Integrate

The key lesson

How is India responding to the crisis? In March 2003, the finance minister of Delhi, delivering his budget speech, promised more money so that the capital could become, as its chief minister has put it, "the flyover city of Asia". Think more road; give vehicles more space: this grand, now globally debunked, style of mobility management is precisely the mantra planners and politicians in India swear by. This in a nation where urbanisation and its resultant heartburns - congestion and pollution - are phenomenal.

More, not merrier
Between 1951 and 2000, while the total urban population in India increased just 4.6 times, the number of vehicles bounded up 158 times. According to the planning commission, transport demand in the country has grown at 1.2 times the gross domestic product growth rate. And metropolitan cities, with just about 11 per cent of the total population, have 32 per cent of the country's vehicles.Most of this increase is in the form of two-wheelers. According to a May 2000 article in the Indian Journal of Transport Managementin 1988 one in every 16 families in Bangalore owned a car and one in four had a two-wheeler. By 1998while there was a car per 10 familiesalmost every family owned a two-wheeler. Two-wheelers today form about 64 per cent of the fleet in Delhi and about 73 per cent in Chennai. However, in such cities, a shift towards cars is apparent. In Delhi, for instance, transport department statistics show 164 cars are registered every day, compared to 117 two-wheelers.

With the increase in number of vehicles, the rate of travel in urban centres is also shooting up. In Delhi, the average number of trips per person per day has increased from 0.49 in 1969 to 1.00 in 2001, says a household travel survey by Operations Research Group. There is also a rise in average distance traveled due to the physical expansion of the city.

Despite Indian cities having lower vehicle ownership rates than cities in developed countries, the problem of congestion is far worse here. In Kolkata, says Sudarsanam Padam, former director, Central Institute of Road Transport, Pune, the average speed during peak hours in the central business district (cbd) area is as low as 7 km/hr. Bangalore currently has average speeds of about 13-15 km/hr in its cbdbut this is expected to go down to 3-8 kms/hr in the next 15 years, says M N Reddi, the city's Additional Commissioner of Police (Traffic). According to Padam, congestion on Indian roads means a loss of Rs 300crore every year.

Public means pallid
An efficient and adequate public transport network is obviously a dire need. But when available rail and bus mass transport facilities provide only 37 million trips against a demand of 80 million trips per day by no means can such a system be called adequate or efficient. In fact, there has been a decline in the percentage share of buses from 11.1 per cent in 1951 to 1.3 per cent in 1997 for the whole country.

Dedicated city bus services are known to operate in only 17 cities and rail transit exists only in three out of 35 cities with populations in excess of a million. Even where they operate the bus service is grossly inadequate. While the bus fleet in Chennai Metropolitan Area increased just about three times between 1972-73 and 1996-97 passengers increased more than four times in the same period. In comparison between 1981 and 1997 the number of passenger cars went up by more than four times and two-wheelers by 11 times.

The failure to develop a reliable bus system has spawned various explanations: ancient crumbling vehicles; lack of skills or capacities of state transport authorities; a philosophy of loss-making and political pressure. Also, buses in India use the standard truck engine and chassis and so are not specifically designed for urban conditions.

Going urban with a vengeance The trend in India is demonstrably to move into metropolitan cities, especially from smaller urban centres
Year	Percentage of urban population living in cities with
	1 lakh and above people	Up to 1 lakh people
1901	22.9	77.1
1991	65.5	34.5
Source: Sudesh Nangia et al: ‘Road transport network and social interface in India’, B C Vaidya, Geography of Transport Development in India, Concept Publishing Company, New Delhi, 2003

India needs buses that are more energy efficient and less polluting, with lower cruising speeds, higher acceleration rates and lower payloads. Buses provide mobility to large numbers (see box: Any 'ayes' for public transport?). In a 1998 report for the (then) Union ministry of urban development and employment (now Union ministry of urban development and poverty alleviation)rites - a government enterprise of engineers, consultants and project managers - says: "The policy for various cities with regard to public transport will be that the cities with population up to one million would be fully dependent upon buses." A 2002 World Bank report concurs: "Priority should be given to strengthen and optimise bus services and every effort should be made to divert traffic from personalised modes to the public transport system." Cars, jeeps and taxis account for about 22 per cent of total vehicles and only about 10 per cent of the tax revenue, while autorickshaws account for 10.9 per cent of total vehicles and a disproportionately low 2.3 per cent of tax collections.

ntprc believes the road taxation structure in India should reflect factors such as vehicle price and capacity, its impact on traffic congestion and environment and damage to roads. Since older vehicles pollute more, consume more energy and are less roadworthy, the government should set statutory age limits for all types of vehicles used intensively. A road tax surcharge should be imposed on these vehicles to discourage their use and fiscal incentives should be given for their early replacement.

