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This was meant to be posted yesterday but, the euphoria of Mangalyaan was so infectious that I decided to leave alone morose contemplations of health and disease for a little while. There is much too much that public health service delivery should learn from ISRO even if, the canvasses of space science and health are vastly different and make for tenuous comparison. Mangalyaan and ISRO’s success provoke the question of when (if ever) will health have its Mangalyaan moment? Perhaps, our comparative moment was with Pulse Polio. Perhaps too, euphoria moments are rare in health whatever the achievement. Unlike a World Cup or a Mangalyaan; with health, it is very hard to mobilise a sense of ‘us’, ‘community’ or ‘nation’. The subject seems to engage interest only when it makes a personal house call. Until then it is ever straitjacketed as the outsider other. This indifference is responsible for much health related crises irrespective of whether the sphere is public or personal. Almost universally, governments wake up to the huge price that must be paid for ignoring Health up and until the time when disaster hits. It is just such a situation – a tragic, devastating, and heart breaking crisis – that the West African nations of Liberia, Sierra Leone and Guinea face today with the latest Ebola outbreak. It is a crisis so grave that its spill-over consequences threaten the economic and social stability of these nations and their very future.

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Yesterday, both CDC and the WHO released their modeled predictions for Ebola. The picture is expectedly bleak and both agencies stressed the imperative necessity of an immediate and all-out international response to control the epidemic.

Total number of cases in 2014 (CDC figures)

On 23rd September

5864 (3341 confirmed) Cases are spread over four countries; three of which are completely ravaged and overwhelmed

On 25th September

6263 (3487 confirmed)

Deaths

2811

2917

The total number of people reported to have the disease, in 2014 alone, is greater than the sum of all cases since 1976 when Ebola was first discovered in the DRC

More worryingly, the disease is seeming to grow exponentially with a doubling every three weeks – 47% of all deaths have occurred in the last month. Liberia, especially, is reeling with a 68% increase in the cases in just the past month

 

Prediction figures

Total number of cases by end September

21,000 (CDC)

Total number of cases by early November

20,000 (WHO) More conservative but agrees with CDC on overall long term projection

Total number of cases by mid-January

1.4 million (CDC)/ 500,000 to 1.4 million (WHO)

Public Health response to epidemics. Preparedness as response

A public health crisis of this kind – unexpected with devastating consequences – brings to fore the role of governments in the health of people. The poverty, poor social indicators of health, and inefficient health systems that exist in these African nations are prevalent in many other parts of the globe. Naturally, anxieties are high, world over, about preparedness and response in what really is a time of war for public health. In such a situation, the role of government narrows down to the swift execution of classic Disaster Response and Containment. An effective response strategy is executed with: a) the ready availability of a health force equipped with necessary tools for infection treatment and containment, b) a robust technological database that maps numbers and geography with necessary intervention and, c) a coordination force that links field staff with central command structures for effective exchange of information and response. 

Preparedness is the best response in a health crisis. A lesson India will do well to learn and implement.

But, can a government respond effectively in war when it has not equipped itself during peacetime? What is the level of preparedness that the Indian Government has in place? Peacetime public health interventions require an investment in preventive mechanisms, primary health and, health and sanitation literacy to pre-empt and curtail the spread of an infectious epidemic. A vital public health system should demonstrate:

1.    Adequacy of Healthcare Personnel – Our current Doctor to Patient ratio stands at: 1:1800 The WHO recommended ratios are: 1:1000. Even less airtime is given our acute shortage of nurses. In India, it is estimated that, to reach a Nurse to Patient of 1:500 we would need to shore up the number of nurses to around 2.4 million. There is a growing understanding that a significant amount of medicine and foundational healthcare can be delivered by para-medical training through ancillary academic programs. Such training will concentrate on a more practical hands-on-the-ground training with less of an emphasis on theoretical rigor.  At every level of health care delivery, whether primary generalist or tertiary specialist, nursing care is the most critical pivot around which containment and cure revolve. Degree certification in Rural Medicine and Nurse Practitioners aim to do just that and the government must institute them at the earliest. Not only will such a training empower local population; it will also provide a vital cultural connect to facilitate behavioral change.

