CURRENT SCENARIO
India has crossed 15 lakh persons detected suffering from COVID-19 the dreaded
disease which spread across the world since the New Year Eve. About 35 thousand
died and rest recovered as per data available as on today. (Ref india covid 19
tracker). Fact that the authenticity of this tracking data remains doubtful and
that the sample serosurvey conducted by ICMR in April 2020 is more reliable, at
its national average rate
of population infected 0.73%,
one can infer that about 10 million should have been infected, on end of April
2020! Applying the doubling rate in India, till today about 150-160 million are
already infected - 16 times more than in April! If one assumes that the death
models are accurate and estimated as per Infection Fatality Rate suggested by
Lancet, then around 5,6 million are infected. Therefore, it is clear that
between 5.6 million to 160 million of us are infected with Covid 19. This means
0.04% to 12% of our population is having or had Covid 19 during past 5 - 6 months.
Do you remember the past pandemics our ancestors had faced - Bubonic Plague
which took away 12 millions over 44
years while the same number of people succumbed to Spanish Flu in 3 months in
1918? In both the epidemics, the Government and our own volunteers,
missionaries jumped in to provide services, so, did Gandhiji! the Government
stepped in with masks and isolation. No medicines and vaccines were not
available. The undetectable, rapidly spreading virus took tolls in a very
short period of Spanish flu. When the enemy is invisible, an instinct takes
over one's rational thinking, it seems - we start blaming 'the other' - the
government, the neighbour, the religion or even a voo doo. 102 years later we
are facing similar challenges: during the current pandemic it is learnt that it
also generates denials, rumours and mischiefs.
WHAT CHANGES OCCURRED IN OUR HEALTH STATUS POST INDEPENDENT
India faced poverty,
illiteracy, lack of information, superstitions, absence of health care services
- public or private, people dying at home due to cholera, plague and flu, at
the time of Independence. We have gone far ahead since then. Let us take
a stock of the current health scenario today. .Birth rate was around 40
(no. of live births/1000 population) in 1947, it is 20 today. Infant mortality
rate (no. of children die before completing 1 year/1000 live birth) was 200,
reduced to 33, now! Maternal Mortality Ratio per 10000 live births has
reduced from 2000 during 1950-57 to 113 in 2016-18. Life expectancy then was 32 years, it is 69
today. In 1947, 27 out of every 1000 people died every year, today 7.
DEMOGRAPHIC AND
EPIDEMIOLOGICAL TRANSITION IN INDIA
In the past 70 years there are several changes in our nation. some Good,
some Bad and some Ugly.
Age Structure of Indian Population:
Births equal Deaths-
Before independence, we were in Stage 1, wherein Birth rate and death rates
were almost equal, hence Population was stable and age distribution was
different than today. Today, we are in Stage 3, there is an increase in 25-64
age group and decrease in 0-14 age group.
Rural population shifts to Urban-
83% of Indian population rural population was living in villages and 17% in
towns and cities in 1951. ( https://censusindia.gov.in/DigitalLibrary/data/Census_1951/Publication/India/23685-1951-REP.pdf)
As of today, 68% are living in rural and 32% in urban areas.
Communicable Diseases as killers level off with Non communicable ones-
Similarly, there are transformation in causes of deaths: more people die due to
non-communicable diseases like Cardiovascular diseases, Diabetes, Strokes,
Diabetes and Cancer or Suicides, Substance Abuse or accidents are emerging.
There is reduction in deaths, increase in age of deaths, causes have changed.
This in technical term is an Epidemiological Transition across the country,
more so in states like Goa, NCT, Kerala, Karnataka, Andhra Pradesh, Maharashtra
and Gujarat. Instead of child deaths and severe communicable disease, the non
communicable illnesses like mental illnesses, backaches and joint pains,
diabetes, heart diseases or obesity, deafness like chronic illnesses are the
burden on the longer living human beings.
In a sense, living longer is a boon; but living with chronic illnesses is a
bane.
