viral outbreak

How to create a fever outbreak: Lessons from East Delhi

Almost every home in Rajiv Camp in the Jhilmil Industrial Area has at least one person with fever and chikungunya-like symptoms.

On Wednesday, Rani Sharma, 40, finally became sick from the deadly viral fever that has gripped the Jhilmil Industrial Area in East Delhi for the past month. Everyone else in her family had already had a spell of it. Over the previous weeks, Sharma had already taken several days of leave from the sticker factory at which she works to tend to her husband and her three grown-up children, aged between 17 and 20.

“My bosses cribbed about my leave and said I take a lot of leave," said Sharma. "But I really cannot go to work. I cannot sit, or stand, or lie down without hurting.”

Rajiv Camp, where Rani lives, is bursting with cases of this viral fever. “Knock any door, and you will find a sick person,” said Neelam Chaudhary, the Accredited Social Health Activist or ASHA for the area. There are about 500 families in the slum with a population of approximately 2,500, she said. She herself has been struck by fever and suffers severe body aches.

A few houses from Sharma lives Mustari Khatoon, 35, who lives with her three children aged 20, 18 and 8. When this correspondent went to their home, they were all lying on a cot and watching a movie on television. Asma, the 20-year old who works at a beauty parlour, said that she could not even sit up without her body aching. All of them had chikungunya-like symptoms.

Shabana Khatoon and her daughters suffer from fever and body pain. They were never tested for chikungunya. Photo: Menaka Rao.
Shabana Khatoon and her daughters suffer from fever and body pain. They were never tested for chikungunya. Photo: Menaka Rao.

The viral fever, which has seldom been confirmed as chikungunya among the patients at Rajiv Camp, is debilitating. “I have lived in Delhi for so many decades, but I have not seen a disease like this,” said 70-year-old Jasin Shaikh. His wife Gulshan Khatoon, who also has the fever symptoms, has now resorted to using a walking stick. Three other people in their family are ill.

Unnamed viral fever

The Delhi government and municipal authorities said that the city saw 412 chikungunya cases in the last week of August alone. This was around the time, people in Rajiv Camp started falling sick.

A total of 3,695 cases of chikungunya and 5,982 cases of dengue have been recorded so far in Delhi, the government claimed. Some cases of scrub typhus, a bacterial infection, which also have chikungunya-like symptoms have been recorded in the city. There are also scores of other people diagnosed with chikungunya-like symptoms with high fever for a few days, followed by rash and severe body pain and swelling of joints. There are other people with other kinds of viral fevers doing the rounds in the city, which are equally crippling. People complain of symptoms such as high fever, headache, body ache, cold, cough, among others, which seem to last for over a week sometimes.

“For dengue, we have good diagnostics," said Dr Abhay Chaudhary, the head of the microbiology department at JJ Hospital in Mumbai. "We can detect it even during the illness. However, for chikungunya, the tests are weak and the sensitivity is less.” This would essentially mean that very few fevers would be confirmed chikungunya.

The other viral fevers could be arboviral infections, caused by mosquitoes or ticks. “These viral fevers may not have anything to do with dengue or chikungunya, and could have unique manifestations, including neurological symptoms or encephalitis,” said Chaudhary. He admitted, that often they have no answers for the kind of fevers that are there in the community, especially those which cause sudden deaths.

In August, a fever outbreak in a Noida village killed 10 people. The authorities were not able to explain why those deaths took place, but blamed it on other underlying illnesses. In a similar incident, 12 people in Delhi died after being diagnosed with chikungunya, a disease not known to cause death. What is, however, common to all these outbreaks is the pathetic state of sanitation in areas where people who contracted fevers resided.

Neglect by civic authorities

Residents of the Jhilmil Industrial Area complain of neglect by civic authorities. Their houses are in narrow lines abutting a running open drain. There is a perpetual stench in the area. The big storage drums of water outside each house, apart from coolers, that serve as ideal breeding grounds for mosquitoes.

“Our area was fogged once,"said Murari Singh, referring to the practice of spraying mosquito repellents and larvicide that the Delhi government has undertaken to control mosquito populations this season. "I do not think it has had any impact.”

