Former Health Secretary Rajeev Sadanandan is a name synonymous with healthcare policy in Keralam. Currently a member of the technical advisory panel of the World Bank’s Pandemic Fund, he was closely associated with the state’s successful Nipah battle and later during the Covid pandemic.
Amid controversies including those over Nipah and SMA medicines, the former additional chief secretary shares with TNIE his views on the health of the state’s health sector, Keralites’ obsession with healthcare and specialists, and his own experiences in handling the deadly Nipah and Covid. Excerpts
The Kerala Model remains widely accepted with health and education as its cornerstones. But you recently said we must drop the assumption that Keralam is unconditionally number one in public health…
There is a common misconception that Keralam’s healthcare sector was exceptionally advanced from the start. The foundation of public health investments dates back to the 1830s in Travancore, with the establishment of the first hospitals. After Kerala formation, successive administrations invested heavily in health and education. By late 1960s, we had reached the pinnacle of the Kerala Model. When Keralam invested heavily in human capital, it created a structural challenge: public expenditure kept climbing without corresponding economic returns, culminating in a fiscal crisis by 1975. Complacency crept in after we achieved international reputation. We must adapt our policies to secure continuous gains in the sector. We are often too fixated on our past achievements to adapt fast enough.
Could you elaborate on how this gap affects the public healthcare delivery mechanism today?
In 2011, when I became health secretary, I saw a major problem—hypertension and diabetes had both spiked significantly. It happened because we neither collected actual data nor recognised the changing circumstances to formulate a response. We are yet to look at new issues. What will be the difference in climate health? What are the problems of ageing? We lack the tradition to understand such scenarios or respond to it.
But we usually get health data from institutions. So, did the flow decrease or was it because surveillance cells became deficient that we didn’t get early data?
Health data comes from two reliable sources – National Sample Survey and National Family Health Survey. Based on its data analysis, we ponder over policy changes. The problem is that transparency is politically expensive. I told Shailaja Teacher that we must not hide data. She agreed. During the Nipah outbreak, we got a lot of credit for being 100% transparent.
Handling Nipah was a major task. How was your initial response?
There was a lot of panic at the time. I used to get up from sleep at midnight. Nipah mortality is between 70 and 100%. We were 18 days late and could not identify the extent of the spread. Simulations assessed it could go up to 254 cases in the whole of Malabar. We were prepared for 300 cases. We were short of PPE kits. We didn’t know what to do. Some say it was a PR exercise, but those who went through it knew how serious it was then. The things we did were against the rule books. We set up a research committee with assistance from WHO. The state can’t do these on its own, but we still did it as the times demanded so. I could have been dismissed for each of the steps taken at the time.
How do you rate the leadership of Shailaja at the time?
She always respects advice. I had a free hand. Credit should also go to T P Ramakrishnan, MLA, who was on the ground from the onset. They both played a role in the leadership. Shailaja Teacher led from the front. There were people who refused to talk to the press at that time. But she took responsibility. She could have put the onus on officers and sat back, but she didn’t.
The way Nipah was handled by the then state government was much appreciated. However, there are recurring outbreaks...
The medium is Pteropus medius, a fruit bat. When these bats contact each other, the virus spreads. But bats don’t die; rather, they become carriers and spread the virus fast. Around 22% of them were infected then. So we knew the colony would always remain. Nipah is reported in Bangladesh every year. In Keralam too, there will be a recurrence every year. The very next year, I issued a circular urging everyone to be prepared because the host population is heavily infected. In a densely-populated state like Keralam, and with the high human-animal interaction, it will keep recurring. Fifty percent of the bats there must be infected now.
Why are cases reported only from Kozhikode?
In 2019, there was a case in Idukki. It can happen anywhere. We are transparent and disclose the numbers. Others don’t.
Has there been any attempt or pressure to hide the data?
Some media do create issues. So, politicians get extremely worried. During Covid, the number of deaths should not have been under-reported. There is always pressure to hide data.
Has the Nipah episode exposed any problems in our system? Have we tried to rectify the same?
Our review gave out two important outputs: surveillance and infection control in government hospitals had to go up. Firstly, according to our guidelines, if a young person comes with brain-related issues, we must take a sample and send it for testing. Since that was not done, around 13 infections occurred there. Secondly, the highest number of infections occurred in hospital settings, which meant that infection control in hospitals was very poor. We made a major improvement and its benefit was reaped during the Covid-19 period.
Speaking about Covid, what’s your assessment on how it was handled?
Screening people who came from Wuhan based on epidemiological intelligence and picking up their samples was an excellent move... only Keralam could have done that. During the Nipah period, we acquired the skill of contact tracing. When lockdown happened, not even a single case from outside could enter. Once that control eased, a huge wave was bound to happen. But overall, I think we did a fantastic job, except for the case of unnecessary cover-up of the death toll.
