. Agreeing that public health systems needed to be strengthened immeasurably, T. Sundararaman, Visiting Professor at Jawaharlal Nehru University, New Delhi, and former director of the National Health Systems Resource Centre, told Frontline that while mortality and infectivity were high, it was not impossible to control them.

Liberia faced the brunt of structural adjustment policies under the dictates of the World Bank and thereby its public health system could not withstand the onslaught of the virus. The problem, he said, was that most public systems, facing the kind of pressure that Liberia did, opted for a minimalist package of health care. This was a highly selective package of health care. “Whenever there is an emergency, there is a maximalist response,” he said, but the approach continued to be minimalist.

He advised that at all times, there should be a certain degree of redundant capacity. “This is to say that large hospitals should not target 80 per cent occupancy. We cannot expect a private hospital to keep beds vacant. There should be enough and more number of beds to respond to situations of emergency,” he said, emphasising that most hospitals in India were overcrowded. “The government has responded in terms of identifying places where the infected can be isolated and in creating awareness, but the overall preparedness is not there,” he said.

One of the foremost requirements, Sundararaman said, was an efficient system of notifying diseases. The symptoms of Ebola are similar to that of dengue hemorrhagic fever. “One cannot prepare for an epidemic like Ebola without having prepared for tackling epidemics on an ongoing basis. The integration between clinical care and the city health office is an example of such coordination and, to my knowledge, Kolkata and Chennai are two cities that have such a system in place,” he said. There could be a guarantee that the virus could be restricted in the airport areas. However, most cities, he said, including second- and third-tier ones, did not have a robust public health system in place. “There has been much talk of a health policy since the 12th Plan, but nothing seems to have taken off. Public expenditure on health has remained stagnant,” he said.

That seems to be the fundamental point. Writing in Journal of the Association of Physicians of India , Falguni Parekh and Shweta Shah say that the WHO has identified some basic principles in dealing with public health emergencies of national and international concern. Assuming that Ebola is one such emergency, a strong and efficient response should include—after considering the socio-economic, demographic, environmental and ecological factors that facilitate the occurrence and spread of the disease in India—infrastructure for transport, triage and isolation of patients; provision for treatment to the patients and the implementation of infection-prevention practices, including environmental cleaning procedures according to national and international guidelines of the National Centre for Disease Control (NCDC), India, the WHO and the CDC; use of unlicensed drugs and vaccines according to the WHO recommendations; laboratory facilities for diagnosis and sample collection; an efficient surveillance and reporting system; and provision of information and training to public health officials and the community through mass communication systems.

The Ebola disease outbreak is a wake-up call for the government to spend more public health. According to the Jan Swasthya Abhiyaan (people’s health movement), even though public health care systems account for only 29 per cent of the total health expenditure and employ less than 20 per cent of the medical workforce, they provide about 33 per cent of all outpatient care as provided by a qualified provider and 40 to 50 per cent of all inpatient care and 100 per cent of all preventive and promotive care. If anything, health care requires a maximalist approach in terms of everything beginning with public expenditure.