ASHA worker Neelam Chaudhary with Sukhba Devi who suffers from severe body ache. Photo: Menaka Rao.
ASHA worker Neelam Chaudhary with Sukhba Devi who suffers from severe body ache. Photo: Menaka Rao.

Chaudhary, the ASHA worker, said that she cleaned out three coolers and drums that were swarming with mosquitoes last week. On Friday, she had been distributing posters about mosquito prevention and treatment of dengue and chikungunya.

In a Facebook post, a women-based political organisation, Mehnatkash Mahila Sangathan, a non-profit that works on labour rights, calls out the ineffective measures taken by government authorities. The post also highlights the plight of health workers, three of whom died after high fever last month.

“Looking at the serious condition in the capital as well as in the whole country, it can be said that it is not going to subside only by calling for 'Protect yourself from mosquito bites', a few weeks every year,” said the post.

The organisation made representations seeking to improve the state of sanitation, and healthcare in the area to the state government, the civic body and the local MLA.

Inaccessible healthcare facilities 

There are two tertiary level hospitals near Rajiv camp – the Guru Tegh Bahadur Hospital and a polyclinic – as well as a mohalla clinic in the area. All these are at least two km to four km away from the colony. Not many people about the polyclinic or the mohalla clinic. The latter runs only between 9 am and 1 pm, which is inadequate to serve the needs of the large number of daily labourers who are free to visit a doctor only in the evening.

Healthcare facilities are visibly better at the nearby Dilshad Gardens, a more upmarket neighbourhood.

The lack of primary health care facilities has left very few options for Rajiv Camp residents. Many have visited quack doctors just to get pain relief. “I went to a jholachap nearby," said Sukhbai Devi, who was limping. "The government doctors do not listen to you. The medicine is very weak.”

A doctor without medical qualifications operating out of a slum in Jhilmil Industrial Area. Photo: Menaka Rao
A doctor without medical qualifications operating out of a slum in Jhilmil Industrial Area. Photo: Menaka Rao

Most government hospitals give patients complaining of fever a few doses of paracetamol. Though it is the recommended treatment protocol, it does little to relieve the pains of the Rajiv Camp residents, who stand to lose their daily wages if they do not go to work. That the government doctors did not listen, as people complained, doesn’t help.

Loss of wages

While the fact that ideal treatment is simply taking paracetamol thrice or four times a day, what does a person who wants to go back to work do?

“My sons simply pop pain killers and go to work. We cannot afford to sit at home,” said Shabana Khatoon, whose entire family of six was down with fever.

One of the labourers who attempted to go back to work with severe body pain met with an accident. “My husband who works as a mason fell from the first floor while working,” said Rita Devi. "Now he has stitches."

Devi's entire family of seven people, including her four daughters, and a son, had the same illness. She works in a factory and lost seven days' worth of wages as a result of the sickness.

Each visit to the doctors, including travel, costs at least Rs 200 to Rs 300. Most families have spent about Rs 2,000 to Rs 3,000 on the recent bout illness.

The medical camp organised by Mehnatkash Mahila Sanghatan where doctors spoke about the epidemic and distributed medicines. Photo: Menaka Rao.
The medical camp organised by Mehnatkash Mahila Sanghatan where doctors spoke about the epidemic and distributed medicines. Photo: Menaka Rao.

The government, public health experts feel, needs to do more to reduce the panic among residents.

“We need to be able to tell people that a large number of these cases are not serious, and there is no reason to panic,” said Dr Ritu Priya Mehrotra, from the department of Community Medicine at Jawaharlal Nehru University in Delhi. “Only vulnerable people like the elderly, pregnant women, and children need to be careful. They need to be told that its best to take paracetamol and not any painkillers.”

Mehrotra said that the government may need to do more than spreading messages via radio, television and posters.

“The government needs to have people on the ground who can talk about the epidemic directly to the community," said Mehrotra. "They need to talk about what they are doing about it. The people will then feel that it is tallying with their experience. That will help keep the panic down,” she added.

