The Microbes are nothing, the terrain everything.

– Louis Pasteur, the French microbiologist, circa 1890

 

THE burden of infectious diseases continues to be large. Tuberculosis still affects 27 lakh Indians every year, and as many as eight lakh episodes of malaria are reported annually. Leprosy, a disease that was prematurely declared as having reached a ‘low and acceptable’ level afflicting one in 10,000 people every year in 2005, has shown increasing incidence in several states in the last few years due to a slackening of the programme meant to restrain it. Childhood infections such as acute respiratory infections and diarrhoea continue to take a toll of large numbers of lives in the under five age group.

Over the last two decades, there has been an increase in several vector borne diseases such as dengue, chikungunya, Japanese encephalitis, among others. Leptospirosis and scrub typhus are being reported from areas previously uninvolved, contributing to morbidity and mortality, undoing the gains made in controlling malaria. New threats like H1N1 swine flu, zika, nipah virus and other infectious agents lurk around the corner to attack the vulnerable.

Our older foes like diphtheria, whooping cough and cholera surface with alarming regularity waiting to strike when our guard is down. Hepatitis B, E and C continue to cause much morbidity and deaths too. Even though there is a slowing down of the epidemic, 21 lakh people live with HIV in India with 88000 new people diagnosed with the infection in 2017.

There is adequate evidence to suggest that the poor and those marginalized along several axes such as social groups, geography, sexual orientation and gender pay a heavier price as far as infectious diseases are concerned. As a case in point, tuberculosis occurs at a frightfully higher rate among the poor and those suffering from undernutrition. While only 8% in the country are adivasis, they suffer more than 50% of the consequence of falciparum malaria. Leptospirosis has been rightly called the disease of the very poor as it is rare to the better off being affected by it.

Besides absolute poverty, it is inequality that is associated with this unequal and unjust distribution of infectious diseases. The political economy of several illnesses such as MDR tuberculosis and HIV indict inequality. The continued justification of inequality within and between countries has led to unacceptable technical recommendations where cost effectiveness dominates effectiveness and human concerns.

Not only do we see a higher incidence of infections like tuberculosis among the poor and undernourished, the chance of recovery from the disease is far lower among the poor. For most populations the possibility of acquiring infection, developing disease and lacking access to care are structured by a series of systemic forces. The risk of dying with tuberculosis while being treated is three times higher if undernourished. The inequalities of outcomes are by and large biological reflections of social fault lines.

Further, not only is the cost of inequality a cost we incur for no economic benefit, but all indications are that it imposes a substantial burden which reduces the competitiveness of the entire society. As Paul Farmer convincingly argues in his book, Infections and Inequalities, inequality constitutes our modern plague.

 

Poor people get poor health systems. Not only is clinical care for complicated infections poor, public health systems where the marginalized reside in larger numbers are poorly equipped with surveillance systems, laboratories to diagnose existing and new infections in time, and are poorly staffed without competent public health practitioners.

Ironically, urbanization which is seen as a marker of societal development often increases the risk of illnesses due to a more degrading environment with inadequate water supply, drainage, waste disposal and sanitation, leading to recurrent outbreaks of mosquito and waterborne diseases. New construction pays scant regard to drainage that causes water-logging which increases after the monsoon. No wonder outbreaks due to the urban aedes mosquito breeding, such as dengue and chikungunya, besides vivax malaria transmitted from the anopheles mosquitoes, are commonplace in the urban shanties every year. Recently, the township of Bhilai in Chhattisgarh, in the 2018 monsoon, had over 6000 dengue patients over a five week period with over 45 deaths. It seems rather obvious that fundamental social forces and processes come to be embodied as biological events like death from disease, illness and residual disabilities.

 

Historically, we began addressing infectious diseases, which seemed to cause the bulk of human misery till the mid-20th century, with social measures. Perhaps this was because infections were believed to be due to poor environment and other social and economic factors. In the 19th century, the assurance of adequate food and nutrition was shown to be the most important variable that led to the sharpest decline in most illnesses, with tuberculosis as a case in point. McKeown, a British physician and epidemiologist, whose thesis influenced a whole generation of health professionals, best captured this trend. Even though McKeown did not credit hygiene and other public health measures for the decline in mortality due to illnesses, reforms in Europe regarding sanitation, better housing, water supply and sewage disposal, access to education and healthcare, and better wages for all workers accounted for a further decline in infectious illnesses prior to the advent of antibiotics and vaccines in the first half of the 20th century.

And then came the germ theory that tried to explain that all infections were a result of microbes and their effects on the human body. The germ theory of disease led to some important breakthroughs that helped in the eradication of some diseases and the near elimination of others through the use of vaccines and antimicrobials. But it resulted in de-socializing infectious illnesses by removing the focus from its social and political roots. Due to the emphasis on the individual as opposed to the community, due to its biomedical roots, this theory attracted practitioners of modern medicine.