Conspiracy theories about Covid are still active in the public sphere, as in it was deliberately manufactured. Is it an American-funded project?
When we look at the genome sequence of the Covid virus from Wuhan in China, it looks normal. A small section that would aggravate infection was found. That was the accusation. The conspiracy theory was that it escaped from the lab and infected people. No one knows whether the SARS virus, which was created in the lab, escaped from there.
You once mentioned in an article that Nipah deaths totalled 23...
Nipah case was first detected in 2018. But that was the third or fourth case, and by then, three others had died. On tracing, we found that one of the cases arrived on May 5. If there is reasonable ground to suspect Nipah based on contact and clinical symptoms, that can be termed a case. We counted only 19 cases. In my article, the number of deaths is mentioned as 23 because we retrospectively added cases that were not counted earlier.
The current health minister recently alleged that outdated medicines were given to Nipah patients...
It is highly unlikely and can be proved easily. He should have made the statement only after verifying. They can check the case-sheets and see if Remdesivir was given to patients. KMSCL (Kerala Medical Services Corporation Limited) has a procurement invoice, stock register and a register to record transfer of medicines to hospitals. When a minister makes such allegations, it raises concerns among the public. Also, such talk demoralises healthcare workers.
In Keralam, after the corporatisation of hospitals, common people have only government hospitals to go to. We have to verify and take action if there are lapses. If unverified, it should not be disclosed because even the PR (machinery) of corporate hospitals tries to stoke controversies. Government hospitals are under attack. We should not worsen the issue.
You have served as health secretary under both LDF and UDF governments. How do you rate the approach of the respective chief ministers?
Both Oommen Chandy and Pinarayi Vijayan were supportive. Oommen Chandy used to tell me that we have to do a lot of things in the health sector. Whenever ministers posed problems, I went to him. The same with Pinarayi as well. He had genuine interest in the health sector. (Former) Finance Minister Thomas Isaac was among the faculty at CDS (Centre for Development Studies, Thiruvananthapuram) and I had a connection with him. I channelled a lot of his cash (laughs) to the sector.
The healthcare-seeking tendency among Malayalis is quite high. We go to hospitals even for a cold...
In NSS (National Sample Survey), there’s a question on whether a person has sought treatment for a disease. The number of patients who sought treatment divided by the population and multiplied by 1,000... that’s how the exact number is arrived at. Kerala’s data is 320. In Tamil Nadu, it is 180. In other states, it is less than 100. It is an inculcated habit to consult a doctor even for a cold. The industry fosters this habit. There’s another tendency. We go to a neurologist for a headache. What the doctors urge is to consult a specialist doctor. When we say healthcare expenditure, it is mostly caused when we bypass a primary physician and go to specialists and do all the tests.
Health experts are calling for the family physician system to be implemented in Keralam, but we failed. Why?
If a family physician comes in, many issues will be solved easily. When ESI was implemented, it was said there should not be any direct reference, and only references through clinics were allowed. People raised an issue in Keralam. People here think they have the right to consult any doctor based on the symptoms. This leads to increased healthcare expenses.
You once said there will come a time when treatment will become unaffordable even for the upper middle-class...
Health inflation is high mostly because of technology. The price will always increase as new technology will keep coming. The expectations of people will also go up and the price of drugs will rise. The government does not have any regulation. In places where the expense is controlled, there will be gatekeeping and rationing of hospitals. We can use many techniques to control healthcare expenditure, as done in many countries except the US. However, we emulate the US model.
In insurance, the claim rejection rate is very high. Is there a regulatory body in the sector to work between the people and the insurance agencies?
In all the places I’m talking about, one thing is common: universal health coverage for every individual, except the US. At one point, this wasn’t a problem for us because our costs were very low. Now, without bringing insurance companies and perhaps health managed-care institutions together into a consolidated system, this kind of control may not be possible.
Medical inflation is a major issue. Do we have data on this?
No such data is available. I made an attempt, around 2012-13, to get data from private hospitals. But they did not provide it. There is deep mistrust between the private sector and the government. Unless that changes, no one will give this data... unless it is made mandatory.
Why would private hospitals not trust the government?
I don’t know much about the private hospital business. But looking at their costs, around 20-25% goes on doctors’ salaries and another 25% on other salaries. Some doctors are like Mohanlal and Mammootty; they are paid whatever they ask for and that cannot be disclosed. Why are the hospitals unwilling to share prices? They have blocked it for the past seven years, because they fix prices based on people’s income. Suppose you have insurance; your rate will be adjusted. If they see that you are reasonably well-off, the rate will be higher. There’s opposition because they think price disclosure will affect their business model.
