With the ongoing spread of Ebola in West Africa, it is becoming increasingly likely that the disease will make its way to India. So what should India do to prepare? The Union government has already taken several meaningful steps. It has designated hospitals in major cities as Ebola management centres and formed rapid response teams in every state, each of which will include physicians, nurses and epidemiologists. The state teams are being trained by the WHO and the US Centres for Disease Control and Prevention, and will disseminate their training to local first responders. Also, the government has put in place screening protocols at international airports, established 24-hour Ebola helplines staffed by doctors and shortlisted the authorisation of 10 new Ebola-testing labs.
These are all important steps, but they may not be enough. Indeed, if the disease were to arrive and begin to spread, India would need a strategy that is bigger, more aggressive and comprehensive than what it has now. We propose three main areas where policymakers should concentrate additional effort: a stronger focus on diagnostics and therapeutics, greater partnership with the private sector, and a more aggressive approach to public communication. Even if Ebola were not to arrive in India, this would serve as a way to prepare for future similar medical threats.
The first potential weakness in the diagnosis and containment of Ebola is in the identification of potential cases. Stopping an outbreak becomes substantially more difficult as diagnosis is delayed. For a nation of 1.2 billion, India’s 12 prospective diagnostic labs are scarcely enough. The cost of the Ebola test is dropping and a diagnosis can now be made in hours. The US Food and Drug Administration recently approved two new Ebola tests that require just two hours to make the diagnosis. While some of these new testing systems are expensive, having more of them in India will be worth it. Further, cheaper tests are coming soon and as they come on the market, India should make additional efforts to ensure these tests become widely available. If a patient arrives in Patna, having the blood sample sent far away not only needlessly delays that patient’s diagnosis but also allows the disease to spread to others if she is not properly quarantined during that time.
If the disease burden in India increases beyond a few sporadic cases, having diagnostic centres in every state and region will be critically important.
Beyond effective diagnostics, India needs a plan for treating Ebola. The current death rate for Ebola patients in West Africa is approximately 75 per cent. In the US, the death rate, albeit among just nine patients, is 11 per cent (the one patient who died had his diagnosis severely delayed and the treatment came too late). Why this difference? While some of it is clearly about having better healthcare systems that can provide more comprehensive supportive treatment, nearly every American patient received new experimental treatments, many of which likely made a difference, although we cannot be sure. There are several antiviral drugs that appear to be active against Ebola and transfusions from Ebola survivors who have fully recovered and, therefore, whose blood is free of the virus but contains potentially therapeutic antibodies, may be helping. Will these treatments be available for Indians who might come down with Ebola? We think they should be — and the Indian government needs a strategy now to work with manufacturers of these products should Ebola appear in India.
The current Indian government strategy focuses primarily on government hospitals to contain and manage the disease. While this makes sense, we believe it is not comprehensive and fails to take advantage of the strong private infrastructure that has developed across India in recent years. There are dozens of modern, well-funded private hospitals across India, and not just in a few major cities. The government should recruit those organisations willing to play a helpful role. As the Central and state governments work on their strategy for centres of excellence and for the identification and management of Ebola, ensuring that private hospitals play a role is critical. They can bring resources, expertise, and capabilities to the table and can greatly increase the effectiveness of the national response to Ebola. Specifically, we would like to see, at least in some cities, private hospitals designated as Ebola centres for excellence (with the responsibility of taking care of any Ebola patient irrespective of the ability to pay). It is in the nation’s best interest for the government to subsidise this care as needed.
There have been important failures of communication in nearly every country that has so far confronted Ebola. India can and should be different. Learning from the mistakes of others, India should focus its efforts on better education of the population and creating a sense of trust that will be critical should Ebola break out in the region. While helplines are a good start, they are not enough. In Nigeria, which is widely seen as a success story for controlling its Ebola outbreak, effective, widespread dissemination of information about the virus, how it spreads and how the healthcare system can prevent and treat it, was critical. Nigeria was able to harness radio, social media and text messaging to communicate information about the disease to the public. The Nigerian government also led an aggressive campaign against the stigmatisation of Ebola patients, and recruited volunteer groups to provide timely and factual updates to the Nigerian public.
We believe this strategy would work in India as well. First, it would show that the government is preparing for the disease and would help citizens to understand what their leaders are doing, and why. Second, if and/ or when the disease strikes India, having had a clear messaging campaign in the weeks prior will allow healthcare leaders to provide context for the outbreak and create greater trust in the response. Finally, a more effective and broader public health campaign around Ebola can allow healthcare leaders to build trust in the healthcare system as a whole. This is critically important, and not just for Ebola. When people trust the healthcare system, they are more likely to come in early before diseases spread widely, more likely to be compliant with the treatments offered and more likely to encourage others in the community to engage with the system. Increasing trust in the healthcare system will have enormous benefits for Ebola and for other ongoing and future disease outbreaks.
This is a pivotal moment for the Indian healthcare system. The nation is undergoing substantial changes with greater privatisation and a new Central government dedicated to creating trust in public institutions. At the same time, the world is facing one of its greatest global health challenges in years, a challenge that has so far spared India, but may not for long. In the face of that challenge, Indian healthcare leaders must bolster the national response to Ebola.
Along the way, they can achieve two more goals: first, India can aspire to be a global model for how countries can tackle dangerous infectious diseases like Ebola and second, it can create a framework for effective, trusted healthcare delivery in the context of such infectious diseases that will reap dividends in the years to come.
Jha is K.T. Li Professor of International Health and Health Policy at the Harvard School of Public Health. Khanna is Jorge Paulo Lemann Professor, Harvard Business School, and director, South Asia Institute, Harvard University, US.