With the daily nationwide tally of coronavirus cases scaling new peaks every day, The New Indian Express speaks to health experts, who agree that the Central government needs to change its approach to deal with the pandemic and adopt customised strategies based on the local situation.
Dr K Srinath Reddy President, Public Health Foundation of India, and member, National COVID 19 Task Force
Where do you see India in the fight against COVID-19 as of now and what could be the way forward?
We are seeing rising numbers of cases in big cities and across several states. This represents both greater spread and better detection through increased testing… However, the fact remains that a very large population has not been touched by the virus as yet.
There is need for continued vigilance and more effective action to keep the unexposed population safe for as long as possible. Recognising that different parts of India are at different levels of exposure and health effects, we need to adopt differentiated strategies which are configured to match the local situation. This calls for decentralised planning at state level and customised implementation strategy at urban ward and village level.
Lately, there has been a lot of discussion around the term ‘community transmission’, with many epidemiologists arguing that accepting it is a critical point in the pandemic as the focus then shifts from containment to mitigation. What do you think?
Even if there is community transmission in some parts, that will not be a uniform feature with simultaneous occurrence across the country... So, both containment and mitigation have to be simultaneously implemented and not treated as distinctly sequential strategies. Even in a big city, there will be variations in the speed and intensity of spread in different parts. So, both types of countermeasures will be needed. We cannot equate a village in Jharkhand with a containment zone in Delhi. We have to customise our response, according to the contours of the epidemic in each place.
The case-fatality ratio seems lower than some Western countries but the proportion of younger people succumbing to the infection in the country is higher as opposed to many other countries. How do you think India can ensure the lowest possible fatalities and what all do you see as major challenges?
Death rates in other countries have been mostly determined by factors like old age and presence of co-morbidities. In India, the co-morbidities occur at much younger ages, being widely prevalent in the age group of 35 years and above. Diabetes is seen at even younger ages in India. Air pollution levels, another factor for adverse respiratory outcomes, are much higher in India. Just to provide a comparison between India and Italy, in the 20-59 year age group, diabetes is three times more prevalent in Delhi than in Italy. In the 40-49 year age group, prevalence of hypertension is 40% in Delhi compared to 10.7% in Italy…So, younger age alone cannot protect if there are other risk factors. A strong public health system and determined environmental action are needed.
Lockdown gave the governments time to prepare healthcare infrastructure and resources but we are seeing cities like Mumbai earlier and now Delhi struggling as the cases surge. Why do you think that is happening and what can be the way to handle the situation in a better way?
We did not utilise the lockdown to prepare our containment strategy for effective implementation on the ground. Syndromic surveillance of households for early testing and isolation should have been implemented early on… Contact tracing should have been more vigorous. Hospital readiness should have been at a higher level… Citizen volunteers and trained youth groups like NSS and NCC should have been engaged to help with case identification, contact tracing, support for home isolated persons and de-stigmatisation. Even now, such citizen participation is essential.
Since very few patients require ventilators, we should use home isolation for mild patients and admission to oxygen supply-assured hospitals for moderately ill patients, reducing the load on advanced intensive care units. Temporary hospitals can also be set up. The challenge will be to find healthcare providers in required numbers. Young medical and nursing graduates as well as self-employed doctors should be recruited.
K Sujatha Rao, Former Union Health Secretary
There is so much debate happening around whether or not community transmission is taking place. While Union Health Ministry and the agencies under it have been maintaining that the pandemic has not reached that stage in India yet, most epidemiologists and public health experts stress that admitting it for hotspots such as Delhi, Mumbai, Gujarat and Tamil Nadu is important because that will lead to change in strategy from containment to mitigation. What do you think?
I agree with the epidemiologists and public health experts. Of course, the Indian Council of Medical Research (ICMR) director general is right when he says there is no community transmission in India. But then, India is a large country with different characteristics and so it requires differential strategies. While there are areas with no signs of the infection, there are cities like Mumbai, Delhi, Chennai and Ahmedabad that are causes of great concern and are definitely having community transmission as there are cases with no known source of infection.
Once this is recognised, strategies need to change with much more focus on testing, identifying the infected and isolating them or treating them based on their condition. I am at a complete loss to understand this rigidity on part of the government not to accept community transmission and shifting strategies and policy responses. In these areas, those likely to be vulnerable need to be protected so as to minimise loss of life.
Cities like Delhi, Ahmadabad and Mumbai seem to be struggling in terms of health infrastructure and resources to accommodate and support a large number of patients. What do you think are the steps required to deal with the situation?
They had two months’ time; I am surprised that they have not utilised that to ramp up their delivery system. They need to immediately rope in human resources, train them quickly and have them take charge. Private sector needs to be co-opted and infrastructure ramped up. 85 per cent do not need institutional care; it is the 10-15 per cent that need attention. Of these, it is 3-5 per cent of the patients that need very close care. So triaging is important and in accordance with clinical need, patients must obtain appropriate care at home, in decentralised facilities like district hospitals and specialised tertiary hospitals.
What do you think are the short term and long term lessons from the pandemic for the health sector in India?
Several, but I think it is premature to talk about lessons now as the last word has not been said as yet. The epidemic is evolving and so we need to see how the curve finally begins to flatten.
One issue many experts have been pointing out is that it is the National Centre of Disease Control, and not the Indian Council of Medical Research that should have been leading the outbreak management. What is your view on that and why do you think ICMR has been allowed to overshadow NCDC during the crisis?
Well, NCDC is the institution that is mandated to undertake disease surveillance in the country and has been engaged with implementing infectious disease control programmes. So they have the institutional memory and knowledge that would have been useful in working out strategic options in dealing with this epidemic. The Indian Council of Medical Research (ICMR) is a research body that is mandated to do research and advise the government on issues that must get policy attention.
So, research is one thing – for example, it was ICMR-National TB Research Institute, Chennai, that provided the basis for DOTS (Directly Observed Treatment Short course), but it was the department of health that then designed the operational strategies for implementing it in the country. So why ICMR got into providing testing strategies and accrediting laboratories for testing, laying down price caps for tests etc. is unclear to me and I don’t know the reasons for giving this new mandate to them.