The Fight Against Malaria

Earlier this week I was in Mumbai. Monsoons in Mumbai usually mean unrelenting rain, it drizzles and then suddenly it pours and is again back to the drizzle, it never appears to stop raining. Weatherman have been unanimous in asserting that this year so far has been one of the wettest in Mumbai in the last 5 years. While the rains have been bountiful, Mumbai has been shivering like never before-it is in the grip of an epidemic of malaria.

The evening broadcast on the television confirmed a few deaths and put the numbers affected by the disease to a few thousands, with over 800 fresh cases reported in the last few days itself. The hospitals are overflowing with the sick. In fact such is the press of patients that Mumbai Hospitals are setting up huge tents on their premises and putting additional beds to cope with the patients. Raj Thackeray the looniest Shiv Sainik has already blamed the North Indians living in Mumbai for the disease. Incredibly he believes that these people living in squalor in Mumbai are spreading the disease and the outbreak will stop if Mumbai was rid of this scourge.

Unknown to Mr. Thackeray, malaria parasite has a history, which dates back to over half a billion years. The origin of Malaria can be traced to Western and Central Africa. About half a billion years ago the pre parasitic ancestors of the malaria parasite adapted to live in the gut of a some aquatic animals. They subsequently proliferated and evolved to live in insect larvae found in still water bodies. These insects first appeared around 150 million to 200 million years ago. During this period, certain lines of the ancestral malaria parasites achieved two-host life cycles which were adapted to the blood-feeding habits of the insect hosts. In the 150 million years since than, many different lines of malaria and malaria-like parasites evolved and radiated. The malaria parasites of humans evolved on this line with alternate cycles between human and the blood-feeding femaleAnopheles mosquito hosts.

With the advent of agriculture and human settlements, the density of the human population increased. These settlements largely concentrated along inland water bodies. Thus the mosquito population thrived feeding itself on a large and stable supply of human blood. From its origins in Africa Malaria spread rapidly across the globe and became the worst killer disease known to humans. The Chinese knew about Malaria 5000 years ago and Egyptian mummies with enlarged spleens are believed to be the remains of ancient Egyptians who died of Malaria. The disease was rampant in the Indian sub-continent 3000 years ago, Alexander the Great is believed to have died of Malaria in 323 BC, on his way to India. The disease reached the Mediterranean about 2000 years ago and invaded Europe almost a 1000 years ago. Increasing trade and military conquests spread the disease globally and by the 18th century the scourge was at its peak with half the world’s population at risk. Poor living conditions, famine and poverty contributed to high mortality.

As the western world advanced, living conditions improved contact with the vector declined leading to a spontaneous reduction in Malaria in those parts of the world. By the middle of the 20th century Malaria had been conquered in North America and Europe. However, the fight for eradicating Malaria continues in the tropics.

As the fight against malaria accelerates the world over, an estimated USD 10 bn are being spent in an effort to eradicate it. The goal of this world wide effort is stop all malaria deaths by 2015 and finish the disease by 2035. The fight is a global effort to improve the living conditions of people in the third world, provide effective protection (such as chemically treated mosquito nets and new generation mosquito repellents) and provide easy access to medical care even in the worst affected and remotest parts of Africa. Global pharmaceutical companies are researching the disease like never before in the hope of finding more effective drugs that can significantly bring down mortality.

Going by what I saw in Mumbai, I shudder to think how ordinary people must be coping with this outbreak in the rural areas, where healthcare services are almost non-existent. The time has now come to take up the fight against Malaria pretty much like the government has been fighting tuberculosis and polio in the country. The government’s flagship health scheme the National Rural Health Mission, must take the lead and orchestrate a nation wide initiative against malaria. A sustained effort should be made in educating people about the perils of Malaria. The government should take preventive steps such as defogging of the vector’s breeding grounds the distribution of medically treated mosquito nets and free distribution of mosquito repellents may help prevent the disease. The Primary Health Care centres must be equipped with kits needed to quickly diagnose and treat the disease. The government health workers should be able to proactively report the likely cases and the PHC doctors should be able to intervene to stymie the disease before it becomes fatal.

All this and more is possible only if there is a will. The money can be found. More than anything else we need dedicated people who feel strongly about this ancient scourge and who are willing to lead in this final battle.

The Government's Apathy to Healthcare in India

The Union budegt presented last month by the finance minister, Pranab Mukherjee, is hugely disappointing for the healthcare sector in the country. For many years now people associated with healthcare in the country have been waiting for big-ticket reforms in the sector, but the government has been turning a deaf ear. This year too, the story is no different.

The healthcare services in the country are not only woefully inadequate but also unevenly distributed. The healthcare industry, which is hugely dependent on private enterprise is just not attracting enough investments. Setting up and managing a hospital till it breaks even and makes money requires huge upfront investments. Presently, India has 860 beds for a million people, way below the WHO's norm of 3960 beds for a million people. Studies by E&Y and KPMG have indicated that India needs to add 100000 beds per year for the next 20 years to reach close to this figure. This alone entails a spend of Rs. 50000 Cr. per annum. Compare this with what the government proposes to spend on healthcare in the next financial year, Rs. 22300 Cr. While this is 14% more than what the government spent last year, this amount is clearly insufficient.

The National Rural Health Mission, the flagship government programme for providing healthcare services in rural areas is riddled with inefficiencies. The government-run Primary Healthcare Centres are usually understaffed, ill-equipped and provide the most basic level of healthcare. Rural and semi urban India also needs good professionally managed secondary and tertiary care hospitals, which provide reasonably good quality healthcare at affordable rates. It seems that the government does not have the will power or the resources to usher in healthcare reforms.

Amazingly, the private sector entrepreneurs are willing to step in and bridge the gap. All they need is a little help from the government in the form of tax holidays, duty reduction or abolition of duties on medical devices, easy availability of funding from government institutions at soft rates, longer payback periods and land at concessional rates. The government should also set up a regulatory body, a watchdog, which will keep an eye on hospitals being set up through this mechanism. The watchdog is critical as it will establish guidelines for setting up the hospitals, monitor progress, ensure quality through regular audits, lay down a fair pricing mechanism and in general ensure that the private sector, while availing of government policy benefits delivers on the promise of efficient, good quality and easily accessible care.

This is really not too difficult to achieve. Look at how private participation has revolutionized telecommunications in our country. Today India has more than half a billion mobile phone connections, the tariffs are the lowest in the world and even remote, far-flung and fairly inaccessible areas are connected (I had my phone working in the Nubra valley in Laddakh). The phones generally work, the services are efficient and the private sector companies, who had the foresight to start early are making profits. Some are even planning to go global and compete with the best in the world. The TRAI, which is the government watchdog is seen as an impartial and fairly efficient body, doing its job of advising the government on policy matters and ensuring compliance and a level playing field amongst all the operators.

No country can progress and aspire to be an economic superpower unless its citizens have access to good quality healthcare services. Considering India's size and a population of over a billion people, (the majority living in rural areas), it is imperative that the government kick-start reforms in this critical area sooner than later. If no significant policy initiatives have been announced this year, can the healthcare industry bodies (like those associated with CII and FICCI) lobby with the government, initiate debate and fuel informed discussion amongst all stake holders so that public opinion can be rallied in favour of these reforms.

Healthcare services impact the health of the nation. It is time all the healthcare stakeholders including the government sat together to prepare the blueprint for the next generation healthcare services for the country. This is very important because, unless we have robust, universally accessible, reasonably priced healthcare services for our citizens, all our claims about being an economic superpower will remain hollow and truly meaningless.