Categories
Public Health

Post Covid19 will healthcare become a poll issue in India?

Recently, Dr Devi Shetty, the founder of Narayana Hrudayalaya, authored an article in the Times of India Sunday Edition where he said that healthcare will become a poll issue in the future. Given the historically low percentage of budget allocated to public health in India, can Covid19 realistically push the government to prioritise this area?

An analysis[1] of select 2014 election manifestos indicates that we may be woefully behind on the path to a more comprehensive health plan for citizens.

  • India spends about 1.2% of its GDP on health services and in 2018 this number went up to 1.4%. However, this is still significantly lower than the time and efforts allocated to areas like physical infrastructure development and jobs.
  • Women Led parties had more space dedicated to healthcare in their election manifestos (AIADMK – 6% and TMC – 5%). AAP follows closely with 4%, whereas national parties BJP and Indian National Congress (INC) dedicated around 2.3% and 2.1%, respectively. Interestingly, the AIADMK appears to have been implemented given that Tamilnadu leads on several health parameters, the TMC in West Bengal needs a stronger implementation policy to suitably action on its promise.
  • Most parties tend to pay little attention to preventive health. There is almost no mention of areas like nutrition in election manifestos and while the BJP manifesto does talk about Swachh Bharat, there is no mention of ways to tie that back to measuring health outcomes. The INC manifesto talks about malnutrition and mentions Anaemia and HIV but does not spell out anything concrete in terms of action plans to prevent or tackle the disease.
  • All election manifestos considered for analysis missed addressing non-communicable diseases and the measures to tackle them. Given the high incidence of non-communicable diseases such as diabetes and hypertension in India, this is a glaring miss.
  • Most of the focus on health in manifestos is on building hospitals – more beds and more clinics and so on. But there is no focus on the quality of care provided at these centres or the variety of ailments they can treat. One cannot provide hospitalisation and expect improvement in the state of health without tackling the underlying social and sanitation causes for the ailments.
  • Strangely, while the focus remains on building new facilities, there is no mention of improving existing primary health centres and community health centres that have suffered from decades of neglect. Even in Ayushman Bharat these have not been addressed. While the insurance part of Ayushman Bharat is doing well, the wellness program can be significantly improved.
  • There is no mention of disease surveillance in any manifesto. This is surprising considering most developing countries in the world have some semblance of proactive disease surveillance to curb the spread of disease and manage its citizens’ health.

In summary, even if all that has been promised in the election manifesto is delivered, it would not even make a dent in the state of health in the country.

Why is this so?

Historically India missed the boat in prioritising healthcare reforms recommended by the Bhore committee in 1946 (See box in the next page), particularly the delivery of health at the grass root levels through primary health centres (PHCs).

Further, religious beliefs that tie poor health to karma and a generally fatalistic outlook have ensured hospitals and external care providers are seen as the last resort for patients. Preventive healthcare was largely provided at home. In line with this, the government has not undertaken research connecting the health of its citizens to their productivity. For instance, a study in the UK found that those who smoked were twice as likely to take time off work. Another study found that workers with obesity (BMI over 30) annually took an average of three sick days more than those with normal weight (BMI less than 25), and those with severe obesity (BMI over 35) took six days more. In India, a large population and limited availability of jobs means employment remains a bigger issue than health for the government.

The relatively affordable cost of healthcare so far has also meant citizens have remained negligent about lifestyle diseases. Until recently health insurance wasn’t understood and perhaps without the tax exemption many citizens may not opt for it.

Until the time healthcare is viewed as a discretionary spend, political parties may see no value in contesting elections on the plank of better healthcare for citizens. Citizens themselves need to demand for better health from its government for parties to take the issue seriously. A possible reason why some of the Southern states have overall better health indicators is the relatively high proportion of senior citizen population that resides alone, without support from younger people who tend to live outside the state/ country. This changing demographic of voters may have prompted political parties in the region to place greater emphasis on public health and deliver results.