Why this epidemiological transition
All these changes have occurred thanks to government policies, health
programmes, new knowledge and new technologies, no doubt. Malaria, Leprosy, TB
elimination occurred due to effective national health programme co-ordinating
upto each village and town. Universal immunization indeed eradicated small pox
polio with a robust implementation and surveillance programme. We hardly have here
diphtheria, whooping cough or tetanus, nowadays. Better safe potable drinking
water and sanitation has also made illnesses like cholera, diarrhea almost none
or declined. These programmes are driven from top to bottom, from MoHFW, GoI to
the Primary Health Centre in the villages. All this assures us that though the 1918
Flu epidemic killed 12 million in India, 2020 Coronavirus would not kill so
many. (Even though the current death figures due to Covid 19 are challenged, most
experts consider it that it may not be exceeding 1 lakh!) All this achievement
and assurance is certainly due to strides in science, technologies, increased
awareness and community involvement as well as government's policies,
programmes and mechanisms to implementing them.
One must be cautious of the 'victory' of declining communicable diseases, as
Coronavirus has taught us! This is not the end of them. It is natural that out
of millions of viruses 'living' here or other germs in symbiosis may mutate into
new viruses, germs (pathogens) and use the living being to survive, if other
source is not abundantly available in our environment. This ecosystem has
sustained our living planet for the past billions of years. And it will
continue to do so till the cosmological changes end the planet itself. Till
then, diseases like AIDS, Covid 19 may emerge and infect the humankind.
THREE STEPS FORWARD; TWO STEPS BACKWARD
We have acquired leaps of knowledge, skills and technologies, management
systems to understand human bodies and health systems therein; ecosystem which
affects the human body - environments incl. other animals, human made pollution
and changes in its effects, natural disasters and its amelioration; diagnose,
treat or prevent illnesses of communicable and non communicable or genetic
types using devices and drug; removal of organs creating the problem and replacing
with other healthy living or human made organs since the last 40 years, with
all the banes of organ transplant scams. There are backward steps in human made
pollution, in overuse of medicines, deterioration of human values while
treating the human being.
One step Forward: Health knowledge and Care providers
In 1947, as per the Bhore Committee, India had about 56,000 doctors mostly
practicing and 8050 trained nurses, 725 PHCs, 29 Medical colleges in 1950
have now grown to about 8 lakh doctors, 11 lakh nurses, 22000 PHCs and now more
than 537 medical colleges and and continue to grow. Here, the distribution has
changed, while in 1947, there were hardly any medical practitioners in rural
areas, they are now available though the growth in urban area is faster.
This is a national
picture; the variance in each state and in rural, urban and tribal areas the
distribution is very different and gives the clear situation. A McKinsey Study
in 2001 had shown that while urban location have 34 doctors villages had
6 doctors only per 10,000 population,! While, the health infrastructure is
growing but its distribution and reach to the population is not maintaining the
required pace. Covid 19 has shown us the deficit of all the four indicators to
match the need, in any state and city.
Second Step
Forward: Diagnostics and Medicines
Medicines -
Available, Affordable and Accessible
India is one of
the largest pharmaceuticals producing company in the world, more than 25000
companies including multinational ones will produce about 100 billion USD worth
medicines in 2020. 80% of Anti retrovirus medicines are produced in India and
so is generic medicines.
Cipla, East India
Company like pharma companies established in 1935-36 continuously produce
medicines at affordable drugs. There are many companies established by the
government like Hindustan Antibiotics, Bengal Chemicals &
Pharmaceuticals Ltd., Haffkine Bio-pharmaceutical Corporation Ltd. etc. which
is producing antibiotics, painkillers, vaccines, antivenines etc. (See https://thingsinindia.in/pharmaceutical-companies/#:~:text=Cipla%20can%20be%20called%20as%20a%20pioneer%20of,a%20presence%20in%20many%20countries%20around%20the%20world.)
We have a robust regulatory authority which establishes the drug marketing
and pricing limits, hence not just for us but for other countries quality and
affordable medicines are available thanks to this sector. Even so, its availability in public health sector is a challenge. According
to a recent study done by Brookings Institution India published in March 2020.(https://www.brookings.edu/wp-content/uploads/2020/03/Medicines-in-India_for-web-1.pdf ) medicine cost form 43%
of Out-Of-Pocket-Expenditure in India, which in itself is 65% for India versus
world average of around 20% in 2016 of total cost of health care. Rest portion
of OOPE consists of private health care, diagnostics, transport etc.
The other pathies
- AYUSH medicines were being produced by authentic Ayurvedic medicine producers
- the vaidyas, following the their pathy directed by them. Particularly, the
Ayurvedic medicines are being produced by these companies but its uptake is
less. Partially, because of committed AYUSH practitioners. Mostly graduates join
allopathy and conduct cross-practicing. This has repercussion on quality of
services also leading to neglect of their own education, their nighantu,
ras-shastra, nadi parikshan, Repertoire, Materia Medica etc.
