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.
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.
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.
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.
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.
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.
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:
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
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)
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!
What is to be done, for Public Health as self health and health
care!
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