By Shreehari Paliath
In the aftermath of the 2018 floods in Kerala, one of the priorities for the government was to contain an epidemic. Updates and meetings with health department officials and medical professionals, and information dissemination were a daily routine for Rajeev Sadanandan, then additional chief secretary, who worked closely with K K Shailaja, the state's health minister, and helmed the health department during this crucial phase.
But this was not the first time Sadanandan and his team were facing a health crisis. The Nipah outbreak in Kerala had killed 17 people in May 2018, a few months before the devastating floods. He was instrumental in developing and executing a strategy to contain Nipah, and had predicted a second outbreak. It happened in June 2019. "With Nipah we were handling a virus we did not know, which was stressful," Sadanandan told us in September 2018.
You cannot build an adequate health system to respond to an emergency during an emergency, says Rajeev Sadanandan, Kerala's former additional chief secretary of health. The resilience of the health system has to be built up over time, he says as India fights to contain COVID-19. Image credit: Indiaspend
"The resilience of the health system has to be built up over time," said Sadanandan, who is now retired from the Indian Administrative Service, as India faces an increasing number of COVID-19 cases.
There are 31 confirmed cases of COVID-19, noted a March 6, 2020 government press release. This means that 26 more patients have been found positive since March 2, 2020. There have been 95,333 confirmed cases and 3,282 deaths worldwide, as per a March 5, 2020, World Health Organization (WHO) report. This amounts to a 288 percent increase in confirmed cases globally over a month to March 5, 2020.
"You cannot build an adequate health system to respond to an emergency during an emergency," he said. Although China managed to put cities and millions of people under lockdown, he does not " foresee this being done coercively" in India.
During three tenures as health secretary of Kerala, Sadanandan initiated transformation of the health system in the state with a focus on primary care, designing and executing disease prevention and health promotion programmes, integrating social and epidemiological determinants to health care and applying technology to improve healthcare delivery. He was the Chief Executive Officer (CEO) of Rashtriya Swasthya Bima Yojana, a national social health programme.
He has been a member of technical committees set up by UNAIDS and WHO. Sadanandan is currently CEO of the Health System Transformation Platform, a not-for-profit company carrying out health systems research, and the Indian Council of Medical Research chair for health systems research.
With a suspected case being confirmed for #COVID19, number of cases has now reached 31. Please read details here:https://t.co/dMfW3jlxg4#CoronaOutbreak #SwasthaBharat @PMOIndia @drharshvardhan @AshwiniKChoubey @PIB_India @DDNewslive @airnewsalerts
" Ministry of Health (@MoHFW_INDIA) March 6, 2020
In an interview with IndiaSpend, he talks about the response to COVID-19, his views on handling disease outbreaks, and the need for efficient information dissemination.
You were the health secretary in Kerala during the Nipah outbreak in 2018 that killed 17 people. "With Nipah we were handling a virus we did not know, which was stressful," you told us. How do you compare the response to Nipah and the government's preparedness for COVID-19 given the latter is more infectious but less fatal?
COVID-19 is also unique. We know the epicentres, starting with Wuhan and now many more. So, anyone with links to that centre is a potential high-risk person, who must be observed and cases picked up early. Once picked up, they must be isolated and contacts observed. This was possible when the epicentres were few. It is no longer an easy task, with most countries in the Gulf being affected.
It will become much more difficult if community spread begins in India. But the exercise must be done. For this the entire health system and community must be mobilised to identify and report cases. The private sector including informal providers must be trained to recognise symptoms and refer [onwards]. The surveillance system has to be revamped so that the cases are reported for corrective action.
Fortunately while COVID-19 is highly infectious it is not very dangerous. Less than 10 percent will need acute care and five percent intensive care. The latter will need oxygen therapy. If the number of infected persons becomes large this would be difficult. Government and private sector need to increase capacity for intensive care, recruit and train additional staff, identify and equip additional buildings for triage [to decide how to prioritise patients when limited medical resources must be allocated to maximum results, as in wars, disaster zones and emergency rooms]. The government has to decide whether to pay for treatment of such cases. China has made diagnostic tests and treatment free of cost.
The number of confirmed cases of COVID-19 in India has increased to 31. Initially there were three cases in Kerala, all of whom have recovered. How would you assess the Centre's preparedness?
The preparedness is adequate for the present situation. But capacity shortages will make a proper response to demand for care very difficult if infections increase substantially. The case fatality rate is about 15 percent for persons aged above 80 and eight percent in patients aged above 70 [based on this study].
If community spread happens in India the number of people who need oxygen supplementation will be large. Most Indian states do not have adequate ventilators and trained staff to handle this load. This will lead to people who need the treatment being turned away as happened in Wuhan. Since the pressure to treat COVID-19 cases will be high, health workers may turn away other patients who need intensive care even more. This also happened in Wuhan.
