Fighting dengue: Too many questions, very few answers

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HT logoShailaja Chandra | Updated: Sep 21, 2015 01:23 IST

A view of Hindu Rao Hospital's dengue ward. Dengue continues to be rampant in New Delhi. (Saumya Khandelwal/ HT Photo)
A view of Hindu Rao Hospital’s dengue ward. Dengue continues to be rampant in New Delhi. (Saumya Khandelwal/ HT Photo)

The dengue deaths in Delhi have brought to the fore the apathy and ineptitude of the city’s hospitals. They have also exposed the acute absence of coordination between those responsible for health care services and the people.

The dengue epidemic in Delhi is still to peak: It is only by mid-November that the visitation from Aedes Aegypti mosquitoes that spread dengue will end. So unless and until there is clarity about response and responsibility, the number of cases and deaths will spiral, not just in Delhi but in other states too. In fact, of late, there has been an increase in the number of dengue cases across Southeast Asia. The World Health Organization has put out several preventive strategies that are being used by other countries, underscoring the point that dengue epidemics are an indication of the failure of a country’s public health system.

The preventive measures undertaken by the three municipal corporations of Delhi this year have been abysmal and we must seek answers to several questions: How many sanitary inspectors are available for each of the city’s 272 wards? How many institutions and individuals have been fined for ignoring mosquito breeding on their premises? What is the amount of fines levied on them each month? How many places with stagnant water have been covered or treated? What is the ward-wise result of anti-larval measures undertaken in July, August and September? Did the city’s health department provide resources on a normative basis for insecticides, wages and test monitors? Did the officials take notice when the preparation for the dengue season was found unsatisfactory? No one seems to have hard data or credible answers to these questions.

Instead, all we hear are persistent laments about the non-cooperation of private hospitals and implausible claims of increasing beds (sans commensurate medical manpower). This quest for adding more beds is diverting attention from the important referral and case management issues. Delhi’s health department had the responsibility (starting June 2015) to identify tertiary and secondary care hospitals (both in the government and private sectors) and link them for managing dengue-related medical emergencies.

Denouncing private hospitals without notifying the system to be followed by them is the best way of losing allies. The city has some 22 public sector hospitals and more than 30 hospitals in the private sector that have blood banks. At least, a third of all these hospitals could have been designated as nodal centres for providing blood components to attached satellite hospitals.

Undoubtedly public sector hospitals have to bear the brunt of epidemics, despite being over stretched even in normal times. But certainly more than 60 private hospitals in Delhi, which run emergency departments 24X7, can support them. Private hospitals cannot deny competence and refuse dengue patients. Most often, all that is required is to observe and interpret the vital parameters of a patient and provide immediate intervention. Checking blood pressure, administering intravenous fluids, assessing laboratory test results and getting fresh tests done are among the basics that any hospital claiming to run an emergency department has to provide. Hospitals which claim inability to perform these services should be directed to close down their emergency departments.

A canard is being spread that the government has no powers to enlist private hospitals. This is untrue. All private hospitals require a plethora of approvals from the government and they have to comply with a host of laws. As such they respect government authority and respond to reasonable appeals for short-term support during emergencies. No private hospital would wilfully risk losing goodwill by getting publicly shamed for callousness.

Every doctor wants to heal and emergencies often bring out their best. But for this to happen everyone in the hierarchy and in the wider network of health facilities must understand roles and responsibilities. Once they do that, written instructions need to be issued in simple, consistent and implementable language. Those links are missing today. Central monitoring of availability of beds and dengue admissions in designated hospitals would further promote quick response and accountability and the Union health ministry and the Delhi government need to jointly operationalise this. Most important, the network of emergency and tertiary facilities must be notified locality–wise, using all forms of communication.

Dengue management is comparatively routine work, but it can suddenly become complex and daunting. Unlike many other medical emergencies, dengue has the added disadvantage of becoming life-threatening just when signs of recovery show. So if a hospital (government or private) lacks the capacity to deal with a patient, there has to be a common protocol for transferring a case to another designated hospital. Otherwise the tendency to first refuse admission and then push less educated and poorer patients out will not abate.

This phenomenon was studied by the Law Commission, which gave a report in 2006 based on The Emergency Medical Treatment and Labour Act of the United States, also called the ‘Patient Dumping Law’. Once US hospitals too refused to accept poor or uninsured patients brought in an emergency medical condition. The Commission not only gave a comprehensive report on emergency medical care but also provided a model law for the use of state governments, including a protocol for transferring patients. The Delhi government would do well to adopt portions of the Bill. The Centre is unlikely to stand in the way.

