Article
Managing Dengue Outbreak in Lahore, Pakistan: Efficacy of Government Response and Lessons for the Future
Journal of Health Management 16(4) 471–480 © 2014 Indian Institute of Health Management Research SAGE Publications Los Angeles, London, New Delhi, Singapore, Washington DC DOI: 10.1177/0972063414548559 http://jhm.sagepub.com
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Iram Anjum Khan Faisal Abbas
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Abstract This article aims at exploring and analyzing reasons for the spread of dengue outbreak in Lahore, Pakistan, in 2011. This led to about 300 deaths. Also, this study intends to review the appropriateness of government response in managing the dengue outbreak. The contributing factors in the spread of dengue disease included, among others, the demographic structure of Lahore district, environmental conditions, and urbanization and slum development with lack of health facilities. Furthermore, managerial and coordination failures at the level of city district government aggravated the situation. The governance failure was manifested by the non-framing of dengue disease as a public policy concern, especially when it had affected almost 4,500 persons leading to three deaths in the year 2010. There were coordination failures with tertiary level health institutions, and the city government was unprepared. Concrete and effective steps were taken when chief minister of the Punjab province intervened personally. The strategy adopted by the provincial government was so successful that in the year 2012, there were only 252 dengue cases and no deaths were reported. However, there is still need to improve coordination at the city government level and to institute a preventive regime to manage an outbreak in the future.
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Keywords Dengue epidemic, public health, health management, health systems, Pakistan
Introduction Dengue fever (DF) is globally accepted as one of the most rapidly spreading vector-borne viral diseases.1 Current estimates are that 50–100 million people are infected by it every year (Jahan 2011; Porter et al. 2005; Sherin 2011). It has non-specific signs and symptoms (Hakim et al. 2011) and lacks specific treatment (Sherin 2011). Only about 1 to 3 per cent dengue patients are diagnosed with dengue haemorrhagic Iram Anjum Khan, Assistant Professor, Department of Management Sciences, COMSATS Institute of Information Technology, Park Road, Chak Shahzad, Islamabad 44000, Pakistan. E-mail:
[email protected] Faisal Abbas, Assistant Professor, Department of Management Sciences, COMSATS Institute of Information Technology, Park Road, Chak Shahzad, Islamabad 44000, Pakistan. E-mail:
[email protected]
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fever (DHF), requiring hospitalization and careful fluid management (World Health Organization (WHO) 2010). South Asian region has been found conducive to the spread of dengue and DHF. In 2011, virus appeared in Lahore in the monsoon season, and though the number of suspected cases were 496,490 (WHO 2011), those actually infected were much less (see Figure 1). Figure 1 also substantiates the panic-cum-crisis hypothesis when people started attributing even simple cold to dengue virus, which lab tests showed was not the case. Analysis of data reported by WHO (2011) also indicates that out of all suspected cases, about 4.15 per cent were found confirmed as dengue patients. Media further contributed to the panic when it showed scenes of long queues outside hospitals and reported deaths occurring due to the disease. Scale of the outbreak, panic in the city and almost complete helplessness of the city administrators, health officials and provincial government require that the whole episode spanning several months be investigated. This article discusses reasons for the spread of the disease in the city of Lahore, the appropriateness of government response for managing it and the challenges for containing dengue virus in the future (especially in cities as populated as Lahore). The article is based on both primary and secondary sources. The primary sources of information are the concerned public health officials in the city of Lahore. Different officers at City District Government, Lahore, were approached to share their experience and knowledge of DF in the city, and discuss the effectiveness of government response. For this purpose, an unstructured interview guide was prepared and used at the time of interviews. The persons approached were four officials of City District Government, Lahore, namely Director (Health), Executive District Officer (EDO Health), District
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Figure 1. Confirmed and Suspected Dengue Cases in Lahore (22 September–29 November 2011) Source: Punjab Health Line (www.dengue.punjab.gov.pk). Accessed on 14 June 2012.
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Officer (DO Health) and EDO Finance, as well as one health practitioner who attended training sessions conducted by Sri Lankan experts, and who subsequently imparted training to his colleagues. The field work also included interviewing one Sri Lankan expert who described his country’s experience of dengue virus management. The secondary sources are data and information available in published form by the federal and provincial governments. The rest of the article is organized as follows. The following section gives an overview of the dengue disease in Pakistan. The next section gives basic information about the city of Lahore, its population and health infrastructure, etc. Then different steps taken by the government for managing DF are discussed, followed by discussion on reasons for the failure of government response. The last section analyzes the efficacy of plans for the future and sums up the discussion.