Kerala has a robust primary health care system and the public trusts the government to deliver. But it also heavily relies on private health care. What are the challenges and approaches to efficient coordination?
The private sector has more intensive care beds than the government. They can always be requested to make them available. Private and government sectors have always worked together in Kerala when the need arises.
It is time for every state to mobilise the capacity of the entire health system including the private sector. But the government must agree to reimburse the cost of treatment and then compel private hospitals to treat every referred case.
What are the best international practices during such outbreaks? How must the government respond ideally during public health emergencies, and how must it remain alert?
The best practices in any public health emergency are the same: vigilance against spread from known epicentres; surveillance to pick up cases early; isolation and proper care of infected persons; tracking their contacts; transparency in sharing information; addressing the economic and psychological needs of the infected and the affected. Government has to inspire trust in the community.
Are there lessons for other states based on Kerala's experience with tackling Nipah and the aftermath of the floods?
You cannot build an adequate health system to respond to an emergency during an emergency. The resilience of the health system has to be built up over time.
Government must be seen to be caring and competent. Only then will people trust the government and not panic. People who spread panic and try to profiteer from the situation must be severely and publicly punished.
The most important asset is early and reliable information. Use existing systems and put in place new ones to gather and analyse information. Procure adequate supplies of needed drugs and consumables.
Above all, display proper and visible leadership. The morale of the team depends on a leadership that is supportive, assumes responsibility and has the courage to take decisions.
The Centre has >announced that all international passengers will be screened at airports. Are thermal screenings at ports of entry enough? How does the state infrastructure handle such large loads of people in a connected landscape?
Screening symptomatic cases is useful. But currently such persons will not be allowed to even board a flight. Most of the imported cases are likely to be asymptomatic on arrival. There must be a system to observe them as they go back to their communities.
This can be done only by the community-level health workers, supported by the community. However, urban areas do not have such workers. Here non-governmental organisations that work with urban populations and residents' welfare associations should be roped in.
China put nearly >11 million people in Wuhan under quarantine to prevent the spread of COVID-19. There are larger issues of restrictions on basic freedoms which can create fear among the public. As an administrator, how do you tackle such problems and is the Centre capable of imposing such restrictions in India?
COVID-19 cannot be handled by the Centre [alone] any more. The major role will be that of state governments, gram panchayats [village councils] and urban local bodies. If a specific super spreader epicentre emerges in India the area can be cut off for 10 days at the most.
But this would not be adequate as cases would continue to emerge in the epicentre, requiring extension of quarantine. I do not foresee this being done coercively. But the unrealistic fear about the virus will cause an unofficial quarantine of the community.
China managed to >build health facilities >in a matter of days. How prepared is the health infrastructure here to handle a spike in cases including availability of >personal protective equipment and gear for frontline healthcare workers and doctors? What is the best approach that may not cause alarm or panic buying, and are there other countries whose approach can be adopted?
How well the current infrastructure is ready to handle a small spike will vary from state to state. Many buildings have been identified for isolation. Some can be converted for triaging and routine management. But the possibility of getting enough diagnostic equipment and ventilators, and recruiting and training staff will be difficult for most parts of India.
The whole personal protective equipment may not be needed as the infection is droplet mediated and does not spread through the air. The public should be educated that the only purpose a mask serves for a normal person is to prevent him/her from touching her face. This can be done by covering your mouth and nose with a cloth.
Convergence between departments within a state government and other states' governments seems to be vital in case of COVID-19, which has seen cases across the country including in New Delhi, Telangana, Kerala, Jaipur and Agra. How can this be best managed to ensure a coherent public health strategy and response?
The most useful tool would be sharing of information especially for contact tracing. The Centre is best placed to provide the needed coordination.
There is misinformation about the use of natural remedies to prevent infection including use of cow dung and cow urine, traditional medicine, yoga, etc. How crucial is information dissemination in the age of social media? How do states and the Centre coordinate, and where must the buck stop?
It is important to take a zero tolerance approach to false information. During the Nipah outbreak Kerala had educated the media and engaged them as partners. This included carrying educational messages, busting false propaganda and eschewing sensationalism. In return they were assured full access to information. This worked well and has become a standard practice in Kerala. Similar engagement with mainstream media has to be in place.
Social media has to be managed mainly through social media itself. The Facebook page of the department of health was the main source of information on which every query was answered and accurate information provided. It also debunked the false messages floating around. All state and central governments have to get proactive on the media.
The current IT Act provides for punishment of people spreading false information that can cause panic. This has to be used and people spreading patently false information punished for their action. Natural remedies will not fall into that category. Providing accurate information would be the ideal response in that case.