No space for roads Roadspace in most south Asian cities are abysmal
City	Roadspace as % of city area
Kolkata	6.4
Sanghai	7.4
Bangkok	11.4
Seoul	20.0
So Paolo	21.0
New York	22.0
London	23.0
Tokyo	24.0
Source: E A Vasconcellos, Urban Transport, Environment and Equity — the Case for Developing Countries, Earthscam Publications Ltd, London, 2001

Institutional logjam
Indian cities are perfect examples of how not to have an integrated institutional mechanism to manage transport. The responsibility of managing transport - policy, planning, investment, operations and maintenance, and management of urban transport-related infrastructure and services - is usually scattered among central state and local authorities. This, according to the World Bank, leads to debilitating institutional weaknesses. It creates a lack of technical capacity to manage urban transport, especially at the local level. Municipalities or states usually have no money to fund urban transport infrastructure to make new investments or put money into maintenance. They are hardly able to pay attention to cost recovery and user charges.

According to ritesthough it is not uncommon in different parts of the world to find several government agencies involved in urban transport the central issue in India is that responsibilities assigned to different agencies are rarely responsive to the cities' demands. Although public agencies are collectively responsible for nearly all aspects of urban transport (including planning)as individual agencies they operate only on the basis of departmental priorities and procedures rather than the city's needs.

Last November, a trader in Foshan, a small industrial town in Guangdong province in China, fell seriously ill with an incurable high fever and cough. He was suspected to be suffering from pneumonia, a non-infectious disease common in the area. But then four health workers who had been treating him in the local hospital also fell critically ill. This confounded Chinese clinicians. Initially, they believed this was just another variant of the flu and countered it with traditional concoctions and high doses of antibiotics.

To be sure, the affliction resembled any pneumonia or viral infection: moderate-to-high fever accompanied by shivering, headache and body ache; after three to seven days, the formation of dry, non-productive cough. Strangely, the Chinese authorities kept the outbreak under wraps.

The panic button was pressed only after conventional treatment methods failed and more cases of the strange fever surfaced.

Several strains of influenza or flu have been named after Guangdong province, where the first sars cases surfaced. This dubious distinction stems from the agricultural practices prevalent in the region. Rice fields support ducks and chickens, which feed on pig waste. The waste of one becomes the food of the other, resulting in a perfectly self-sufficient nutrient cycle. Helped by their ability to exist in faecal matter, conditions become ideal for viruses to evolve very quickly in different animals.

Luis Villarreal, director, Center for Virus Research, University of California, Irvine, usa, believes that China's otherwise ecologically sound agricultural systems facilitate recombination between silent viruses in farmed species and other organisms. This, he says, increases the likelihood of the emergence of new human infectious agents. "The domestication of the duck has brought a 'harmless' virus from its natural, aquatic avian habitat into the farmyard, with economic consequences for the poultry industry and serious health implications for humans," says Kennedy Shortridge, professor of microbiology at the Hong Kong University.

If this is the case, then highly potent zoonotic infections like Ebola kill many, but appear sporadically. sars is a zoonotic -- animal to human disease that belongs to the Coronavirus family. Often zoonotic viruses become less virulent over time and become part of the normal disease cycle of humans. sars could be one such example. The virus spreads today much faster because of the integration of the world air travel, large-scale migration and crowding in cities. Hong Kong, the airline hub of Southeast Asia, was successfully exploited by the coronavirus to spread to other countries.

