The dengue virus has infected 25,000 people in India this year, with about 6,000 in Delhi alone. In this article, Chandrakant Lahariya, a public health policy expert, contends that the dengue situation represents a failure of local public health administration, and calls for a holistic approach to address the root causes and ensure long-term solutions.
While several cities/states in India have been affected by dengue1, dengue cases and deaths in Delhi have received a great deal of media attention in the past three months 2. The blame games, counter charges and shifting responsibilities have provided fodder for several prime-time debates on news shows. As the number of cases climbed up, the immediate response of the government (both at the Centre and state levels) was to provide more hospital beds and doctors. Some efforts were also made to prevent breeding of the Aedes mosquito which spreads dengue virus, and to encourage people to undertake preventive measures. But apparently, it was all too little, too late. It is expected that the number of cases would go down in October and no case would be reported in November; however, the reason would more likely be lower temperatures rather than effective government actions. This is the tragic tale of public health measures and population-level efforts, which have traditionally not received sufficient attention in India (Lahariya 2015).
Failure of local health administration
Dengue is spread by Aedes mosquitoes that breed in artificial water collections. Hence, a few weeks after the beginning of the rainy season, hospitals start getting dengue cases. Some of the patients suffering from the more severe form of the disease called Dengue Haemorrhagic fever (DHF), which leads to development of other complications, do not survive. It is the responsibility of local health authorities to generate awareness regarding the disease, take measures to prevent mosquito breeding and the spread of dengue, and ensure availability of health services for those infected. The occurrence of dengue indicates a lack of sufficient and timely preventive and public health efforts by the local health administration3. Hence, when cases start occurring, the initial reaction of the health officials is to deny the occurrence of dengue cases and deaths. Year after year, health authorities claim that adequate preventive measures are being taken, and dengue keeps returning to haunt the poor and rich alike.
Not just dengue
Death due to multiple preventable health causes is a common phenomenon in India. The infant and child mortality rates and maternal deaths in India are much higher than in other BRICS (Brazil, Russia, India, China, South Africa) nations. Malaria and Tuberculosis (TB) kill thousands of people; treatment facilities are suboptimal and inaccessible to the rural and urban poor alike. The disease burden and illness costs (in the form of loss of wages and indebtedness) and the cost of treatment (if there is access) are much higher and have deeper and longer-term impacts. The perennial denial of public health problems by health authorities is a road block for any corrective measures. Limited efforts are made to strengthen the reporting system for diseases, which in turn leads to only a small proportion of cases being reported and a rosy picture is painted of the health status of the population. The first serious step to solve any problem is to recognise it; however, denying or ignoring public health issues has become the standard approach.
The situation is similar for many other diseases. Since 1978, almost every summer, several children in Gorakhpur region of eastern Uttar Pradesh and Muzaffarpur in Bihar die due to what was earlier thought to be Japanese Encephalitis and is now identified as Acute Encephalitis Syndrome (AES). When cases are reported, there is a lot of media attention; teams are sent to the affected areas and commitments are made. However, policy attention shifts as soon as the cases disappear – only to return next year. Not enough systematic and sustained efforts are made to ensure that such deaths do not occur in the future.
One of the commonly cited reasons for the poor health scenario in India is insufficient spending on health by the Central and state governments. Public expenditure on health in India is a meagre 1.1% of GDP (Gross Domestic Product), which is among the lowest in the world. (The globally accepted practice is to spend 3-6% of GDP on health by government). In India, while experts have strongly recommended raising public expenditure on health to 2-5% of GDP, it has continued to remain low. This low expenditure is reflected in outbreak of diseases such as dengue as public health measures such as health education, prevention and control of mosquito breeding, community awareness and so on fall within the purview of government authorities and the private health sector (which mainly focuses on curative and diagnostic healthcare) rarely invests resources in such measures.
What can be done?
The dengue situation in Delhi has led to unprecedented media coverage and public debate. This should be leveraged to bring about required changes in public health policies and systems so that the situation is not repeated next year – in Delhi or elsewhere.
Rather than restricting to curative and diagnostic services, a systematic and concerted strategy is required that would incorporate all four broad components of the health system – services provision, resource creation, financing, and stewardship/governance. A partial approach is not likely to succeed.
Service provision: Health facilities need to be kept ready for surge capacity at the out-patient and in-patient levels so that patients can visit and consult doctors in a timely manner. There should be more focus on population services including awareness generation prior to the disease season, mosquito control etc.
Creating resources: Availability of sufficient public health staff should be ensured to visit communities to check mosquito breeding sites, conduct fogging and take other preventive measures. Adequate supplies of insecticides, spray machines etc. should be provided. On curative side, clinics and other health facilities should be equipped with trained manpower and regents for conducting tests for dengue virus, and human resources for counseling patients etc.
Financing: As described above, often either sufficient financing is not available to conduct community outreach efforts for prevention, and whatever is available is not released on time. Sufficient funds need to be allocated for prioritising public health activities, including recruitment and training of the staff.
Stewardship and governance: As for all diseases, the mechanisms for reporting of dengue cases are poor. There is a need for strengthening disease reporting systems and to use the information on cases/ deaths as a basis for action. Policies should be informed by learning from local experiences, and accountability mechanisms should be put in place to ensure that planned public health actions are implemented in a timely manner. Big metropolitan cities such as Delhi have a multitude of agencies delivering public health services. There needs to be strong leadership to coordinate the efforts of various agencies.
Prevention better than cure
The current approach to crisis management in the context of dengue focuses excessively on treatment via clinical care and hospitals; equal if not more attention needs to be given to public health functions for prevention of the disease. Detailed mosquito control plans should be developed prior to the dengue season. There is a need for public awareness generation to prevent mosquito breeding. Local bodies should undertake regular assessments and checks, including punitive measures such as fines for violation of suggested processes. The different government departments should coordinate to ensure sanitation and avoid mosquito breeding. The existing health facilities including district hospitals and medical colleges need to be involved in the process. Community engagement should be ensured through councillors in municipal corporations, MLAs (Member of Legislative Assembly) and MPs (Member of Parliament).
In summary, mosquitoes are an integral part of our ecosystem. All attempts to make them disappear have failed. Hence, dengue is not likely to go away entirely. However, the burden of dengue can be reduced significantly through coordinated efforts by public health authorities, with focus on all components of the health system. The dengue problem in Delhi has received widespread attention partly for the wrong reasons; however, this should be used as an opportunity to learn and develop strategies to curtail the disease and set an example in public health efforts to control dengue for other states of India.
The views expressed are personal and do not necessarily reflect those of the institutions that the author has been affiliated with in the past or present.
- Dengue is a mosquito-borne viral disease (similar to malaria) transmitted by the bite of infective Aedes Aegypti mosquito. People develop the disease 5-6 days after being bitten by an infective mosquito. The disease occurs in two forms: Dengue Fever and Dengue Haemorrhagic Fever (DHF). Dengue Fever is a mild flu-like illness, with symptoms such as fever and body ache. Dengue Haemorrhagic Fever (DHF) is a more severe form of disease, which may cause death. More details are available at: http://nvbdcp.gov.in/DENGU1.html
- Indian Express has provided details of the number of reported dengue cases in cities/ states outside of Delhi: http://indianexpress.com/article/explained/why-dengue-threat-could-be-up-to-1000-times-bigger-than-you-think/
- There are a multitude of reasons for insufficient public health efforts in these cities such as a lack of role clarity amongst multiple agencies providing services, insufficient funding, lack of trained and motivated workforce, more attention on curative care, etc.