Dev 360: Smart cities need smart healthcare
Dengue in Delhi is hogging the spotlight but the situation is pretty bad in several other states as well
Update: 2015-09-24 00:49 GMT
What do Delhi’s headline-grabbing Aedes mosquitoes have in common with the city’s equally notorious political aides? To start with, neither feels threatened by mere talk about clean surroundings. Both — the aides and the Aedes — know how to slink into the toniest enclaves and grotty nooks and crannies. Over the past month, however, it is the mosquito species, Aedes aegypti, the prime dengue carrier, which has been causing ripples.
In Delhi alone, over 3,000 people have been affected by dengue and the death toll has crossed 20. The disease has stormed the front pages and prime time television. Dengue in Delhi is hogging the spotlight but the situation is pretty bad in several other states as well. The Delhi high court has now stepped in and directed the Aam Aadmi Party-led Delhi government to submit a detailed reply on the funds released to the three municipal corporations to control the spread of the disease. This is among the worst dengue outbreaks in recent times, but the big picture is monotonously familiar.
Every monsoon there are outbreaks of all sorts of mosquito-borne and other infectious diseases. Sometimes more people die, sometimes fewer. But each time we act as if the disease has crept in stealthily, whereas we all know why it has happened and what needed to be done to prevent it. Every once in a while, an incident happens which shakes us up. In 2012, Bollywood film maker Yash Chopra died of dengue and the disease became the top talking point for some time. This year, it was the gut-wrenching story of the parents who jumped to their death in Delhi after their seven-year-old son succumbed to dengue. The boy had been turned away by several city hospitals and did not get timely treatment.
Ever since, there has been a flurry of activity. Government hospitals have added beds. Doctors have been asked to cancel their leaves. Private hospitals have been told they cannot turn away any emergency dengue cases and are on watch. There is a cap on what private laboratories can charge for tests for dengue. The obvious question — why could this not be done earlier? With the overload of information on dengue outbreaks over the years, one would have imagined that some key lessons would have been learnt and fundamental changes pushed through, not only to deal with dengue but other infectious diseases as well. Sadly, that is not quite the case.
What will make change possible? The simple and short answer — political will, funds and micro-planning. The first step to prevent dengue or any other infectious disease from spinning out of control is to have a system in place which emphasises prevention. Take the example of Surat, which exploded on the front pages of newspapers worldwide in the aftermath of a devastating plague in 1994. More than 50 people died and thousands more were forced to flee the city, the hub of India’s diamond and textile industry.
Surat used the lessons from the 1994 plague to rejig its health system under dynamic municipal commissioners like S.R. Rao and S. Jagadeesan. Its prevention approach entails employing a network of around 500 health and surveillance workers to routinely check on people, administer medicines and collect data that can help health officials see outbreaks before they are reported in hospitals. Once every fortnight, they visit every home in the city checking for not only malaria, but dengue, chikungunya and filariasis. Most other municipalities in India trail in surveillance, data and human resources. They do door-to-door disease surveillance, but only when there is an outbreak. In Surat it is done round the year and there is strict monitoring.
Prevention is a big piece of preparedness for a health emergency, but equally important is to strengthen crisis response. In a recent column, Shailaja Chandra, former chief secretary, Delhi, pointed out that Delhi’s health department had the responsibility to identify tertiary and secondary care hospitals (both in the government and private sectors) and link them for managing dengue-related medical emergencies. But the mechanism has to be put in place in normal times, before a crisis strikes. Delhi has around 20 government hospitals and more than 30 private hospitals that have blood banks. Many of these hospitals, Ms Chandra argues, could have been designated as nodal centres for providing blood components to attached satellite hospitals.
What is needed is a coordination template. Public health expert Anant Bhan suggests a transparent mechanism which provides real-time data on availability of beds, ambulances and blood. This needs to be monitored regularly to make sure there is accurate and updated information. During a health emergency, someone who needs urgent medical attention should be able to access this information at once. If a hospital (government or private) lacks the capacity to deal with a patient, there has to be a standardised protocol for transferring a case to another hospital. Otherwise, hospitals will carry on refusing admission to poorer patients.
In a health emergency, government hospitals will be stretched. How does one make sure that private hospitals do not deny treatment to any patient brought to it? The government has the authority to ask them for support during emergencies. For this to work smoothly during a crisis, everyone must understand their respective responsibilities. Verbal and adhoc requests are not enough. There have to be written instructions in simple language. The Supreme Court has upheld the professional obligation of doctors and hospitals not to turn away a patient in need of emergency care.
Then why are hospitals that turn away such patients not hauled up? How do some private hospitals which have benefited from subsidised land on the condition that they keep aside a certain number of beds for the poor wriggle out of doing their bit? You don’t have to be Einstein to sense a lack of political and administrative will behind the lack of action against such defaulters. Government officials and their families form a big chunk of the clientele of empanelled private hospitals. They don’t even have to pay. It is difficult to dispel the suspicion of a cosy club.
Despite so many outbreaks, there is still no systemic approach to deal with infectious diseases. Gujarat has a law which is supposed to deal with emergency medical care and now, Maharashtra is planning to follow suit. But all of India needs is an Emergency Medical Services (EMS) law and smart plans to face a public health emergency.
The writer focuses on development issues in India and emerging economies. She can be reached at patralekha.chatterjee @gmail.com