(task) Plans need funding from the beginning, not when outbreak occurs | Interview | Oped

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Nepal

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> Plans need funding from the beginning, not when outbreak occurs
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> APR 20 - More than two weeks later, the mystery disease in Jajarkot has finally been identified as swine flu. With 24 people dead and thousands infected in a number of remote VDCs in Jajarkot, the disease has made national headlines. Yet, many have criticised the government for its lackluster response to the outbreak. A team led by Health Minister Khaganath Adhikari visited the outbreak sites only after a dozen people had died. The team returned with inadequate samples for testing, prolonging the diagnosis period. Since then, a medical team of roughly 40 medical personnel from the Epidemiology and Disease Control Division (EDCD), the World Health Organisation, and the Nepal Army have been deployed to the outbreak sites. Yet, there is little sign of the disease abating. Manish Gautam and Pranaya SJB Rana spoke to Dr Baburam Marasini <http://www.ekantipur.com/en/related-news/dr-baburam-marasini-57666.html> , the harried director of the EDCD, on the state’s response to the outbreak, the EDCD’s complaints of a lack of funding, and the state’s preparedness for such epidemics.
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> How did we get to this point where two dozen people have died and thousands are infected?
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> Public events like these can occur anywhere and you cannot stop them; they are inevitable. The only thing you can do is prepare for them and have an adequate response plan. And this is where we have failed. If there had been even one properly-equipped hospital in Paink VDC, we could’ve had them collect samples, do chest x-rays, and treat patients round the clock while we send a helicopter to get those samples for testing. This would’ve provided some level of support. But the fact is that our health system is not prepared for these kinds of outbreaks. I am not saying that we need hospitals in every VDC. What we need to do is map our three or four strategic points in every district, between maybe seven or eight VDCs, and build hospitals there. There was a recent study conducted in a remote VDC in Dolpa on good governance. The people’s main concerns were health, education and sanitation. There was one health post nearby but it closed down after 5pm and the health in-charge lived two hours away. Where would the locals go if they needed emergency care? This is a very sensitive issue that locals are demanding but our health care system is not providing. In the absence of this kind of system preparedness, we alone cannot do much; the system will not support it.
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> There was a serious cholera outbreak in Jajarkot district in 2009. Shouldn’t the EDCD have learned from that outbreak and planned accordingly?
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> After that incident, we came up with contingency plans for 52 districts and are now working on plans for eight more districts. These plans include responses to epidemics, natural disasters, etc. But in Jajarkot, there are many problems. The literacy rate is quite low so locals are unaware of simple precautionary measures they can take to halt the spread of disease. There are also a number of risk factors. Many people smoke and alcohol consumption is high. Indoor air pollution has also led to ailments in many. In the absence of an adequate health care, dhami-jhankris and superstitions are also widely prevalent. All of these factors have contributed to the current outbreak in Jajarkot.
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> This sounds like an excuse. It is clear that the government’s response has been inadequate.
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> Look, we don’t have resources and we don’t have an adequate budget. You can speak to the Home Ministry and they will tell you the same thing—that the Ministry of Finance and the Planning Commission do not prioritise funds for the Health Ministry or for disasters. We have already spent more than Rs 1 million on chartering helicopters and we just don’t have the resources to deal with this problem adequately. The Finance Ministry complains that the budget that they allocate to us never gets spent. But the fact is, we proposed numerous budgets to prepare for epidemics and natural disasters but the Finance Ministry cut the budgets down to the barest minimum. We do not have the authority to reprogramme the budget and switch funds around when we need it. This is a very watertight, bureaucratic process that takes a long time. Preparedness plans must be funded from the very beginning, not when an outbreak occurs.
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> Epidemiology deals with emergency outbreaks of diseases. Do you not have a contingency fund?
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> Yes, we do, but the funds are inadequate. Since the budget was released, just look at how many incidents we’ve had to deal with. We sent health teams to deal with the aftermath of the floods in the Mid West. Where hundreds of people could’ve died from water-borne diseases, not a single person perished. After that, there was the Sindhupalchowk landslide where people were injured and needed care. There was also a dysentery outbreak in Rautahat that we managed to control with difficulty. The contingency fund holds about Rs 3 million, which is nothing. Right now, it costs around Rs 50,000 just to deploy one doctor to Jajarkot. And this is just the doctor’s expenses. How then are we to pay for medicines or for awareness programmes? If I had the funds available, I would’ve chartered helicopters to airlift my doctors to Jajarkot but instead, they have to travel by road, which means that they will only reach the outbreak site after three days. This is not being efficient when the incident calls for a quick response.
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> The Health Minister visited the outbreak sites with a team of doctors. But they only brought back throat swabs when they should’ve brought back more blood samples. This delayed the diagnosis by three days. Was this also not a failing on the part of the authorities?
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> The minister and his team were not there for long. They spent around 15 minutes at each site and collected blood samples from those who had high fever. Since most of the patients there seemed to be suffering from cough and cold, the team only brought back throat swabs. But this is just one part of the larger problem. There is a multisectoral angle here. There was a lack of communication, a lack of information, and basic infrastructure like roads and water supply were inadequate. Our topography also presents a big problem. You cannot send helicopters and air ambulances when the weather is bad or after dark. Clearly, there is a bigger problem here with our health care infrastructure.
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> What then can the government do in a situation like this?
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> The problem will need long-term solutions. We can allocate Rs 3 million to Jajarkot’s district hospital but will that matter when the doctors cannot reach Nayak Bada VDC in time to treat a patient? This situation reminds me of a question that the princess of Japan once asked me while on an official trip there. She asked, “How will Nepal treat a mother in Kalapatthar, who has just delivered a baby and is bleeding?” I answered as honestly as I could and said that Nepal cannot answer this question for the next 30 years. The solution to this problem is local preparedness. We need to build community-level preparedness for such incidents. We also need local representatives to demand support and make their issues heard at the national level. We can make sure that there are at least rough dirt roads that connect remote VDCs. At least then, we can send motorcycles. Currently, we are in a terribly difficult situation and this needs long-term planning. The social determinant of health must be understood.
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> What do you mean by social determinant?
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> Everything else that contributes to public health. Education supports better health, so do roads, bridges, and adequate drinking water supply. Employment provides opportunities to purchase health care. Even women’s empowerment has been shown to have a significant effect on the health of communities. So public health is not just about doctors and hospitals. It is about taking an inter-sectoral approach to health care. In the Jajarkot case, the Nepal Army and helicopters should have been part and parcel of the response since the very beginning. If the Finance Ministry had just allocated about Rs 12 million for flights and helicopters, we could’ve airlifted doctors immediately.
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> You have made it clear that our rural districts are not adequately prepared to handle such outbreaks. But what about our cities, where the population density is higher? Is Kathmandu prepared to handle an epidemic?
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> We did have an H1N1 outbreak in Kathmandu but that was handled adequately by private and public hospitals. Kathmandu is well-prepared since 90 percent of the country’s resources are invested here. Unless it is something highly pathogenic, like Ebola, which even the US government admitted to not being prepared to handle. There is also the issue of a pending earthquake. If a big earthquake occurs, hospitals and health care will be crucial. We have a plan where we have identified major hospitals and nodal points in the Valley and have planned for rescue teams. But again, for rural districts, local empowerment and local capacity building will be key.
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> Posted on: 2015-04-20 08:17
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