Most importantly, without 24×7 political will to confront these challenges, prospects of overcoming dengue appear doomed, and mid-November is still a long way off.

The Big Picture – Bureaucratic reforms: Retiring non-performing officers

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rjtvPublished on 17 Sep 2015 Rajya Sabha TV | RSTV

Bureaucratic reforms: Retiring non-performing officers

Guests: A N Tiwari, Former Secretary, DoPT ; Shailaja Chandra, Former Chief Secretary, Delhi ; K.N.Bhat, Senior Advocate, Supreme Court of India and former Additional Solicitor General of India ; Sanjay Kapoor, Editor, Hard News.

Anchor: Girish Nikam

Air date: Sep 17, 2015

Desh Deshantar – The Dengue Menace: Tackling the outbreak and bolstering public healthcare

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rjtvPublished on 17 Sep 2015

The Dengue Menace: Tackling the outbreak and bolstering public healthcare

Guests: Dr. Punit Mishra, Professor of Community Medicine, AIIMS ; M Wali, Senior Physician ; Shailaja Chandra, Former Secretary, Ministry of Health, Government of India ; Nitin Sethi, Associate Editor, Business Standard and
Anchor: Qurban Ali

Air date: Sep 17, 2015

A Billion Plus: India to Have Largest Population by 2022

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ndtv_logoPublished On: August 30, 2015 | Duration: 36 min, 49 sec

India will have the largest number of people in the world, more than China, which should perhaps be India’s biggest policy issue at the moment. Will this be demographic dividend or disaster? How are we gearing up for this? Joining the discussion are Shailaja Chandra, former head of the National Population Stabilisation Fund, Sudha Pillai, former secretary of the Government of India, and others.

Click for play video
Click for play video

Guests: Shailaja Chandra (Former ED, Population Fund) ; Sh. Shaurya Doval (Director, India Foundation), Sudha Pillai (Former Secretary, Ministry of Labour & Employment and Planning Commission), Vikram Singh Mehta (Chairman, Brooking India), Sanjay Kumar (United Nations Population Fund )and Anchor: Sonia Singh, Editorial Director, NDTV.

I come in at 1.14 minutes, 19.08 minutes, and 35.06 minutes.

मुकाबला : क्या अति महत्वकांक्षी हो गए हैं केजरीवाल

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ndtv_logoPublished: Aug 22, 2015 08:00 PM IST |
क्या अति महत्वकांक्षी हो गए हैं केजरीवाल

लोगों की बड़ी उम्मीदों के साथ केजरीवाल सत्ता में आए थे। 70 में से 67 विधानसभा सीट जीतकर केजरीवाल ने दिल्ली फतह की। लेकिन हाल के दिनों में उन पर कई सवाल उठने लगे हैं। लोग कहने लगे हैं कि ये लोग तो राजनीति बदलने आए थे, लेकिन पुराने नेताओं की तरह ही हो गए हैं। मुकाबला में बहस इस बात पर कि क्या केजरीवाल अति महत्वकांक्षी हो गए हैं?

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Click to view video

Youtube video

Guests: Shailaja Chandra (Former Bureaucrat) ; Saurabh Bhardwaj (APP) ; Nirmal Pathak (Political Editor, Hindustan) ; Harish Khurana (BJP); Kiran Walia (Congress) and Abhisar Sharma, Anchor .

Nation at 9: Are netas imperial overlords or are they public servants?

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By NewsX Bureau | Friday, August 7, 2015

When you walk into a netas office, do they get up and greet you. The answer probably is no despite the fact that it is you who elect them. But netas in Maharashtra have come up with something bizarre. This is a story of unacceptable VIP privilege and high handedness. This is a story of our netas crossing all limits. In what comes as a diktat to the bureaucrats in Maharashtra, the government has issued orders asking them to stand up every time a neta walks in to their office.

Why India needs a new population policy

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the-financial-expressBy: Shailaja Chandra | July 10, 2015

The World Population Day is time to ponder on a policy that protects our demographic assets while preparing for challenges that lie ahead

The National Population Policy (2000) flagged off by the then Prime Minister Atal Bihari Vajpayee has failed to achieve the basic demographic goals set out for 2010.
The National Population Policy (2000) flagged off by the then Prime Minister Atal Bihari Vajpayee has failed to achieve the basic demographic goals set out for 2010.

