Elicit contrary opinions:
Ex-secretary
Frontpage
G.S. MUDUR New Delhi
Some public experts, while acknowledging India's early
initiatives to curb the spread of the novel coronavirus, have expressed concern
about what they believe are signals of inadequate planning and poorly
coordinated responses to the pandemic.
The Telegraph had requested former
Union health secretary Kanuru Sujatha Rao, who had spent in the health
sector 20 of her 36 years as an IAS officer, to share her thoughts about how
India has handled the epidemic. Rao was the Union health secretary in 2009-10.
"It is important to find
independent voices and con- trary opinions to optimise final decisions,"
Rao, who has been a Takemi Fellow at the Harvard School of Public Health, said.
She highlighted the absence of
epidemiologists at the helm of India's responses and said the lockdown imposed
with only four hours' notice has been problematic.
Rao said the quicker India moved out
of the lockdown the better, but the government should through micro-planning
ensure the infection did not slip into the green zones.
Excerpts from an interview follow:
Q: How would you describe India's
response? Could things have been done differently? Do you see avoidable
mistakes or judgement errors?
Rao: The challenges the Centre and the state
governments are facing are extraordinary. In hindsight it is always easy to
find something that could have been done better or differently. This virus is
like no other -- in its speed, stealth and virulence -- and calls for highly
sophisticated responses.
Very little is known about this virus.
So a response is beset with uncertainties and unknowns that necessitate doing
by learning -- step by step. Given these circumstances, there is an urgency to
fall back upon the science of epidemiology, past experience -- after all, this
is not the first time India (has encountered) a new virus -- and a careful
weighing of options based on evidence.
I would perhaps have opted for a
calibrated response like Kerala's. I would have closed borders for foreign
travel in the first fortnight of February, with the World Health Organisation
declaring the novel coronavirus to be a Public Health Emergency of
International Concern on January 30, enforced a strict protocol of isolating
the infected, and rigorously traced all contacts and tested them. It would have
been advisable to engage with state health ministers and alerted them to ensure
close coordination with the MEA (ministry of external affairs) and the states
early on.
The second set of actions would have
been to focus on expanding testing, launch information campaigns towards
physical distancing, (encourage the) use of masks to ensure people don't get
into panic or fear. These are standard responses and must have been considered
in the department of health. I don't know the reasons for not acting along
those lines.
Q: You mentioned the need to fall back
on the science of epidemiology in decision-making. Do you believe India has
done that in the best possible way?
Rao: I'm not sure who ultimately is
driving the decisionmaking of our response. If it is the Indian Council of
Medical Research (ICMR), I would find it strange as it is the department of
health that has the experience of having handled and operationalised interventions
to contain epidemics over decades -- from small pox, polio or HIV to the spate
of viral outbreaks we've faced in recent times such as SARS, H1N1 influenza,
Zika or Nipah.
The ICMR has always provided the
knowledge base on which the department of health would formulate the response
in consultation with states. Here, I find the ICMR laying down strategy to the
extent of even fixing test rates for the private sector.
Be that as it may, I didn't see
many of the known epidemiologists in the initial phase of the response. Even
the technical committee constituted by the Niti Aayog /ICMR on March 18 didn't
have any of the wellknown epidemiologists.
They have one or two but they work
under the DGICMR and that could have circumscribed their ability to give their
frank views in case they were different from that of the DG or other seniors in
the department. What is important is to find independent voices and contrary
opinions for optimising the final decision.
It would seem odd if an
epidemiologist, no matter how famous, guides policy on clinical disciplines. So
too public health or epidemiology is a distinct discipline and a science on its
own. That needs to be respected. I'm not sure what epidemiologists would have
recommended but I think they would have argued for strategic interventions and
differential approaches based on evidence rather than a one-sizefits-all
approach.
I think they would have asked for more
testing and ring-fencing of vulnerable populations such as the elderly and
people with comorbidities.
Q: Over the past week, we've seen
government efforts to show evidence that the nationwide lockdown has been
timely and effective and given India the opportunity to ramp up testing and
hospital facilities. Some officials have argued that without the lockdown,
India's confirmed cases would have by now exceeded 100,000 instead of being
less than 35,000. How do you view these efforts to showcase the
"success" of the lockdown?
Rao: I don't think one should get
defensive and at this stage of the battle try to justify past decisions with
data. Who is to say whether we have averted 1 or 2 lakh infections? It could
even be 3 lakh depending on the assumptions you make. Those estimates may well
be true. But the issue is not that. The issue is why everyone from Kashmir to
Kanyakumari had to be locked up at a four-hour notice.
On March 24, we had around 500 cases
and barely 10 deaths. In over 600 districts, people had not even heard of the
infection. In locking down the whole country, our attention and scant energies
were diverted in managing the lockdown instead of focusing on persons returning
from abroad and international travellers.
This does not mean the lockdown is a
bad decision. But it could have been a planned act instead of a kneejerk
reaction as there is no evidence to suggest that if we didn't, we would have
lost many lives the very next day.
In planning a week (ahead), we could
have saved the huge amount of human suffering, got medical supplies and ration
shops stocked, placed orders to buy kits and PPE (personal protective
equipment).
But it has been said again and again:
the lockdown does not eliminate the virus; it just slows it down. To contain
the virus, we need to know where it is spreading and that can be known only by
testing. We should have called on our biotech companies to work on good kits,
bought high-quality kits and ramped up our lab capacity to expand testing in
what would be the red and buffer zones.