2.    Regional/ District hospitals dedicated to Infectious Disease, Primary care, Maternal and child health and Prevention – Instead of setting up large tertiary centers and medical colleges in urban areas that compete with private enterprise; public health is better served by the ramping up mid-size district hospitals that are equipped to treat and respond to acute care. In the scenario of an outbreak, acute care entails early diagnosis, aggressive supportive therapy and isolation. The delay in the diagnosis of Ebola 2014 underscores the need for diagnostics on the ground. While remote tertiary centers can confirm the same with more sophisticated technology; immediate preventive measures can be kick-started on the ground. These nodal centers have great expertise with common and indolent chronic infections but need to be equipped and drill-prepared for more acute and unexpected scenarios.

3.    Training for all ancillary support staff in standardized supportive care and isolation protocols – Apart from training in supportive care, all healthcare personnel must have periodic training in methods of isolation, contact tracing and data recording. When this is enforced in the daily practice of medicine by doctors, training preparedness is easily scaled up on demand. The primary aim of all these measures is for containment to restrain an outbreak to as close as possible to its source. Our population density and 21st century mobility underline the importance of this vital step.

4.    Technology – Coordinated action is a vital part of health. Telecommunications, data and record keeping and telemedicine must link regional health centers with a centralized chain of command to oversee and coordinate. There are enough reasons for such an interlinking to be in place during peacetime. Reasons such as maternal and child health, malnourishment, tuberculosis and immunisation; all of which can benefit from a standardized and coordinated action. It is not just the technology that will be in place if crisis strikes; the work ethic of coordinated and cooperative team action with an adherence to protocols will also be ready to hit the ground running.

5.    Last but, perhaps, most important of all – Health literacy. This phrase has been in use in policy manuals and training modules for so long now that it might well have lost its meaning. The most critical aspect of health is the end-consumer. When that person at the bottom of every policy initiative is empowered with basic health and sanitation literacy, it is then, and only then, that vitally important behavior change can happen which in turn will ensure the effectiveness of public health measures. Without the cooperative involvement of the community, public health investment will continue to be good money down a long leaky drain.

Can Universal Health Coverage – a peacetime strategy – mitigate the consequences of an epidemic? Can it mitigate the spread of an epidemic? There is ample reason to believe it can. UHC is not an end-game. It is the strategy that opens up the door to more strategic allocation of government resources in health.

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In the NEJM’s special issue on Ebola; the President of the WHO writes on the critical role of poverty in the spread of disease through the poor and underdeveloped regions of the world. It is the nature of epidemics to strike first at groups that lack access, to health and to support factors grouped together under ‘social determinants of health’. Some of which are poverty, overcrowding, malnourishment, poor immunity due to other chronic debilitating diseases, poor access to water and sanitation and, illiteracy. Access to health, sanitation and literacy are the game changers in this cocktail. Armed with these, people have the necessary enterprise themselves, to equip for push back against the others.

Public Health Coverage does not only empower the poor. Critically, it also opens a window of opportunity for the government to streamline its engagement with health delivery – how much, in what and to what spread? In India, there is an extensive public health network that is  already in place. Much of it is poorly staffed and inefficient forcing people to choose private medicine with the burden of heavy out of pocket expenses. Rural Medicine and Nurse Practitioner certification will provide the necessary manpower.

With a focus trained on delivery of specific services, public health can concentrate its energies on foundational primary care, prevention mechanisms and health literacy. Further, mapping tertiary treatment to coverage in private centres (as is already underway with RSBY) will ensure access to all tiers of healthcare. Health insurance coverage must be made mandatory for the middle class and above. Both arms of Universal coverage will need strong government regulation and price controls.

For India’s health policy makers the Ebola epidemic is a critical wake-up call to review strategy for the way forward. In 1991, an economic crisis forced India to deregulate and push through reforms that were totally alien to the existent climate. Decisive, out of the box thinking at that crucial juncture put the Indian economy on a trajectory of growth and economic development. This is Health’s 1991 moment. A carpe diem moment to strategize for 21st century realities with the aim of creating a health system that is prepared and delivers.

Universal Health Coverage is the lead wagon on the new track.  The constant chatter of economics, investment, free markets and trade is jarring when there is no parallel movement on the critical sector of health. What will it take to get the Ministry of Finance to share space with the Ministry of Health? For our policy makers to comprehend that it only takes one wretched, measly little virus to bring the whole pack of glittering cards tumbling down. To comprehend that our health system needs an urgent revamp and needs it now.

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Supplementary information:

Atypical presentation of Ebola 2014

The current outbreak has two specific and distinct geographical clusters – one centred around three adjoining nations of Western Africa and the other, in the DRC (Democratic Republic of Congo). These two loci are sharply distinct with no traceable contact and have been declared to be separate and independent of each other.