Epidemic control

Although the government is disseminating information on mosquito control, action may not be feasible. “Once there is an outbreak, the options to control it are limited," said Amit Sengupta from the public health non-profit organisation Jan Swasthya Abhiyaan. "There is not much anyone can do apart from treating patients.”

Health surveillance helps predict an outbreak of this sort. “There has to be disease outbreak sentinel which will identify areas where people need to be screened. This can help anticipate outbreaks of this kind and help control them,” said Sengupta

As this Indian Journal of Medical Ethics article written in response to the 2006-2007 chikungunya epidemic in South India, says, "Health depends, at the barest minimum, on access to adequate food, sufficient safe water, housing and sanitation. The provision of these basic requirements dramatically brought down the occurrence of communicable diseases in the West, long before modern vaccines or antibiotics were discovered. We should address these foundations of public health while we create public health foundations. “

In the context of disease outbreak, urban planning again stands out for its failure. “Delhi is a bad example of city planning. All the poor in the city have been moved out into ghettoes,” said Sengupta. Indeed, just a few kilometers away from Jhilmil Industrial Area are gated communities with paved streets and good sanitation facilities.

“In such a situation, there is no one left to speak up for the poor," said Sengupta. "It is a case of out of sight, out of mind.”

We welcome your comments at letters@scroll.in.
Sponsored Content BY 

What hospitals can do to drive entrepreneurship and enhance patient experience

Hospitals can perform better by partnering with entrepreneurs and encouraging a culture of intrapreneurship focused on customer centricity.

At the Emory University Hospital in Atlanta, visitors don’t have to worry about navigating their way across the complex hospital premises. All they need to do is download wayfinding tools from the installed digital signage onto their smartphone and get step by step directions. Other hospitals have digital signage in surgical waiting rooms that share surgery updates with the anxious families waiting outside, or offer general information to visitors in waiting rooms. Many others use digital registration tools to reduce check-in time or have Smart TVs in patient rooms that serve educational and anxiety alleviating content.

Most of these tech enabled solutions have emerged as hospitals look for better ways to enhance patient experience – one of the top criteria in evaluating hospital performance. Patient experience accounts for 25% of a hospital’s Value-Based Purchasing (VBP) score as per the US government’s Centres for Medicare and Mediaid Services (CMS) programme. As a Mckinsey report says, hospitals need to break down a patient’s journey into various aspects, clinical and non-clinical, and seek ways of improving every touch point in the journey. As hospitals also need to focus on delivering quality healthcare, they are increasingly collaborating with entrepreneurs who offer such patient centric solutions or encouraging innovative intrapreneurship within the organization.

At the Hospital Leadership Summit hosted by Abbott, some of the speakers from diverse industry backgrounds brought up the role of entrepreneurship in order to deliver on patient experience.

Getting the best from collaborations

Speakers such as Dr Naresh Trehan, Chairman and Managing Director - Medanta Hospitals, and Meena Ganesh, CEO and MD - Portea Medical, who spoke at the panel discussion on “Are we fit for the world of new consumers?”, highlighted the importance of collaborating with entrepreneurs to fill the gaps in the patient experience eco system. As Dr Trehan says, “As healthcare service providers we are too steeped in our own work. So even though we may realize there are gaps in customer experience delivery, we don’t want to get distracted from our core job, which is healthcare delivery. We would rather leave the job of filling those gaps to an outsider who can do it well.”

Meena Ganesh shares a similar view when she says that entrepreneurs offer an outsider’s fresh perspective on the existing gaps in healthcare. They are therefore better equipped to offer disruptive technology solutions that put the customer right at the center. Her own venture, Portea Medical, was born out of a need in the hitherto unaddressed area of patient experience – quality home care.

