K. Sujatha Rao served as Union Secretary, Ministry of Health and Family Welfare for the Indian government, until 2010, where she was involved in the process for a national policy for use of antibiotics, introducing vaccines in public health, and the first-ever national programme for non-communicable diseases. Her extensive experience in government puts her at the very heart of the debate on the global coronavirus ( COVID-19) pandemic, especially questions surrounding system preparedness in India.
Do you think that there’s a higher risk of infection cases surging in rural areas after the lockdown was announced and large numbers of migrants moved out of the cities?
We are not getting the sort of data we need for such an analysis, to answer that question on urban versus rural. We know that 30% of districts today have shown some sign of infection. But is it still continuing to be a metro or semi-urban phenomenon, or has it penetrated rural areas – we don’t know until we get the locations of the cases and an analysis from each State. This also applies to other categories such as gender and age.
Having said that, it is normally believed that since migrants have gone into rural areas, they are likely to be spreading the infection there. If, as the government says the virus hasn’t penetrated the community yet, continues to be a locally transmitted infection, and is very much in a containment phase around hots pots, then the source of infection assumes importance. It has come mainly from those middle class people who have been abroad and come back to India.
The probability of these middle class individuals could have had these symptoms and the infection intermingling with informal workers is the point that we need to think about as the reason for spread into rural areas. There is a class dimension to this infection that needs to be understood.
Regarding India’s preparedness in terms of public health infrastructure, especially in rural areas, how ready are we to deal with cases there? At points of contact such as the Primary Health Centres at the village level, what mechanisms exist to actively stop transmission, and TO treat the patients who have been identified?
Let’s look at the medical system in India. The answer depends on how many people get infected. Whatever the number be – and not just in rural but also in urban areas – the health system will be overwhelmed. I don’t think we can handle a big number of critical cases even in the urban, metro areas. We don’t have that infrastructure. We have a very weak health system.
There is also a substitution effect going on. That means, if there is a large number of people coming in, the rooms have to be vacated and isolation wards have to be set up. It is not that we have spare capacity in our government or private hospitals – we are substituting other patients, people who have come in for elective surgery, non-serious cases and so on. There is this stress on the health system as such.
In rural areas the PHCs cannot handle such stress. It requires massive training and information dissemination to tell each healthcare worker and doctor what protective measures to take. According to the data put out on this infection, only about 5% of identified cases may need hospitalisation and 80-90% can treat themselves by staying at home. It is a self-limiting disease. Even in the UK, doctors are consulting with patients on the telephone, prescribing medicines and the medicines are being left at the patients’ doorsteps. The patient remains in self-quarantine. So, this infection doesn’t need that much treatment in that sense. It is possible that if there is good communication with the PHC and district hospital specialists, they will relate the symptoms with the right medication and the patient will be isolated until they recover. Those who are serious will of course need intensive-care treatment and ventilator support and that is acutely in short supply. If the number of cases in this category is at a manageable level, we will be lucky, but if it goes up manifold, say twenty to a hundred times the present level, then we will have a real challenge on our hands.
The problem with the novel Coronavirus is the rate at which it spreads, how infectious it is. The concern is that if we are looking at a large total number of cases, even 5-10% of that total as hospitalisation cases overwhelm whatever health infrastructure is available. In that context, has the government’s preparedness moved in tandem with the disease so far?
There are two levels of preparedness. One is to get the health infrastructure into shape, and that is exactly what the public health systems at the Central and State levels are focusing on right now, during the lockdown period. In fact, part of the rationale for the lockdown was to pause and take time out to sort out the infrastructure challenges, in case of a surge. That is the reason why the government has now placed orders for ventilators and PPEs.
Yet in places like the well-known Gangaram Hospital in New Delhi 110 doctors are already in quarantine. We cannot afford to have the few doctors and nurses that we have, who can give the kind of specialised treatment that the Coronavirus infection necessitates, to get infected and be sent off into quarantine. It is not easy to treat people in the ICU for lung infection. It requires specialised skills and training, and these personnel need to be protected at all cost.
