Pandemic Influenza Exposes Gaps in India's Health System (Editorial‪)‬

An editorial in IJMR in 2005 had strongly argued why and how India should prepare to face a pandemic of influenza (1). There were two reasons for anticipating a pandemic. First, there had been 3 pandemics in the previous century--in 1918, 1957 and 1968--and the next was due some time in this century. Second, a new highly pathogenic avian influenza virus H5NI had emerged as pan-epizootic in 2003 and caused occasional human infection with high case-fatality ratio in a few countries (1,2). At the request of the World Health Organization (WHO), many countries including India had made a detailed Pandemic Preparedness and Response Plan (PPRP) (3). Many experts believed that India would, for the first time in our history, be well-prepared to face an epidemic. The expectation was that influenza PPRP could be implemented through the National Institute of Communicable Diseases (NICD) * under the Department of Health Services (DHS) of the Ministry of Health and Family Welfare (MoHFW), supported by the Indian Council of Medical Research (ICMR) *. Fortunately the H5NI did not develop as pandemic since its human to human transmission was inefficient. The plan was influenza-specific, without applicability to other diseases. For example, when another pandemic (Chikungunya fever) created havoc in many States in 2005 to 2007, the nation remained mute witness without effective public health response. The events in first half of 2009 completely changed the global scene on the potential of influenza pandemic. A novel re-assortant influenza virus H1N1, carrying seven gene segments from non-human influenza viruses (five from North American and European swine and two from avian viruses) and one from human influenza virus appeared in Mexico in March (4). It was popularly named as swine influenza virus although it had not been found in any swine (unless infected by humans). By April the novel H1N1 virus had already caused a large epidemic in Mexico and a small outbreak in California. The novel H1N1 was antigenically different from earlier human H1N1 viruses; therefore the entire world population was susceptible to infection. Also, its human to human transmission efficiency was high. From then WHO kept a close watch on its spread (and pandemic potential) and kept informing the world of its expanding territories almost on a daily basis. On 11 June WHO declared the pandemic. India soon prepared a new version PPRP replacing the older one (3,5). The events that took place in June, July and up to mid-August (as we write this) are still fresh in our memory. The expectation that India would face the pandemic with confidence and competence gradually gave way to disappointment and dismay. While the virus is reaching many places and spreading among the population, as anticipated, India does not have a public health infrastructure that could put into practice the PPRP (6). Therefore, ad hoc and make shift plans were made and implemented in urban communities to fit the available (but scanty and grossly inadequate) healthcare facilities, ignoring the majority rural population. While facing the immediate problems of the pandemic, steps should also be taken by the government to establish public health infrastructure for long term benefits and equity in healthcare services (6).