Nipah virus: Kerala govt acted quickly, but recurrence a sign that state's once immaculate healthcare system is failing

The scare of another Nipah outbreak in Kerala, the second in a year, seems to have been quelled with the state government announcing that except one person who was hospitalised all the other “suspects” have tested negative. Probably the state got lucky for the second time, or the authorities have been nimble-footed with the immediate isolation and treatment of the infected person, tracing and quarantining those who could have come into contact with him, implementing standard protocols, setting up fever clinics, and spreading awareness to contain the infection. This time around, the virus that had killed 18 people, scared the entire state with near-certain death and threatened to spread like a major epidemic last June, seems to have just grazed the surface and disappeared. Certainly what made state’s pushback against Nipah successful on both the occasions was the rapid response of the Kerala government, particularly the health department led from the front by minister KK Shailaja. The ruling party and its supporters, that included a vast army of its cyber-proxies, celebrated the “success” yet again. Last year, they called Shailaja the “iron lady” and “Jhansi-ki-Rani” and a party sympathiser even made a movie called “Virus” that made Nipah look like Ebola in Liberia and Shailaja, like Dr Adadevoh . [caption id=“attachment_4491495” align=“alignleft” width=“380”] Representational Image PTI[/caption] Although the jubilation was somewhat justified, what has been swept under the carpet is how such a deadly viral outbreak occurred in Kerala that boasts of health indicators comparable to that of the West, and how it recurred without getting noticed. Epidemiologically, what the recurrence in Ernakulam indicates is that the virus is still out there - probably in bats or in pigs - and it can hit back any time. The health department has been able to contain the epidemic once it appeared, but hasn’t been able to trace the virus and contain it at source, or least take steps to prevent its spread. It’s like firefighting versus the fire itself. The former only controls a disaster while the latter prevents it. For public health experts worldwide, it must be puzzling as to why a state that has been ahead of most of India in healthcare and was even considered a model for attaining high levels of human development (mostly riding on health and education indicators) at very low per capita cost, hasn’t been able to prevent the Nipah outbreak. If not the first time, at least on the second time. The answer is quite simple and fundamental: The state, that boasts of the best health infrastructure in the country, doesn’t have an exclusive Directorate for Public Health. It doesn’t even have a cadre of trained pubic health professionals who can track infectious diseases, undertake clinical research on existing and emerging pathogens, and mount effective preventive programmes. This is one of the weirdest anomalies of Kerala’s famed health record. The state’s glorious record in health, education and human development draws its strength from Travancore’s progressive social policies more than a hundred years ago. The princely state had adopted European-style modern medical practices way back in the 19th century and had established an exclusive public health agency. In 1929, the government even sought the help of Rockefeller Foundation — one of the two organisations that were involved in international public health work then — to help in setting up its public health programme and by 1929, a dedicated unit was in operation. Later on, the sanitation unit that originally undertook many preventive aspects was merged with this unit and made into a Public Health Department. In fact, it was such forward looking steps of the Travancore princely states in areas of sanitation and public health and their systematic institutionalisation that made Kerala a shining outlier in health and development in India. The systems were so strong, the personnel were well trained and the initiatives were designed with far-reaching outcomes in mind. However, by 1956-57 the department of public health was merged with department of medicine to create a single unit called Directorate of Health Services. The first Communist government of 1957 failed to notice the danger of general health services subsuming the all important public health work. It was the genesis of the structural problem that’s threatening the state’s health now. Apparently, the aim was to streamline health administration, but that move, coupled with the complacency arising out of the early achievements, led to the present lacuna of the state in public health, particularly in disease surveillance and prevention. Today, everything is controlled by the Directorate of Health Services, the focus of which is mainly delivering healthcare. In other words, the focus of the state now is mostly cure than prevention. Unfortunately, while the world is moving towards a better acknowledgement of the importance of social determinants of health such as environment, water and sanitation, pollution, waste-management, nutrition and so on, Kerala is on the opposite path. The state is choking on its own garbage, its rivers are dying, environment is fast degrading, and there’s no modern solid or liquid waste management facility while it’s busy in setting up more and more private and corporate hospitals. The present rules don’t even have the wisdom that the Travancore government showed a 100 years ago when they considered sanitation department and public health as a single unit. In the absence of a dedicated Directorate of Public Health, the state also doesn’t have an exclusive cadre of public health specialists who can study, track and prevent infectious diseases. Because of the absence of such a system, doctors are also not encouraged to get training in public health or taking degrees such as Masters in Public Health (MPH) after their MBBS. The Directorate of Medical Services, which handles public health, doesn’t have adequate number of public health specialists and every time there’s a crisis, they are short of experts and the state of the art knowledge. Ironically, the person responsible for everything related to health in a district (except medical education) is the District Medical Officer (DMO) who is the senior most doctor in service. He/she could be even an ophthalmologist. When diseases such as Nipah silently spreads, he/she will have no clue as to what to do. The decline in public health in the state is borne out by the increasing incidents of infectious diseases. The state is a hotbed of diseases - various viral fevers, dengue, chikungunya and even malaria - and the morbidity associated with viral diseases is very high. The state hasn’t been able to figure out their epidemiology and handle it at source. Every year, thousands of people fall sick, hospitals get full and people’s out-of-pocket expenditure for health skyrockets. The government hasn’t been able to halt and reverse it. In comparison, neighbouring Tamil Nadu has a dedicated Directorate of Public Health and Preventive Medicine with a huge army of well trained personnel that are capable of tracking and preventing infectious diseases. Tamil Nadu doesn’t have the princely state legacy of Travancore and its early advantages, but has been able to catch up despite its more formidable socio-economic challenges. Enquiries reveal that it’s the hegemony of the doctors in government service that has been preventing the establishment of a separate Directorate of Public Health in the state. The previous UDF government had undertaken some initial steps in establishing a separate department, probably under pressure when faced with waves of dengue epidemics, but never acted on it. The present LDF government also took some steps, but has kept the idea in cold storage. It was political will that helped Tamil Nadu acknowledge the importance of public health and establish an exclusive system and cadre for tackling it and the results are evident. And that’s what Kerala lacks. Its health system is oriented towards treatment, which means money. No wonder, the state has the highest out-of-pocket expenses in health in India and one of the most privatised healthcare sectors in the world. When the party proxies, half-baked experts and vested interests in the state’s healthcare sector celebrate the success against Nipah, they don’t realise that what they have seen is yet another early warning sign that the state is in serious trouble. It’s not an occasion to celebrate, but to worry and be careful. Nipah is a metaphor of the state failing its glorious public health legacy.