In September 1896, the city that was then called Bombay recorded its first case of the bubonic plague. The disease quickly spread swiftly claiming victims – estimates peg the death toll at 1,900 every week for the rest of the year. The health crisis prompted the British administration of the city to quickly draft the Epidemic Diseases Act in 1897 to prevent the spread of dangerous epidemic diseases.
The Act, considered one of the most draconian pieces of public health legislation, gave sweeping powers to the government authorities. Officials could enter any house and forcibly examine a sick person or someone suspected to carry infection. In her account of the bubonic plague outbreak, historian Mridula Ramanna says that British officials would drag men and women out of their houses and examine their armpits for buboes, which are swollen lymph nodes.
The Epidemic Diseases Act was later modified significantly to allow the government only to detain international travelers suspected of carrying an infectious disease. The measures of this revised regulation were invoked in independent India.
This century-old act is now set to be replaced. The central government drafted the Public Health (Prevention, Control and Management of Epidemics, Bio-terrorism and Disasters) Bill, 2017 and uploaded it online seeking comments. The deadline to submit comments was March 25.
The Bill is more in keeping with the times and includes provisions on bioterrorism, which involves the deliberate release of hazardous biological agents like viruses, bacteria or toxins in the environment. The Bill also has references to different modes of transport such as airplanes and ships, through which disease can spread.
But public health experts feel that the Bill is as draconian as the older law, maybe even more so.
The Bill empowers medical officers to inspect any premises, isolate people, restrict movement, test a patient and mandate treatment or vaccination of a person suffering from disease. The Bill has does not mention the necessity of seeking consent from citizens for any of these measures.
According to the Bill, after a public health emergency is declared, a state government, district authority or local authority can take measures to prevent and control the emergency. They can quarantine people who might have been exposed to the disease, conduct medical examinations, provide treatment and ban any activity they deem “inimical to public health”.
A public health emergency, as per the Bill, is any sudden state of danger to public health including spread of infection, disaster or bioterrorism that mandates immediate action for its prevention, control and management. The Bill lists a schedule of 33 diseases that are “epidemic prone” like dengue, chikungunya and multi drug-resistant and extremely drug-resistant tuberculosis.
This might allow government authorities to invoke extreme powers of entering houses and forcibly treating citizens during any monsoon season when the country witnesses several outbreaks of infectious diseases like malaria, dengue and chikungunya.
The behaviour of Tamil Nadu state health authorities during the recent measles-rubella vaccination campaign in schools provides a glimpse of what such a Bill might allow. When many parents were opposed the campaign because of lack of transparency, the state health minister C Vijaya Bhaskar announced that schools need not seek consent of parents before vaccinating childern. “The Public Health Act allows us to give vaccine without consent,” she told Times of India last month. “If need be, we will make it mandatory.”
The Act Bhaskar was referring to is the Madras Public Health Act, 1939, which is also a colonial Act and gives similar powers to the state. The Act also lists out many duties such as providing clean water, effective drainage systems, medicines, among others.
What is a public health emergency?
Dr Vijayaprasad Gopichandran who teaches community medicine at the Employees’ State Insurance Corporation Medical College in Chennai said that the Bill provides no definition on who will decide that an outbreak is a public health emergency or how it will be declared.
“A system should be in place with a team of epidemiologists, public health experts, policy makers, public health engineers and so on that can decide and declare diseases as public health emergency,” said Gopichandran. Gopichandran is part of Chennai’s Medico Friend Circle, a group that wrote to the Ministry of Health pointing out concerns about the Bill.
He suggested that the Bill should define a system much like the International Health Regulations agreed on by all World Health Organisation member states. The regulations define the process of declaring a disease as Public Health Emergency of International Concern. They require an Emergency Committee to examine unexpected outbreaks of diseases like polio or Severe Acute Respiratory Syndrome also called SARS, outbreaks of unknown diseases and those like cholera, plague, yellow fever and viral hemorrhagic fevers that can cause serious public health impacts. The committee then looks at strengthening national disease surveillance, prevention, control and response systems and responses at the international level.
The Bill is also silent on the duties of the government during a public health emergency. “There is no mechanism stated in the Bill about the responsibilities of the government in ensuring that the measures are evidence-based and effective, that the duration of time of restrictions are appropriate and that the infringement into the privacy of the population is proportional,” said Gopichandran.
Infringement of human rights
The Bill suspends liberties of people while barely holding the government accountable, said experts.
“There is no emphasis on modern methods of outbreak prevention and disease control such as establishment of surveillance system, early warning systems, Geographical Information System mapping of diseases, which are all less intrusive methods of disease prevention and containment,” pointed out Gopichandran.
Anant Bhan, a researcher of bioethics and global health, said that the country does need a law with a framework for mounting a public health response and elaborating the powers of government at such a time.
“However, there has to be balance between government’s role in maintaining public health and human rights, “ he said. “This Bill neglects it completely.”
The restrictive action prescribed in the Bill can alienate citizens and make them lose trust in the public health system. “It is possible that fearing isolation, the patients will not inform the public health system and instead prefer to weather it out,” said Bhan.
History suggests that respectful engagement with the public will work better. “My research showed that if you introduce public health measures gradually with a pursuance campaign, you can deal with the situation better,” said Ramanna. “The authorities have to keep in mind sensibilities, sensitivities and gender before undertaking a public health campaign.”
Provisions of the Public Health Bill for a health emergency
- Quarantine or restrict the movement of any people possibly exposed to the disease.
- Authorise any official or person to enter and inspect, without prior notice, any premises where public health emergency has either occurred or is likely to occur
- Prohibit any activity “inimical to public health”
- Isolate people infected from the disease
- Conduct medical examination on people infected
- Provide treatment, vaccination, or prophylaxis to infected people
- Undertake disinfection activities
- Ban or regulate the purchase, distribution, sale of hazardous or toxic substance
- Order detention of anyone carrying hazardous substance
- Order hospitals/clinics to admit, isolate and manage cases arising out of the public health emergency
- Disseminate information to the public
- Direct any clinical establishment to admit, isolate and manage cases arising out of public health emergencies and to report to the government.