The Indian Government and Swine Flu - Time to Get Mad.

Our daughter was admitted to the Kasturba Hospital in Mumbai, suspected of Swine Flu. The experience has been Kafkaesque and Shambolic.

I specifically exempt from these criticisms those knowledgeable and dedicated pprofessionals who smilingly work in our hospitals, private and government, mostly at low pay, and often in hazardous conditions. They try and take care of their patients as best they can, given the tools at hand, while having to kowtow to our political classes and bureaucrats.

Worried by continued high fever, and mindful of the fact that we had recently returned from Europe, we took the kid to see her pediatrician. It was clearly the flu, but the government does not allow the private sector to test for the swine flu virus (I will go into why later). Our doctor advised that we take a test that at least lets you know whether the virus is type A, of which swine flu is a subset, or type B. The hope is that it would be type B, as it had been for her other patients to date, so we could all relax.

Unfortunately it was type A, and the advice from the doctor, and the requirement from the testing hospital, was that we go to Kastuba Hospital, the sole provider of swine flu testing in the city. Our GP called the head of the Swine Flu cell, I suppose you would call it, and he said we had to hurry as everything closed at 5. Hurry we did, and given the publicity of the day before, were surprised to see just a few people waiting. Perhaps people knew of the 5 pm deadline and knew that it would be observed, hospital or not, people in need or not.

After a difficult form filling procedure (one cannot fill the forms oneself, one has to dictate to someone who was clearly barely literate) we were admitted to the sanctum, where tables of doctors sat around, with three apparently required to examine one patient, and with half the doctors, including the senior doctor, tied up in showing around some visiting troupe of government or political officials.

After a cursory examination of her history and reports, the doctor decided that she had to be admitted because she looked weak. So one would be, if one had been forced to walk one kilometre with a 103 fever because of road blocks courtesy the Kasab trial (Kasturba is opposite the Arthur Road Jail) and because guards do not allow any but government cars in through the gate.

The doctor said that the Swine Flu test would be done but that the results would not be available for two days. Why two days? Babudom had decided that for ‘quality control’ (sic) all tests will be done only in Pune, where they have been testing, they say, several hundred per day. There samples wait in line for a test that apparently takes 6 hours and costs INR 10,000. Our (AB) test at Bhatia took 15 minutes and cost 900, so I am sure there is a modern method somewhere. See more on this below.

And the doctor said that Tamiflu treatment would start after the test results were received. Our system decreed the wait, not caring that Tamiflu (the only thing that works to shorten the effect of the flu and so reduce its nastier effects) is best given within 48 hours of the onset of symptoms; in fact he seemed clueless about the disease, his role, and supposed government directives on being allowed to send patients home with Tamiflu etc. I managed to persuade him to start the treatment asap as a condition of putting the kid in hospital. But, incredibly, apparently there are people in the hospital who are awaiting tests and not getting Tamiflu, but who are sharing rooms with infected patients.

This cluelessness extends to every level of government (but not to the senior healthcare establishment), and given the prominence that the disease has garnered, and the warning we have had, the ludicrous outcome ought really to be laid at the feet of the PM.

The Babu’s are now talking of enlarging the reach of the effort to the private sector, but being Babus’s are only going to do this through ‘authorized’ hospitals and agencies. Given the speed and the ability to stay ahead of the curve that they have shown so far I would not bet on much progress, so I am doing an exercise to which they can refer as a starting point. It is very close to what their own health advisors are seeking the recommendations freedoms are at such odds with the emergency health code Babudom has slapped on us that they cannot move.

The medical professionals who report to the Babu’s have meanwhile worked out what needs to be done in great detail and have started outreach with civil society to move into high gear when permission is granted. In the meantime we continue to overload our already weak government healthcare system which should be working on the everyday and far more serious concerns of the poor.

All one needs is simple mathematics to analyse the flu biz and apply the results to the population, extrapolate and compare the result with the infrastructure that has been set up. Nor do Babus have a sense of time, suspended as they are in the 19th century. All information is from recent reports and anyone with an internet connection who follows the same method will arrive at the same result. Try it.

WHO has declared this a level 6 pandemic. This means the spread cannot be stopped and the consequence must instead be to minimize damage. The Babu’s have instead tried to enforce old communicable disease laws drafted for the age when TB was called consumption, in an effort to stop what cannot be stopped, and what for all practical purposes need not be stopped because it is for the most part no more virulent or serious than normal flu. Some dummy has even publicly opined on testing intercity travelers and quarantining all foreign arrivals.