Different types of flu viruses mutate in the body of a duck, pig or human. A new strain is considered created when an imperfect version of the original survives and re-infects its hosts successfully. Chances are that the previous strains would confer cross-immunity, but very often some viruses mutate once in each host or each generation thereby acquiring additional virulence. This genetic lottery makes viruses deadly.

The first coronavirus was isolated in 1937 which caused infectious bronchitis in birds, especially in chicken flocks. Since then researchers have found its cousins to infect cattle, pigs, horses, turkeys, cats, dogs, rats, and mice. Most coronaviruses cause either a respiratory or an enteric disease, and some do both. Coronaviruses are relative giants in the virus world. Their genome has more than 30,000 nucleotides and have a complex two-step replication mechanism. Like many rna viruses, it uses the host's nuclear material to produce all viral proteins. But coronaviruses have up to 10 separate genes and use a complex enzyme called replicase, to produce a series of enzymes. These use the rest of the genome as a template to produce a set of smaller, overlapping messenger rna molecules, which are then translated into the so-called structural proteins -- the building blocks of new viral particles.

There is another complication related to influenza, quite similar to the current sars problem. Varying population density and age structures may allow for coexistence of two strains. Changes in population density or transmission potential can alter pathogen virulence. Similarly, different people of different ages have different genetic make-up which make some susceptible and others not. The phenomenon of 'superinfection' by multiple strains, where one strain can infect a host already infected by a related strain, has been confounding scientists. Co-existence means the viruses can jointly manipulate the immune system and form a mechanism to evolve into new forms. Super-infection is a prerequisite for recombinant viruses and, therefore, for new strains of influenza-like viruses. Several strains of sars, if it follows an infectious pattern as the flu viruses, can be assembled in a single generation.

In September 1999, in a seminar organised by the us Centers for Disease Control and Prevention (cdc), based in Atlanta, Georgia, Guangdong was described as an influenza "hotspot". It was said to be the place of origin of the chicken flu virus that caused deaths and widespread panic in Hong Kong between March and early December 1997. The virus was identified as h5 n1 (see: Down To Earth, January 15, 1998). In November 2001, the European Commission's (ec) Health & Consumer Protection Division found food contaminated with avian influenza strains. In this report cdc had pointed towards a need for an effective surveillance system. It is unclear if China lacks a national surveillance system, or if sars is the result of government policy of information control and clamp down.

According to cdc, China has been a source and reservoir for many other recent epidemics and outbreaks. Hantaan virus, the cause of Korean haemorrhagic fever, causes over 100,000 cases a year in China. In 2002, the Crimean Congo haemorrhagic fever and new varieties of pertussis (whooping cough) have re-emerged here.

Between March 25 and 27, 2003, two different groups of researchers in the cdc and Hong Kong University announced that a previously unrecognised coronavirus could have caused the sars epidemic. This family of viruses is the second leading cause of colds in children and premature infants but has never been perceived to be a serious health threat. Other labs in Hong Kong, Germany and Singapore proposed that another virus from the family of polymyxovirus could be a helper or a cause of co-infection in sars. But on April 15, the who confirmed that monkeys experimentally infected with a new coronavirus developed an illness similar to sars.

Close contact with infected persons raises the risk of contracting sars. Transmission usually takes place through direct contact with respiratory secretions and body fluids of patients. But another recent discovery that it can survive in human faeces implies that unhygienic conditions even in homes -- like moist toilets and sinks -- could enable the virus to survive for long periods of time. The people who checked into the Metropole hotel in Hong Kong show that the virus can endure in the area for several days and drift through airspaces into other rooms. In e-block of Amoy Gardens apartments in Hongkong, where 213 people got infected, it is believed to have spread through leaking sewage pipes and drains. "If the sars virus can infect from faeces and is capable of spreading via airborne sources, then we have a persistent killer on our hands," says Kiwana Thapurkakorn, influenza virologist at the Royal University of Bangkok. Cockroaches too have been alleged to carry the virus. Another strange mode of spread of sars is that some individuals spread the virus more prolifically than others. Doctors are still not sure if such patients carry an especially infectious form of the virus or whether some other factor, such as behaviour, was the cause.

What is perplexing is that who confirmed on April 19 that fatality rates have risen to 5.1 per cent of the infected population from 4 per cent at the beginning. Does this mean that the virus is becoming more virulent? Or does it simply mean that treatment is inadequate?

