While the chances of the Ebola virus entering India are low, Ebola and pandemic flu teach us to expect the unexpected and be prepared. New diseases are appearing in the world again and again. We live today in a “global village”. Ebola-infected bats are probably present in Asia. Nipah virus-infected bats are widely prevalent in east Asia; there is no guarantee their territorial flight paths will not extend to peninsular India. Is India prepared? Who exactly is in charge?
Considering that the 2014 Ebola epidemic was confined to four contiguous west African countries (Liberia, Sierra Leone, Guinea and Mali) and affected with autochthonous cases only four other countries (Senegal, Nigeria, Spain and the United States), the chances of the virus entering India, or any other country, are extremely low.
Cote d’Ivoire shares borders with Guinea, Liberia and Mali, but so far no case has been reported in that country.
The “Ebola Haemorrhagic Fever” epidemic began in Guinea in December 2013 and spread to other countries in early 2014, cumulatively recording over 20,000 cases and nearly 8,000 deaths. These are the counted figures – certainly gross underestimate. The death rate is widely quoted to be 70%-80%. The epidemic continues with ups and downs but the peak seems to be over in Liberia; Mali is probably free of the disease.
For India, the threat remains as long as the epidemic continues. If the virus enters India, what might its transmission dynamics be? What is India’s track record of coping with diseases with high fatality? How did other countries prepare themselves to respond in case the virus entered their territory? What is special about Ebola disease setting it apart from others? How prepared is India to cope with its entry in case it happens? How robust is India’s health management system in general?
Details of the Disease
The first outbreaks of Ebola virus disease (Ebola for short) were in 1976 in Sudan and Zaire. It recurred in Sudan in 1979 and 2004; in Zaire in 1995. Outbreaks occurred in Gabon in 1994, 1996 and 2001; in Uganda in 2000, 2007 and 2012; in Republic of Congo in 2001-03, 2007, 2012 and 2014. All of them affected relatively small numbers – 20 to 400, with death rates of 50%-80%. Hospitals were foci of the spread; healthcare workers were at a high risk of infection, like family members who cared for the sick or prepared dead bodies for funeral. The outbreaks appeared to be self-limited with hospitals taking the precaution of safe handling of blood and body fluids. Thankfully, the virus seemed an inefficient spreader between humans. Ebola causing a huge multi-country epidemic was unexpected and remains unexplained. Traditional funeral practices, low literacy and very weak health management system, common to these countries, have certainly contributed to the epidemic this time.
Among directly human-to-human transmitted diseases, Ebola is the most scary, this time with high transmission frequency to caregivers, no specific treatment and very high death rate. The reservoir of the virus is the bat; animals in the bush get infected probably via bat saliva on half-eaten fruits fallen on the ground. Humans get infected from animals, particularly those hunted for “bush meat”. Human-to-human transmission becomes an outbreak. The virus is non-pathogenic in bats, but highly pathogenic in humans with the clinical range from no disease in some, but fever, influenza-like symptoms, diarrhoea, vomiting and haemorrhagic fever with high death rate in others.
Recent information from the new treatment station run by US experts in Freetown, Sierra Leone, suggests that good supportive care can bring case-fatality down to less than 24%. Two nurses who got infected in the US and were treated there, both recovered. Severe fluid loss through watery diarrhoea and consequent low blood pressure are reasons for death; aggressive fluid management seems to save lives. So, high death rate is mainly due to lack of quality healthcare. A moderate death rate is inherent and unavoidable for Ebola; Ebola itself should be prevented to prevent death.
Economic reforms and liberalisation have made India the world’s third largest economy. There is no sign that our health and economic experts realise its implications in terms of health of the people; so too in the context of the African Ebola epidemic. India has donated over $10 million, but in general remains indifferent to the epidemic, with the only response being the narrow and immediate self-interest of screening of passengers from affected countries at airports. Our leaders are not thinking into the future.
Cuba’s response is inspirational. A country of 11 million people, it sent 165 well-trained healthcare professionals to Sierra Leone and 296 to Liberia and Guinea (“In the Medical Response to Ebola, Cuba Is Punching Far Above Its Weight”, Washington Post, 4 October 2014). Cubans’ not-so-good English was a minor handicap. Cuba has some 50,000 health professionals working in 66 countries; this is at once medical diplomacy and expression of solidarity with those in need. An estimated $8 billion is Cuba’s income from this export of medical expertise. Cuba’s own healthcare is one of the world’s best in quality and equity. We have good English but poor understanding of health diplomacy.
It is an eye-opener to learn how China reacted. In addition to several rounds of monetory donations totalling over $10 billion, Chinese infectious disease experts have established two mobile laboratories in Sierra Leone and a state of the art bio-safety-assured 100-bed hospital in Liberia. Earlier they had sent several teams of epidemiologists and experts in infection control and personal protection. China is making sure that they hone expertise combating deadly diseases, and earn West Africa’s goodwill – bonus for business success to grow from strength to strength. Chinese military scientists have also developed a candidate vaccine; this is in addition to two other candidate vaccines from the National Institutes of Health in the United States and the firm, GlaxoSmithKline.