There are enough examples of hospitals that have gained significantly by partnering with or investing in such ventures. For example, the Children’s Medical Centre in Dallas actively invests in tech startups to offer better care to its patients. One such startup produces sensors smaller than a grain of sand, that can be embedded in pills to alert caregivers if a medication has been taken or not. Another app delivers care givers at customers’ door step for check-ups. Providence St Joseph’s Health, that has medical centres across the U.S., has invested in a range of startups that address different patient needs – from patient feedback and wearable monitoring devices to remote video interpretation and surgical blood loss monitoring. UNC Hospital in North Carolina uses a change management platform developed by a startup in order to improve patient experience at its Emergency and Dermatology departments. The platform essentially comes with a friendly and non-intrusive way to gather patient feedback.

When intrapreneurship can lead to patient centric innovation

Hospitals can also encourage a culture of intrapreneurship within the organization. According to Meena Ganesh, this would mean building a ‘listening organization’ because as she says, listening and being open to new ideas leads to innovation. Santosh Desai, MD& CEO - Future Brands Ltd, who was also part of the panel discussion, feels that most innovations are a result of looking at “large cultural shifts, outside the frame of narrow business”. So hospitals will need to encourage enterprising professionals in the organization to observe behavior trends as part of the ideation process. Also, as Dr Ram Narain, Executive Director, Kokilaben Dhirubhai Ambani Hospital, points out, they will need to tell the employees who have the potential to drive innovative initiatives, “Do not fail, but if you fail, we still back you.” Innovative companies such as Google actively follow this practice, allowing employees to pick projects they are passionate about and work on them to deliver fresh solutions.

Realizing the need to encourage new ideas among employees to enhance patient experience, many healthcare enterprises are instituting innovative strategies. Henry Ford System, for example, began a system of rewarding great employee ideas. One internal contest was around clinical applications for wearable technology. The incentive was particularly attractive – a cash prize of $ 10,000 to the winners. Not surprisingly, the employees came up with some very innovative ideas that included: a system to record mobility of acute care patients through wearable trackers, health reminder system for elderly patients and mobile game interface with activity trackers to encourage children towards exercising. The employees admitted later that the exercise was so interesting that they would have participated in it even without a cash prize incentive.

Another example is Penn Medicine in Philadelphia which launched an ‘innovation tournament’ across the organization as part of its efforts to improve patient care. Participants worked with professors from Wharton Business School to prepare for the ideas challenge. More than 1,750 ideas were submitted by 1,400 participants, out of which 10 were selected. The focus was on getting ideas around the front end and some of the submitted ideas included:

  • Check-out management: Exclusive waiting rooms with TV, Internet and other facilities for patients waiting to be discharged so as to reduce space congestion and make their waiting time more comfortable.
  • Space for emotional privacy: An exclusive and friendly space for individuals and families to mourn the loss of dear ones in private.
  • Online patient organizer: A web based app that helps first time patients prepare better for their appointment by providing check lists for documents, medicines, etc to be carried and giving information regarding the hospital navigation, the consulting doctor etc.
  • Help for non-English speakers: Iconography cards to help non-English speaking patients express themselves and seek help in case of emergencies or other situations.

As Arlen Meyers, MD, President and CEO of the Society of Physician Entrepreneurs, says in a report, although many good ideas come from the front line, physicians must also be encouraged to think innovatively about patient experience. An academic study also builds a strong case to encourage intrapreneurship among nurses. Given they comprise a large part of the front-line staff for healthcare delivery, nurses should also be given the freedom to create and design innovative systems for improving patient experience.

According to a Harvard Business Review article quoted in a university study, employees who have the potential to be intrapreneurs, show some marked characteristics. These include a sense of ownership, perseverance, emotional intelligence and the ability to look at the big picture along with the desire, and ideas, to improve it. But trust and support of the management is essential to bringing out and taking the ideas forward.

Creating an environment conducive to innovation is the first step to bringing about innovation-driven outcomes. These were just some of the insights on healthcare management gleaned from the Hospital Leadership Summit hosted by Abbott. In over 150 countries, Abbott, which is among the top 100 global innovator companies, is working with hospitals and healthcare professionals to improve the quality of health services.

To read more content on best practices for hospital leaders, visit Abbott’s Bringing Health to Life portal here.

This article was produced on behalf of Abbott by the Scroll.in marketing team and not by the Scroll.in editorial staff.