The WHO expects total cases to be between 30% and 40% of the world population. If we take our population share, it means that India could have 400MM cases, and Greater Mumbai around 6MM. Infection rates for Swine Flu have been up to 3% per week in Europe (a new 3% of the population gets the infection every seven days); for normal seasonal flu the rate can be as high as 12%. In Mumbai that means anywhere from 450,000 to 1.8MM cases per week. Total hospital beds? Around 40,000 in Mumbai. We just cannot quarantine 10% of the cases even if we kick every sick person out of hospitals and replace them with people with the flu. Sounds silly when put like that, doesn’t it?

The numbers above suggest that the only thing that can work is home and community based treatment, which is what has been adopted the world over. And the quicker the government figures out how to prescribe Tamiflu quickly and securely over the phone the better. We may not have computers everywhere but a secure call and response mobile phone application could be knocked together in less than a week; our BPO industry could put together a check script in less time than that and we could be moving.

These numbers of expected infected have been known for months, and the WHO advises that governments should stockpile enough Tamiflu to cover 30% of their population. A great many European countries go above that, and Japan is above 100% coverage.

The goal of the Tamiflu coverage is to reduce the severity of symptoms and so reduce the number of patients who develop complications. The doctors, hospital beds and ventilators should be saved for the few patients who develop Acute Respiratory Disease, which is what kills the less than 1% of patients who die of the disease. Even there, it is mostly viral pneumonia, not bacterial that kills, though most ARD is caused by bacterial pneumonia, which our country is wonderfully equipped to tackle given that we are the capital of the world for cheap, high quality, antibiotics.

India claims it has 10MM doses, and has ordered 6MM more, which is a bit under the mark of the required 300MM+ courses. And that is if the 10MM and 6MM are indeed 16MM courses, for the government always refers to doses of Tamiflu, never to courses of Tamiflu. A course for someone who is infected is 10 doses, and a prophylactic course is 20 doses. So, are we covering 16MM people or about 1MM? Or is it threading the eye of the needle to quibble whether the government is covering a mere .1% of the population, or going all the way up to 1.6%?

Perhaps the lack of medicine is the reason we have the crazy rationing of the testing procedure and the arrogation by the government of the right to prescribe the medicine. The reason that the government gives is that we are preventing the useless prescription of the drug in order to stop the virus from developing immunity to the drug.

In that case our government, relying on the high principles that have so often been used to betray its people, is again selling them out to the Europeans and Americans. Are our minds so colonized? The UK is handing out prescriptions on the phone. Call, describe symptoms, get code, buy drug and get reimbursement if it’s covered by insurance. That is a sure way to create immunity to the drug in the long term, which is when we in India will get Tamiflu, but a good way to help your citizens in the short term.

The other high minded principle being sounded is that all our citizens should be equal so that Tamiflu cannot be bought by the rich, or the middle class, or the insured, or the employed (most companies would pay up the 1,000 rupee price to keep the workforce coming through the gate). This is not the time to equalize the treatment of rich and poor because the objective should be to safeguard the maximum number of the citizens of the country by all legal means.

Nevertheless, perhaps as a salutary example in (e)quality, the powers that be have decided to quarantine everyone suspected so far (bureaucrats exempt – they can take their dose at home as did a customs and excise commissioner) at a government hospital. It is a chance to show the travelling classes (most of the consignees so far are foreign travellers) how the other 80% live. Or is it because they are using that damn 19th century epidemic act that they are forced to mandate only government hospitals? If so, it is another indictment, and one that will cause deaths, of the laziness of our government in updating laws.

Instead to promote equity and reduce deaths the government should buy Tamiflu at government price and resell at market to subsidize the poor. Allowing private resale would save available medicines for the poor; anyone who has a choice will probably avoid a government hospital or testing service. And the sales would add a boost to the pharmaceutical industry which is providing the drug to every country in the world in multiples of the amounts sold to India.

In the meantime my daughter is trying to keep herself cheerful in a super crowded room full of people suspected of Swine Flu, where the worry shifts from Swine Flu to secondary infections of all sorts. That is a unique way to run an isolation ward and one that none but a bureaucrat, short on time, budget and imagination could design

At least the poor nurses and doctors are giving their all. But the ones working are far outnumbered by the ones loafing at the diagnosis tables (the strength apparently dictated by the cumbersome procedures required at government hospitals). The ones on duty have no way to actually do the work assigned to them at a normal hospital frequency. Overloading them like this will cause a huge breakdown. One doctor and two nurses cannot manage a 12 hour night shift for close on 100 patients.

If we are lucky, we will be told that the plucky child does not have the Swine Flu and can go home. The question is will the Hon. Kafka’s protocol allow the release of Tamiflu to 1) cover the kid for the remaining of the 10 days prophylactic course and 2) cover the rest of the inmates of our house? Never mind – I am sure that we can set up a much nicer isolation room at home!

Postscript - Kid is back at hope and healthy and happy and complaining. The great thing is that she did not complain once while she was in the hospital.