Polio, surveillance systems, and a bit of a rant

January 27, 2007 at 9:50 am (Sarah's Posts)

Today, I heard a lecture from the Pune Municipal Corporation Immunization Officer on his experiences trying to eradicate polio.  Afterwards, he showed me how their surveillance system for polio works.  Every time that there is a case of acute flaccid paralysis (AFP) admitted to one of his 39 reporting units or 141 informers, they call him.  AFP is the surveillance marker for polio because it is the clinical manifestation of paralytic polio, among other diseases.  Roughly 1 in 500 children who are infected with polio virus exhibit AFP and these are the children that have future disability from the infection.  Whenever there is an AFP case, the doctors in all of his centers are supposed to call him so that he can come and examine the child, taking stool samples, determine the likely cause of AFP and generally start the public health system in motion.

The patient today was a 1 ½ year old boy who was admitted to a Pune hospital after seeing three pediatricians over the last five days for AFP.  The doctor’s evaluation determined that the child was an unlikely candidate for polio infection because he had loss of muscle tone in both legs (polio is normally asymmetric), no history of fever, and no known contact with a polio case.  The fact that this child slipped through three doctor’s care without being reported is an indication to me of how cases are going undetected.

Throughout this encounter, I was watching the doctor with such a sense of refreshment.  He was dedicated, knowledgeable and knew the importance of doing things right.  There is a dearth of these people in the public health field here in India.  Sometimes, I look around and wonder where the local visionaries are because there is so many things that outsiders like me simple can’t do.

I don’t think that people in the states are necessarily more dedicated to their jobs, but they are held accountable for their work in so many more ways.  There is an infrastructure that allows for some surveillance, some assurances that things are getting done.  India’s system is running on the energy of relatively few hugely dedicated people who work because they care, but certainly not because anyone is checking what they do.  One look at my professor’s face as she talks about these issues makes it poignantly clear how draining this pressure is, how easy it is to burn these leaders out under the weight of the problems and the lack of support.

I keep coming back to the issue of how to train leaders.   It is pretty easy to understand how many kids need a vaccine in order to stop the transmission of a disease.  It is much harder to think of how to build up an infrastructure that will motivate public health workers and give them the tools they need to successful combat the bazillion potential obstacles, or at least set up monitoring systems to be sure that they meet some minimum standards.  The way that polio is being addressed in India is sucking money and energy out of the health system, leaving other programs like routine immunization underfunded and underloved.  This method simply isn’t sustainable.  However successful we are with polio, we’ll need people to deal with the next epidemic, be it heart disease, avian flu, or something entirely new.  The question is how to find and nurture those people.  So, public healthy folks.  Tell me what you think we need to do to get this rolling.  What sort of institutions/setups/trainings/groundwork do we need? 



  1. msoule said,

    Jeez. That’s not a hard question at all.


    A few thoughts?

    I’m writing in response from the standpoint of a city whose public health infrastructure is under fire because of a lack of resources. The county budget is way over the limit and to cut spending, the board president is planning on closing roughly half of the public clinics that serve poor people. They’re unwilling to raise property taxes to cover the costs and so they are closing clinics instead. So the polio program that’s drawing limited resources away from other programs and leaving them in the cold seems like a parallel case of limited resources. And that seems to be the real hurdle here.

    Theoretically, economic “development” (in terms of an increase in wealth-generating activity) ought to solve the problems of a lack of resources. Economists argue that this is ultimately the most effective, far-reaching solution available to quandaries like this in “developing” countries. “Development” also bypasses the messy, inefficient, bureaucracy-driven method of dispensing resources through redistributive measures (such as increased taxation that could fund programs for indigent people).