In addition states like Karnataka and Kerala have prospered from the investments from the princely states. Tamilnadu alone benefitted by keeping public health distinct from Health Services, this is one of the few states that implemented this recommendation from the Bhore Committee recommendations.  

The article is based on the research report “Healthcare and Democracy: Can healthcare become a poll issue in India”.


[1] About the analysis –

  • The following part manifestos were considered for the analysis – Bhartiya Janata Party (BJP), Indian National Congress (INC), All India Anna Dravida Munnetra Kazhagam (AIADMK), Trinamool Congress (TMC) and Aam Aadmi Party (AAP). The rationale was to consider national level parties and those led by women, as it is widely acknowledged that women tend to prioritise health. (We wanted to include the Bahujan Samaj Party (BSP) but we couldn’t find the manifesto in the public domain). AAP was considered in the analysis as it was a recently formed political party that emerged from a citizen movement demanding a corruption free India. All manifestos from 2014 were considered for the analysis.
  • The following parties have not been considered as their manifestos were unclear on the healthcare aspect – JDS Karnataka, Shiv Sena, Shiromani Akai Dal, and Biju Janata Dal. The communist parties are also missing from our analysis. We are planning a follow up report on the analysis of the 2019 manifestos and we plan to include more parties there.
Categories
Public Health

India and COVID19 – The Story So Far and the Road Ahead

Late January, a medical student fleeing from Wuhan became the first confirmed cases of SARS-Cov-2 in India.1 Couple of her classmates also contracted the virus and India made its initial entry into a leader board no country wants to lead. The three students largely remained asymptomatic and recovered with a month, ending India’s first tryst with the virus.

The second wave started at the end of February. By now, SARS-Cov-2 had spread to 64 countries / regions across the world, with South Korea and Italy reporting over 1,000 confirmed cases. But it is quite possible there were cases in India long before that. It was only in in May that we found that the virus had already reached France in late December itself.2 It is quite possible that the virus had reached India from Europe long before we started screening the flights coming from Europe.

Nevertheless, as confirmed cases started gradually increasing in India, the Central Government took a bold step in locking the country down for three weeks to prevent the spread of the virus. Many countries were opting for lockdown to tackle the virus, but the step by India was a bold one for two reasons:

  1. Lockdown is a strategy for the rich. It meant many will have to live off their savings and those who can’t will have to be protected by the government. US alone has provided for over 3 million via unemployment benefits.3 India, with perhaps the largest number of poor people in the world, would have struggled to provide for those getting unemployed due to lockdown.
  2. It would have taken a phenomenal effort to enforce the lockdown given the size of the country and population density in certain parts. The only comparable country is China, which can rely on heavier surveillance than India could enforce.

By 14th April, Goa, the North East and East India excluding West Bengal were largely unaffected by the virus and had limited the number of cases to less than 100. States like Haryana, Karnataka and Kerala had managed to control the spread as well and showcasing more than one-fourth recoveries.

But it was already evident by then that many places in the country where the infection had reached the community.

Though India officially denied community reach of the virus, on 10th April, Indian Council of Medical Research (ICMR), which was coordinating India’s Covid19 response (Which in itself was odd since there was already another organization fitted for it – Integrated Diseases Surveillance Programme (IDSP) 4) had recommended 36 districts be prioritized to target Covid-19 containment activities. This was based on the Sentinel Surveillance study done till 2nd April.5

By 3rd April, India recorded a little over 3,000 cases of SARS-Cov-2. This was spread across 255 districts in 30 states and union territories. Incidentally, only 66 districts had reported more than 10 SARS-Cov-2 cases then.

And ICMR was recommending stricter containment in 36 districts.

As the economic cost of the lockdown became more apparent, India went on a period of staggered release of lockdown after 14th April. But as expected from a country with community transmission of a virus, India showed a consistent increase in cases as norms got relaxed. What was 104 districts on 24th March, when lockdown started, it became 379 on 14th April, 489 on 4th May, 564 on 17th May and with the last release on 31st May – 654 districts have seen confirmed cases of SARS-Cov-2 across the country.