Diagnostics -
Whether thou so necessary?
According to Dr
Ravi Gaur in his article Growing diagnostics market in India (https://www.biospectrumindia.com/views/70/14454/growing-diagnostics-market-in-india.html) in Biospectrum, diagnotics
is growing annually in India mainly in Tier 2 and 3 cities, at 20% in General
Pathology and 30% and specialized pathology like biopsy,
genetics, oncology, genomic sequency, radiology etc. at 30-35%! Tier
1 cities are almost saturated. In rural areas even in the public health
sector there is little growth in routine lab for biochemistry, microscopy
etc. However, there are some big challenges in this sector. One is its
management: since this sector is rapidly getting digitized from cell counters
to digital radiology. Management of a path lab has 3 components pre-analytical
(sample collection, delivery to the lab and bar coding), analytical
(pathological analysis which is automated long time back) and post analytical
(is concentrating in errors occurring in the post-analytical (i.e. delivery to
the doctors, its reporting, its interpretation and its application - stand
alone or holistically, with other reports - to the patient). Management is
focusing on errors in pre-, and post-analytical sections now. The second
challenge is that it is almost like a market - anyone can open it, no
accreditation, qualification of the person running it, pricing and its
quality. There is no regulation either technical nor professional. Clinical
Establishment Act needs to be nationally applied to provide quality and
affordable service.
Professionally, the challenge is a clinical practice becoming dependant not
on clinical manifestation of a disease in a patient but on the path lab
reports. Thus, all the clinical learning about the human body and mind, the
gaze has shifted to what machines say in order to perform a doctors' duty. What
our teacher used to tell us in 1970, while auscultating a young patient having
heart disease with our ordinary stethoscope in place of his Chugg's, "
What matters is between your ears, and not in your ears!" is becoming
Third Step
Forward: Universal Health Coverage and Health Financing
A
High Level Expert Group (HLEG) on Universal Health Coverage (UHC) was
constituted by the Planning Commission of India in October 2010. The HLEG
had the mandate of preparing a framework for accessible and affordable health
care to all the citizens of India - for the rich and the poor, for all castes,
religion, gender, age groups. urban or rural residents. Main aim of
this initiative was to ensure financial protection, it also covered
healthcare infrastructure, skilled health workforce and access to affordable
drugs and technologies to ensure the entitled level and quality of care to be given
to every citizen. Further, the HLEG recommended that delivering various health
care services/programmes require an efficient management system and
empowerment of the communities. It also suggested that about 2.5% of GDP should
be allocated for health care, state should spend 8% of their total budget, 70%
of all expenditure under the UHC package should be spent for primary care, and
rest on secondary and tertiary care. This includes".. general health information and
promotion, curative services at the primary level, screening for risk factors
at the population level and cost effective treatment, targeted towards specific
risk factors," (http://uhc-india.org/reports/executive_summary.pdf)
National Health
Policy 2017 adopted almost all the components and converted into Swachchh
Bharat for Sanitation, Ayushman Bharat - Health and Well Being programme as
extending Primary care to the villages and PM-JAY a health insurance package
for the poor and marginal population for specific health procedures.
This is a laudable approach
which assures most of the Indian citizen. But we are far from reaching anyway
near the laudable goals. Target 3.8 of SDG 3 Health and Well Being
considers - 100% population coverage,
100% services coverage, and financial risk protection upto 10% of their
Household Expenditure as indicators of monitoring the UHC. India's index of
population coverage for essential health services in 2017 was at 56 and was
worse than countries like Mongolia, South Africa, Sri Lanka, Thailand, Vietnam.
About 17% of the population incurred catastrophic health expenditures behind
countries like Bangladesh, Rwanda, Sri Lanka, Vietnam! 4.2% fell back into
poverty due to spending on healthcare, again worse than the same countries.