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Ebola is a viral zoonotic disease. In other words, it is caused by a virus that is usually found in animals and which infects humans only upon transmission by direct or indirect contact with the animal. Fruit bats have been identified as the most likely reservoir source of the Ebola virus. The initial point of contact between bats and humans (whether it was single point of contact or multiple and if so, how) is not confirmed but suspicion strongly points to improper sanitization of bush-meat. Once Ebola takes root in a human, it can then spread from humans to humans through contact with the body fluids of the infected person. Therefore to contract the infection, one must necessarily be in contact with infected fluids like saliva, vomitus, blood etc. This makes the disease far less contagious than airborne viruses like influenza. Yet, its virulence and its rapid spread due to patient mobility is reflected in the high case fatality rate and the rising numbers of those infected.

The nations of Western Africa have not reported a single case of Ebola before this outbreak. The only known case from Cote d’Ivoire was in a vet who was infected while performing an autopsy on a chimp. He recovered and the disease ended its run in him. No other case has ever been recorded from the region. Further, the symptoms are very similar to two other diseases – Cholera and Lassa fever – both of which are endemic to the region. Naturally, it was these more common diseases that were initially suspected to be causative. With no prior experience with Ebola and with no sophisticated diagnostics on the ground, the crucial diagnosis was delayed for four months between the initial breakout in Dec 2013 and confirmation.

How are epidemics like this controlled? Ebola spreads by contact. So, the first measure is strict and comprehensive isolation. Isolation is the most effective method of containment of rare and rapidly spreading epidemics. With isolation, the virus is denied access to another host (an uninfected human body), terminates its life cycle in the infected patient and the infection’s spread is halted.

The other measure by which the infectious outbreak is controlled in the group is by raising immunity through vaccination. Responding to the urgency of the deadline many experimental drugs and vaccines are currently being rushed down the pipeline but it is an enormously difficult task to research, put through trial, and manufacture sufficient quantities of drug. Antiviral therapy is often seen as a magic bullet. It is not. The human body mounts an immune response against the virus. Shoring up the body’s natural defenses and treating the clinical consequences of Ebola (dehydration and electrolyte imbalance) with simple supportive therapy can make a big difference to the case fatality rate.

International Response

The national responses are creditable considering the prevailing circumstances of desperate poverty and inefficient heath systems in countries just recovering from debilitating economic consequences of protracted civil war. But the sum of many delays in diagnosis and the lack of a timely and coordinated international response have been costly. Also, the dissemination of information, in a calm and assured manner, on the importance of isolation and sanitation would have helped win public cooperation and support. Instead, there is now the additional burden of dealing with a fearful and restive public. A climate of mistrust, stigma and superstition has made many patients go underground and a large number of cases are unreported.

MSF deserves much credit for its stellar commitment to the ground task from the very beginning. In August, the WHO declared Ebola an International public health emergency and joined MSF in underscoring the need for urgent and immediate international aid. Significant action on this front has been the establishment of two global initiatives – the Global Health Security Agenda and UNMEER (UN Mission for Ebola Emergency Response). UNMEER has been called the greatest peacetime challenge that the UN will mobilize and for now is centered in Accra and will oversee an international coordination and mobilization effort from there. Established through a unanimous UN resolution on September 23rd; it speaks volumes of the urgency of the situation that an UNMEER team is already on the ground. The UN estimates $600 million as the cost for regaining control over the situation. Individual nations have lent assistance to the international and non-governmental organisations with ground health care workers and aid. India has around 45,000 of its citizens spread over the region and has lent an initial assistance of $500,000. Within the country; airport surveillance, quarantine and contact tracing have been engaged in high gear.

The governments of Sierra Leone and Liberia have repeatedly stressed the urgent need for health care personnel and beds. The NEJM reports that a facility treating 70 patients needs at least 250 health care workers. MSF has a current capacity of 180 beds in Liberia. They need at least 800-1000 more in that country alone.

The difficulty of mobilizing large scale hospital and isolation workers and equipment in a short time has prompted suggestions from the medical community to enlist those that have recovered as a volunteer task force. Another suggestion that has found less unanimous approval is mobilizing local society with training in home care as was done with the last century’s small pox epidemic. This dilemma for strategists is increasingly fait accompli for patients and their families. Treatment centers are overflowing with patients who can’t be treated because of an insufficient number of beds and healthcare workers. It is in this circumstance, of an overwhelmed health system operating in a climate of social unrest and fear, that homecare and home isolation is still being considered (despite its great risk of unmonitored isolation and supportive care) as a viable interim measure.

 

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