Recently, Chief Minister V D Satheesan pointed to how everyone coming for an angiogram ends up with an angioplasty...
Don’t take the former health secretary to court (smiles). Let me come from another angle. Say a cardiologist is paid Rs 10 lakh a month. Does he have to generate money equal to that? Earlier, someone told me a pulmonologist was being paid a huge amount. I asked how they could recover that much. The answer: bronchoscopy made compulsory for every case.
You mentioned price regulation earlier. Do you see any possibility of implementing this in private hospitals in some form?
When we drafted the Clinical Establishments Act, we took the Central Act as our model. It says, “Government shall fix the prices.” I realised that this wasn’t going to work here. At the time, we couldn’t even fix the fees in medical colleges. How could we possibly fix the rates for 2,500 procedures? Instead, we introduced a provision requiring hospitals to disclose their rates. I still believe that’s sufficient. If rates charged by different hospitals are publicly available, people can choose. Under the Clinical Establishments Act, hospitals are required to disclose the names and qualifications of the doctors. If something like this develops, the market itself will determine things to a certain extent. Even without fixing prices directly, some degree of rationality will emerge. In the modern world, transparency is the best remedy for most of the problems arising from withholding of information.
From a policy perspective, when we allocate resources, should we focus on non-communicable diseases (NCDs) or should we prioritise contagious diseases, pandemics and future pandemics?
When we talk about primary care, infectious diseases are certainly one of the important areas. At the same time, data shows that hypertension and diabetes are also increasing. Unless we invest in long-term behavioural change and prevention, we will be overwhelmed. Keralam needs to invest in preventing NCDs rather than continuously expanding treatment facilities.
Keralam is often described as the capital of lifestyle diseases...
I don’t agree with that description. It is incorrect to call Keralam the capital of all such diseases. Our detection rates are higher, and consequently, more people receive treatment. We are also an ageing population. Even in terms of NCD prevalence, we are probably the third highest or somewhere around that. Higher detection rates explain much of the difference.
What has changed in the lifestyle of Malayalis to contribute to the growing incidence of NCDs?
In the past, physical activity was naturally integrated into our lives. Our food habits have also changed, with greater consumption of unhealthy foods including those containing trans-fats. Another major concern is the declining physical activity among children. In many schools, physical education periods are replaced with additional classes. We are effectively creating an obese generation. Also, children spend very little time outdoors, raising concerns about vitamin D deficiency. The future could be much worse.
With life expectancy increasing, nearly 30% of Keralam’s population is projected to be senior citizens soon. How should the state prepare for this demographic transition?
We need to distinguish between life span and health span. The real question is not merely how long people live, but how many of those years they live in good health. Many people spend the last five years of their lives as patients. We don’t even allow people to die with dignity. Is there a difference between the number of years people lived in good health in the past and the number of years they live in good health today? That’s a question that needs to be examined.
What are the major areas where Keralam’s healthcare policy has fallen short?
If I were to look back and ask what I would have done differently, I would identify NCD prevention as one major area. Healthy ageing is another area in which we have not invested adequately. These are two major gaps that could become serious challenges in the coming years. At the same time, Keralam has achieved a great deal in healthcare and several other sectors.
Can you explain the controversy over the Medical Service Corporation’s membership at the Thiruvananthapuram Tennis Club when you were the health secretary?
There are other PSUs which take membership. I had just joined there from the KSEB, which too has a membership at the Tennis Club. At the time, we held several conferences at the Mascot Hotel. The Tennis Club has similar facilities. In fact, I don’t play tennis
Is it true that unemployment is increasing among doctors?
I think we now have 23 medical colleges. They are producing 4,000 doctors. Naturally, there must be unemployment. In certain specialties, it is very difficult to get jobs, for instance cardiologists. We don’t need more medical colleges.
There are speculations of a possible future pandemic. How do you assess the Keralam scenario?
It isn’t a question of ‘if’, instead it’s about ‘when’. We could easily have another pandemic. We should all be ready. My suggestion is to go for dual use buildings. When you construct buildings, it should also have a facility for use as a hospital, if needed.
How can you be sure of a recurrence?
Climate change is happening. The genome of many pathogens could be altered. Also, human-animal interactions could go up. Viruses that were inside animals for long could reach humans and become deadly. The possibility is very high.
What could be the nature of another pandemic?
It’ll be an RNA virus... it will jump species. Going by simulations, it’ll be a respiratory influenza-type virus. Aerosol-mediated respiratory kind of virus, which is more contagious. We don’t know whether it is deadly or not. RNA viruses mutate much faster than other viruses.
