Mosquitoes acquired prime time stardom this week. All the elements were in place. The geography was well located—it happened in Delhi, the national capital. The physiology of distress was acute—an estimated 3,000 persons affected and 30 killed by dengue and chikungunya. Then there is the anatomy of politics—everybody accountable was apparently missing. What followed was the usual endless blame game.
It is this failed politics of allegations that renders India vulnerable to real and potential pandemics. Fact is, vector-borne diseases—jargon for diseases caused by mosquitoes and organisms that thrive in filth and chaos—are a real threat. The data is stark. Between 2011 and mid-2016, every year a million persons or 3,000 a day have been afflicted by diseases—malaria, dengue and chikungunya—spread by mosquitoes. Chikungunya and dengue cases are rising. In 2015, 27,553 cases of chikungunya—that is 75 cases every day—were reported. Dengue cases, which averaged 110 per day since 2011, have spiralled and touched 270 cases per day in 2015.
Every year nearly 500 persons are killed by malaria—an ailment discovered by a French Army surgeon in 1880. In 2015, dengue claimed 220 lives. The two types of encephalitis claim an average of 1,500 lives every year—mostly of the poorest of the poor. Add the threat of Zika hovering on the horizon. The operative phrase here is “reported”—much of it from urban India and even the system does acknowledge gross under-reporting.
Mind you, India has had a National Vector-borne Disease Control Programme since 2003. It evolved from the malaria control programme and focuses on control of vectors, behavioural change, early detection and treatment. Indeed, the National Health Policy of 2002 aimed to eliminate Kala Azar by 2010, Filariasis by 2015, and mortality in vector- and water-borne diseases by 50 per cent. That clearly hasn’t quite panned out.
The high incidence of these diseases is located in complexities—of societal behaviour, structural flaws, poor funding and pure sloth. The occurrence is directly related to—and often proportional to—population density and deteriorating quality of habitation. There is no running away from the fact that society must bear some responsibility for passively and actively allowing accumulation of filth. Worse could follow. Barely a third of the sewage generated is treated. Cities and towns—and 4,000 dots on the map that are neither town nor village—are burgeoning without appropriate water and sanitation programmes.
The crux of the problem though is systemic. The ensuing brouhaha in Delhi is illustrative. The city has large open areas, uncovered drains, lets off untreated sewage, untended water bodies, poor garbage and waste management, and multiple layers of sloth. The city state is managed by municipal bodies, the state government and the Central government. Typically the Congress blamed everyone, the AAP government in Delhi blamed the BJP-ruled MCD and the BJP blamed Kejriwal and company.
Structurally the administration of healthcare is trapped in a nightmarish maze. Health is on the Union list, the concurrent list and the state list. Policies are designed at the Centre and administered by states through local bodies. The local bodies—municipalities, zila parishads and panchayats—lack both funds and functionaries. At the implementation level, issues relating to health are governed by 78 different Acts administered by over 20 dozen ministries. Then there are health issues dealt with by more than one ministry. The issue of medicines and drugs is overseen by chemicals and fertilisers and health, milk food by food processing and child development, pests and insects by rural and agriculture, and environmental issues by environment and science and technology. The subject of water is dealt with by six different ministries.
This chaotic multi-layering of authority and accountability—at the Centre and in the states—haunts decision-making and leads to the compromise of national health objectives. To implement control of vector- and water-borne diseases, the health ministry has to depend on local bodies, state governments, departments of water, sanitation, rivers, urban development, housing, rural development, agriculture and environment. The control of encephalitis, for instance, is overseen by the ministries of health and family welfare, water and sanitation, women and child development, social justice, rural development, housing and urban development.
Worse, the health ministry scarcely has the funds it needs. Successive governments waxed eloquent about health, but failed to provide for the objectives. India spends less than smaller nations like Thailand, Sri Lanka and even its peers Brazil and China on health. Government spending on healthcare is less than 2 per cent of GDP and translates into `957 per capita. The lack of funding impacts service delivery, regulation and research.
Typically India does well in terms of lofty intent. Health is an assurance articulated under Article 39, Article 42, Article 47 and Article 48A. India is also a signatory to nearly a dozen international conventions. The execution of intent though is stalled in the cess pool of politics, by structural issues, by battles of turn and terrain. This is most visible in the struggle of Swacch Bharat and Smart Cities —ideas that have been waylaid by multi-layered confusion.
The aspiration of better health and outcome-orientation demands a structural overhaul. Decentralise implementation of national objectives to panchayats, municipalities, zila parishads, municipal corporations and state governments—prioritise bottom-up empowerment with funds, functions and functionaries. At the Centre, the health ministry must be empowered to have the final say—why must drug policy be decided elsewhere. There is a great need to review the plethora of archaic laws that delay decisions. On the ground, India needs a national water and sanitation grid—a $100-billion programme like the PMGSY, which will clean up the mess, systemise urbanisation and also create an economic multiplier. Cities need smart solutions, ranging from PPP for solid waste management to adoption of water bodies.
It is no secret that quality of life improves with quality of habitation. The co-relation has been highlighted now in medical journals, policy papers and by organisations such as WHO. Yet seven decades after Independence, water-borne diseases continue to claim lives and mosquitoes acquire prime time stardom.
shankkar.aiyar@gmail.com
Shankkar aiyAr Author of Accidental India: A History of the Nation’s Passage through Crisis and Change