Tuberculosis need no longer be seen a consequence of food or other social deprivation and could be considered a mycobacterial infection primarily affecting the lungs, resulting in an infective illness. Thus, drugs needed to be administered to those afflicted, to kill the microbes to ensure cure. Most of our present strategies to address infections are still heavily influenced by the germ theory. The tuberculosis control programme considers drug resistance the biggest problem without working on its social roots such as persistent undernutrition. Even in malaria control, the focus is on finding the best drug regimen to kill resistant parasites rather than look at the way our development regime mismanages waterbodies.

 

Tuberculosis is clearly a problem with its roots in food and other societal deprivations, made worse by poor health systems. Malaria persists due to a lack of environment management and inadequate health systems for the poorest in our society. The problem highlighted by leprosy is missing diagnosis and unseemly haste by funding organizations to stop the control programmes. The problem with dengue is poor urban planning. The problem with zika is globalization. The likely reason for the increased occurrence of scrub typhus and leptospirosis is climate change. Cholera, hepatitis E, typhoid fever and other diarrheal illnesses are due to our inability to ensure safe drinking water.

In light of the inability to adequately address old problems like tuberculosis, and now emerging and re-emerging infections and antimicrobial resistance, we know that an undisciplined approach to infectious disease control is no longer sufficient. At the same time, one must attend to its biologic and social underpinnings. It is ironic that at this time when scientific progress in medicine has reached unprecedented heights, our neglect of social roots that Virchow so clearly identified, cripples our effectiveness. This is essentially a clarion call to go back to basics if we wish to win the war against infectious diseases, or even control them. A return to the simple and most important fundamentals is the best way forward.

 

A neglect of the social origins of infections and complacency in the 1980s and 1990s resulted in a resurgence of tuberculosis in the US and the occurrence of MDR TB in Russia and several other countries while the Indian situation remained persistently grim. A lack of focus on undernutrition and overcrowding, unregulated expansion of pharmaceutical and private health care, and primary and secondary care that picks up disease early to take cognizance, emerged as major reasons for this upsurge.

The emergence of antimicrobial resistance such as multidrug-resistant tuberculosis and extended spectrum beta lactamase producing bacteria causing untreatable infections is arguably one of the biggest problems in city hospitals. In 2018, most typhoid patients in Karachi had to finally resort to an expensive drug that could only be administered in large hospitals. Due to a lack of effective regulation and use of antibiotics by physicians, pharmacists readily dispense them for use in animal feeds. We are thus on the cusp of an unimaginable spectre of abandoning sick infected patients on grounds of not having anything to offer. New infectious diseases (e.g. the ebola virus) and the re-emergence of old ones thought to be vanquished (e.g. diphtheria and pertussis) have also challenged our complacency, but we have still not got our act together.

Strategies that we should take assume some urgency because we hear our political leaders wishing to eliminate these old diseases post haste. For example, the Indian deadline for elimination of leprosy was 2018, for malaria 2030 and for tuberculosis it is an ambitious 2025. These unrealistic targets show a lack of understanding among policy makers of how complex, multifactorial and often inextricably linked these diseases are to socioeconomic conditions. Any plan that targets an end to TB by 2025 clearly relies on ‘quick fix’ – fight the microbe rather than fix the terrain.’

 

If the major determinants of health are social, the remedies must be too. Treating existing disease is urgent and will always receive high priority but should not be to the exclusion of taking action on the underlying social determinants of health. Wider social policy will be crucial to reduce inequalities in health. We need to go back to the drawing board to plan overall control and elimination strategies, using a biosocial approach to infection control. We should revisit to see if the declarations regarding eliminating (having no new episodes) specific infections are realistic. The first milestone of leprosy elimination is unrealistic. Even in a small hospital in rural Chhattisgarh where I work, we get about 120 new cases of leprosy with advanced presentations every year. Regarding malaria, we still have a significant burden of the disease in several central Indian and Northeastern states.

The ideal policy should first look at controlling the disease and reduce deaths to zero. Embarking on an elimination strategy now would present some problems. First, funds would be divided equally among states with a high burden and those with a minimal disease incidence. In high burden states, there is a need to ensure treatment to the large numbers affected, and in low burden states to track any hidden cases by an active search strategy. These require different strategies and it is likely that high burden states like Odisha and Chhattisgarh might get reduced funds like Punjab and Uttarakhand. Such a national programme design will starve curative and control activities in these high burden states.

