Subject: Health

Context

In some ways, China is setting the standard for a public health response that may become a way of life in the 21st century.

Origin of the outbreak and deadly it could turn out?

• Outbreak of unknown virus: In December 2019, an outbreak of viral pneumonia of unknown etiology emerged in Wuhan, a city in the central Chinese province of Hubei.
• Discovery of novel coronavirus:  A few weeks later, the World Health Organization (WHO) and Chinese health authorities announced the discovery of a novel coronavirus, known now as 2019-nCoV, as being responsible for the pneumonia.
• Important questions: The two most important questions asked in a fast-evolving pandemic of this nature are:
  • 1) How deadly is the disease, and;
  • 2) Can it be contained?
  • The latest available figures suggest that the death toll in China is 304 and 14,411 have been infected. The current fatality rate estimate of 2% is unstable and is likely to fall as more cases are detected.

Containment attempts by China and spread to the other countries

• Unprecedented attempt by China: The attempt at containment started late, but has never been attempted in the fashion that China has gone about it.
  • Wuhan lockdown: Belatedly, on 23 January, China locked down Wuhan and 12 other cities, quarantining 52 million people in one sweeping action.
  • This is the first known case in modern history of any country locking down an entire large city.
• Reports of confirmed cases from other countries: Confirmed cases have since been reported from Hong Kong, Macau, Taiwan, Thailand, South Korea, Japan, Singapore, Australia and the US.
  • India reported its first case from Kerala of a medical student from Wuhan University, followed by two more.
  • Singapore and the US have now banned foreign nationals who have recently been in China from entering the country.
  • Russia, Canada, the UK and India have begun evacuating citizens from Hubei province.

Research on coronavirus so far

• Coronaviruses (CoVs) are characterized by club-like spikes that project from their surface, an unusually large RNA genome and a unique replication strategy.
  • CoVs cause a variety of diseases in mammals and birds, ranging from enteritis in hoofed animals to potentially lethal human respiratory infections.
  • Genome sequence: The 2019-nCov genome was sequenced in China in early January and reported in The Lancet last week.
  • It suggests that the original host of this coronavirus was a bat reservoir, though it is unclear whether there was an intermediate host.
• A recent entry to the human host: The uniformity of the sequenced genome suggests that the virus has entered human hosts very recently.
• Recent emergence from the animal reservoir: Several other countries, including the US and France, have sequenced the RNA of the 2019-nCoV as well. These sequences and their similarity to the initial samples from China suggest a single, recent emergence from an animal reservoir.

Tests and vaccine development

• How is the virus tested? Testing for 2019-nCoV requires a reverse transcription polymerase chain reaction test (RT-PCR) which converts RNA into DNA, making study and comparison easier.
• No vaccine yet: There are no vaccines yet for this virus, but promising paths have been identified, borrowed from the SARS related vaccines.
  • Development of an effective vaccine may only come after the 2019-nCoV is contained, but it may still be useful if there were to be a subsequent outbreak.
  • The frequency of future outbreaks is only likely to increase because of climate change, global travel and fast mutating viruses.

What lessons can India learn?

• Develop framework and capacity: For India, this global health emergency should serve as an eye-opener.
  • If lockdown turns out to be a useful tool to prevent the spread of a deadly virus, India will need to develop the framework and capacity to implement such a drastic measure.
  • Under-equipped municipalities: Our municipalities are hopelessly under-equipped to implement strict isolation and containment strategies.
  • We will need to develop the capacity to build large facilities for housing patients in isolation wards.
  • Use of pre-cast: This will require India to accelerate the use of construction methods like pre-cast technology.
• Protocol and instructions: The National Centre for Disease Control (NCDC) has been proactive in updating its protocol related to the 2019-nCov and has clear instructions for reporting and assay preparation.
• Develop capacity in geographically diverse regions: Samples in India need to be sent to the National Institute of Virology in Pune.
  • While the public health and epidemic escalation framework appears capable of handling a small number of cases well, it is not clear how it will stand up to a large number of cases in a specific geographic region.

