COMMENTARY

Ebola and India

How Will the Country Cope?
T Jacob John

While the chances of the Ebola

virus entering India are low,
Ebola and pandemic flu teach us
to expect the unexpected and be
prepared. New diseases are
appearing in the world again and
again. We live today in a global
village. Ebola-infected bats are
probably present in Asia.
Nipah virus-infected bats are
widely prevalent in east Asia;
there is no guarantee their
territorial flight paths will not
extend to peninsular India. Is
India prepared? Who exactly
is in charge?

T Jacob John (tjacobjohn@yahoo.co.in) retired

as professor and head of the Department of
Clinical Virology at the Christian Medical
College, Vellore. He chaired the India Expert
Advisory Group on Polio Eradication and
co-chaired the National Technical Advisory
Group on Immunisation from 2000 to 2009.
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JANUARY 31, 2015

onsidering that the 2014 Ebola

epidemic was confined to four
contiguous west African countries (Liberia, Sierra Leone, Guinea and
Mali) and affected with autochthonous
cases only four other countries (Senegal,
Nigeria, Spain and the United States),
the chances of the virus entering India,
or any other country, are extremely low.
Cote dIvoire shares borders with
Guinea, Liberia and Mali, but so far no
case has been reported in that country.
The Ebola Haemorrhagic Fever epidemic began in Guinea in December
2013 and spread to other countries in
early 2014, cumulatively recording over
20,000 cases and nearly 8,000 deaths.
These are the counted figures certainly
gross underestimate. The death rate is
widely quoted to be 70%-80%. The epidemic continues with ups and downs but
the peak seems to be over in Liberia;
Mali is probably free of the disease.
For India, the threat remains as long as
the epidemic continues. If the virus enters
India, what might its transmission dynamics be? What is Indias track record of
coping with diseases with high fatality?
How did other countries prepare themselves to respond in case the virus entered
their territory? What is special about Ebola
disease setting it apart from others? How
prepared is India to cope with its entry in
case it happens? How robust is Indias
health management system in general?
Details of the Disease
The first outbreaks of Ebola virus disease
(Ebola for short) were in 1976 in Sudan and
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Zaire. It recurred in Sudan in 1979 and

2004; in Zaire in 1995. Outbreaks occurred
in Gabon in 1994, 1996 and 2001; in Uganda in 2000, 2007 and 2012; in Republic of
Congo in 2001-03, 2007, 2012 and 2014. All
of them affected relatively small numbers
20 to 400, with death rates of 50%-80%.
Hospitals were foci of the spread; healthcare workers were at a high risk of infection, like family members who cared for the
sick or prepared dead bodies for funeral.
The outbreaks appeared to be self-limited
with hospitals taking the precaution of safe
handling of blood and body fluids. Thankfully, the virus seemed an inefficient spreader between humans. Ebola causing a huge
multi-country epidemic was unexpected
and remains unexplained. Traditional funeral practices, low literacy and very weak
health management system, common to
these countries, have certainly contributed
to the epidemic this time.
Among directly human-to-human
transmitted diseases, Ebola is the most
scary, this time with high transmission
frequency to caregivers, no specific
treatment and very high death rate. The
reservoir of the virus is the bat; animals
in the bush get infected probably via bat
saliva on half-eaten fruits fallen on the
ground. Humans get infected from animals, particularly those hunted for
bush meat. Human-to-human transmission becomes an outbreak. The virus
is non-pathogenic in bats, but highly
pathogenic in humans with the clinical
range from no disease in some, but fever,
influenza-like symptoms, diarrhoea,
vomiting and haemorrhagic fever with
high death rate in others.
Recent information from the new treatment station run by US experts in Freetown, Sierra Leone, suggests that good
supportive care can bring case-fatality
down to less than 24%. Two nurses who
got infected in the US and were treated
there, both recovered. Severe fluid loss
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through watery diarrhoea and consequent low blood pressure are reasons for
death; aggressive fluid management
seems to save lives. So, high death rate is
mainly due to lack of quality healthcare.
A moderate death rate is inherent and
unavoidable for Ebola; Ebola itself should
be prevented to prevent death.
Economic reforms and liberalisation
have made India the worlds third largest
economy. There is no sign that our
health and economic experts realise its
implications in terms of health of the
people; so too in the context of the African
Ebola epidemic. India has donated over
$10 million, but in general remains indifferent to the epidemic, with the only
response being the narrow and immediate
self-interest of screening of passengers
from affected countries at airports. Our
leaders are not thinking into the future.
Cubas response is inspirational. A
country of 11 million people, it sent 165
well-trained healthcare professionals to
Sierra Leone and 296 to Liberia and
Guinea (In the Medical Response to
Ebola, Cuba Is Punching Far Above Its
Weight, Washington Post, 4 October
2014). Cubans not-so-good English was
a minor handicap. Cuba has some
50,000 health professionals working in
66 countries; this is at once medical diplomacy and expression of solidarity with
those in need. An estimated $8 billion is
Cubas income from this export of medical expertise. Cubas own healthcare is
one of the worlds best in quality and
equity. We have good English but poor
understanding of health diplomacy.
It is an eye-opener to learn how China
reacted. In addition to several rounds of
monetory donations totalling over $10
billion, Chinese infectious disease experts have established two mobile laboratories in Sierra Leone and a state of the
art bio-safety-assured 100-bed hospital
in Liberia. Earlier they had sent several
teams of epidemiologists and experts in
infection control and personal protection.
China is making sure that they hone
expertise combating deadly diseases,
and earn West Africas goodwill bonus
for business success to grow from
strength to strength. Chinese military
scientists have also developed a candidate vaccine; this is in addition to two
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other candidate vaccines from the

