With more than 2000 swine flu deaths and 35,000 infections in India this year, could the country’s health system have done more to control the disease?
Does India need to build its capacity to respond to epidemics?
Since the first case of swine flu in India in 2009 the number of deaths have risen dramatically, with an estimated 2123 fatalities already this year, and 35,000 infections – and climbing.
Influenza A is caused by the H1N1 virus and this year the strain (H1N1) pdm09 is proving particularly nasty.
It’s true that a change in the genetic structure of the virus has made it more virulent, but a properly functioning health system in India could control such a disease.
The good intentions are there. State governments and the central government coordinate efforts. The Integrated Disease Surveillance Program (IDSP) has also enhanced its surveillance of H1N1 infections with its 12 laboratories, along with nine laboratories of the Indian Council of Medical Research (ICMR).
Oseltamivir, the medicine used to treat H1N1 infection, is given free to people from public health systems. Additionally, 358 private pharmacies in Northern Indian, 804 in Southern India, 1072 in Western India and 143 in Eastern India have been permitted to sell Oseltamivir to people infected with H1N1. The government has also recommended vaccinating health workers, and the distribution of free masks.
Close networks of clinicians have also been established to strengthen response to H1N1 at the peripheral level.
Seen like this, the health system is prepared. Why, then, so many cases and deaths? And a more intriguing question, why are the numbers rising? After all, the longer the prevalence of an infectious disease, the more prepared health systems become.
Firstly, we need to understand that India has a mixed health system, where 70 per cent of its population access health services from the private sector, paying out of pocket, and only 30 per cent access it from the public sector, financed mainly through taxes.
So when we talk about India’s health system’s preparedness to deal with H1N1, we need to see it in this context.
The prevention of H1N1 infection is the prerogative of the public health system, with some linkages and support from the private sector. However, existing surveillance systems need a lot of strengthening at various levels – including availability of testing facilities, human resources and financing – to detect infected cases as early as possible.
Along with this, the enhanced role that private medical practitioners can play in early case detection needs to be acknowledged and systematized to a far greater extent.
The public availability of accurate information also has a huge role in preventing outbreaks. In India, with many vernacular languages, dissemination of accurate information is a challenge – but achievable.
The availability of vaccines is another big challenge. In addition, there are mixed views on their public health impact. On one side, it is argued that vaccination limits access to prevention, on the other, that lack of availability ensures its rational – rather than indiscriminate – use. But in both scenarios, the availability of vaccine needs to be ensured, and its current lack of availability is a barrier to access to treatment. And currently, government recommends vaccine for health workers closely working with people infected with H1N1.
On the treatment side, the first and foremost requirement is an accurate and faster test. Currently, it takes 72 hours of testing before H1N1 infection can be confirmed, but this delays treatment and increases the chances of spreading infection. On top of that, only a few private laboratories and some public health systems offer these tests. The private laboratories are prohibitively expensive and public health systems are scattered, making access difficult. Effective testing is the first step to effective treatment.
Treatment facilities are another hurdle. Isolation facilities in both public and private sectors are limited, and skewed towards urban India – as is the case generally with health care facilities. This seriously limits the ability to contain infection for any form of infectious disease.
There are systems that can respond effectively to H1N1 outbreaks, but they need considerable improvement. Given the mixed nature of the health systems in India, a synergy between public and private health care is needed to break the infection cycle.
So it’s not that India can’t rise to the challenge, but rather that resources are put to better use. And then, even when the health system is properly prepared, informed communities will play a pivotal role in breaking this cycle.