Outside In | Why 1,731 Indians died of swine flu
I got myself a flu jab the other day. It’s a protective vaccine against seasonal flu but probably won’t offer protection from swine flu, the H1N1 virus that has claimed more than 1,700 lives in India so far in its latest outbreak.
I am in a very tiny minority of people who have been able to access the jab—you have to book it in advance—as a preventative measure.
My doc at a shining private hospital suggested it, and I dutifully grabbed the opportunity when it came my way. Weeks earlier, somewhat paranoid about wet sneezes that travel in public places at great speed, I had found myself in a crowd of people thronging one of Delhi’s oldest and best-stocked pharmacies, looking for the flu vaccine.
“There’s none here, sir,” the polite man who manages the shop informed me. “You can go to (the government-run) Ram Manohar Lohia Hospital if you want to,” he added with a look that said: “I wouldn’t bother if I were you.”
“Even members of Parliament and ministers are calling up, asking,” his assistant chipped in, grinning. “They don’t much care for us otherwise.”
Not quite seeing the point of light banter in the midst of what looked like an epidemic (but isn’t), I asked him to fetch me as many of the E-95s as he could. These are face masks that are recommended by the government as a prevention against swine flu.
It’s dreadfully easy to panic in India.
The most recent government figures show 1,731 people have died from swine flu since January and that more than 30,000 have been infected.
These figures need to be put in perspective, of course: tens of thousands of people die from flu or related infections around the world every year, including in the most developed of nations.
Still, the steadily climbing death toll in India is an indictment of its abject public health system—without doubt, many lives could have been saved. There is little doubt, too, that most of the victims of swine flu are poor—people with little access to emergency medication, leave alone protective seasonal flu jabs.
The outbreak has exposed the hollowness of the public health system, especially in the matter of preparedness and monitoring of drug stocks.
The reason my pharmacy in Delhi did not have stocks of the swine flu drug is poor planning and execution of government regulation. The approved versions of Tamiflu that are sold in India are classed as Schedule X drugs. There are restrictions over their sale for reasons that uncontrolled use may lead to the virus mutating, rendering the drug ineffective and posing a fresh public health challenge. This is a perfectly reasonable public health measure, but the entire purpose is defeated if the authorities are unprepared for emergencies and are caught out without stocks.
Astoundingly, in a country of more than 1.2 billion people, a mere 2,500 chemists have the licence to stock Schedule X drugs—that’s one pharmacy for nearly half a million people! But that cannot be the full story: no doubt, the distribution of these pharmacies would be heavily skewed in favour of big cities and towns, with rural India, as ever, left untended.
What does a Schedule X drug mean for pharmacies?
Firstly, you need to have a licence to sell Schedule X drugs. Second, government rules require these pharmacies to preserve—for a period of two years—every piece of paper (prescription, address, contact number, etc.) that is transacted for every Schedule X drug that is sold. Besides, the drugs have to be preserved at certain temperatures.
Not surprisingly, many of these pharmacies don’t bother to stock these drugs even when they have the licence to do so, especially when there has been a spell of low demand—the incidence of swine flu, for instance, dipped after an outbreak in 2009.
But it’s not as if Oseltamivir has been completely missing from their shelves—apparently, chemists who have been saying they have run out of stock have been selling supplies under the counter for a premium.
Now, with the death toll steadily climbing and questions being raised in Parliament, India’s drug authorities have woken up. They seem to have come up with two immediate strategies: 1. They will force the Schedule X-licensed pharmacies to stock Oseltamivir and 2. They are considering changing the drug category for Oseltamivir, making it easier to be sold to patients—not over the counter, but with prescription—by all pharmacies.
Amit Sengupta, national convener of Jana Swastha Abhiyan, or People’s Health Movement, an India-wide network of organizations working on health and healthcare, says the availability of Tamiflu is a bit of a red herring—or “a minor adjunct”, as he put it.
“In any case, Tamiflu is fairly useless. It is effective only when started in 48 hours, and all it does is reduce the course of the flu by about a day.”
In his view, the numbers being put out by the government do not tell the whole story. For starters, the 5.66% mortality rate in this outbreak is unimaginably high. By comparison, the fatality rate in 2009 was 0.02%; and in the post-World War I Spanish flu epidemic, which killed 50-100 million people, it was 2-5%. “If it is indeed 5% now, then the government has a real problem at hand.”
Sengupta suspects the figures show that the vast majority of swine flu cases are actually going unreported—either people do not have access to testing, or do not realize they have the symptoms. “This is a failure of the system.”
Is mass vaccination a solution, I ask him.
Sengupta replies with a counter: “Is there a system in place to be able to vaccinate people? Today, we are unable to deliver even routine immunization. There is data to show, for instance, that because of the pulse polio drive, routine immunization suffered in many states.”
There is a clear need for more data on the swine flu outbreak: is it spreading in certain geographical clusters within the states? In some population groups? Why is the incidence high in Gujarat, Rajasthan and Madhya Pradesh? Why is the mortality rate low in Delhi, a city that remains a magnet for migration from the rural areas?
Sure, some of it is about protecting yourself: the experience of rich nations shows the comforts of a five-star hospital are no guarantee against the spread of swine flu.