October is usually a month of festivals, and a major holiday season. First there is Dussera and then Diwali and Bhaiya Duj. This year the festivities were spoiled by the resurgence of an old disease everyone - at least in Lucknow - had forgotten. Dengue, (pronounced den-ge) achieved notoriety a few years ago in Delhi when stagnant water in air-coolers was thought to be the main reason for the sudden breeding of the tiger mosquito. To me, a person who had not had the misfortune of being in Delhi during that time, dengue was a comparatively unknown phenomenon. I remembered it as one of those short questions in the final MBBS examinations when we memorized a mnemonic for diagnosing different kinds of fevers which were accompanied by rashes. My few years in medical college and in the paediatrics department in a Kolkata hospital did not acquaint me with the disease either. In Lucknow, in twenty first century India, I found myself face to face with the disease.
First there were the many newspaper reports, which like most newspaper reports (be they of riots or wars) I initially treated with a distant cynicism. From the newspapers it would appear that dengue is something like the plague and anyone who gets it is sure to perish. Political parties organized demonstrations as many controversies surfaced. Even the state high court had stepped in with advice for the health department. All this would have been hilarious, when suddenly my daughter first got high fever and then the characteristic rash appeared all over her abdomen. Luckily most of the 50 million or so dengue cases every year recover, and so did my daughter. But when all the din was over, more than 200 persons in Lucknow alone had lost their lives.
The health care systems in Uttar Pradesh are currently undergoing reforms through a US $110 million loan from the World Bank towards the implementation of the Uttar Pradesh Health Systems Development Project. One of the two objectives of this project is to improve the performance of the health system through improvements in the quality and effectiveness of health services at the primary and referral levels, and increase access to health services in selected areas that have the greatest needs. The project aims to increase the access to health care by 2 million persons each year. The 5 year project was approved in April 2000. The project closes on December 31, 2005. Against this background, the outbreak of dengue - an old infectious disease making a comeback - provided an opportune moment to study the effectiveness of the health care system.
World Health Orgn: Dengue
What one heard, read and saw in Lucknow did little to raise the confidence of average citizen in the health system. While the health department brought out newspaper inserts and large public hoardings listing the preventive measures to take - wear full-sleeved clothes, avoid the pooling of water, etc. - there was little effort to explain to the public that not all dengue was necessarily dengue hemorrhagic fever. The newspapers were full of the conflict between the doctors of the cities' two premier medical institutions the King George Medical University (KGMU) and the Sanjay Gandhi Post Graduate Institute (SGPGI). The KGMU did not possess the required equipment to make platelet infusions, while the SGPGI felt that its services were required for more serious illnesses.
Primary Health Centres, Community Health Centres and District Hospitals from neighbouring areas referred cases to Lucknow at the slightest suspicion. Some doctors prescribed expensive tests which could confirm diagnosis but were of no value where treatment is concerned. We sent two suspected cases to the city civil hospital and the doctors here referred them to a private laboratory to determine the blood platelet count.
All this while the newspapers carried reports of people dying of the disease in different places. We also learned that the fogging machines (for spraying insecticides) belonging to the municipality were not working and a political party tried to get some quick popularity by conducting fogging operations. The high court stepped in and ordered the city authorities to start spraying insecticide. In the middle of this chaos we learned that a machine for platelet separation had arrived at the KGMU, but it would not work for the next month or two because that much time would be required to get a certificate from the Central drug authorities. Predictably, the epidemic ended before the certificate was received.
These events bring into sharp focus the inefficiency of the health system of the state. It is especially galling to note that this inefficiency is despite the fact that the state has taken a huge loan to improve the health system, - and especially the curative system - both at the primary and referral levels. Responding to dengue required coordination between the curative and the preventive systems, between the private and the public health care systems, and last but not the least between the primary and the secondary/tertiary care systems. The experiences in Lucknow proved that none of these linkages are working.
Also, they raise some very pertinent questions about the way health care reforms are ongoing throughout the country. In this era of increasing privatization what is the clear role of the government system? The private sector will surely not take up the responsibility for dealing with epidemics. As the focus in health care is increasingly moving towards curative medical care, who will remain responsible for public health? And even if managers of the Uttar Pradesh Health Systems Development Project have learned an important lesson, are they accountable for their failures?
A new festival season has arrived with Eid, and temperatures have dropped sharply across the northern plains. The mosquitos have slowly gone away, and the spectre of dengue has lifted. But the real epidemic - the unconcern of the health department - continues without respite.