Mumbai,  15 September – The Author, Sagar Atre from Intellecap uses his previous work experiences in fostering health innovations in the domain of infectious diseases, to talk about a recent outbreak through this article.

 Sagar’s article, which was covered by Financial Express titled,  Fighting Fever outbreak in Firozabad, UP and Ill preperaed health systems: Need for multi level approach is pertinent given the recent outbreak and gives us a sense of the hinterlands of India, where unsanitary conditions, poor preventive behaviours and a lack of surveillance mechanisms make it a breeding ground for many diseases.

In a recent article, Dr. Raj Panjabi, a noted public health professional and the head of the U.S President’s Malaria Initiative (PMI) wrote, “Alarm bells don’t ring in health crises, community workers do.” This is especially true in the hinterlands of India, where unsanitary conditions, poor preventive behaviours, and a lack of surveillance mechanisms make it a breeding ground for many diseases.

The unfolding crisis in Firozabad, Uttar Pradesh is an example of what such micro health crises can do if we don’t work towards enhancing our public health capabilities. Similar crises have occurred in 2015 and 2019, where outbreaks of similar fevers were attributed to dengue and scrub typhus. U.P. ‘s Bareilly has been one of the few urban areas to report a spike in malaria cases, reporting up to 20,000 cases in a span of weeks in 2019, at a time when malaria is nearly non-existent across much of India barring a few scant pockets.

Battling old scourges

Diseases such as malaria, dengue, scrub typhus, and leptospirosis are remarkably good indicators of glaring gaps in health systems. They can lay bare the hollow claims of policymakers by bringing health systems to their knees and giving doctors barely any time to respond. A lack of discipline in implementing prevention programs can lead to spectacular failures such as the one in Firozabad, where according to recent figures, around 5000 people are suffering from symptoms similar to dengue, while more than 100 confirmed deaths have occurred in Firozabad and other districts in Western UP.

Dengue fever is easy to ignore in usual public health systems. It causes mild illness in many people, but can prove to be fatal for the young and healthy with supposedly strong immune systems and wreak havoc among children. Aedes mosquitoes are suited to breed in cleaner water, in small water collections such as water coolers, among others and they bite mostly during the day, making bed nets and ointments redundant.

Another threat is scrub typhus, caused by a bacterium (O. tsutsugamushi) and spread through bites of small insects called larval mites which dwell in dry scrubs and bushes near the fields in rural areas, where children often play and many of those practicing open defecation need to go. Unlike Dengue and Malaria, scrub typhus has remained largely off the radar, and no real estimates can be gleaned from public health data. The third purported culprit of this outbreak is leptospirosis, usually contracted through contaminated water, soil or food. While scientific evaluations are unavailable, the Delhi government’s effort at making Sunday a day of clearing stagnant water in domestic settings was a doable task for most households.

Ill-prepared health systems

Most of India, especially the rural and semi-urban parts are ill-prepared to deal with most of these diseases. Most labs in such places struggle to perform tests which can differentially diagnose these ailments. The international pressure to control malaria helped the discovery of rapid diagnostic kits, but others such as dengue, scrub typhus, leptospirosis remain undiagnosed, or need a skilled diagnostician. Investments that are needed are often missing, and that means that most of the tests performed for diagnosing diseases remain inaccurate. While multiple forms of dengue tests are available, the RTPCR remains the most reliable. Tests for scrub typhus and leptospirosis remain unreliable and it is unlikely that they will be performed even in district hospitals in the country due to the facilities required. In sum, India’s In sum, India’s scientific efforts need to be directed towards developing tests which can help in diagnosing these diseases, or at least providing a provisional diagnosis for them.

The need for multi-level approaches

The key challenge remains the lack of a holistic thought process for tackling the challenge at multiple levels. Impact of infectious diseases on public health can be dealt with at four key levels. Primarily, it is our inability to implement basic practices of hygiene, sanitation and build strong primary health systems. The second issue is identifying and building strategies and strategic capabilities specific to India’s regions. The third is a lack of focus on developing innovative solutions which can tackle these health challenges through the country’s growing scientific capabilities as was done for COVID-19. Many of India’s institutions such as BIRAC, the DST, the IISc, IISER’s and IIT’s are now proving to be useful in creating innovative solutions for diagnosis and management. They need to be given the mandate of building solutions to tackle them. The final, and probably most complicated challenge is designing interventions which inculcate appropriate health behaviours and improve uptake of health services by the community. Many NGOs and institutions across India have been at the forefront of designing such initiatives across challenging geographies in India.

It would probably be appropriate to say that for India, apart from the fundamental capabilities to ring the alarm bells, we also need the capabilities to nimbly tackle the cause of the alarm, and prevent such incidents in the future.