    Well, Mr Economist, answer me this: in the most “developed” country in the world, there is still a public health crisis in which millions of people can’t get the care they need. My county’s health budget cuts and the mismanagement that lead to the cuts are just a small part of the whole problem. How is it that in the richest country in the world we still have these problems? Partly, it’s because trickle-down economics doesn’t work by itself. Sure, it raises all boats some but it doesn’t solve inequality. Our bottom half is better off than the bottom half in India but comparatively to our top half, they’re just as badly off as the bottom half in India is as compared to the top.

    My idea with both countries is that the bureaucracy has a role to play. There needs to be more taxation and more redistribution. However, this means that the money will have to be well-spent where it is needed. It also means that taxes must be collected. I read somewhere that in India, income and property taxes are super, super undercollected. Somehow, the corruption and inefficiency in the structures runs so deep that they can’t collect government revenue. Bureaucratic reform is the answer. In Cook County (Chicago), the funding for these clinics was sort of gerrymandered out of federal money that wasn’t really there (I don’t get it) and so when this money actually disappeared (which they knew was going to happen), they had a crisis on their hands. Who was holding these people accountable? Well, the doctors and workers in the health system are trying to hold them accountable now, but it’s a little late. If they had done their job right in the first place, we might not be in the hole we’re in. Bureaucratic reform.

    I know, easier said than done. And it’s just about as theoretical as the “economic development” answer (how will it actually happen? What reforms are needed? Etc.).

    I think that we need committed, agile health bureaucracies in which doctors and health providers play an active role. There must also be more people with health backgrounds and fewer career politicians running these shows. That might help focus the bureaucracies in question on their goals.

  2. misarita said,

    Couple of thoughts:

    Firstly, I had a great chat with one of the best (of the few) epidemiologists in India, who happens to live down the road from me. When I posed the leadership question to him, he had a few thoughts. His idea that he wants to see pushed forward involves an Indian Public Health Corps that does intensive trainging and recruits from fields that are typically strong here in India. It would give good jobs and strong training to students selected from management, biology, business… whoever has a foundation in some of the softer skills like leadership and critical thinking.

    As per your taxation comments, I’ve read a lot about how direct taxes (on things like income and property) here in India simply aren’t feasible because of how many things fall into the informal sector. There are so few registered property rights and so many people making money in ‘unofficial’ ways that the infrastructure needed to register all this activity and therefore tax it is formidable. I read The Mystery of Capital a bit ago, and have been thinking about how much stronger the economic situation even in the slums would be if property rights could be established in a more formal way. I don’t think that it is an end-all solution, but it would certainly help people to be able to invest in small ways.

  3. sstolper said,

    Everything about public health is so daunting to one lousy scientist. I like the ring of an Indian Public Health Corps, and it reminds me how important it is to have a depth of knowledge and navigational skills in health care systems that are so entangled in economics and culture. Everytime I say anything about policy, about which I feel supremely unqualified, I feel as though I’m only repeating something else someone has already said over and over again. But it seems so obvious, in light of this thread, that health policy needs to be waaay decentralized. It’s so unbelievably overwhelming to tackle GLOBAL reform. I acknowledge that I vacillate quite a bit between feeling the exigency of the need to heal and feeling the wisdom of training, preparing to heal. But this thread definitely puts me in the latter mood – in public health, there needs to be a much more native, self-sustaining role and less of a bureacratic trickle-down ending with temporary, transplanted contributors.

    I initially only clicked on ‘post a comment’ to ask about the book you mentioned, Sarah, called ‘The Mystery of Capital’. Is that any good? It sounds as though it would make me smarter. I have never taken an economics class, and as such, I have no idea how to navigate the congested superhighway that is economic policy.

  4. misarita said,

    Sam, TMOC isn’t a strictly economics book… it mostly talks about the theory of property rights as a basis for development. It is certainly interesting and came to me by someone whose world view I respect… so I would recommend it as a dry but important book. I’m in the same boat as you are. I don’t nearly have the economics understanding that I’d like to, outside of reading books like Freakonomics and The End of Poverty. Does anyone else have recommendations for the layperson interested in tackling economics, more from a theoretical side than a mathematical one?

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