Aedes aegypti mosquitoes at the dengue branch of the US CDC in San Juan, March 2016. Photo: Reuters/Alvin Baez.
The coronavirus pandemic has altered our lives in myriad ways, and has become central to our everyday existence. This centrality, however, could push aside the simultaneous existence of other disease pathogens. Specifically, erratic weather patterns and the monsoons are a cause of worry for Delhi, and which will soon observe a steep rise in vector-borne diseases like dengue, if the past is any indication.
Physical distancing, an overburdened and crumbling public health infrastructure, reliance on private providers and facilities, a faltering economy – all together, Delhi is at risk of a double whammy. Dengue outbreaks in the national capital reached epidemic-like proportions in 2015, with 15,867 cases and 60 deaths. The city’s government then launched several campaigns to fight the fear gripping the capital. However, our preparedness in the face of dengue this year is questionable on many fronts.
New public healthcare policies design disease-control programmes embedded in public-private partnerships. The government has often sought to rationalise such endeavours using the excuse that the public sector is short on resources. Public hospitals are overcrowded, waiting hours are long, and there are often not enough doctors. Partnerships are thus seen as an efficacious step towards preventing and controlling diseases. Recently, to ensure large-scale testing for the novel coronavirus, the Supreme Court allowed private laboratories to conduct tests – free of cost. This prompted a huge backlash; private laboratories complained that they hadn’t been consulted before the decision. The court subsequently limited the free tests for economically weaker sections of society. The whole incident wasn’t surprising, however.
The National Vector Borne Disease Control Programme (NVBDCP), the apex institution for dealing with vector borne diseases in India, emphasises such partnerships at various levels to prevent and control dengue. These partnerships take form at the level of testing, by aligning with private diagnostic clinics. The fundamental problem affecting dengue is that the symptoms more or less resemble that of a simpler viral fever. The patient and the doctor are often unaware of the right course of action, except for a dose of paracetamol.
So early detection, case confirmation and differential diagnosis from other diseases is very important. To this end, in 2015, the Government of Delhi capped the costs of NS1 antigen tests at Rs 600 and platelet count tests at Rs 100. These were previously priced at Rs 1,500-2,000 and Rs 200, respectively.
“There is no committee to prevent and control dengue,” an employee of a private laboratory told me. “But each year we get a notification around the monsoon season to cap the rates for the dengue test.”
But like with the Supreme Court’s U-turn on the COVID-19 tests, the employee said adhering to the notification means little to no profits for the lab. “There are patients coming to me and I have a reputation to maintain,” he added; his establishment is located in a posh area of Delhi. A better way for the government would be to cap prices and “provide subsidies to the private sector”. Cold calls to a few private laboratories located around East and West Delhi suggested that, as a result, many labs didn’t implement the price caps.
It often goes unsaid that private laboratories have their own organisational idiosyncrasies, conflicting objectives and motivations. A former director of the NVBDCP said that a number of private labs were taken on board, including some of the ones this correspondent contacted. The director said they had agreed to reduce the price for dengue tests and even ruled out the platelet test. But “it is true that private laboratories are engaged in foul play when it comes to capping rates,” he said – although he admitted persuasion remained the only way to get them on board.
This insistence on provisioning private healthcare services has notable consequences. For one, the state is actively engaging in underwriting the private sector’s risk of investment in healthcare, such as by providing subsidies for land and hospitals or through public-private partnerships (PPPs). In recent years, PPPs have also entered the domain of health insurance, with the government paying the premiums. This results in higher out-of-pocket expenses for middle-class and poor patients because accessibility to healthcare for the poor rests on economic capital as well as on social and cultural capital.
Targeted behaviour and preparedness
The absence of a prophylactic, like a vaccine, and an unpersuadable private sector prompted some changes. For example, in 2011, after the setback PPPs faced vis-à-vis controlling malaria, the NVBDCP emphasised reduction and elimination at source, according to a former nodal officer at the body. So, together with the fact that the state’s health budget often doesn’t suffice to support PPPs, for dengue the focus has shifted to curtailing the disease’s spread by encouraging behavioural changes.
These behavioural changes require regular messaging and reminders about dengue’s dangers and what people can do to minimise them. These messages are typically circulated through print, electronic and social media. However, a problem arises when these messages are not well thought out, and disseminate information that may be hard to properly understand or prioritise. “This could lead to information overload where you get a lot of information. You do not know what to do with that information, which becomes a challenge. So, it is as good as not sending you any information,” Aditya Jagati, an engagement director at the Busara Center for Behavioural Economics, a nonprofit research and advisory firm.
“In this particular scenario, a couple of things need to be taken into consideration. First, timing really matters. What is the right time and frequency of messages and how is it triggering people’s thought process? Is it received at a time when people are about to make a decision or take an action?” Jagati explained. “Second, [we need to attach] a more visible and salient consequence to that bit of information. A ‘loss’ frame versus a gain frame would be more helpful – like eliciting people’s identity or attaching an economic disadvantage for not adhering to health protocols.”
An NVBDCP guideline stresses behavioural changes on three key fronts: a) to control larval habitats around homes, workplaces construction sites; b) to decrease human-vector contact and ensure personal protection by wearing long-sleeved clothes, and using repellents and insecticide-treated nets; and c) to ensure early diagnosis and prompt treatment in case of a fever. These messages depend on information, education and communication material for their circulation. But in spite of these guidelines, messaging on controlling dengue and malaria is often confused – more so when a dengue outbreak coincides with outbreaks of other infectious diseases.
In addition, the transition in disease prevention to more patient responsibilities can backfire. The patient could misdiagnose themselves, potentially delaying the right diagnosis and appropriate treatment. “With any behavioural change, currently, [we need to] make sure the individual recognises the value of doing something and then only it becomes effective,” Jagati said. “There is a large body of literature on habit formation – how you can make somebody take up an activity and how that activity becomes a part of their habit,” Jagati said. “It takes time and is … a long-drawn process. Until that time, it needs to … involve frontline health care workers as well as give people the right kind of information on how to act.”
The process of sifting through information and being prepared for other infectious diseases can be arduous during an ongoing pandemic. But Jagati said the pandemic also makes for a great opportunity to reflect on how health communication policies are designed, and how they affect our preparedness for other diseases. For example, people have lost jobs and peace of mind, which might compromise their ability to pay attention and/or resources to tackling other diseases.
The NVBDCP has developed protocols for preparedness in the event of a dengue epidemic – and a significant part of it is rooted in individual behavioural changes. So it’s important to understand “the human in the context of the environment in which she makes her decisions,” Jagati said. Health policies can’t misplace the value of the local context in its design of disease control programmes, or it may not be able to avoid a double disaster.
Smriti Sharma is a doctoral candidate at the department of social and cultural anthropology, University of Lucerne, Switzerland.