Budget 2017 must factor in better health of India's children
2014. That landmark year when we finally trumped polio. Two young Indian athletes, Sharad Kumar and Varun Bhati (both afflicted with polio before the age of two), established India in the international paralympic annals by striking golds in the high-jump category at the Asian Para Games and the China Open Athletics Championship. Paralelly, India was declared polio-free. Both these feats – extraordinarily momentous and examples of a resolve to achieve an audacious goal via a tough grind of over 20 long years.
Two years hence, the boys carried on with their winning attitude to add more laurels to their fame, creating history in high-jump at the Rio 2016 Paralympics. India followed suit, strengthening the Universal Immunisation Programme with new vaccines to save her girls and boys from the tyranny of three additional preventable viral diseases.
The expanded spectrum of the vaccines rainbow under Mission Indradanush now includes one against Rotavirus diarrhoea (that kills 80,000 children every year) since March of 2016. Next month onwards, it will also have a potent one against Pneumococcal infections (pneumonia, common ear and blood infections, and meningitis – responsible for 1.3 million deaths of children under five every year), and another one against German Measles.
The Supreme art of war: Deceive or die
Viruses and bacteria are fast and smart self-learning biological machines. Being lean and mean in structure and resources, they are incredibly agile in adapting to change. They quickly unlearn, relearn and modify their survival algorithm to tide over hostile environments.
Their ever-changing forms make them the emperors of deceit, coronated with the title of the most successful and populous inhabitants of biosphere. Time and again, they have shown us their might – we are currently in the midst of a terrifying, socio-economic pandemonium caused by the Ebola and Zika outbreaks.
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| Besides the threat of emergence of new infectious agents, old foes have to be kept at bay at all times. |
Human history is replete with victories of these invisible beings over us through massive epidemics. Virus onslaughts have decimated monarchs (Pharaoh Ramses V died of smallpox), brought down powerful empires to dust (Incas and Aztecs wiped out by smallpox), fuelled movements (the death of Louis XV by smallpox sparked the French Revolution), and handicapped economies (2-4 per cent reduction in annual growth rates across Africa due to AIDS pandemic).
Our ancestors, who survived such invasions, were either one of the fortunate cohorts that remained outside of the infectious battle zone due to natural or enforced quarantine, or those empowered with an innate ability to fight the progression of disease or immune.
The siege. Of the Trojans, by the Trojans
Our immune system defines us. It is the sum total and the degree of one's survival privileges against diseases. Some of these protective privileges are a gift of genealogy that one is born with, others acquired over a lifetime as medallions and experiences of one's daily battles with the disease-causing co-inhabitants of our world.
As the controller of homeland security of our body, the immune system is a network of cross-functional agencies – an alert immigration and border control to screen all agents accessing our body, to certify them as "self" or "non-self"; an intelligence department, well-stacked with diligently memorised information records of all past adversaries that could resurface in future with an even more audacious attack; an action cell, to recruit and train troupes for surveillance, defense planning, and combat techniques enabling disaster prevention.
But, it knows only what it knows. Unpredictable in its reaction time and combat strength against unknown, unseen dangers. Not to leave protection against common agents of disease to chance, the immune system must be primed against them, to bring the troublemakers in its records.
This priming or simulation training is commissioned externally in the form of vaccination or immunisation. Vaccination is akin to wheeling seemingly harmless Trojan horses into the body that will trigger an immune response to the faintest battle cry from the invading pathogens to wreak havoc on them – a preventive strategy to nip the onset of disease in the bud, by self, without any medicines.
It is a strategy as cunning as the invisible ones it is directed towards, and it works well as long as its specificity and effectiveness keeps pace with the changing forms and tricks of the pathogens. This is a complex scientific challenge and a considerable economic burden. The cost of developing and testing a new vaccine is roughly $150 million. Topped up with other essential components, such as that of immunisation personnel, mass-production, supply chain (injection supplies, maintenance of cold chain for transportation and stocking), quality control, social advocacy, surveillance, and many more, the total cost build-up can go in excess of several billion dollars.