The ICMR should have swung into action
and set up surveillance sites to monitor the spread of the virus. There is an
important distinction that needs to be understood. The tests for surveillance
and epidemiology help us know where the virus is, among whom and at what speed
it is circulating; the tests to diagnose the infection (are meant) to isolate
and treat.
Q: There have been anecdotal reports
of private hospitals/clinics denying patients healthcare services. Recently,
the health secretary asked all states to ensure that private hospitals/clinics
continue to offer such services to patients. Could such a situation have been
avoided?
Rao: The private sector has reacted
somewhat irresponsibly at one level by shutting down OPDs and refusing elective
surgeries. I don't think this was necessary at all. At the same time, with the
conversion of almost all government facilities for Covid patients, it is
private hospitals that have helped patients get some care at least. This should
have been managed better at the state levels.
The letter from the health secretary
is timely and I hope the states pay heed to it. We must remember that we'll
soon face outbreaks of vectorborne diseases that are seasonal and preventive
actions need to be taken now to avert deaths and outbreaks of dengue. While
Covid is important, it is not a choice a government can offer -- die of Covid
or dengue.
Q: You have tweeted about the ICMR's
embarrassing recall of antibody test kits that its own lab (NIV) had earlier
approved. Does this not cast doubts about the ICMR's test validation process?
Do you view it as unusual that the ICMR became involved in procuring test kits?
Rao: The ICMR is a reputable organisation.
It has people of high calibre and integrity. When kits are recalled and found
substandard it affects its credibility. This could have been avoided. There are
procurement processes and procedures. The ICMR procures kits or consumables for
its own laboratories. I have never come across an instance where procurement
for a programme like this was done by the ICMR.
Q: Some experts have said India's poor
capacity to respond is partly the outcome of the low priority given over the
years to investing in disease surveillance, which they describe as the
"radar" for infectious diseases. Has India under-invested in this
radar?
Rao: Absolutely. There cannot be doubts or
opinions Sujatha Rao about this. India not only under-invests in health but has
completely neglected public health at its own peril. Today we are witnessing
the results of our past neglect. Our surveillance systems are hopeless. More
than 250 epidemiologists' posts are vacant at state levels, forget the
districts. The public health cadre of the Union government is becoming extinct.
This is worrying as 36 per cent of our
disease burden is still communicable diseases. Since 1995, several expert
committees have recommended that a department of public health be created with
the director-general of public health as its technical head. The DG public
health would be a qualified public health person with experience in primary
healthcare institutions implementing disease control programmes. But that has
not found traction.
Our technical wing in the ministry has
been gradually weakened as clinicians after working all their life in an
operation theatre in Ram Manohar Lohia Hospital or Safdarjung Hospital become
the DG. This has to change. We need a strong public health cadre and expertise
in every state.
The directors of public health and
chief medical officers in the districts must be qualified in public health,
infectious diseases or family medicine. But in India, I feel no one cares and
when a Covid strikes, we get hysterical. Unfortunately, we don't respect
science. I earnestly hope the government will act at least now after this
horrific experience and develop public health cadres and our public health
institutions.
Q: We're still in the middle of the
pandemic. Are there any course corrections in India's technical or operational
response that you would like to or hope to see?
Rao: Not course corrections. Our challenge
is to get out of the comfort zone of the lockdown and restore normality and
have the ability to face any surges in infection. It is sad to see that the
lockdowns are so arbitrarily being extended by chief ministers. On what
grounds, may I ask? Goa had seven infected people, all cured. Not a single
death and not a single infection. Why should it have a lockdown? I'm afraid
such decision-making reflects a fear and an inability to face the tougher job
of restor- ing normality. My hunch is that this up and down, hide and seek with
the virus will continue till a vaccine is found or we develop herd immunity.
But for any herd immunity we have to get out of the lockdown and allow our young
and healthy to get exposed to the virus. The quicker we move towards that by
getting out of the lockdown the better.
That said, I feel that the lifting of
the lockdown has to be gradual and planned in microdetail. District collectors
must come up with micro-plans of how they would ensure that public health
principles are adhered to by the public and under no circumstances is infection
allowed to enter the green zones.
As for the red zones, very detailed
planning (is necessary) and a humane enforcement of the lockdown needs to be
enforced. We have the institutional capability for this.
Q: What lessons do you believe India
can take away from this pandemic?
Rao: The positive outcome of this pandemic
is that people are more disciplined, maintaining social distance, wearing
masks, not violating lockdown rules and so on. I have to compliment our people,
the police authorities, our caregivers and the administration for doing such a
great job. It's not easy.
In several cases, people have come out
to help and also shown great respect to healthcare workers and doctors. The
people have borne huge inconveniences with a great sense of resilience that is
truly remarkable.
But at the policy level, as said
above, institutional reform needs to be brought in without further delay.
Health is a state subject but infectious diseases are very much a concurrent
subject and so the central government has an equal responsibility.
Second, we have to learn to
incentivise and engage civil society and NGOs. Health and education are sectors
that need people's engagement and can never be done by the government alone
through fiats and orders.
Third, we must invest more in
research. The ICMR has some fine institutions, all struggling for funds. The
department of health research should be more like the US National Institutes of
Health, focus on fundamental research, strengthen disease surveillance, and
build capacity to assess disease burdens at district levels and even below.
Until we have that kind of knowledge
base, our policies and their implementation will always be found wanting or
inadequate. And finally, it is very important that in health, the spirit of
federalism is fully maintained.
The states must be encouraged to build
their own capacity and capabilities and the GOI must not be prescriptive (but)
facilitative. There is great merit in differential planning and differential
focus..
Curtecy : The Telegraph,Calcutta
