Knowing the cause of death is much more important than just numbers

Accredited Social Health Activists, or ASHAs as they are popularly called, were chosen for the World Health Organisation (WHO) Director General’s Global Health Leaders Award, announced in Geneva on May 22. WHO recognised the ASHAs’ “outstanding contribution towards protecting and promoting health”.

“ASHAs support maternal care and immunisation for children against vaccine-preventable diseases, tuberculosis, neglected tropical diseases, communicable disease prevention and control, and core areas for nutrition, sanitation and healthy living,” read the WHO citation. The Indian Prime Minister stated on Twitter: “They are at the forefront of ensuring a healthy India.”

ASHAs are technically “volunteers” from the community, paid an honorarium of Rs. 2,000 per month effective 2018-19, with an additional Rs.1,000 as maximum incentive (based on visit/ services rendered, like preventive antenatal care, immunisations etc.) and Rs. 1,000 further added for Covid-related work. States add top-up payments that vary. Billings and payments are often not transparent, verifiable or audited easily. In essence, ASHAs are minimally trained and poorly paid volunteers, seen now as the backbone of India’s health delivery.

India’s response to the Covid-19 pandemic however received a very different mention from the WHO, which said five million Indians died as result of the pandemic, nearly ten times the official count of 520,000 deaths. India stood out as the worst performer of all nations by this count. India was also the only nation to oppose the WHO findings, which were based on independent and robust models upheld by a range of global experts.

That huge disparity triggered a dispute but limited to numbers, thus diverting the discussion from how number of deaths are counted or not counted and from quality of the government’s health management. Almost 75 years after India got independence, we still do not have a system to count deaths as ‘health events’ with reasoned out causes of death. We rely on a civil registration system that counts deaths as “demographic events” for estimating, for example, the number of deaths during the pandemic.

This reduces death to just a number but provides no insight so as to prevent more deaths, if the cause of death is understood and spread of disease is deduced. It is not that only Covid numbers were underreported.

We do this with all diseases because the system is geared to undercount. We underreport mortality from all important diseases like pulmonary tuberculosis, extra-pulmonary tuberculosis, malaria, cholera, typhoid fever, leptospirosis, brucellosis, scrub typhus, haemolytic uremic syndrome, viral encephalitis, influenza, acute respiratory distress syndrome, bacillary and amoebic dysenteries, red-tide algal toxicity, and so on. Even death by snake bite is not well reported or appropriately counted.

This is because we just do not have the public health infrastructure to collect reliable numbers of health events and place facts in the public domain every week.

Thus, while ASHAs make us proud, the state of the health management system makes us hang our heads in shame. Is this where India should be in the 21st century?

Globally, health management comprises two parts – a) healthcare, which is the response to disease and b) public health, the eyes and ears watching health events, studying microbial spread and building the dashboard that managers must use to mount a meaningful response to diseases.

Without such a dashboard, the healthcare car will not know where to drive, at what speed to drive and where it has to reach. In other words, the lack of a watchful eye on diseases renders all response less scientific, less timely or less useful than it ought to be.

It is only the public health system that demands real-time, comprehensive disease surveillance under which every registered medical practitioner has a legally binding duty to report any of the many notified communicable diseases. Once clinically suspected, that fact has to be reported without any delay. India has none of this in place.

Without this understanding, it appears not to matter why the patient died. The number may be reported but the underlying cause is not. This is where the Indian system is going wrong. When the cause is not well reported and understood, it will lead to more deaths, more pressure to under-report these deaths and a reinforcing loop is created that confounds, confuses and leaves us vulnerable.

Either by default or by design, we do not have a “public health” wing while we have a whole ministry to supervise the widespread health care hardware, software and personnel under the governments, Union and State, and we have a flourishing set of private sector health care establishments that the MoHFW qualifies as the “health care industry”.

The term “public health” originated in a Parliamentary Act in England in 1848, which came about as a result of the advocacy of a lawyer-cum-social reformer, Edwin Chadwick. He understood that epidemics of communicable diseases had environmental determinants; only the government had the jurisdiction over environment. The Public Health Act mandated the government to bring about comprehensive sanitation and that resulted in a drastic reduction in disease burdens.

Diagnosing and treating individuals with disease, be it communicable or non-communicable, remained in the realm of the duties of physicians and the medical establishment. Thus, a clear distinction was obvious – health care was for individual needs whereas public health was for the benefit of the community as a whole.

Over time, all European nations adopted the twin systems – public health and healthcare, for health management. All governments accepted the new political health philosophy that disease prevention and health promotion were the duty of the government.

We have made huge strides in fighting diseases. India created two excellent vaccines – the adjuvanted, inactivated SARS-CoV-2 vaccine (Covaxin) and a live attenuated Rotavirus vaccine (Rotovac) developed from an indigenous virus isolate (by Late Dr Maharaj K Bhan) and extensively researched by US investigators who found it to be suitable for a vaccine. Thereafter Indian scientists developed and evaluated it until approved as a vaccine that is in current use in our national immunisation programme.

And yet, in terms of the simple cause of death, we appear not to understand that numbers are more than mere numbers, because they can potentially tell us exactly how we are performing. Awards and recognition should spur us to act and not sit self-contented with a pandemic death toll that is the worst anywhere in the world.

(Dr T. Jacob John is retired Professor of Clinical Virology, Christian Medical College, Vellore. Jagdish Rattanani is a journalist and faculty member at Bhavan’s SPJIMR.) (Syndicate: The Billion Press)

(This was first published in National Herald on Sunday. Views are personal)