Population stabilisation has gone off everyone’s radar as India basks in the security of having the world’s largest, yet youngest populace. Even so, there are robust reasons to announce a new population policy—because unforeseen changes are taking place. While some of them bring unexpected good news, others could be harbingers of potential disaster.

First, the bad news. The National Population Policy (2000) flagged off by the then Prime Minister Atal Bihari Vajpayee has failed to achieve the basic demographic goals set out for 2010. The infant mortality rate (IMR) was to have been reduced to 30 per thousand live births and the maternal mortality ratio (MMR) to less than 100 per 1 lakh live births. Today, in 2015, five years after the goals were to have been realised, India has achieved neither. Were the goals unrealistic? Not so, if one considers how much neighbouring countries have achieved with far fewer resources and minuscule technical strength.

Sri Lanka’s MMR according to international statistics is 35, whereas India’s according to our country statistics is 167.

Sri Lanka’s IMR is 8, while India’s is five times higher. Even Bangladesh and Indonesia have succeeded in lowering the IMR below that of India. Likewise, India’s MMR today is double what the population policy expected the country to have achieved by 2010. The total fertility rate (TFR)—the average number of children a woman produces during her reproductive years—was to have been reduced to 2.1 by 2010; a figure which may not be achieved even until 2020 by present indications.

Despite this dismal result, some good things have happened. Two successful strategies which had not been envisaged by the population policy managed to achieve the unthinkable. One, the erstwhile BIMARU states of Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh, and Odisha together with Chhattisgarh, Jharkhand and Assam, comprising 261 districts and a little less than 50% of the country’s population received focused attention for the first time.

Euphemistically christened the Empowered Action Group (EAG) states, their demographic indicators began to be monitored relentlessly.

The results have been phenomenal. For the first time the decadal growth rate in these states has reduced. The age of marriage went up, so preventing thousands of maternal and new-born deaths and stillbirths. In 2005, with the launching of the National Rural Health Mission (NRHM), prominence was given to hospital-based deliveries which doubled in some EAG states with near-tripling in Madhya Pradesh and Odisha. One of the main causes for maternal deaths is the absence of emergency obstetric hospital-based care—a deficiency which was substantially overcome.

The success of institutional deliveries has been unprecedented but recent data shows a plateauing out. This beckons a renewed policy thrust and reinforced monitoring to prevent sliding back.

Another phenomena which a population policy must address is the skewed female and child sex ratio which is spreading from urban into rural areas. Discriminatory social barriers like the absence of women’s ownership rights over land and property are responsible for the continuing son preference. Couples will continue to try for a male child even after having two or three female children and alternately resort to illegal female foeticide. These developments need to be confronted as part of a new population policy. It is too serious a matter to be left to political persuasion and occasional nabbing of guilty doctors.

The third important area that a new population policy must address relates to migration. The Census 2011 has given the picture of interstate and intrastate migration triggered by employment, business, education, marriage and other variables. While migration is welcomed by the manufacturing, construction, software and service sectors, it can spell trouble when it leads to insider-outsider tension. Unplanned migration to the metros and large cities also puts pressure on the infrastructure, housing and water availability. If this is factored into of the population policy, it would make for more foresight and greater coordination, and avoid the inevitable outcome of mushrooming slums and unplanned habitations. Other countries factor migration into the population policy but unfortunately we have relegated it to the narrow confines of the urban development sector which is driven by different priorities.

Next comes the ageing factor. The growing population of the elderly and the increase in life expectancy accompanied by chronic diseases have the potential to deflect resources from the primary task of providing education, skill development and increasing employability. In the next 10 years, the elderly will account for 12% of the country’s population. Until now policies on the elderly have been buffered with soft talk about old-age homes and protective laws—despite the fact that the elderly are virtually unable to take recourse to such provisions. Dependency ratios are increasing rapidly while the joint family system has disintegrated. The market of caregivers is today unregulated, expensive and undependable. The business opportunity to match the growing needs of this population cohort after factoring in their growing disability needs to be a part of the population policy.

Scores of countries have population policies which cut across sectoral paradigms. India is fortunately the envy of the world because of its youthful population. But several related factors are pulling back great achievements. A population policy that protects our demographic assets while preparing for difficult challenges that lie ahead will protect future generations from catastrophic consequences. The World population Day is time to at least think.