The Road Ahead

Image 1 – Italy

Image 2 – India

After a long three month struggle, Europe is finally starting to hope they can move beyond Covid. While most of the European countries peaked in cases late March, they have seen a gradual decline in cases over two months.

This long tail foreshadows what we may see in India. But for that, we have to reach the peak first. So, we can expect considerable pain, both from Covid and the economy, for at least the next two months before things start to get better.

The 66 districts that saw more than 10 cases on 3rd April, now account for 66% of the SARS-Cov-2 cases in the country.

As cases increase, hospitals get stressed and treatment gets delayed. This leads to an increase in fatality rate. While India is doing remarkably well with around 7,500 dead from 267,000 SARS-Cov-2 cases (2.8%), there are over 100 districts with a fatality rate of 3.7% and above. The ones to watch out for over the coming weeks:

Jalgaon (Maharashtra), Dhule (Maharashtra), Kolkata (West Bengal), Solapur (Maharashtra), Aligarh (Uttar Pradesh), Meerut (Uttar Pradesh), Dewas (Madhya Pradesh), Patan (Gujarat), Khargone (Madhya Pradesh), Amravati (Maharashtra), Nashik (Maharashtra), Mathura (Uttar Pradesh), Gorakhpur (Uttar Pradesh), Sagar (Madhya Pradesh) and North 24 Parganas (West Bengal).

All these districts have shown consistent growth the past week and has high fatality rate. With more testing, it may be possible to weed out the SARS-Cov-2 carriers and catch patients early, although districts like Kolkata and Nashik may already be stressed, given the high number of cases there.

Ujjain (Madhya Pradesh), Anand (Gujarat) and Panchmahal (Gujarat) have seen low growth in cases recently, but has an overall high fatality rate. Increasing testing in such places may reveal the extent of the spread, since high fatality rate may be due to late stage discovery of the disease.

On a positive note, there are 48 districts that show a high growth rate in cases with a less than 1% fatality rate. This would indicate better testing and good potential to keep a check on the virus. These include Chennai (Tamil Nadu), Chengalpattu (Tamil Nadu) and Gurugram (Haryana). All of the three districts have recorded over 1,000 SARS-Cov-2 cases

Among the 25 districts that have over 1,000 cases, Indore (Madhya Pradesh) and Jaipur (Rajasthan) have shown the slowest growth rate the past week, indicating a positive road ahead.

Late March, George Gao of the Chinese Center for Disease Control spoke to Science Magazine about the road ahead with SARS-Cov-2 – Trace all SARS-Cov-2 carriers with mass testing, Isolate the carriers and trace out their close contacts, Quarantine and isolate the close contacts.6 As we officially start to slowly unlock our economy in June, despite the numbers on the rise, it will be a difficult road ahead for all of us in India.

A century ago, the Indian subcontinent was the biggest graveyard for the Spanish flu virus. In all probability, we are again headed there and the only way to have some form of control is to trace the infected early by mass testing and ensuring strict quarantine of the infected and their contacts. We also need a workable serological test7 to determine who have already been infected (and not initially traced) so that they can get back to work.

By Ranjith Kollanur

Bout the Author

Ranjith Kollanur is the Managing Parter with the Unseen Ink,

1https://www.outlookindia.com/magazine/story/india-news-wuhan-to-kochi-an-indian-medical-students-great-escape-from-epicentre-of-coronavirus/302922

https://www.bbc.com/news/world-europe-52526554

3https://www.marketwatch.com/story/a-staggering-number-of-laid-off-workers-are-receiving-more-money-from-unemployment-benefits-than-when-they-were-employed-2020-05-26?mod=article_inline

4https://idsp.nic.in/index1.php?lang=1&level=1&sublinkid=5778&lid=3707

5https://www.businesstoday.in/latest/trends/icmr-sentinal-surveillance-finds-39-percent-coronavirus-patients-without-travel-history/story/400629.html