 

Second, the elimination strategy is often controlled at a very central level like the regional WHO office and not at the district and state level. Thus, local and regional planning would get short shrift. Third, an elimination strategy is in direct conflict with the control strategy and is likely to be counterproductive. In tuberculosis, even the mere talk of elimination is unrealistic and akin to daydreaming. With no significant effort being made to address its determinants like hunger, with over 10 lakh people who get diagnosed dropping off the radar and not even getting the right treatment every year, hoping that new cases will stop happening in the next decade is being out of touch with reality.

Specific disease control strategies are also needed. First, we must ensure treatment for all people with infectious illnesses. We should not undermine the urgency and the importance of providing care for those who are sick. Cost effectiveness or programmatic efficiency should not trump effectiveness or equity. As a case in point, we should not deny the best treatment for MDR tuberculosis or HIV to anyone who needs it in all situations. In the treatment of MDR tuberculosis, if providing Bedaquiline to all becomes a standard of care, then the state programme should provide nothing less. Besides being immoral, belittling the role of clinical care tends to unburden policy of providing equitable access to such care. If an expensive vaccine is considered necessary, then the state should ensure its availability to all.

There are three critical elements in public health efforts: (a) strong public health fundamentals that include disease surveillance, laboratory detection and epidemiologic investigation; (b) high-impact interventions identifying and validating new tools for disease prevention and control and accelerating the uptake of proven methods for decreasing illness and death from diseases; and (c) sound health policies to ensure appropriate development and delivery of infectious disease prevention measures; reduce health disparities and improve the health of vulnerable populations and address determinants of illnesses proactively and with intersectoral coordination.

 

Disease surveillance is critical to comprehend the burden of infections in real time so that prompt action can be taken. Laboratory methods, including point of care diagnostics, should be available in as decentralized a manner as is feasible. Epidemiological investigations should be done promptly to pick up new outbreaks as well as to understand the links between the determinants and diseases. The huge burden of tuberculosis in Mumbai is because of widespread drug resistant tuberculosis and poor quality treatment practices in the private health care sector while that in Chhattisgarh it is due to food deprivation and unavailable health services.

High impact tools for disease reduction may include new vaccines that have passed muster on grounds of effectiveness for preventing a disease that has significant adverse public health effects, is proven to be safe, meets cost effectiveness considerations and does not obfuscate the need for addressing the social roots of illness. Most of the new candidate vaccines still have to prove themselves on these accounts. Strategies and tools for infection control and treatment such as insecticide treated bed nets for preventing malaria and interventions to reduce disease transmitted by animals or insects also need to be encouraged.

 

We need good functioning public health systems and cannot expect a predominantly privatized health system to deliver on managing infectious diseases. In fact, only universal health care provided through a dominant public health system will do. Can we even start to hope that people will be able to seek care for HIV from a for profit private health system? Will the private system ever be interested in preventive strategies that are central to controlling infections? There is no country in the world that has either managed infection control or universal health care through private health systems.

Addressing social determinants has to be the other strategy for addressing infectious diseases. When it comes to preventing common infections that bother us, can we escape from working on reducing raging hunger and undernutrition among both adults and children? India, which contributes to one-fourth of the world’s tuberculosis, has one-third of its adults being undernourished with their Body Mass Index being less than 18.5. The situation with children is worse. While we should not slacken in tuberculosis diagnosis and treatment programme activities, the only sustainable way to prevent new cases is to reduce the occurrence of adult undernutrition. This will require better agriculture practices, land reforms and other livelihood support.

While we may find newer vaccines for waterborne illnesses such as for rotavirus diarrhoea, hepatitis A, typhoid fever and cholera, we can’t avoid working to ensure safe drinking water for everyone. It will protect against several other waterborne infections against which we still don’t have any vaccine. For most vector borne illnesses such as falciparum malaria or for dengue, no vaccine is likely to be ready to use on a large scale in the next decade. But ensuring proper town planning, sanitation practices and managing water bodies are likely to reduce or eliminate such mosquito borne illnesses. These measures are also more cost effective than vaccines against single agent diseases. Adequate flood control strategies will be important for preventing leptos pirosis, which reportedly killed over 100 people in Kerala due to unprecedented rains made worse by poor water management.

 

While working on social determinants of infections is the way forward, we have to be cautious of certain trends. Often, and specifically seen in management of tuberculosis, strenuous insistence on the causal role of culture or personality in explaining treatment failure runs the risk of conflating cultural difference with structural violence. Throughout the world, those least likely to comply are those least able to comply.

As health care professionals we have to say it loud and clear that the social and political factors are also within our domain by articulating the problems accordingly. We should not remain apologists for faulty health programmes whose budgetary allocations are being reduced. We should move away from the germ theory of infections and try to see them from a social origins framework and question technical fixes being pedalled for handling infections. We need to look at it sociologically but act medically. We need to be aware that as long as inequity remains so will infectious diseases.