Conclusion

“Nothing happens quite by chance. It is a question of accretion of information and experience,” said Jonas Salk, the virologist who developed the polio vaccine, in some ways, China is setting the standard for a public health response that may become a necessary way of life in the 21st century. India must use this as a guidepost to greater preparedness.

Context

The policy currently being pursued is intended primarily to incentivise potential investors while social objectives and help in indigenisation are being jettisoned.

Call for more liberalisation and its possible impacts

• What reforms are asked for?
  • Reforms such as labour market liberalisation and removal of constraints on the acquisition of land for industrial purposes are demanded.
• What could be their possible impacts?
  • The negative impact such reform measures are likely to have on the incomes, living conditions and the economic security of the workers and the agricultural class.
  • Counterproductive labour policy: The policy of freedom of hiring and firing of labour will be counterproductive as it would squeeze demand further in a situation of huge demand deficit.

Social sector and demand

• Neglect of human infrastructure: While talks of economic revival focus on infrastructure there is little talk of investment in human infrastructure, particularly in education and 
  • Conditional expenditure: On the contrary, the expenditure in social sectors is made conditional upon a higher rate of growth. 
  • The flawed premise of long term impact: Most mainstream economists believe that public expenditure in social sectors can only have a long- term impact on growth. Which is not entirely correct.
• The benefit of investment in human infrastructure:
  • Increases demand in short-run: Investment in social sectors results in creating demand in the short run by way of opening avenues for large-scale employment.
  • Competitiveness and sustainability: It imparts competitiveness and sustainability to the Indian economy in the medium and long run.
• Example of RTE, teacher employment and demand creation
  • The recruitment of 5.7 million additional teachers over a period of, say, five years, can create huge scale demand.
  • And, this is only one factor essential for universalising quality school education.
  • There is also a large gap between the requirement of infrastructure in the schools and that available and built recently.
  • The gap between requirement and availability: According to government data, only 12.5% of the schools covered by the RTE Act were compliant with RTE norms.
  • Meeting these norms has the potential of creating employment on a large scale.
• Importance of health and education
  • Education has a crucial role to play for an individual in gaining employment and retaining employability.

Conclusion

The gestation period of projects in social sectors is not as long as it is made out to be. It is, therefore, time for reprioritising education and health in the scheme of development strategy and the allocation of budgetary resources.

Context

As the government tries to overhaul the public health system in India, its time to take into account the advent and the role played by the private sector and its implications.

The advent of the private sector

• Increase in the role of the private sector in the post-Independence era: Post-Independence, the private sector increased its footprint in India.
  • Perpetual sub-optimal investments in public health allowed the private sector to capitalise, flourish, and increasingly gain the confidence of the masses.
  • The private sector went from having about 1,400 enterprises in 1950 to more than 10 lakh in 2010-11.
  • To doctors, this promised greater professional liberty, lesser restrictions, and higher incomes.
  • After liberalisation, the greater focus shifted to the lucrative tertiary-care sector and led to an onslaught of sophisticated private health care in cities.

The dominance of the private sector and malpractices

• The scale of dominance: Private sector has over 70% of the health-care workforce and 80% of allopathic doctors, has meant that it is scarcely possible for a health-care provider to function in defiance of its norms.
  • Pervasive malpractices: The pervasiveness of malpractices in this market has come to ensure that few could survive without condoning them.
  • Nexus of the private players: Players in this market, in much of their malpractices, have also learnt to function as a harmonious family.
  • Organised form to safeguard interest: The family plays its role in safeguarding its members, acquainting them with its norms and interests, and leveraging the power of its patriarchs to defend its interests in society.
  • Standards of success dictated by the markets: It is little wonder that the market has also come to dictate the avenues of aggrandisement and yardsticks of professional success for health-care professionals.
  • Benchmark of quality changed: Business finesse and social adroitness rather than clinical excellence and empathy become the touchstones of calibre in this market.