This is the reason why a partially-developed Ebola vaccine was kept off the bench for years; it wasn’t ready when we needed it the most. In Seth Berkley’s (CEO, the GAVI Alliance) words, “The sad reality is, we develop vaccines not based upon the risk the pathogen poses to people, but on how economically risky it is to develop them”. We have been habitually reactive to the ever-growing threat of new outbreaks, notwithstanding SARS, H1N1, MERS emergencies in the last decade.
Besides the threat of emergence of new infectious agents, old foes have to be kept at bay at all times, with improved vaccines. For example, worryingly, just last week, Ahmedabad was put on "high alert" by the WHO after some sewage samples during surveillance tested positive for Type 2 Polio virus. Telangana had a similar situation in June 2016, when Hyderabad announced a similar "high alert" after an active virus strain was detected in sewage. This comeback virus is not the "wild type" that we had laboriously eradicated, but a mutated variety that emerges by developing resistance to the vaccine (Vaccine-derived Polio Virus or cVDPV). Such a mutation has been sporadic and rare thus far, but it is not to be taken lightly.
WHO had understandably been proactive about the emergence of the mutated trickster, and had issued the advisory to all countries in April 2016 to replace all Oral Polio Vaccines of the trivalent type (tOPV) with the bivalent type (OPV2). With a goal to end polio once and for all, this replacement will eventually lead to total cessation of oral drops, to be substituted with an inactivated variation of Polio vaccine (IPV) that is expected to eliminate all types of Polio viruses.
It is commendable that the ministry of health and welfare of India remains highly committed to the cause. OPV2 was adopted for the Pulse Polio programme in April 2016. IPV has also been introduced in the immunisation programme in Assam, Gujarat, Punjab, Bihar, MP and UP in its first phase. This year’s Pulse Polio that got launched by President Pranab Mukherjee on January 28, had additional objectives to expand coverage, to protect any spillover or importation from other countries, and to manage emergencies through rapid response teams across the country.
Fortune favours the prepared
Vaccination is akin to education for a nation, securing its very foundation – the health of its children – for long-term economic development and intellectual progress. India has increased its immunisation spend by an encouraging 73 per cent since 2013. The share on routine immunisation in the country’s total health budget has gone up from 2 per cent in 2011 to 20 per cent in 2016.
It is hoped that this year’s Union Budget will carry forward the trend, given that we still are home to one-third of the world’s unimmunised children. In absolute terms, however, the increased spend on immunisation was achieved by diverting a high proportion of an otherwise near-stagnant public health budget during these years to this initiative over other public health programmes. Will future budgets address this broader concern of spending a paltry percentage of GDP on health?
One can only hope that a similar goodwill percolates on health as a category by the Centre in years to come – focus pays off well, as the encouraging success of the immunisation programme has evidently shown. In addition to the success with polio, reported cases for tetanus and diptheria have gone down by 94 per cent, and that for pertussis and measles have decreased by 84-86 per cent in the last 30 years. The practical implementation of this colossal mission would not have been possible without the collective participation and help from the global leaders of the cause – WHO, UNICEF, GAVI, Gates Foundation, among others.
India’s continued belief in the socio-economic value of vaccination is further confirmed by the praiseworthy step by the Indian government in joining the recently formed Coalition for Epidemic Preparedness Innovations (CEPI) as a founding member along with the Bill & Melinda Gates Foundation, the Norwegian ministry of foreign affairs, the Wellcome Trust, and the World Economic Forum. CEPI aims at eliminating pathogens identified as serious health threats to the world by developing vaccines against them, as stated by Trevor Mundel, President, Global health, Gates Foundation. Prime Minister Narendra Modi also confirmed India’s full membership of the International Vaccine Institute (IVI) Governing Council.
Slowly but surely, the empires of the invisibles is being thwarted. We have no choice. Their defeat means our survival. Let us hope this year's Union Budget would shore up our fast depleting artillery for a decisive attack.