Human influenza, while causing ordinary sneezes, occurs in three types. In 1918, a Type A influenza pandemic, involving the H1N1 influenza virus, infected 500 million across the world, including in remote Pacific and Arctic regions, and ultimately killed 100 million, five per cent of the world’s population. Considered the “greatest medical holocaust in history”, this virus killed more in 24 months than AIDS has killed in the past three decades. In India, 17 million died, five per cent of the population. The virus tilted the balance against the Central Powers in the First World War, with mortality and morbidity in Germany and Austria far higher than in France and Britain.
More recently, in 2006, the avian influenza virus A/H5N1 affected poultry farmers in Maharashtra, Gujarat and Madhya Pradesh. By 2008 and 2009, it had affected backyard chickens in West Bengal, Assam and Sikkim. A massive cull within a three-km radius contained the spread, preventing human infections. Yet, 262 people died worldwide of 442 infected.
In 2009, another virus, A/H1N1 or swine flu, highly transmissible but with low virulence, spread rapidly across North America. Of late, with nearly 14,000 people affected and 833 dead, the courts and citizenry are rightfully asking questions about the country’s preparation to deal with the swine flu pandemic. Aside from a high body count, a pandemic, whether Ebola or influenza, has a cruel and sudden economic impact that can be devastating and lead to political instability.
A crisis in health resources makes people panic and change their behaviour to avoid exposure. Consumer demand decreases suddenly as people stop going to markets and their jobs. The World Bank estimated China’s severe acute respiratory syndrome (SARS) losses at $15 billion in 2003, while the global GDP was reduced by $33 billion. And SARS killed just 916 people. A global pandemic would trigger a major global recession.
Public health responses to such events don’t come cheap. But having a sound public health law infrastructure ensures that the powers and duties of the government are well defined during a time of public crisis. Legal frameworks help define the scope of a government’s response at local and international levels.
The World Health Organisation has defined specific public health measures that require policy-making to ensure transparent assessment. These include isolation or quarantine of infected persons, travel or movement restrictions, closure of educational institutions, prohibition of mass gatherings, availability of vaccines and drugs and usage of privately owned buildings as hospitals.
Specific trade-offs, prior to and during an epidemic, require policy-based evidence. Does shutting schools down, for example, contain viral spread, saving healthcare costs, despite the increased childcare costs? According to the Brookings Institution, closing all American K-12 schools for two weeks would cost between $5.2 billion to $23.6 billion. Increase that to four weeks and the cost gets pushed up to $47.6 billion.
India’s existing legislations for epidemic preparedness are numerous — Epidemic Diseases Act (1897), Livestock Importation Act (1898), Drugs and Cosmetics Acts (1940), etc. The National Health Bill (2009) provides that the Central government will review regulations, standards and protocols for port quarantine, seamen’s and marine hospitals, every five years, along with monitoring maintenance of vaccines and medicines in stock.
Our legislations are focused on “policing” instead of creating a consolidated public health approach to respond to an outbreak. Our only public health legislation focusing on pandemics, the Epidemic Act (1897), is 118 years old. It is archaic and only provides for action to deal with small outbreaks and emergencies. It doesn’t cater to pandemic scale healthcare needs and the resultant socio-economic breakdown. Respect for human rights under such conditions is also ignored.
In India, where the district collector is in charge of overall coordination during an epidemic, with the chief medical officer in a supporting role, roles and responsibilities need to be delegated and defined.
There is an urgent need to assemble all public health provisions under a single legislation, to ensure that implementation is not hampered, and a regulatory agency for proper implementation of these laws. A “public health standards agency”, akin to the UK’s National Institute of Health and Clinical Excellence, that sets standards and builds uniformity in implementation, might just be the answer. India’s National Health Bill needs to be expedited by utilising the National Development Council for inter-state dialogue.
India needs a multi-pronged strategic plan to contain and mitigate epidemic-like situations. It needs to reduce opportunities for human infection. An early warning system could be strengthened to ensure that affected districts, local health officials and the ministry have all data and clinical specimens needed for accurate assessments. Rapid containment operations must be planned and intensified when an epidemic is declared, decreasing transmissibility. Local capacity, interlinked with international organisations such as the WHO, should be developed, with pandemic response plans formulated and tested. Local and global scientific research and development should be coordinated, to ensure that vaccines are created, tested and made affordable and available quickly.
Instead of demonising NGOs, engagement with civil society needs to be encouraged. The UK’s national pandemic framework engages the public and civil society in the development of policies, plans and realistic choices, while sensitising the public to the hard choices that need to be made. Ensuring that advice and information are readily available during such a situation helps cut down on civil disorder. Complete integration of legal frameworks with such intentions will ensure adequate healthcare before, during and after a public health crisis.