The tragic drama of Novel H1N1 flu epidemic in Pune; the controversy surrounding the first death; the overburdening of the city’s meagre public health system and the unnecessary, long queues in front of the Sarojini Naidu Hospital, the Pune Municipal Corporation’s infectious disease hospital, call for much introspection by all the contributors to this tragedy.

(Swine flu is a misnomer as the virus is derived from four sources, only one of which is the swine flu virus, and the Pune epidemic has nothing to do with pigs.)

On August 3, Rida Sheikh, a 13-year-old schoolgirl, died in the well-known and elite Jehangir Nursing Home due to pneumonia following Novel H1N1 influenza (hereinafter referred to as H1N1 influenza). With her death, the gathering flu epidemic in Pune took a serious turn. This tragedy was sensationalised by the media reporting on the accusation, by Rida’s parents, that the Jehangir Hospital had been negligent. Without going into what exactly happened, the electronic media in particular propagated the notion that this death was due to medical negligence (1, 2, 3). The media glossed over the distinction between a pardonable error of judgment, a legally punishable gross error of judgment, and reprehensible negligence (which too of course is legally punishable) (4). Even Maharashtra’s health minister declared that Rida’s death was due to medical negligence. Jehangir Hospital as well as the Ruby Hall Nursing Home, which tested Rida’s throat swab for influenza A and B virus, maintained that they did nothing wrong (4).

Bungling of the throat swab

A detailed examination of what happened shows that on July 21, Rida was being treated by a private practitioner for fever, and her fever had come down somewhat. But when her fever spiked again she was brought to the casualty ward at Jehangir Hospital. This was at around 10.30 pm on July 27. Nobody suspected H1N1 flu and Rida was given antipyretic treatment and sent home. She was brought back to Jehangir at around 3 am on July 28 with fever and distress (breathlessness). Her chest x-ray and haemogram were done within hours of her admission. The results indicated pneumonia and hence antibiotics were started.

To be fair to Jehangir, till then, the official guidelines for suspecting swine flu referred only to a history of travel to a foreign country within the previous eight days or close contact with a known case of H1N1 flu. Rida met neither criterion. Jehangir Hospital can be legally and politically safe on this account. (Of course, in the context of the H1N1 flu epidemic, if any doctor had suspected H1N1 flu when she was admitted, that doctor would have earned laurels.)

When Rida did not respond to antibiotics and her pneumonia worsened, the doctors eventually suspected atypical, viral pneumonia and even H1N1 flu. Based on this inference, they sent the patient’s sample to the National Institute of Virology (NIV) for viral screening and to Ruby Hall’s laboratory to test for the presence of influenza A and B (this new flu is a sub-type of influenza A) which might have ruled out H1N1 but could not confirm it.

What transpired later is not very clear and is a matter of controversy. Did Jehangir contact Naidu Hospital as well? If so, in what way was the contact made? What was the response of Naidu Hospital? Did Jehangir Hospital tell the parents that all throat swab samples must be sent only to the NIV for “real time polymerase chain reaction” (PCR) testing for H1N1 flu? In the context of the epidemic in the city, why did Ruby Hall accept a throat swab sample for influenza A, B testing? Rida’s parents say that Ruby Hall told them verbally that Rida did not have H1N1 flu. Ruby Hall should have known that their test was not good enough to detect H1N1flu with certainty. Did they tell this to the parents? Jehangir issued a press statement to give its defence (5). But Jehangir was not ready to engage with the media on such questions, which raised more questions about Jehangir.

Only an expert committee which would have access to all the relevant papers and interview all the people concerned can find out what went wrong.

But the media was not interested in what exactly happened. It declared that Jehangir and Ruby were negligent.

It is clear that Jehangir was not negligent in the usual sense of the word of not attending the patient with due care. But Rida’s parents are bound to ask some questions: why was Rida’s throat swab sent to Ruby Hall? Why was it not tested in NIV? NIV does not accept samples from private hospitals for H1N1 flu testing. But why was no mechanism found to get her throat swab tested in NIV when her serious condition ruled out transfer to Naidu Hospital, which has no facilities to tackle serious patients and has no ventilators? It is questionable whether Rida would have survived if oseltamivir had been started after her admission to Jehangir, a couple of days earlier. This uncertainty arises out of the fact that she had already deteriorated a great deal when H1N1 flu was first suspected. But this does not condone the bungling of throat swab testing.

Public services inadequate but worked anyway

Most of the other H1N1 flu deaths in Pune have also been due to acute respiratory distress syndrome. Some of these patients deteriorated insidiously and did not receive oseltamivir in time. Nobody was geared to face these emergencies in the initial phase of the epidemic. Hence one should resist the temptation to blame the concerned personnel without taking into account the complexity of the situation.