6https://www.sciencemag.org/news/2020/03/not-wearing-masks-protect-against-coronavirus-big-mistake-top-chinese-scientist-says

7https://www.cdc.gov/coronavirus/2019-ncov/lab/serology-testing.html

Categories
Public Health

The paradox of tobacco and cigarettes in India

Smoking is bad for health. Period. I think that debate has been over for a long time. The idea of having a smoke once in a while is not so bad as the addictive nature of cigarettes. The same I can say for all forms of Tobacco consumed in India.

Smoking is not a few phenomena in the country. There is evidence of Bhang and Cannabis consumption for almost 2000 years. It is even prescribed in ancient texts as a medicinal practice to manage pain and neurological disorders. Most recently Hookah has been used by both the royalty as well as the common people.

Now tobacco accounts for almost 10 million deaths in the country. Add to it the impact it has on the cardiovascular system and respiratory system would make it a very lethal habit to cultivate. Cigarettes for example contain more than 7000 chemicals out of which more than 250 are harmful and more than 60 are carcinogenic. This brings me to Cancer which continues unabated in the country. Non Communicable diseases also continue to be boosted by the habit of chewing and smoking tobacco.

While India has implemented many laws including Cigarettes and Other Tobacco Products Act (COTPA) with the creation of a National Tobacco Control Programme (NTCP) in 2007. But the real reason why Indian government can never control or remove tobacco is the economics of it.

Today the tobacco industry caters to almost 120 million customers in India. The vast majority of tobacco is grown in Karnataka, Andhra, and Gujrat. Almost 50% of the tobacco consumed in India is the chewable type used in Gutka, Khaini and Zarda. Almost 30 % as bidis and only about 20% as cigarettes.

The below graphs give us a sense of the revenues from tobacco. This graph is particular to the cigarettes and the tax collection from smokers in the last decade.

There are many measures for controlling the consumption of cigarettes, there are Laws like COPTA, the ban on advertising, and the increasing control of public smoking in the country. But then who would kill the golden goose that gives almost 30,000 crores of revenue to the government from sale of tobacco products.

So on this World No Tobacco Day, I started thinking about what can be done to control the habit and reduce the disease burden of cigarettes while balancing the loss of revenue to the government?

Here is what I think can be done

  1. Treat smoking or chewing of tobacco as addiction. These individuals should enter therapy just like how we would expect people with drug addiction to undergo therapy.
  2. Focus on nutrition and health for the rural areas. One of the reasons why tobacco consumption is very popular, is because many people do not receive adequate nutrition. Tobacco consumption quells hunger and thats the sole reason why it should be tackled.
  3. Create smoking zones and tobacco consumption zones all over cities to ensure that the concentration of efforts to manage the communication and addiction can be well coordinated. Ban all consumption outside of these zone.

But the biggest challenge is how can the government substitute the 43,000 crores that it receives from tobacco sales. Now that is a question I leave open for economists. Do let me know how and I would be happy to make that discussion to the right authorities.

Sources

  1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5648391/
  2. https://www.thehindubusinessline.com/news/science/smoking-causes-over-11-deaths-india-among-top-4-countries-report/article9618981.ece#
  3. https://www.indianmirror.com/indian-industries/tobacco.html
  4. https://en.wikipedia.org/wiki/Smoking_in_India#cite_note-8
Categories
Public Health

Covid19 Test. Trace. Treat… Are We Doing Enough?

We have been hearing this advice from many sources for the management of Covid19 effectively. For understanding more about Covid19, I went on to check for a simple metric i.e. percentage of confirmed Covid19 cases vis-a-vis a total number of tests conducted by various countries affected with Covid19. My data sources are shared at the end of the article. I have used a different data source for the month of May; the reason being comparable dataset was not available with the earlier source.

