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India's amateur handling of the H1N1 pandemic

Our panicky leaders have adopted the very strategy that the WHO warned against in dealing with the H1N1 outbreak, says leading virologist Dr T Jacob John, pointing out in this exclusive article for Infochange how government should have handled the pandemic

“Don’t look where you fell, look where you slipped.” - African proverb 

The moment one responds to any threat with fear, one loses rational cognition and shifts into emotional and reflex decisions. Fear comes from lack of confidence, which comes from lack of understanding.  

For the 2009 flu pandemic, there should have been a war room in New Delhi for cold and factual strategy planning. But we do not have a subsystem of ‘public health’ – the function of which is to look at the community and the environment and learn about the behaviour and tactics adopted by pathogens for their survival and spread. Based on observed facts that are analysed epidemiologically, public health personnel consider various options and choose the best interventions.  India’s health system – sans public health – functions in an amateur rather than professional manner when it confronts public health threats like this pandemic.   

As a result, fear took root among the top leaders.  Fear reflects lack of confidence and leads to over-reaction and errors of judgment.  This time we may have got away with our less-than-professional approach because the disease is a mild one; the next time around we may not.  Recall how our governments responded, with callous neglect, to the chikungunya fever that emerged a few years ago, causing far greater misery and a death rate that remains unmeasured.  No one had instilled fear ahead of that event. So it was not even recognised as a public health problem to worry about.   

The approach was wrong both times. Forewarning should lead to preparedness, not panic. Lack of forewarning should not lead to absence of professional response and interventions.   

As the scene emerged and evolved from April through July/August 2009, the World Health Organisation kept everyone well-informed and well-guided.  Our leaders were not paying attention. "A strategy that concentrates on the detection, laboratory confirmation and investigation of all cases, including those with mild illness, is extremely resource-intensive," the WHO said on July 16. "In some countries, this strategy is absorbing most national laboratory and response capacity, leaving little capacity for the monitoring and investigation of severe cases and other exceptional events." The international agency said it would no longer issue case counts by country, but it would send out periodic updates on pandemic developments.  

India obviously wanted to do one better and continue down the path the WHO warned against.  Who does not like a good epidemic?  Look at the media visibility.  

When the minister of health himself comes to the frontline of the battlefield and shouts “Don’t panic!” who will not panic?  The first directive through media channels was for ill persons to appear at designated centres for collection of specimens for testing. Anyone who saw the crowds either directly or on TV would certainly believe that there was a huge epidemic.  There were other messages that echoed the panic. Apparently the municipal commissioner of Mumbai sought public opinion via SMS on whether or not schools should be closed, allowing people’s imagination to fly wild.  

Why was the discretion to selectively test individual patients not left to doctors?  The lack of confidence in doctors got out of control and the threat of lawsuits added yet another dimension to the confusion and cacophony. Had the government not responded in panic and plunged into kneejerk responses, instead of taking proactive and deliberate steps, soothing the fears of the public and appointing specific, informed spokespersons to present the official view, the anarchy witnessed over the past couple of weeks could have been avoided.  

The media played its part in magnifying the fear psychosis. They pictured a disastrous epidemic when there were only a few cases, and carried on with the self-fulfilling prophecy of projecting the growth of the epidemic, with more expert opinions than facts – were they taking the opportunity to say our channel did this first or better, had more experts, etc.?  Medical experts who were interviewed generally doubled up as public health experts. 

Significantly, India does not have a public health department in the Ministry of Health and Family Welfare.  The director of the National Institute of Communicable Diseases was recently designated as the official in charge of public health. He should have been the official spokesperson of the government. Another potential spokesperson could have been the director general of health services – although the DG is in charge of healthcare, major disease control activities and the NICD come under his purview.  Instead, we heard from several spokespersons, who were like the many cooks who spoiled the broth.  

What is the purpose of testing ill individuals for presence of H1N1 pandemic influenza virus?  Testing in general can serve two purposes.  One is a public health purpose, to detect the arrival of the virus in a new locality and see if it has begun to spread – to serve this purpose testing is done on a ‘selected sample’ of ill persons chosen by the public health subsystem. That function is within the government’s purview and the private sector can be excluded from it. The second purpose is to check ill persons for their personal benefit – such testing fits into the healthcare mode and subsystem; it is obviously not ethical to exclude the private sector. India’s response appears to have mixed up these different purposes and separate subsystems. 

In healthcare, in cases involving persons at risk of pre-existing pathology that could be complicated by flu, it is the physician’s decision to test or not.  If the flu has arrived in the town/community, then it is a good idea to test such persons.  But then, as soon as the sample is taken and pending the result of the test, the person should be given Tamiflu. If the patient tests negative, the drug can be discontinued; if he or she tests positive it can be continued. It is not appropriate to start Tamiflu only after a positive test result since the window of usefulness would have passed by then.  

The government’s job was to make these processes systematic and equitable, instead of leaving it to a first-come-first-served free-for-all in public sector hospitals. The latter situation ultimately and predictably resulted in designated centres being overwhelmed and test reagents and even drugs running out.  At any rate, deliberately crowding ill people into a limited number of testing centres is clearly against basic public health principles.  People should remain where they are and specimens should travel.   

With no information on how many persons die of ordinary (endemic and seasonal) influenza, it is not possible to compare data from regular flu and pandemic flu. In both cases the true viral pneumonias and acute respiratory distress syndrome are unpredictable and unpreventable. That is why some people die in the best of circumstances in many countries.  However, in those countries, secondary bacterial pneumonias (in the second week of illness) would be diagnosed and treated and death thereby averted.   

The influenza virus predominantly infects the windpipe and the lungs, not so much the nasal mucosa.  This weakens the body’s ability to prevent bacterial extension into the lungs from the throat and upper airways, which are constantly colonised by bacteria.  So, if someone with flu gets worse during the second week of illness (more than the first week) it is due to bacterial pneumonia. That is eminently treatable with antibiotics.  

So we need to know the details of death in the Indian context – how many died from what. I haven’t heard the experts distinguishing between the two – true viral pneumonia and secondary bacterial pneumonia. If bacterial pneumonia is not suspected, and the illness is assumed to be solely due to the flu virus (especially in cases where the test was positive), the patient is very likely to die a preventable death.  

Public health policies and decisions must be science-based and not opinion-based.    

(Dr T Jacob John was formerly Professor and Head of the Department of Clinical Virology at the Christian Medical College, Vellore. He was President of the Indian Academy pf Pediatrics in 1999.  Presently he serves as the Chair of the India Expert Advisory Committee on Polio Eradication) 

Infochange News & Features, August 2009