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Dengue Disease in Pakistan
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Historically speaking, dengue virus has been endemic in the southern parts of Pakistan. The first dengue outbreak was reported in 1994 in Karachi (Chan et al. 1994; Vijayakumar et al. 2005) in which one dengue patient died. Since then, various studies have pointed out dengue epidemics in different parts of the country (Jamil et al. 2007; Siddiqui et al. 2009). In October 1995, for example, 57 persons were found suffering from dengue virus in Hub Chowki, Southern Baluchistan. In October 2003, a dengue outbreak was reported in the northern part of the country in the semi-mountainous districts of Haripur, Khyber Pakhtoonkhawa, and Khushab, Punjab, that claimed 6 lives of 717 reported cases. In October 2005, Karachi was hit by dengue and this time there were 21 deaths out of total 103 confirmed cases. In 2006 again, about 4,750 people were infected and 50 lives were lost (Ahmed et al. 2008). Since then, the disease has been seen as a major public health concern in Pakistan by health practitioners with 26,270 cases and 156 deaths till 2010 (Jahan 2011). In Lahore, the first dengue outbreak was reported in 2009 when more than 1,300 people were affected. In 2011, the number of suspected cases increased to around 496,490, while the number of deaths were more than 300 (WHO 2011). The news reporting and hype created by the media created panic in the city. People visited hospitals and clinics for DF tests even in the case of a sore throat, suspecting that this might be the beginning of a dengue attack. The health infrastructure, which could hardly cater for a normal medical situation, was overwhelmed with requests for the DF test. The result was that government lab facilities proved inadequate, allowing private labs to charge as much as PKR 500 (about 5 US dollars)2 for the tests. A large number of suspected dengue patients were admitted in hospitals. There were around 3,000 such patients in, for example, Jinnah Hospital alone from 15 August to 13 December 2011. If we analyze the spread of dengue virus in the city, it had three peculiar characteristics. First, it was mostly concentrated in the urban areas of Lahore metropolitan, which accounted for 73 per cent of total dengue infections. Second, though the disease affected almost all age groups, the group (63 per cent) that suffered the most fell between 15 and 44 years (WHO 2011). Third, predominantly the male population was affected by the disease. The last two reasons can be attributed to the fact that it was the most active/ mobile and economically productive group, visiting places like academic institutions, offices (other work places) and markets during day time.
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Lahore: Demography, Health Infrastructure and Its Administration
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Lahore metropolis with a population of 6.69 million is the world’s 40th and Pakistan’s second largest city (Punjab Bureau of Statistics 2011). It is overcrowded, with a population density of 8,029 persons per kilometre in 2006 (Mazhar and Jamal 2009), getting thinner from city centre to suburban areas. According to Punjab Bureau of Statistics (2011), health infrastructure in the city included 42 hospitals, 121 dispensaries and 50 basic and rural health centres. The indoor treatment capacity was 12,850 beds. This infrastructure was in addition to 44 private sector hospitals. Almost 92 per cent of the population could physically access a hospital within 30 minutes. An overview of the public health management system in the city of Lahore is given in Figure 2. It shows that District Coordination Officer (DCO), the administrative head of the city, was responsible for coordinating all functions between various departments and offices operating at the district level. These included health, education, agriculture, revenue collection and community management. The public health department was headed by an EDO, who was assisted by a DO and a Deputy District Officer (Health). At the provincial level, the health department was headed by Director General (DG Health) responsible for operational matters, and Secretary Health, who looked after public health policy and its development. Administratively, EDO (Health) reported to the DCO for coordination at the local level, while he was accountable to DG (Health) for carrying out his functional responsibilities. The city’s several large public sector hospitals also reported directly to the Secretary Health and provincial government, bypassing the DCO. Lahore, being the provincial capital and the largest city of the Punjab province, also had a number of autonomous bodies that contribute to public health management, but reported directly to the provincial
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Indicates that there is one-way coordination and reporting.