Antivirals like ribavirin supplemented with steroids have been suggested as treatment for full- blown sars.

Testing time
The who and cdc have a clinical diagnostic protocol for those affected by sars. They have laid down clear-cut guidelines in order to prevent suspected patients from coming into contact with infected people.

A team of scientists in the department of microbiology, University of Hong Kong, was the first to succeed in culturing the viral agent that causes sars. Using a special cell line, the Hong Kong scientists isolated the virus from the lung tissue of a patient who developed pneumonia following contact with a professor from Guangdong. Both persons have ince died. The scientists have devised a basic test that relies on neutralising antibodies. This "hand-made" technique will now be developed into a more sophisticated diagnostic test.

India's Mumbai-based srl Ranbaxy Limited is checking for the presence of coronavirus with its influenza test panels. These can be used to identify Influenza a virus, Influenza b virus, parainfluenza virus, respiratory synctial virus (rsv) and enterovirus. According to the company, if the virus does not turn out to be any of these, the disease can be assumed to be sars. "This is a diagnosis by exclusion," says Shishir Malwankar of Ranbaxy.

On April 16, the Institute of Medical Research in Malaysia and Germany's Hamburg-based company Artus announced that they had developed the first and only commercially available diagnostic kit. Since April 12, Singapore has used a high-tech thermal-imaging thermometer at Changi airport. The device automatically checks the temperature of air travellers as they step off the plane. These sensors alert health authorities to quarantine and isolate an infected person.

But sars is slippery. Singapore's ring-fence approach -- cordoning off the infected-seems to have suffered a setback when another hospital in the city was declared to have a patient of sars. Hong Kong on the other hand has had a significant rise because it believed in voluntary measures (self-reporting) rather than the military-style quarantining in Singapore. Germany, too, was able to isolate the single victim that reached Frankfurt airport and is reportedly keeping a keen watch.

In India, the first confirmed case in Goa was found to be a passive carrier who had crossed the "window" period. "As per who norms, the patient was released but asked to take rest and remain indoors," said Suresh Amonkar, Goa's health minister. Till Down To Earth went to press, the Pune case was the only active and confirmed sars case. A neighbourhood in Mumbai has been reportedly cordoned off by the hapless state government.

Singapore airport uses tempera (Credit: AP / PTI)

sars is a stark reminder that there is no universal safeguard against infectious diseases. The syndrome has actually exposed the lack of preparedness with regard to infectious diseases -- from hospitals, public hygiene and sanitation, to access to drugs.

David Heymann, executive director of the communicable disease programme at who, believes that emerg-ing infections can be controlled by containing known risks, responding to unknown risks and improving preparedness.

When the case made headlines on March 12, in Hong Kong, it was found that the syndrome has devastated the Chinese healthcare system. With the virus reaching distant provinces and even Mongolia, Chinese authorities have been forced to clamp down on migration between villages.

While China dithered, Singapore responded by quarantining even its healthy citizens and shut all schools after the first sars death. Taiwan has successfully prevented a potential public health crisis from mainland China and Hong Kong through its stringent seven-level surveillance systems operating since l999. These include monitoring of poultry markets, wild birds and pig stocks. An active repository of flu virus strains is maintained that keeps track of the presence of any new strains.

In India, the two nodal agencies responsible for detecting and diagnosing suspected sars cases are the New Delhi-based National Institute of Communicable Diseases (nicd) and National Institute of Virology (niv), Pune. niv would receive all samples from tests and would present results within four days. "As a precautionary measure, the Union government is only screening all incoming passengers at the international airports and ports," reveals a nodal project officer of nicd. Further, all hospitals dealing with infectious diseases in the country are required to report suspect cases to the nicd. Cases detected in any state should also be reported to the Directorate General of Health Services (dghs). The dghs would then intimate the nicd and send samples to the niv.

Global preparedness against infectious diseases in recent times has been from the perspective of bioterrorism. But this cannot address the possibility of prevention from an ecological perspective. Through better sanitation and disciplined monitoring, and understanding what ecological changes can trigger release of microbes, governments can ensure that they keep ahead of outbreaks by microbes.