The inadequate public health system in Pune was suddenly faced with the huge task of dealing with a rapidly spreading epidemic. The staff was initially overwhelmed but later swung into action. Privatisation ideologues should note that whatever may be the lacunae of public health services, Pune could face this epidemic only because of this system. Whether it’s a matter of doing “real time PCR” on hundreds of samples every day (costing at least Rs 10,000 per sample) or screening about a lakh people within a week for H1N1 flu through many centres exclusively doing this work, or the judicious use of the limited stock of oseltamivir, the private sector would not have been able to do all this. Moreover, providing all these services free of charge by the private sector would be out of the question.

Government rigidity and lack of dialogue

This epidemic did expose the weakness of the public health system – its worst failure was due to its rigidity and lack of dialogue with private doctors and the public. Central government guidelines in force when Rida Shekh died had only epidemiological criteria for selecting a person for H1N1 flu testing. Amongst those who had influenza like illness, those who had been abroad during the previous eight days, or had been in close contact with a H1N1 flu case, or those who resided in or had visited a community reporting cases of H1N1 flu, would be throat swab tested for H1N1 flu. They would be given oseltamivir if they were found to be positive. Neither Rida Sheikh nor some others who died of H1N1flu had this history. Many other people got H1N1 flu without this history. But for almost 10 days no clinical criteria were added to these epidemiological criteria.

What is worse, it was not announced that only those who fulfilled these two criteria would be throat swab tested. As a result, thousands of people who thronged to the Naidu Hospital and waited for hours together in a long queue were told to go back if they did not fulfil these two criteria. A proper announcement in the media would have spared the people and staff of these unnecessary queues.

After a week, throat swabs were taken only of people who had severe symptoms. But this too was not communicated to the people. As the death toll and cases of H1N1 flu mounted, more and more people with cold, cough and fever thronged to the Pune Municipal Corporation’s screening centres, only to be turned away without testing if they did not have severe symptoms.

Once it was established that it was an H1N1 flu epidemic, it was not necessary to test every suspected case of H1N1 flu and oseltamivir could have been given to a certain category of patients without throat swab testing. But the system was inflexible. Finally by August 14, it was announced that it had been decided to put cold, cough and fever cases into three categories based on clinical criteria. Private practitioners could cater to Category A patients. (Those with mild fever plus cough or sore throat with or without body ache, headache, diarrhoea and vomiting are unlikely candidates of H1N1 flu. It was decided that they should be given routine antipyretic treatment and observed for 48 hours.) It was also decided to give oseltamivir to certain patients without doing a throat swab test or without waiting for the report. These revised guidelines should have been published in all newspapers, and space bought for the announcement. This was not done. Only some papers published these revised guidelines verbatim. The Indian Medical Association was given a copy of these guidelines but though there was no way to immediately reach out to all doctors and people except through an announcement in the papers, this was not done.

The Jan Aarogya Abhiyan, Pune, the local outfit of the People’s Health Movement, through its press release on August 7 (6) and its letter to the district collector on August 11 (7), demanded that the guidelines be revised and communicated to doctors and the public through an announcement in the papers. But there was no response from the government. The only advertisement that the directorate of health services published was one threatening doctors that their registration would be cancelled if they did not cater to H1N1 flu patients.

No public private partnership

During the first 10 days the private health sector hardly played any role in controlling the epidemic, mainly because there were no guidelines from health officials to private practitioners on how to manage a suspected case of H1N1 flu. Second, private doctors reacted to the criticism of Jehangir Hospital by sending all patients with cough, cold and fever to Naidu. The government responded with threats but no instructions on how private practitioners were supposed to attend to these patients – when they should refer patients and where.

Later private doctors started attending to H1N1 patients, and some private hospitals agreed to admit patients with acute respiratory distress syndrome in their ICUs, but most private hospitals do not have the capacity to reserve and isolate one ICU for H1N1 patients. The Indian Medical Association offered to send volunteers to schools to talk to students; they also offered to send private practitioners to volunteer for a couple of hours a day at the corporation’s screening centres. But they wanted N 95 masks for these doctors and a stock of oseltamivir tablets with the IMA in case some doctors developed symptoms of H1N1 infection. This demand was not met. Experts from private medical colleges have been silent and have played no role. On the whole, the much talked about public private partnership has not materialised.

Conclusions from the Pune epidemic

The electronic media in particular sensationalised the controversy regarding Rida’s parents’ allegations that Jehangir had been negligent. The media also declared Jehangir to be guilty of negligence without trying to find out what went wrong.

Though Pune could face the epidemic only because of the public health system, this public health system was too slow in changing its guidelines in the face of the realities of the Pune epidemic. It also failed in communicating its strategy to doctors and lay people. This rigidity and lack of dialogue with the people caused a lot of unnecessary anxiety, unnecessary suffering of patients who stood in long queues, and unnecessary strain on doctors and other healthcare staff.

The role and responsibility of private doctors in such situations needs to be clearly laid down.

Can we expect a better performance from health officials and the TV media when there is a similar epidemic in the future?