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government rather than to the DCO (see Figure 2). These included, among others, Lahore Development Authority, Water and Sanitation Agency (WASA), Solid Waste Management Company (SWMC) and Punjab Horticulture Authority (PHA).3 This administrative polarization limited the effectiveness of the DCO as a coordinating officer. The introduction of the district government system in Punjab in 2001 also eroded his pivotal status as the lynchpin of administration at the district level (Khan and Ghalib 2012), and this has persisted even after the district government system was rolled back in 2008. Town and Municipal Administrations (TMAs), part of the City District Government of Lahore, had their own rudimentary public health management system, primarily responsible for the spraying of insecticide and fumigation to pre-empt malaria. However, they were constrained by shortage of staff and lack of technical expertise to tackle the situation. They reported to the DCO, though in the now defunct District Government (Zila Nazim) set-up; they also used to work independently of the DCO (Khan and Ghalib 2012). The above discussion shows that there was unnecessary overlapping and bypassing of higher authorities in the present city district government health management system.
Government’s Response to Dengue Epidemic in Lahore
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The government’s response to the dengue epidemic can at best be called a ‘knee-jerk’ reaction. The outbreak started in July 2011, with the start of monsoon season. Ideally, the DCO should have handled the situation locally. However, the scale and severity of the disease as well as his inability to coordinate due to diminished authority, as discussed in the previous section, forced the chief minister to intervene personally in September 2011, when the disease had turned into an epidemic. Thus, two months of critical time was lost for managing the disease, which contributed to the spread. A Central Emergency Response Committee (CERC) was formed which, in addition to bureaucrats, included local politicians and members of parliament. The Committee held daily meetings to allay the media and appease the agitating masses. With the help of CERC and other district and provincial level functionaries, government took different measures to curb the outbreak of dengue which are briefly described in Box 1. In the absence of a proper public health management system, it was crisis management at its extreme. At the height of dengue crisis, all meetings at the provincial levels were postponed and the whole provincial government machinery was engaged in its control and management. The chief minister of Punjab started holding daily meetings, which would start early morning (around 7 am) and continue until noon. The secretaries and heads of different departments, for eample, health, agriculture, environment and horticulture, would attend them. The idea was to coordinate and integrate the efforts of all the departments and synergize their resources. Provincial government allowed the recruitment of additional 1,500 health personnel to manage the situation. In early September 2011, schools, colleges and universities were closed for 10 days for intensive spraying (Shakoor et al. 2012). Realizing that mosquitoes need to be completely eliminated, the provincial government allocated PKR 450 million for spraying larvicide and fungicide. Similarly, the number of platelet counting machines was increased from 8 to 60 at a cost of PKR 240 million. However, Sri Lankan experts who visited Lahore during the dengue outbreak pointed out subsequently that blood transfusion for increasing platelets was not required. PKR 80 million was also used for the import of 100 blood test machines.
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Box 1. Measures by Punjab Government after Dengue Outbreak in Lahore 2011
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Institutional Measures: • Establishing a province level task force and steering committee to be headed by Chief Minister and Chief Secretary of Punjab, respectively. • At district level a district implementation committee formed under the aegis of DCOs. • Chief Minister Dengue Research and Development Cell established in Lahore for the purpose of carrying out applied and operational research in dengue. Technological Measures: • Provincial Government emphasized on utilizing latest technology in combating against dengue epidemics. • Online system of dengue surveillance put in place. • Global positioning system (GPS) mapping of dengue cases, vectors and digital monitoring of dengue prevention and control being carried out. Environmental Measures: • Environmental management measures taken, for example, proper disposal of waste water, repairing leak pipes and plumbing system, using water filter for drinking water, management and regulation of used tyres, etc. Health/Medical Infrastructure: • Isolation wards established in teaching hospitals and dependency units having all facilities. • 200 extra beds in every teaching hospital allocated for dengue patients. • 10,000 insecticide treated bed nets provided to each teaching hospital for dengue isolation wards. • At Jinnah Hospital Lahore, Children Hospital Lahore and Lahore General Hospital, cell separator machines with platelet kits made available on urgent basis. • Remaining hospitals got centrifuge machines for platelet segregation. Capacity Building Measures: • Sri Lankan and Indonesian experts reviewed the strategies and provided guidance on larva surveillance and capacity building on vector control and case management. • 875 sanitary patrols, 337 CDC supervisors, 292 LHWs and 66 data entry operator job positions created.
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Source: Economic Survey of Pakistan 2011–2012.
