I’m not sure who it is I’m misquoting but it’s often said “India can handle famines but not malnutrition”, that is, we respond well to crises but not to the day-to-day to problems that continually plague us. The current crisis is the death of one fourteen year old girl from swine flu in Pune. For this we see great mobilisation of public resources and individual precautions in many parts of the country. Whether this degree of concern is warranted or not is beyond my expertise to judge.
I suspect it is not but I certainly wouldn’t want to stand in the way of standard procedures on the part of health ministries for fear of blame if it turned into a full-blown epidemic. But I sure wish that a small fraction of this concern were given to the grinding, day-to-day problems of the health of many Indians, particularly our poorest and most vulnerable.
Compared to about 600 confirmed cases and one death of a (mysterious?) new disease over several months we have tens of thousands of cases and hundreds of deaths every day from diarrhoea and other routine, unglamorous health problems. These diseases are not mysterious at all; they are not news-worthy in the least and are eminently preventable by public and individual action. Why do we not see panic such as that in Naidu hospital in Pune over these problems?
It is a well known result in the study of attitudes toward risk that people wildly overestimate the probability of very rare events. Clearly one out of a billion is pretty rare in comparison to the daily tragedies of deaths that we seem to accept as a part of life. In our reaction to risk we seem to be responding true to form.
We know about and are kept informed hourly about the new problems, we find out about and, briefly, worry about the usual ones with a lag of years. Public reaction may be explicable psychologically and may also explain the politics behind hasty reactions that determine health ‘policy’ but is not a good guide to the economics of health policy. Forget economics: this sort of reaction is not a good guide for any common sense approach to the problem.
In the US there were numerous cases of schools being closed, businesses shut and other aspects of daily life disrupted. These all carry costs to people in the value of the activities. If they didn’t, why do we make children go to school in the first place? Should we bear this cost?
That’s a hard decision. What I worry about is that specialised technocrats see their own issues as of crucial importance and tend to downplay the consequences in other realms of life. To balance this tendency we have politicians or officials that take a broader view of peoples’ many needs. Of course, in cases when the politician makes a mistake and the technocrat was right, we blame the politician. When the politician is right and there was no real threat, no one notices since the consequence was a normal day. Normal days without disruption are good things but are not newsworthy.
Of the measures to avoid the spread of swine flu infection, some were in response to health authority warnings, some were initiated by the public as, say, parents in the case of schools. Some lessons can be gleaned from both the tendency to overestimate rare and new events for both government and for behaviour of the public. The latter, perhaps, with a few words of advice from health authorities.
First, panic is part of the problem, not a helpful, energising conviction to solve it. Again, in the US, visits to emergency rooms in New York City from mid-May to mid-June increased by a factor of ten for flu-like symptoms relative to the year before, from about 4,300 in 2008 to 45,000 to 2009. This resulted in 40-50 people being hospitalised per day, most without swine flu. In fact, throughout flu season, less than 50 died from swine flu compared to over 1,000 from all other, standard, flu strains. This represents an enormous burden on resources that could better be used elsewhere. New York may well be able to absorb these patients and their attendant expenditures. Pune, and India as a whole cannot with its dozens of other problems that have urgent claims on the same money and personnel. Credible announcements from government could well save resources for higher priority needs and, ultimately, save lives. Unfortunately those lives are anonymous and the names of the those victims are not printed in the newspapers.
Second, surveillance of disease is, indeed, a high priority for public money. Who else has the incentive to collect information that has no particular commercial value? There are two types of surveillance activities. The first, applicable to swine flu, is to search out a particular problem and trace its origin. The ‘target’ is uniform, usually concentrated in urban areas (or among people in contact with those who travel abroad) and can trigger a rapid response from health officials. For this, there are international standards for procedures that could be valuable to India for the sake of its people, and at least defend the ‘Brand India’ name in international opinion.
For the sake of the vast majority of the Indian public, though, surveillance is even more critical but takes a very different form. Instead of waiting for people to come to facilities, it is important for outreach on a regular basis to find out what the health status and needs of the people are in normal circumstances. This would be a much more reliable guide to good public policy, saving large numbers of lives on a continuous basis.
“What gets measured, gets done” is a standard quip from the management gurus. In the case of health surveillance, this is clearly the case. It is a shame that this message does not inform standard policy discussions in health and must wait for emergencies, possibly minor emergencies, to grab the measurement, the spotlight and the policy response from much bigger and deadlier problems.
—The author is Charles and Marie Robertson visiting professor of economic development, Woodrow Wilson School of Public & International Affairs, Princeton University