OPDs have also been suspended in many places so that the infection doesn’t spread to other patients there. There is a certain price that we are paying, and the government is trying to get its infrastructure in shape.
But is the integration, for example in the referral system from the lower to higher levels of care, worked out? We don’t have a proper referral system even in the best of circumstances across the country.
This is an emergency and an extraordinary situation. I have the confidence that our people will rise to the occasion. The massive amount of information that has gone out during the past one month has ensured that most health field workers know the basics of what to do.
Another important dimension is testing, which should be our focus right now. We are really fighting the battle blindfolded. We really don’t know where the infection is, to the fullest extent. Kerala had the most infections until some time ago, now it has dropped down to fourth place. Tamil Nadu has suddenly surged to the top of the list, and things are changing rapidly. There is concern over the case found in Dharavi in Mumbai, given that it is a densely populated area. This is a race against time to stop the transmission, so they need to test madly. Unless they conduct tests, they will not be able to get on top of the situation. It must go much faster. Rapid-test kits are coming but they only test antibodies, which it can only show a person’s infection after the seventh day.
I also believe the tests should be made free. It is ridiculous to price the test at Rs.4,500 at a time when testing is the only positive solution for checking this epidemic. The private sector has a huge potential for outreach and testing much more rapidly than our government facilities, but they must make it free and they must encourage people to come forward and get themselves tested in those places where a positive case has been detected. A saturation of hotspots by testing must be done. This is the second aspect the government will be concentrating on, as it ramps up the infrastructure for the surge of patients who are likely to turn up for treatment.
Do we have a broader pandemic preparedness policy which is real in terms of actions on the ground, for example procurement of excess capacity in ventilators, ICU beds, which could be deployed in the event of a future pandemic?
No, not at all. There have been reports that at a meeting attended by NITI Aayog CEO Amitabh Kant it was said that potentially up to 30,000 ventilators may be lying dysfunctional across the country. We are not even keeping the few that we have in good working order. It’s amazing, we’ve had this epidemic for nearly two months, and we should have got them repaired and functioning. We live for the moment and don’t seem to have made plans.
What is the disaster management authority doing? We have our act together for tsunamis and cyclones, as we have seen in Tamil Nadu and Kerala. We face it and we do such a remarkable job in such cases. But we never really thought about a disease spreading on this scale – it is the first experience that anyone has had. I don’t think it occurred to anyone to make the sort of backup plans that matter. So, that is a takeaway from this pandemic – that we need to be better prepared for surges in infection of this sort.
This is not the first instance of a disease of this virulence coming out of China in particular – there has been SARS before this. Do you think the truly important lessons will be learned so that future outbreaks are more effectively tackled?
Other countries learn. When SARS happened, I know for a fact that China then called in the Harvard School of Public Health and they learned about the whole process of how to contain a disease. They learned the lessons. That is one of the reasons why they were able to confine the Coronavirus outbreak to Wuhan, and they managed it quite well even though the case load was quite high.
In India, we have seen SARS, bird flu, swine flu, traces of Zika, even if we’ve avoided Ebola. We’ve had all these viral infections over the past decade or more. We have eradicated polio, are working on HIV infection. We have had all this experience but at the same time health is given such low priority among the political and development agendas, that even this government, which has emphasised the importance of health, has focused more on Ayushman Bharat and on non -communicable diseases. The latter is certainly a burden that we cannot ignore, but this country still has 36% of the disease burden on account of communicable and infectious diseases. We cannot let down our guard and shift our attention away from communicable diseases, including tuberculosis. We have a dual burden of diseases, but public health is in very bad shape in India. I’m hoping that this outbreak will carry some lessons to our political leadership in creating a Department of Public Health, in focusing on surveillance, epidemiology, biostatistics and other crucial public health disciplines. Given the low immunity level and poverty of 300 million or more of our population, and the speed at which infections travel in this globalised world, we have to be on guard all the time like our soldiers on Siachen.