With the possibility of a graded exit from the the 40-day lockdown approaching, K. Srinath Reddy, President of the Public Health Foundation of India and member of the ICMR’s COVID-19 task force, takes stock of what has been achieved during this period in respect of the public health systems. With systemic weaknesses still remaining, he cautioned that we would have to be on guard against the virus for at least one year. Excerpts:
A key objective of the lockdown was to give us time to scale up our public health systems in case there is a surge of cases going forward. Has this been adequately achieved?
Our public health system has been quite weak for several decades, because of poor investments, not only in infrastructure, but also in the health workforce. And in a number of other areas like the non-availability of public health cadres, the non-availability of adequate regulatory structures, and of course very low levels of health financing, which were barriers to access and affordability of healthcare.
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Obviously, we cannot say that we have actually accomplished a transformation in each of these areas, whether it is from the point of view of a steady state functioning of the health system or the surge response that is required to meet a pandemic challenge like this. However, I believe that lockdown has given us an opportunity to try and ramp up our resources in each of these areas, particularly in terms of building up more hospital bed capacity for isolation in intensive care. Also, for ensuring that our testing capacity has improved with acquisition of more testing kits, pressing into service of a large number of healthcare workers for contact tracing and isolation, as well as bringing in more doctors and nurses, including from the retirees, for providing healthcare services if required. We have also seen that the manufacturing capacity of medical equipment as well as personal protection equipment has gone up quite substantially.
The great debate throughout this period has been the balance between the lockdown and containing the virus and the economy. That’s likely to take on even more complicated dimensions now.
What’s your advice on how to restart and what are the activities that can be avoided?
I believe that it is time for us to now start moving out of the lockdown for most of the country where we do not have clearly identified hot zones with high caseload. It is in those zones that we probably will have to continue, if not the full, rigorous form of the lockdown, at least the slightly loosened form of lockdown.
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I believe we ought to look at urban and rural areas slightly differently. Rural areas are likely to be highly protected at the moment. As we restart our economic activities, rural areas should get up first and it’s already happening in terms of harvesting and other fieldwork. Even as urban areas resume activities, we must try and restrict the travel and transportation of goods between urban and rural areas to absolutely essential goods and essential travel needs, because we should prevent the ingress of the virus from urban areas into rural areas.
We have to avoid mass meetings, we have to avoid malls and cinema halls, but smaller group meetings should be possible, and of course social distancing in public would still have to be maintained. And in education, I would give preference to school education over college education immediately, because school education is something that has to be done through personal contact. College education can come a little later because college education can also be done through distance education.
There is concern that over the winter we may see a second wave of the virus even if it slows down now. What do you think is the kind of time period we’re talking about in which we are going to be seeing the effects of the virus not just in our health system, but in the way our economic activities are also affected?
There is anticipation that we will see a slowdown in summer as the temperatures rise and even when the humidity rises. But there is also an apprehension that it could actually raise its head again in winter. We have to see whether it behaves like other coronaviruses, which do have a seasonal pattern, or whether this is an atypical virus, which behaves with virulence unabated throughout the year.
If we anticipate that this actually is going to happen, that is the temperature effect, and we’ll go into a bit of a slumber during the period between summer and onset of winter, then we still have to be prepared for a possible resurgence in winter and we cannot let down our guard till April or May next year. In the interest of safety, we have to plan as though this is going to be a phenomenon that we have to deal with for over a year.
What are the public health lessons that we can learn from other Asian countries that have been doing well?
South Korea has of course been held up as an exemplar, countries like Malaysia have also done a good job in keeping infection rates in check.
Actually the champion in this region has been Vietnam. It is a sort of unreported, unsung hero. Of course, Singapore is now having some problems in terms of resurgence among the migrant workers, which has been a bit of a lapse, but it has been a good example, particularly in healthcare and fair amount in public health.
What we have seen in Southeast Asian countries is that because they have had the experience of the H1N1, the H5N1, the so called Swine Flu, as well as the avian influenza, as well as the SARS, they have actually prepared public health as well as healthcare systems to respond very quickly to any such threat. They’re ready to get into high gear very quickly. So I think that Southeast Asian countries have been particularly well performing because of that; same thing with Hong Kong and Taiwan and so on and so forth, which actually have similar experiences.
We have had other things that have been favouring us but from the point of view of investments in public health, it is absolutely important that we build up a very strong surveillance system, a very strong primary healthcare system. And we also ensure that investments in our entire health system, including the health workforce, as well as advanced care are there. So that we do not have weak chinks in our armour.
As an expert in India’s public health systems, what would you be most concerned about if an event came along like COVID-19 that sucked up all the resources from elsewhere?
We have had the Sustainable Development Goals and various targets that were fixed to various health conditions and goals there. All of those remain important, but from the point of view of immediate attention, and from the point of view of equity in particular, I would look at maternal and child health as very, very important issues. We cannot afford to slip back upon the attention that we are giving to antenatal check-ups, care of pregnant women, safe deliveries and ensuring that the children are not only born in safe conditions, but the immunization is also provided, the nutrition is provided. So, I believe that these routine public health functions, which are particularly important in our context, should not be ignored. As far as elements like blood pressure, diabetes and other chronic conditions are concerned, they also demand attention, but they possibly can be attended to even by telemedicine. A slight deferment should not be a problem in terms of actual consultations. But when it comes to things like emergency surgeries, or trauma, snake bites, these are not the kind of things that can be ignored.
At the same time, mental health is an area that is going to suffer a fair amount because of the lockdown, confinement at home — anxiety, high levels in the general public and certainly people who already are predisposed to that will have a problem. There could be issues of domestic violence, these are all challenges that will come in. So mental health is an area that I believe also ought not to be neglected at the same time.
Obviously, tuberculosis is an important program that should not be neglected; we have already declared that we’ll get rid of TB by 2025. That clock is going to get reset, but in the case of tuberculosis etc., we also recognise that we will have an opportunity to provide medicines on a long term. So, instead of giving medicines for one month, you might as well give medicines for two months or three months. So, the medication should not be interrupted. Clinical assessment may not necessarily be done as needed, but certainly from the point of view of medication of already diagnosed cases, we should not neglect it, and investigation of suspected cases should not be neglected.