India's indicators for financial risk protection were not upto the global
averages and the averages for Low and Middle-Income Countries (LMICs) (https://openknowledge.worldbank.org/bitstream/handle/10986/29042/122029-WP-REVISED-PUBLIC.pdf?sequence=1&isAllowed=y). The
variance in states, districts and locations where vulnerable groups are
surviving would be high inequalities by socioeconomic status and across
than what.national averages show. ( https://apps.who.int/iris/bitstream/handle/10665/259817/9789241513555-eng.pdf;jsessionid=452A5CD87F4B75E22321D432765DC3C3?sequence=1
One Step Backward:
1.Tribal women, youth, children and elderly requires special attention:
India has 645 distinct tribes including 75 primitive tribes in the country
having distinct language, culture, social practices and certain genetic traits
causing certain illnesses like sickle cell anemia, alpha- and
beta-thalassemia, glucose-6-phosphate dehydrogenase (G6PD) deficiency etc.
Other health indicators like malnutrition, life expectancy, maternal
health etc. requires a different approaches due to their socio-economic,
residency etc. The total population of Scheduled Tribes is 10.43 crore as
per the Census 2011 which accounts for 8.6% of the total population of
the country. The share of the Scheduled Tribe population in urban areas is
a meagre 2.8%.
Madhya
Pradesh, Maharastra, Orissa, Rajasthan, Gujarat, Jharkhand, Chhattisgarh,
Andhra Pradesh, West Bengal, and Karnataka are the State having a larger number
of Scheduled Tribes These states account for 83.2% of the total Scheduled Tribe
population of the country. Assam, Meghalaya, Nagaland, Jammu & Kashmir,
Tripura, Mizoram, Bihar, Manipur, Arunachal Pradesh, and Tamil Nadu, accounting
for another 15.3% of the total Scheduled Tribe population. The share of the
remaining states / UTs is negligible. The Scheduled Tribes in India form
the largest proportion of the total population in Lakshadweep and Mizoram
followed by Nagaland and Meghalaya. There are about Madhya Pradesh has the
largest number of scheduled Tribes followed by Orissa.
Bo tribe of Andaman & Nicobar got extinct in 2010, Jarwa tribe is
facing a threat now due to Covid19.
According to the NFHS 4, 45.9% of scheduled tribe members were in the
lowest wealth bracket compared to 26.6% of scheduled castes, 18.3% of other
backward caste.
They are along with the rural population, on the frontline to face
animal-human conflicts and increasing zoonotic diseases as they are core or
peripheral forest dwellers. Their livelihood is unstable and their income comes
in the lowest percentile
They are in a transit phase from education, social status and practices,
political power and economic conditions. This adds on to the subtle
discrimination and inequality of the poor and rich, women and men, rural and
urban, the elderlies and the youth communities in India. There are certain
governance norms for tribals, with specific education, social, economic and
political provisions as well as public health infrastructures norms, a Health
Policy and Programmes are required to address specific disease burdens
challenges of them.
Two Steps
Backward: 2. Blurred preventive health and promotive health
As per basics of
epidemiology there is a Triad of Causes, curative care - clinics, hospitals,
medication etc. can tackle the Agent factor, can alleviate the Host factor
partially - effects of Agent factors, but cannot do much on Host and Environment
factors nor can it control these other factors themselves becoming Agents!
It requires heath
promotion and preventive health care. Nutrition status and food security,
behaviour changes for nutritious food and exercises/sports, health
communication and education, accident prevention, environmental health to
prevent pollution of air, water, land, prevention of work stress and work
related diseases, lifestyle based illnesses like high blood pressure and
diabetes, reverting social determinants depression and suicides, domestic
violence, child abuse all require social, environmental, economic,
psychological and political preventive actions. That is missing. The tobacco
chewing and smoking has been reducing thanks to consistent behaviour change
communication, taxation and change social norms could change the
situation. Universal Imminization isn't enough preventive care for averting
deaths and diseases as the Global Burden of Disease study, 2019 shows: (http://www.healthdata.org/india)
While malnutrition
as a risk factor has reduced, it is dietary intake which has added to the risk
of deaths and disabilities.
There are
contradictions in India's progress in its Health status, in its infrastructure
and in its health care system since Independence - it has achieved much, has to
go further far more. It is a 70 year old republic sovereign nation, there are
older than us nearby or other continents, we can set up health care system
accessible and affordable to all, as some of the older nations like Thailand,
The Netherland, Sri Lanka or Canada have done. There are visions, models,
options available to us. Choice is ours! Can Covid 19 be an eye opener?
INTERVAL!
Let us see....my
next Blog - Blog Beta!
What is to be done, for Public Health as self health and health
care!
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