The past few weeks have witnessed substantial media coverage on the dengue outbreak in Delhi. Heartrending stories of clearly avoidable deaths gave the crisis a human face. Focusing on Delhi, most sought to expose the lack of preparation of the recently elected government, while a few reflected on the dysfunction in India’s health system, particularly on the supply side — low public health spending, non-availability of beds and shortages of human resources.
The media glare forced governments at all levels to take action. However, public health experts were not impressed. Most felt that the hype generated fear, panic and a chaotic environment, and resulted in a loss of perspective, shifting focus to less-important interventions like expanding access to hospital beds.
Dengue, a vector-borne disease, thrives in tropical climates, making its elimination impossible. The caseload has been increasing steadily each year. In February, the Centre alerted all state governments to expect a higher incidence of dengue this year. Delhi lost the window of opportunity to avoid an outbreak because of a governance deficit; first because the state was in election mode and then because of the AAP’s internal squabbles and conflicts with other institutions of governance. The sharp spike in the number of dengue cases is a result of neglecting to implement critical interventions in a timely manner. Though the authorities have of late taken several measures, they’re too little, too late. The neglect will take its toll.
Controlling dengue requires strong community outreach through the primary healthcare system. However, clinical specialists from corporate hospitals featured in the media skewed the debate towards infrastructure gaps, rather than highlighting the inequities in accessing public health services. Considering that no more than 3 per cent of dengue cases require hospitalisation and blood transfusion, bed availability need not be a major issue.
Instead, overcrowded hospitals reflect the collapse of the primary health system. And rather than asking why district hospitals are unable to address the demand for institutional care, the debate has circled around earmarking beds or providing free care in costly specialty corporate hospitals that may not even have the expertise to handle infectious diseases.
A health system based on strong primary care would have meant that, irrespective of the quality of political leadership, health workers would have visited mohallas, educated people on the risks of dengue outbreaks, identified potential mosquito breeding grounds and worked with households and communities to ensure implementation of public health measures to prevent the Aedes mosquito from establishing itself. As the Aedes mosquito cannot travel beyond 100 metres, the involvement of people and households is a critical need, not a choice.
Second, good primary care also implies a strong surveillance system, where case-reporting is routinely monitored, data is reviewed, and geographic areas exhibiting unusual patterns are assessed for field investigation and prompt action. Finally, a good primary health system would have educated families on the actions that needed to be taken in case someone develops fever, as well as on when and where to seek medical help. In other words, a community embedded system of primary care would have as its core strategy elements related to behaviour change, risk communication and timely referral.
Ironically, the AAP was, in fact, well poised to implement such a strategy and control the situation. With the vibrant Delhi Dialogue community-based communication network and a sound polio surveillance system in place, mohalla-based dengue prevention programmes could easily have been activated. But instead of involving the community and unleashing a media campaign for anti-larval operations, the leadership’s focus was on hospital inspections and regaining political legitimacy. Perception, not technical solutions, dictated the agenda.
The lack of coordination between the Central and state governments and between local bodies — the New Delhi Municipal Council and the Municipal Corporation of Delhi — also stood out. As per Schedule VII of the Constitution, infectious disease control is a concurrent responsibility, making the Centre equally liable for outbreaks of infectious diseases. Therefore, when the state government and local bodies were squabbling, the Centre ought to have stepped in and taken charge.
The lesson that emerges from this drama is that the operational guidelines issued in 2014 need to be accompanied by an accountability framework explicitly laying down who has to do what at every level of government. Health actions that need to be taken in infectious-disease control programmes — be it for dengue, Sars, H1N1, avian flu, TB, HIV or ebola — must be governed by a public health act that makes individual functionaries/ households accountable, and dereliction of duty punishable, as it is in Singapore, for example. Public health is too serious a matter to leave to politicians and should be based on sound evidence, detailed protocols and the routinising of systems. In other words, a prime minister- or chief minister-level review of routine matters should be seen as a reflection of a failed system, not concerned leadership.
The public health act also needs to make denial of treatment and non-reporting of notifiable infections by public or private facilities punishable. The government should fix treatment fees for such emergency care. Clear protocols and guidelines need to be laid down and the authority responsible for such coordination spelt out. Not adhering to protocols or overcharging by hospitals should invite prosecution.
Building such an institutional architecture for responding to infectious disease outbreaks is long overdue. Public health should be the first charge on health budgets. It is nothing short of political brinkmanship to ignore the political and economic costs of neglect. It is worth remembering the socio-economic devastation caused by HIV/ AIDS, and how Sars cost China 0.5 per cent of its GDP. According to the World Bank, the recent ebola crisis has resulted in Liberia’s growth forecast for 2015 being cut by half and projected growth in Sierra Leone and Guinea shrinking to below zero due to trade embargoes and displacement of workers as a result of fear and panic. These countries had healthy growth rates predicted for 2015 before the epidemic.
The Narendra Modi government, which slashed health budgets in such a cavalier fashion, should ask itself whether India can afford such losses. Can the government shrug off its constitutional obligations and responsibilities under the new mantra of minimum government and maximum governance, which may work well for promoting tourism but not in matters of public safety? These are important issues that merit serious attention, as the price of inaction and mismanagement can be far higher than expected.
The writer is a former health secretary, Government of India