To become a world leader, India must learn to behave like one; that requires a realistic world view. The importance given to human health is strikingly different in Cuba and China from that of India. Will India be judged as an enlightened well-wisher of underprivileged African nations? The countries named above and several European counters have special treatment centres for infectious disease with high mortality. India does not have such well-prepared hospitals or trained health workers. We could only remain indifferent as we are unprepared for getting involved in international health problems. We must first take national health problems seriously before aspiring to become a global leader.
Direct physical contact with blood, body fluids, excreta and vomit was, until now, believed to be the channel of virus transmission, in which case precautions we use in the care of AIDS patients should have sufficed for personal protection of healthcare workers. The magnitude of the present epidemic and its rapidity of spread suggest that virus transmission occurs more easily than believed in the past. Mucosal contact, including inhalation, of droplets and aerosol of body fluids, perhaps including oral/throat secretions, are feared as channels of transmission, although there is no clear evidence. Space suit-like personal protection equipment (PPE) is mandatory now for every healthcare worker for every patient room visit. For this eventuality, namely having to treat Ebola patients, India is ill-prepared.
According to press releases on 25 August 2014 by the World Health Organization (WHO), over 240 doctors, nurses and other hospital workers had fallen ill with Ebola in West Africa and over 120 have died. The loss of so many doctors and nurses made it difficult for WHO to secure support from foreign medical staff. By end September the number of deaths climbed to over 200. In the US, in spite of all precautions and personal protective equipment, two nurses got infected from the first Ebola patient treated in a US hospital. Both of them were detected and treated early; both recovered.
Another haemorrhagic fever, due to Crimean-Congo virus, is transmitted to humans from animals by ticks and human-to-human through contact with blood/body fluids. In 2011 a case was hospitalised in Ahmedabad, and a nurse and a doctor got infected and died. This illustrates that our medical staff is not well-versed with safe care of any haemorrhagic fever. In 2012, another doctor died in the same city, with the same disease, after contact with the blood of a patient. Ebola will be more easily transmitted human-to-human.
India’s Health Management
In countries that take human health seriously, the health management system has two wings: public health and healthcare. Public health is the government infrastructure for health protection from preventable diseases and from social and environmental risk factors of diseases – akin to the police force protecting citizens from law-and-order incidents. Sectors of health, animal management, agriculture, environment, water, sanitation, local government, tourism, food, etc, are involved in generating risk factors. The overarching “health protection agency” that sets standards and monitors them, is public health. Thus a separate ministry or at least a full- fledged department under the Union Ministry of Health, with trained cadre in every district and city, supported by an adequate work force must be created if India takes human health seriously.
Our cultural beliefs are that illness is either due to personal mistakes of daily routine, wrong foods, etc, or due to malignant planetary influences; the consequence of karma from past lives; punishment from god or deities. All these are at variance with the concept of social and environmental determinants of diseases. Microbial causation of diseases is not accepted by our traditional culture. All these seem to tell our leaders that diseases are not preventable by human interventions; hence public health, for organised human interventions to prevent diseases, is both culturally alien and unnecessary.
Healthcare is service rendered to individuals after they fall ill – akin to protecting victims of crime or calamity. Healthcare can be rendered by institutions by the public sector using revenue funds or by private sector billing the clients. The inequity of some getting service free while others paying cost plus an unregulated profit margin, is of no concern to our leaders.
Healthcare cannot stand in for public health. The lack of public health has resulted in India being unable to prevent diseases that the West got rid of before the early 20th century – cholera, typhoid fever, malaria, tuberculosis, to name a few. Our healthcare institutions are overburdened with such diseases.
Learn from Experiences
In late September 2014, a Liberian arrived in Texas and reported with fever to a big hospital. He was otherwise well enough to be sent home with simple medications. Two days later he came back, severely ill, and that is when the penny dropped; he was tested for and found positive for Ebola. Every one of his fellow passengers in the flight and in the local community were counted, and followed up for 21 days to make sure none was infected; none was. Ebola does not spread during the incubation period.
What should have alerted the emergency room physicians? Travel history; arriving from Liberia should have been taken seriously. Imagine such an eventuality in one Indian hospital. The disease would have been undiagnosed until late into its course or after death, by which time several hospital staff would have been infected and they would start small outbreaks in their families and wherever they went for treatment.
What should India do? First, the Government of India should name one “event manager” who would develop a plan of action in case Ebola enters India, through a traveller. India should create a mechanism for the event manager to communicate with every hospital in the country to inform the dos and don’ts. Doctors take a history of the patient’s illness; this should include travel history. Also, the event manager should be the spokesperson for the government to inform the public authentic information. If this process is closely linked with all states and union territories, then every state will be prepared.
Remember what happened when the pandemic influenza reached India in 2009? Infected persons were made to crowd in selected testing centres, thereby rapidly spreading infection to many others. This is exactly the opposite to what other countries did – they asked those with influenza-like symptoms to stay home and report only to a chosen doctor. The fire department must be open all the time; not just after a fire is reported.
Ebola and pandemic flu teach us to expect the unexpected and be prepared. New diseases are appearing in the world again and again. We live today in a “global village”. Ebola-infected bats are probably present in Asia. Nipah virus infected bats are widely prevalent in East Asia; there is no guarantee their territorial flight paths will not extend to peninsular India. Is India prepared? Who exactly is in charge?