A toll-free hotline titled ‘Punjab Health Line Project for Dengue’ provided basic information about dengue disease, and informed general public which hospital to approach in times of emergency and for treatment. Experts educated the public about the symptoms of dengue disease. The Social Welfare Department launched public awareness campaigns, and 49 camps were established in Lahore for this purpose. UNICEF and WHO helped distribute 1.5 million pamphlets in the city. Private laboratories were put under legal obligation to charge only PKR 90 for complete blood count test. Previously, they were charging as much as PKR 500 per test. The extent of panic can be gauged from the fact that Special Branch, Punjab police, was directed to independently monitor the efforts of all the stakeholders and generate a report on a daily basis, while daily progress report on disease spread monitoring was compiled from hospitals by the Irrigation Department. Journal of Health Management, 16, 4 (2014): 471–480
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Reasons for Poor Government Response
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There are several reasons that aggravated the dengue situation in Lahore in 2011. These can be broadly classified into two categories. The first one relates to demographic and geographic factors over which the public health officials had little or no control in the short to medium term, while the second one relates to government inefficiency and mismanagement, which should have been avoided. These are discussed in the following. Lahore is one of the oldest cities of Pakistan with high population density, and has been expanding at a very fast pace due to high birth rate and rural to urban migration (Mazhar and Jamal 2009). The result is the establishment of a large number of katchi abadis (urban slum areas). Open sewers and jointly used leaking municipality taps provided ideal breeding ground for the dengue vector. High population density also meant that once the contagion started, it was difficult to stop it. The monsoon spell during late June to mid-September 2011 provided a suitable environment for dormant eggs survived from the 2010 dengue epidemic to hatch larvae.4 Like other countries, its breeding sites existed both inside and outside the houses. These were in the form of stagnant water in lawns/parks, flower pots, air conditioners, room coolers and water drainage pipes etc. Tyre stores and open tyre shops in commercial areas also proved safe havens for the virus (Jahan 2011; WHO 2009). By the time, the public health authorities reacted to the situation, the larvae was already a fully grown vector. The paramount governance failure was manifested by the non-framing of dengue disease as a policy concern, especially when it had affected almost 4,500 persons leading to three deaths in the year 2010. The result was that when the dengue virus spread, the city district government was not prepared for it. There was ineffective spray regime, poor spraying techniques, issues with the quality of chemicals and serious resource constraints that impeded timely intervention. However, the biggest constraints were lack of dedication and commitment towards the cause.5 The government also failed to understand the importance of prevention in dengue epidemic, with the lowest priority accorded to preventive health care. This assertion is backed by the fact that budgetary allocations for preventive health care amounted to only 7.2 per cent of city government’s health budgets during 2011–2012. With this low allocation, 75 per cent of the preventive health funds were earmarked for salary and other fixed expenditures,6 leaving little room for awareness campaigns and other measures. The organization of public health infrastructure in the city led to serious issues with coordination leading to mismanagement. DCO, Lahore, had little resources and authority to tackle the epidemic. Though responsible for the primary health care infrastructure of the district, he could not involve the city’s hospitals in the campaign against dengue, which were under the administrative control of Provincial Secretary, Health. Different autonomous agencies also tried to guard their independence and autonomy. Another immediate reason was that the entire sanitary staff of Lahore District Government had been transferred to Lahore Waste Management Company, and that staff refused to work for dengue virus eradication. The result was that no effective and coordinated steps could be undertaken until the dengue virus had turned into an epidemic and the chief minister was forced to intervene to ensure coordination between different government departments. The medical practitioners had little knowledge and no experience in treating dengue patients. It was only after the arrival of Sri Lankan experts that seminars were held and local medical practitioners were educated about the management of dengue patients and the epidemic. Since the safe havens for the dengue virus were ubiquitous, it was practically impossible for the government to enter every house in the city and remove the breeding sources. It was crucial to involve civil Journal of Health Management, 16, 4 (2014): 471–480
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society in the elimination of larvae and adult vectors. However, no public awareness campaign was launched in the initial days of the outbreak. The result was that the focus was mainly on clinical treatment even after it had become clear that the best mode of combating the disease was through community participation and changing the social approach.
