Strengthening public health capacities in disasters

Much of Europe today is witnessing a menacing second wave of COVID-19, which is seemingly worse than the first. Infections have waned in India, although some are anticipating another wave around winter. While appearing unlikely, it is impossible to guarantee that a second wave will not be worse for India as well. However, one does not get to witness the sharp reaction today that the early days of the disaster evoked, albeit except for the fresh round of lockdowns imposed in parts of Europe. Neither is a second wave necessarily less dangerous nor is a vaccine freely available, but living with the pandemic for months together has had a desensitising effect on the collective psyche. Owing to such ‘desensitisation’, disasters that are not sudden and striking tend to be minimised. Unfortunately, the same has characterised India’s disaster management framework in writing off many pressing public health issues.

More a reactive approach

In 2005, India enacted the Disaster Management Act, which laid an institutional framework for managing disasters across the country (https://bit.ly/3eKDG9N). What hitherto comprised largely of reactive, ad hoc measures applied in the event of a disaster, was to be replaced under the Act with a systematic scheme for prevention, mitigation, and responding to disasters of all kinds. Disaster management considerations were to be incorporated into every aspect of development and the activities of different sectors, including health. While some headway has indeed been achieved, the approach continues to be largely reactive, and significant gaps remain particularly in terms of medical preparedness for disasters. The Disaster Management Act is one of the few laws invoked since the early days of COVID-19 to further a range of measures — from imposing lockdowns to price control of masks and medical services.

The common theme is that the public health angle in disasters and disaster management has been under-emphasised. Two important lessons emerge, which will be discussed: first, that health services and their continuing development cannot be oblivious to the possibility of disaster-imposed pressures; and second, that the legal framework for disaster management must push a legal mandate for strengthening the public health system.

Drawbacks in private sector

Since the capping of treatment prices in private hospitals in May, many instances of overcharging by hospitals in Maharashtra have surfaced, in some cases even leading to suspension of licences. It illustrates how requisitioning of private sector services during disasters can hardly be a dependable option in the Indian context. This is particularly important since the future development of hospital care services is being envisaged chiefly under publicly financed health insurance, which would very likely be private-sector led.

Health systems with large private sectors do not necessarily flounder during disasters. But the Indian private sector landscape, characterised by weak regulation and poor organisation, is particularly infelicitous for mounting a strong and coordinated response to disasters. During disasters, the limited regulatory ability could be further compromised. While publicly financed insurance could be a medium to introduce some order into this picture, a large majority of private hospitals in the country are small enterprises which cannot meet the inclusion criteria for insurance. Many of these small hospitals are also unsuitable for meeting disaster-related care needs. And while requisitioning can be done under law, punitive action against non-compliant hospitals becomes tricky during disasters since health services are already inadequate.

Also, development of certain services and competencies that are crucial for disaster response could lag behind. Private hospitals are known to prefer lucrative and high-end ‘cold’ cases, especially under insurance, and are generally averse to infectious diseases and critical cases with unpredictable profiles. Eric Toner (2017), under the “parking lot conundrum” (https://bit.ly/3eJdwUI), describes how disaster preparedness does not make a strong “business case” for hospitals, which prefer to invest in more profitable areas.

Strong public sector capacities are therefore imperative for dealing with disasters. While the Disaster Management Act does require States and hospitals to have emergency plans, medical preparedness is de facto a matter of policy, and, therefore, gaps are pervasive. There is a strong case for introducing a legal mandate to strengthen public sector capacities via disaster legislation, including relevant facets such as capacity-building of staff. A desirable corollary will be that it will also serve us well during normal times.

Integration with primary care

Critics have indicated that the Disaster Management Act fails to identify progressive events (which nevertheless cause substantial damage, often more than sudden catastrophes) as disasters, thus neglecting pressing public health issues such as tuberculosis and recurrent dengue outbreaks. Had they been identified as disasters, they would have attracted stronger action in terms of prevention, preparedness, and response. Again here, a legal mandate can contribute to strengthening the public health system at the grass-roots level.

There is also scope for greater integration of disaster management with primary care. Primary care stands for things such as multisectoral action, community engagement, disease surveillance, and essential health-care provision, all of which are central to disaster management. Evidence supports the significance of robust primary care during disasters, and this is particularly relevant for low-income settings. Synergies with the National Health Mission, the flagship primary-care programme which began as the ‘National Rural Health Mission’ concurrently with the Disaster Management Act in 2005, could be worth exploring. Interestingly, the National Health Mission espouses a greater role for the community and local bodies, the lack of which has been a major criticism of the Disaster Management Act. Making primary health care central to disaster management can be a significant step towards building health system and community resilience to disasters.

While the novel coronavirus pandemic has waned both in objective severity and subjective seriousness, valuable messages and lessons lie scattered around. It is for us to not lose sight and pick them up.

Dr. Soham D. Bhaduri is a Mumbai-based physician, public health commentator, and editor of ‘The Indian Practitioner’