What is the actual cost of preparedness? A study by Dutch researchers found that an additional investment of us $120 million would be needed to avoid influenza-related mortality. But then, even a "prepared" country like the us has looked uncertain in its approach towards sars. A study by Martin Melzer and his associates at cdc estimate that for flu control, if the current strategy is employed unchanged, would cost the economy us $71.3 billion to us $166.5 billion annually.

Meanwhile in China, international crisis management efforts are underway. The cdc has activated its emergency operations center. A similar initiative has been taken up by who in Hongkong, Beijing, Shanghai and Geneva. With who's assistance, China has developed a national sars reporting system and elevated sars to the status of cholera and yellow fever. Law & beyond
To some extent, the crisis spawned by sars is a failure of global health governance. The International Health Regulations (ihr) -- a set of rules proposed by the who -- are a legally binding framework for preventing the spread of disease across the world. These laws, however, focus on plague, cholera and yellow fever. They have not been modified significantly enough since its inception in 1969 or recent amendment in 2002.

The World Health Assembly in Geneva is specifically authorised to administer "sanitary and quarantine requirements and other procedures designed to prevent the international spread of disease". But current regulations are also restricted to the three diseases and based on outdated quarantine practices.

Even if ihr's scope was expanded to cover all infectious diseases, implementation of health-based trade barriers by member nations would throw a spanner in the works. Driven by political and economic pressures, neighbours and trading partners of countries affected by epidemics often overreact. The restrictions they impose are far in excess of those permitted by the ihr.

sars has curtailed liberty, where individual rights are pitted against public health imperatives. Legal action can now be enforced to isolate, hospitalise, and quarantine individuals. Singapore's authoritarian government had no such reservations in imposing strict quarantines for doctors and suspected patients. A more people-friendly and cosmopolitan Hong Kong, on the other hand, did not quarantine at first, and recommended isolation, which led to rapid spread of sars. In the long run such leniency will prove expensive. Enforcing strict quarantine will cause temporary loss of liberty but it is a decision that can prevent health damages of an unforseen nature. sars created a wave of xenophobia -- both in a tolerant Asia and in the intolerant west.

The only strict action that the World Health Assembly is authorised to take under "exceptional circumstances" is to withdraw membership privileges of a country. But such sanctions would also hinder the who's objectives of tracking, controlling and preventing incidence and transmission of disease.

who has been criticised for relying solely on information provided officially by member states regarding outbreaks within borders. Fearing self-incrimination, countries do not report diseases -- as in the case of the sars episode. Unfortunately, the current who regime gives individual nations the liberty to determine whether a disease constitutes a public health emergency of international concern. To some extent, the who's Weekly Epidemiological Record (wer) under the ihr and Global Outbreak Alert and Response Network have helped plug the loopholes. For example in the sars case, the wer reported the sars incidence only by January, almost two months after the first case occurred in Guangdong.

Villarreal is sceptical about legal measures: "Although a new body on international law could well decrease the likelihood of such events, laws alone will not control disease emergence. This phenomenon is possibly inherent in all living systems so I don't expect it to be eliminated."

The fallout
Hong Kong, Singapore and Malaysia have received bad economic hits. Tourism has fallen by more than 20 per cent. Hong Kong's pre-sars gross domestic product (gdp) projection of 3 per cent for 2003 is now down to 1.5 per cent, according to Dutch Investment firm ing Financial Markets. Tim Condon, ing's chief Asia economist, observes: " sars appears to be a more serious threat to regional growth than the war in Iraq." Regional forecasts done for these countries by Merrill Lynch also show lower growth. Ironically the gdp of China is expected to go down by a mere 0.1 per cent. This is because China's agricultural and manufacturing base can offset losses to tourism and the services sector. Airlines, cargo and courier services and the telecommunication industry have been affected worldwide. "If the sars episode is linked to domestic animal origin, then we can see a significant decrease in the near future of agriculture exports largely because countries will put non-trade barrier to goods from the region", opines John Cheung, director of international trade services, government of Taiwan.

The battle may have just begun.

Story co-ordinated by Pranay G Lal, with inputs from D B Manisha, Sarita and Vibha Varshney.