March Numbers

CountryDateTotal TestsTotal Confirmed Cases%Confirmed
SpainMar 18, 2020300001117837.26
ItalyMar 20, 20202068864103519.83
IranMar 14, 2020800001136414.21
United StatesMar 19, 202010394594159.06
IndiaMar 20, 2020145411911.32

May Numbers

CountryDateTotal TestsTotal Confirmed Cases%Confirmed
SpainMay 24, 202035565672823707.93
ItalyMay 24, 202033911882293276.76
IranMay 24, 202078128613352117.08
United StatesMay 24, 202014357969166682911.60
IndiaMay 24, 202029434211326744.50

Just to mention, the source which I used earlier did not have the data for China so I could not include the same. Apart from China, I have shown the data for the countries which have got the maximum number of confirmed cases to date (in March) for illustration purpose and I also included our own country to put this in perspective. Now, if we compare the data for two instances; it shows different positivity rate (i.e. percentage of total confirmed cases / total test)

As we all know that lockdown was imposed in our country for preparing ourselves for fighting this long battle against Covid19 and a very important aspect in this battle is to increase our daily testing capacity as it’s the only way available to us to understand the spread of the virus in any particular community.

We have come close to daily testing capacity of 1 lakh+ tests a day which is almost 100 times increase from the initial days but still we are way behind when we see tests per million vis-à-vis other developed countries. Just to put this in perspective; India is doing 2135 tests / million population whereas Iran which has almost similar number of confirmed cases has been doing 9544 tests/ million population. And if we compare this with developed countries this number is in the range of 20000 – 75000 tests/ million population.

At the same time; we should not forget that various studies world over suggest that actual number of infected individuals are always higher than number of confirmed cases the reason being each country depending upon their testing strategies are able to identify the confirmed cases. Also, we should not forget that number of confirmed cases is a lagging indicator to understand the spread as the symptoms start to emerge only after 2 to 14 days from the day an individual got infected with the virus.

I am writing this article at a time when we are in lockdown 4.0 and have got relaxation in many parts of the country. This would be the real test of our healthcare infrastructure which we have managed to build during the national lockdown.

Key Points:

  1. Positivity rate for India is less vis-à-vis other nations which also got impacted with Covid19 (which is a good sign)
  2. We need to improve our testing capabilities to understand the level of community spread (as it is done in other countries); the reason being based on the historical evidence and current developments globally pandemic strikes in waves so we should not discard the possibility in our case as well.
  3. We should also increase the use of rapid antibody test to ascertain the level of community spread.
  4. We should be more concerned about deaths happening due to Covid19 as it is believed that 80% of the cases would be mild in nature; 15% would need hospital support and 5% would need ventilator support.

In our country, one can also debate the number of deaths happening because many of deaths happening in our country are not certified medically. But that is something we should discuss separately.

Again as always, questions and clarifications are welcome.

About the author

Yatindra Jha is a healthcare consultant with a focus on public health policy.

Sources

Data Source: https://ourworldindata.org/covid-testing – March Data

Data Source: https://www.worldometers.info/coronavirus/ – May Data

Categories
Public Health Uncategorized

Privacy Concerns with the Aarogya Setu Application for Covid19

Just this week, we recorded the second episode for the India Health Talk, with Dr Sumeet Kad. During the recording we ended up discussing the privacy concerns around Aarogya Setu, the contact tracing application launched by the Government of India to track Covid19 cases in the country. Aarognya Setu today has more than 10 Crore downloads and is the largest contact tracing application in the world. How do we balance the privacy concerns with managing a pandemic like Covid19? Alo what can we learn about other applications across the world in this space?

While I understand the concerns, in my opinion, during a pandemic we may need to give up some control over our data and privacy for the greater good of society. Pandemic is a national emergency and Covid19 is probably the worst example of it. But using privacy to derail the efforts to combat Covid19 is not a good idea. In the long run this may be our downfall.

Below is the full recording of the episode. Do let me know your thoughts as well.