National Institutes of Health in the United
States and the firm, GlaxoSmithKline.
To become a world leader, India must
learn to behave like one; that requires a
realistic world view. The importance
given to human health is strikingly different in Cuba and China from that of
India. Will India be judged as an enlightened well-wisher of underprivileged
A frican nations? The countries named
above and several European counters
have special treatment centres for infectious disease with high mortality. India
does not have such well-prepared hospitals or trained health workers. We could
only remain indifferent as we are unprepared for getting involved in international health problems. We must first take
national health problems seriously before aspiring to become a global leader.
Transmission Dynamics
Direct physical contact with blood, body
fluids, excreta and vomit was, until now,
believed to be the channel of virus transmission, in which case precautions we
use in the care of AIDS patients should
have sufficed for personal protection of
healthcare workers. The magnitude of
the present epidemic and its rapidity of
spread suggest that virus transmission
occurs more easily than believed in the
past. Mucosal contact, including inhalation, of droplets and aerosol of body fluids, perhaps including oral/throat secretions, are feared as channels of transmission, although there is no clear evidence. Space suit-like personal protection equipment (PPE) is mandatory now
for every healthcare worker for every
patient room visit. For this eventuality,
namely having to treat Ebola patients,
India is ill-prepared.
According to press releases on 25 August
2014 by the World Health Organization
(WHO), over 240 doctors, nurses and
other hospital workers had fallen ill with
Ebola in West Africa and over 120 have
died. The loss of so many doctors and
nurses made it difficult for WHO to secure
support from foreign medical staff. By
end September the number of deaths
climbed to over 200. In the US, in spite of
all precautions and personal protective
equipment, two nurses got infected from

the first Ebola patient treated in a US

hospital. Both of them were detected
and treated early; both recovered.
Another haemorrhagic fever, due to
Crimean-Congo virus, is transmitted to
humans from animals by ticks and
human-to-human through contact with
blood/body fluids. In 2011 a case was
hospitalised in Ahmedabad, and a nurse
and a doctor got infected and died. This
illustrates that our medical staff is not
well-versed with safe care of any haemorrhagic fever. In 2012, another doctor
died in the same city, with the same disease, after contact with the blood of a
patient. Ebola will be more easily transmitted human-to-human.
Indias Health Management
In countries that take human health
seriously, the health management system has two wings: public health and
healthcare. Public health is the government infrastructure for health protection from preventable diseases and from
social and environmental risk factors of
diseases akin to the police force protecting citizens from law-and-order incidents. Sectors of health, animal management, agriculture, environment, water,
sanitation, local government, tourism,
food, etc, are involved in generating risk
factors. The overarching health protection agency that sets standards and
monitors them, is public health. Thus a
separate ministry or at least a full- fledged
department under the Union Ministry of
Health, with trained cadre in every district and city, supported by an adequate
work force must be created if India takes
human health seriously.
Our cultural beliefs are that illness is
either due to personal mistakes of daily
routine, wrong foods, etc, or due to malignant planetary influences; the consequence of karma from past lives; punishment from god or deities. All these are at
variance with the concept of social and
environmental determinants of diseases.
Microbial causation of diseases is not accepted by our traditional culture. All these
seem to tell our leaders that diseases are
not preventable by human interventions;
hence public health, for organised human
interventions to prevent diseases, is both
culturally alien and unnecessary.

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COMMENTARY

Healthcare is service rendered to individuals after they fall ill akin to protecting victims of crime or calamity.
Healthcare can be rendered by institutions by the public sector using revenue
funds or by private sector billing the clients. The inequity of some getting service free while others paying cost plus
an unregulated profit margin, is of no
concern to our leaders.
Healthcare cannot stand in for public
health. The lack of public health has resulted in India being unable to prevent
diseases that the West got rid of before
the early 20th century cholera, typhoid
fever, malaria, tuberculosis, to name a
few. Our healthcare institutions are
overburdened with such diseases.
Learn from Experiences
In late September 2014, a Liberian
arrived in Texas and reported with
fever to a big hospital. He was otherwise well enough to be sent home with
simple medications. Two days later he
came back, severely ill, and that is
when the penny dropped; he was tested
for and found positive for Ebola. Every

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EPW

JANUARY 31, 2015

one of his fellow passengers in the

flight and in the local community were
counted, and followed up for 21 days to
make sure none was infected; none
was. Ebola does not spread during the
incubation period.
What should have alerted the emergency room physicians? Travel history;
arriving from Liberia should have been
taken seriously. Imagine such an eventuality in one Indian hospital. The disease
would have been undiagnosed until late
into its course or after death, by which
time several hospital staff would have
been infected and they would start small
outbreaks in their families and wherever
they went for treatment.
What should India do? First, the Government of India should name one
event manager who would develop a
plan of action in case Ebola enters India,
through a traveller. India should create a
mechanism for the event manager to
communicate with every hospital in the
country to inform the dos and donts.
Doctors take a history of the patients illness; this should include travel history.
Also, the event manager should be the

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spokesperson for the government to inform the public authentic information. If

this process is closely linked with all
states and union territories, then every
state will be prepared.
Remember what happened when the
pandemic influenza reached India in
2009? Infected persons were made to
crowd in selected testing centres, thereby rapidly spreading infection to many
others. This is exactly the opposite to
what other countries did they asked
those with influenza-like symptoms to
stay home and report only to a chosen
doctor. The fire department must be
open all the time; not just after a fire is
reported.
Ebola and pandemic flu teach us to expect the unexpected and be prepared.
New diseases are appearing in the world
again and again. We live today in a
global village. Ebola-infected bats
are probably present in Asia. Nipah virus
infected bats are widely prevalent in
East Asia; there is no guarantee their
territorial flight paths will not extend to
peninsular India. Is India prepared?
Who exactly is in charge?

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