Failure of the government

• Absence of national system: The larger chunk of Indian health care (and health workforce) could not be brought under a “national system” having some form of overarching state control or involvement.
  • If such a system existed it could avail of essential health care without most people having to rely on a vagarious market, except as a luxury.
  • Example of the UK’s NHS: The National Health Service of the United Kingdom, remains the single largest health-care provider.
  • NHS employs nearly the entire health-care workforce.
  • NHS makes essential health care available to all practically free at the point of service.
• Consequences of the absence of such system: The absence ensures is that the profit-driven private sector, the minor component, caters mainly to the affluent lot as largely a matter of deliberate choice rather than desperate compulsion.
  • Hopes of benefits of free-market belied: The Indian example, much like the United States’, bespeaks the failure of the idea that a free market will compel players to be more efficient.
  • The exploitation of the loops by the private players: Rather than increasing efficiency, the players have found it expedient to scrupulously exploit the prevailing cracks in the system and employ devious methods in order to maximise profits.

Conclusion

• Health-care providers, just like others, are moulded by their social surroundings. When necessary controls are loosened, the connatural vices are let loose; when the habitat is conducive to values, the right traits develop.
• A system that starts off with health care as an overt tradable commodity it threatens the development of virtues in the system.
• On the other hand, a system founded on the concept of equity cultivates a totally different culture of patient care.

Context

The advent of a new tetravalent vaccine against the dengue virus has thrown new light into the evidence-based management of dengue.

Why the holistic approach is needed

• Apart from promoting the use of the vaccine, gaining control over dengue will also require a holistic approach that has to include within its ambit vector control and proper case management.
• Tetravalent vaccine: The vaccine is tetravalent i.e. it provides protection against all the four types of dengue viruses.
  • The vaccine confers about 80% protection to children vaccinated between 4 and 16 years of age without any major side effects.
• Climatic factors: It is essentially a tropical disease that occurs in the countries around the Equator; hot weather and intermittent rainfall favour the sustenance of Aedes aegypti.
  • Aedes eggs can remain dormant for more than a year and will hatch once they come in contact with water.
• Risk factors: Urbanisation, poor town planning, and improper sanitation are the major risk factors for the multiplication of such mosquitoes.
  • Aedes eggs can remain dormant for more than a year and will hatch once they come in contact with water.
  • Aedes mosquitoes cannot fly beyond a hundred meters. Hence, keeping the ambiance clean can help prevent their breeding.
  • Further, these mosquitoes bite during the daytime, so keeping the windows shut in the day hours is also useful.

What needs to be done?

• Source reduction activities: Activities like preventing water stagnation and using chemical larvicides and adulticides.
  • These chemicals need to be applied in periodic cycles to kill the larvae that remain even after the first spray.
• Dealing with the manpower shortage: The number of skilled workers available for such measures is low; many posts in government departments remain vacant despite there being a dire public health need.
  • Due to this deficiency of manpower, active surveillance is not being done in India, says the National Vector Borne Disease Control Program.
• Ending the Under-reporting: Dengue cases are often under-reported due to political reasons and also to avoid spreading panic among the common people. Under-reporting needs to be dealt with.
• Increasing coordination: There is a lack of coordination between the local bodies and health departments in the delivery of public health measures.
  • A comprehensive mechanism is required to address these issues.
• Need for epidemiological measures: Any communicable disease needs the epidemiological approach. Singapore uses one successful model of mapping and analysing data on dengue, using Geographical Information System (GIS).
  • The use of GIS involves mapping the streets with dengue cases for vector densities.
• Emphasis on the WHO guidelines: Fluid management in the body is the cornerstone in the management of severe diseases like dengue hemorrhagic fever and dengue shock syndrome.
  • According to the guidelines, coagulation abnormalities are not due to a reduction in the number of platelets alone.
  • This is why the WHO recommends fresh whole blood or packed cell transfusion in the event of bleeding.
• Caution in using alternative medicine drugs: Modern medicine is not against any complementary medicine; when such a medicine is approved after rigorous testing.
  • However, in the absence of evidence, the efficacy of such medicines remains in the realm of belief instead of science.
  • So, medicines like Nilavembu kudineer and papaya leaf extract are only belief based.

Conclusion

The communicable nature of Dengue and its asymptomatic nature requires the holistic approach to successfully tackle the disease.