First, there was a fever, along with headaches, diarrhea and muscle ache. Few people, or the doctors they visited, paid much attention: the symptoms suggested nothing that couldn’t be handled with paracetamol and immodium. But then came the tremors, mental confusion, seizures and coma. Every third person who developed the symptoms was headed towards a sudden death. Within weeks, the toll had reached 300.
As India faces the prospect of being hit by the global Ebola epidemic, last year’s outbreak of Japanese Encephalitis stands as a grim reminder of ground realities. The central government has announced a slew of measures to protect citizens from the feared disease — and yet, the country remains short on protective equipment, testing labs and professional training.
The long, dark corridors of Delhi’s Ram Manohar Lohia Hospital, packed with thousands of patients and their families, will be the frontline of India’s defences if Ebola hits. In August, an insolation intensive care unit opened on the first floor of the hospital’s old block, earlier used for H1N1 swine flu cases.
But it isn’t quite ready. Nurses who have read of two colleagues in the US who fell ill caring for a critically-ill Ebola patient, are worried. The National Centre for Disease Control (NCDC) has issued guidelines, but those don’t seem to have had much impact. “We do not have respirators, and we have never worn goggles,” a nurse told The Indian Express. “And we have no experience with the virus. We have met the nursing superintendent and asked for classes.”
From October 19, healthcare professionals from around the country will begin to be trained in handling Ebola. They are then expected to disseminate the information to personnel in the states. Health workers have, however, voiced concerns over the lack of protective equipment such as hazardous-material suits, masks and goggles. The Health Ministry said on Thursday that 50,000 kits purchased by the Centre would be distributed to the states, but it remains unclear how long the distribution process will take.
The World Health Organisation has already warned that India’s problems could be compounded by the fact that Ebola’s early symptoms resemble those of dengue and malaria, common across large parts of the country in the next two months.
“We just can’t isolate every patient who shows up with fever, diarrhea or vomiting, which are all non-specific viral symptoms that could indicate any seasonal disease, or Ebola,” said a scientist with the NCDC in New Delhi.
“Our immediate focus is to ensure that not a single case enters the country during the peak of these seasonal diseases. Preparations and public health education by airlines, at airports, and among health workers are being scaled up to ensure this,” he said.
Laboratory tests are the only means to distinguish Ebola from less-lethal diseases. But there are only two labs equipped to conduct the procedure: the NCDC in Delhi, and the National Institute of Virology (NIV) in Pune. They have already tested 96 samples, and staff say their resources are stretched to breaking point.
The government has announced 10 more labs will be strengthened, but government sources said these will only collect and store samples. “A grade-three level biosafety lab is required to conduct the tests,” said a source in the NCDC. “And it takes years to prepare one, and train staff for it.”
There has been no effort to reach out to doctors in private practice — specialists who are likely to be first points of contact for many patients. No private diagnostic facilities have been identified. Peter Piot, who discovered Ebola in the 1970s, recently said he feared for what would happen if the disease hit India, noting that few medical professionals even wore gloves when tending to patients. “They would immediately become infected and spread the virus”, he said.
Dr Ashish K Jha, director of the Harvard Global Health Institute, pointed out that all diagnosed Ebola patients in the United States were currently being treated by private hospitals, with the government “coordinating the efforts”.
“The private sector is a huge pivot that cannot be ignored by the Indian government. What is to prevent the first Ebola patient in India checking in at a small clinic in, say, Patna, with a fever? The longer it takes to diagnose an Ebola case, the more people will be infected, so training and guidelines to this massive chunk of the Indian healthcare system is crucial,” Dr Jha said.
The Indian government, he said, “needed to introspect on its role”. “The government has to see whether it is an agency that runs a few public hospitals, or represents the society at large,” Jha said.
India has so far focussed on airport screening. Since October 15, 22,150 passengers have been screened, seven of whom were identified as medium-risk individuals, and another 56 as high-risk. The high-risk passengers have been placed under observation for 30 days, while low-risk passengers have received information on the need to report symptoms, should they arise.
This, though, is at best a measure of limited utility. “We must realise that Ebola has a long incubation period,” a doctor involved in screenings at Delhi’s Indira Gandhi International Airport said. The WHO recently reported that symptoms have sometimes been showing up as late as 42 days after individuals were infected — which means even someone carrying the virus has no reason to suspect she or he might be ill.
From West Bengal’s experience, it is clear that the reporting structure in the states remains anaemic — which means that outbreaks in the rural areas might pass unnoticed until it is too late. West Bengal’s state plan mandates that its Integrated Disease Surveillance Programme (IDSP) identify outbreaks of disease, and pass up data gathered from local hospitals, labs, and health centres.
But that just wasn’t done. “There are computers at each public health centre (PHC) to facilitate this system,” a senior health department officer in Kolkata conceded. “But PHCs failed to do their duties. There is no medical officer in most of the PHCs,” he added.
Dr G K Pandey, director of the Kolkata-based All India Institute of Hygiene and Public Health, said the problem was far bigger than West Bengal. “Other than in a few states, the situation is the same across the country.”
Even if reporting had been perfect, it is far from certain that the available infrastructure could have dealt with the crisis. Lack of diagnostic kits meant that tests were delayed, and kits ordered from NIV arrived late.
There weren’t enough entomologists. Biswarajan Satpati, West Bengal’s Director of Health Services, said the government “had sent a requisition to the Centre for 20 entomologists last year, but we received only one”.
Four entomologists of the Kolkata Municipal Corporation had to work overtime to cope with the situation. “We formed a special Rapid Action Team which worked virtually round the clock,” recalled Atin Ghosh, an expert at the civic body.
Field teams from the NIV eventually plugged the gaps. Dr Babasaheb V Tandale, Scientist D, Epidemiology Group, NIV, said that “over 40 per cent of the cases were confirmed as JE”.
Experts said the real lessons from the outbreak had not been learnt. “A drill to deal with such an emergency is hardly done. At least I have not seen any,” Dr Pandey said. Another senior official of the health department said it was typical that committees would be set up when a situation arose and, after a few days, when the media had got a new issue to pick up, everything was forgotten.
The National Disaster Management Authority has elaborate guidelines, put together by over 50 top national and international experts, on just how pandemics and even bio-weapons attacks should be dealt with. There are detailed guidelines, too, on Ebola. Like most other states, though, West Bengal hasn’t complied with its suggestions — and the Ministry of Home Affairs hasn’t moved to set up a regulatory legal framework, a key recommendation.