Low budgets and dwindling number of health personnel explain persistence of infectious diseases

In the earlier decades of India’s development, resources — human and financial — were scarce, and disease burden huge. Yet, within the first twenty years, India reduced malaria incidence from 75 million to 2 million cases and eradicated small pox. This was due to the professional commitment of remarkable people — the head of National Malaria Program, walking through villages, talking to malaria vaccinators and leading the team from the front; of doctors, including WHO consultants, sleeping on village charpoys in interior Bihar, stamping out smallpox and so on. What such approaches provided was an intimate knowledge of field conditions and vital information that then fed into policy.

Since then, we still have a huge disease burden:  Vector-borne diseases in their different manifestation going beyond malaria, leprosy and TB stalking the land and communicable diseases still accounting for 30 per cent of the disease burden. TB in India currently contributes to 16 per cent of global TB and 3 per cent of MDR TB that is said to increase to 12 per cent by 2030. MDR TB is not only prohibitively expensive to treat but each case infects another 15-20 persons. Likewise, India accounts for 8 lakh deaths of children under five as compared to 1,900 in Sri Lanka and 3,700 in Thailand. India also has one of the highest rates per 1,000 live births of neonatal mortality at 21.8 compared to the global average of 16.7 and 3.3 of Thailand. Neonatal mortality impacts the longevity of life. India’s average life expectancy is 67 compared to 86 of Japan. Low budgets, dwindling public health personnel, large vacancies in critically required ground troops, unstable policy attention toward several diseases; and the tendency to substitute field travel with computerised data sheets are some factors responsible for the persistence of infectious diseases.

Disease surveillance

As these diseases are preventable and disproportionately hurt the poorest, policy choice has always been to contain and eliminate them. Yet progress, unlike in other countries, is slow. For example, Sri Lanka has eliminated malaria and has no deaths since to vector-borne diseases compared to nearly 50,000 succumbing to it in India. This is largely because of our inattention to data.

For making policy choices, designing and sequencing programme interventions, information is of fundamental importance. India needs to invest in building a uniformly sound system for vital registration of births and deaths, establish sentinel surveillance sites, and periodically conduct bio-behavioural studies. India has no prevalence or incidence data of major diseases. For example, the nationwide prevalence and incidence survey for TB was last conducted in 1956, while for malaria information flow is patchy due to almost 80 per cent of field posts lying vacant. Programme data is flawed and grossly underestimates the size and intensity of the problem. Likewise, there are neither prevalence studies nor registries for cardiac ailments or mental health morbidity and so on. Most data on IMR and under-five mortality are based on the Sample Registration System that provides only statewise data. Such aggregate data are not useful for planning policy interventions at sub-district levels.

During the decade 2002-2012, India implemented the National Disease Surveillance Project with World Bank funding under which an IT network connecting 776 sites was established alongside 70 laboratories and so on. Yet, the required skill base is lacking. India still has only 408 epidemiologists, 181 microbiologists, 25 entomologists and 3 veterinary consultants. Information is not triangulated with other data sets and so barely used for policymaking or advance planning. For example, information of deaths due to diarrhoea needs to be triangulated with availability of safe water and sanitation. Such a systemic approach to analysing programme data, information from field studies and sentinel surveillance sites and data of social determinants is required for assessing impact of the direct and indirect causal factors.

Policy Focus

Understanding the interdependent nature of disease causation would entail focusing on prevention and launching massive health education campaigns to avert disease as key to disease reduction. For example, the “Chronicles of Central India: An Atlas of Rural Health” brought out by a dedicated band of ex- AIIMS doctors battling routine diseases of common people in backward Chattisgarh listed out the profiles of the poor suffering and dying due to 29 common everyday reasons like snake bite or TB. Such suffering and loss can be prevented not by drugs and doctors but more by information, housing, nutrition, and access to safe water and sanitation. These are basic goods that all developed and middle-income countries have provided to their people as a right.

In this connection, it would be appropriate to recall Bhore Committee’s insightful comment made in 1946 and still so valid : “If it was possible to evaluate the loss, which this country annually suffers through the avoidable waste of valuable human material and the lowering of human efficiency through malnutrition and preventable morbidity, we feel that the result would be so startling that the whole country would be aroused and would not rest until a radical change had been brought about.”

The author is former Union Secretary, MOHFW, GOI. Views expressed are personal.