Planning for the Future
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The dengue epidemic in 2011 proved to be an eye-opener for the district and provincial governments. The chief minister took effective and concrete measures to pre-empt the outbreak in future. Another outbreak could potentially be a political disaster for him, as the federal government was run by a political party opposed to him. The following paragraphs highlight medium- to long-term steps taken by the provincial government in late 2011 and early 2012. A provincial cabinet committee was formed to oversee the preparations to combat dengue. This committee included politicians and secretaries of the concerned departments, such as health and agriculture. In addition, province level task force and steering committee headed by the chief minister and chief secretary of the province, respectively, were also put in place. Another initiative was the establishment of Chief Minister Dengue Research and Development Cell to undertake applied and operational research on the disease. A dengue wing was also created in the health department which is headed by an additional director general and aims to closely monitor and review the situation during every monsoon season. Another important step was amendment in ‘The Punjab Epidemic Disease Act 1958’ in October 2011 that has allowed data collection from all health-providing facilities as well as the inspection of places affected by dengue. Previously, dengue was not included in the list of such diseases. Public health managers who had received anti-dengue training from Sri Lanka and Thailand acted as master trainers and imparted training to other professionals regarding preventive and curative measures. WHO also coordinated the training of 60 more master trainers. Provincial government arranged seminars and provided informative material regarding preventive measures against dengue. For this purpose, an international conference was held on dengue control in February 2012. In addition to public sector schools and colleges in Punjab, awareness campaigns have also been launched at private educational institutions. The aim of the social advocacy is to prevent, control and exercise community surveillance on the disease. On the side of health infrastructure, the capacity of public sector hospitals to handle dengue cases has been increased to 2,350 beds. This is in addition to 500 beds made available in private hospitals. 150 dispensaries have been converted into dengue filter clinics and provided with testing equipment. 1,000 nurses have been recruited for the tertiary hospitals of Lahore. In February 2012, high dependency units were established in the teaching hospitals of Lahore for critical patients. The health department has also appointed public health officers in each of the nine towns of the city and made them responsible for implementing plans for the prevention and control of dengue disease spread. A cornerstone of this strategy is that dengue was considered a reflection of social and environmental problems that took on medical dimension. Once effective preventive control measures were put in place, the clinical approach to the disease became a secondary component of an overall anti-dengue strategy. As a result of these steps, there were only 252 reported cases of dengue in 2012 in Lahore and no deaths occurred.7 The panic that had gripped the city in 2011 was nowhere to be seen in 2012. Compared Journal of Health Management, 16, 4 (2014): 471–480
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with Lahore, there were four deaths in Karachi with more than 700 suspected dengue cases registered by health authorities.8 This shows that the strategy adopted by the Government of Punjab for managing DF was a successful one. Proactive and broad involvement of all stakeholders made it possible for the provincial government to control dengue virus.
Conclusion
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The success of the dengue management strategy can be attributed to the initiative of the chief minister. Unfortunately, despite personal interest taken by the chief minister, institutional bottlenecks continue to persist due to myopic vision and prevalence of administrative expediency. Budgetary allocation for preventive health care continues to remain miniscule with the result that in case of another outbreak, sufficient funds will not be available for media campaign or spraying activities. Ingrained weaknesses in the coordinating role of DCO have also not been removed. In case of an emergency, he has no administrative authority to rely on the support of autonomous agencies or tertiary medical units. Dengue is closely related to the society (community) and the way it organizes its livelihood. The experience of Lahore in the years 2011 and 2012 shows that there is a need to develop an optimal solution for instituting a comprehensive and sustainable policy regime which has the ownership of the public and private sectors as well as the involvement of community at large. This requires close institutional linkages and inter-agency coordination, specific job description, training and social awareness. The best way to control dengue is to prevent it.
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1. Before 1970, only nine countries had experienced dengue disease. However, the number increased to more than 100 in the year 2004–2005 (WHO 2009). 2. 1 US dollar = 99.50 Pakistani rupees. 3. This is an excerpt of the district administration in Lahore. The full organogram of city district government is very complex and not relevant to this article. Hence, we rely on rather simpler version to elaborate our point as to how various administrative bodies interact and coordinate in times of crisis (e.g., public health crisis). 4. Interview with District Officer (Health), City District Government, Lahore. 5. Interview with EDO Finance, City District Government, Lahore. 6. Budget Documents 2011–2012, City District Government, Lahore. 7. http://dawn.com/2012/11/11/steps-of-punjab-govt-against-dengue-hailed/ 8. http://archives.dailytimes.com.pk/karachi/13-Dec-2012/4-dengue-fever-deaths-reported
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