An Indian railways employee wearing a mask looks out from the window of a train at Chhatrapati Shivaji Maharaj Terminus in Mumbai
Dr K Sujatha Rao was Secretary, Ministry of Health and Family Welfare, Government of India, until 2010, where she was involved in the first-ever national programme for non-communicable diseases; the process for a national policy for use of antibiotics; and introducing vaccines in public health. She has represented India on the boards of the WHO, Global Fund and UNAIDS. She is currently the first Gro Harlem Brundtland Senior Leadership Fellow at Harvard School of Public Health.
Dr Rao was at the forefront of the battle against H1N1 in 2009, the last viral epidemic that hit India. She shared with The Indian Express her experiences in the light of lessons for today.
What makes COVID-19 a new challenge for India? Is it something independent India may not have witnessed before?
Absolutely. Never has, not just India but the world, since 1918, witnessed anything so devastating in terms of speed, fatality, and spread. We have seen epidemics and pandemics, but they are like the cyclonic waves, while this one is like the tsunami.
What in the current policy mix is a break from how we would have handled things before? Any innovation/lags?
I think the policy mix is similar and is guided by the nature of the infection and trajectory of the epidemic. Today we are far more advantaged in terms of communication and technology. Having said that, yet, how one handles events like this are always judgment calls. There is nothing like right or wrong as it is highly contextual. Persons leading the fight respond based on science, available evidence, historical experience and, in the ultimate sense, a hunch that normally must be to overact — safe than sorry.
So, for example, our responses to HIV/AIDS were different from the response to H1N1. In the initial years, we were very cautious with testing under the HIV/AIDS program while under the H1N1 we were aggressive. This is because the nature of transmission and incubation periods etc. of the two viruses were different. But then, our response to COVID-19 seems to resemble the HIV/AIDS case though the coronavirus is more lethal and also moves much faster, and so the surge factor can be much more fatal…, a situation we can ill afford, and so I would have favoured a more aggressive testing approach once technical glitches were sorted out. I am happy to see an expansion in the testing strategy. Now with availability of rapid kits, we should be able to move fast.
Both in handling H1N1 and now COVID-19, political leadership has been of a very high order. In fact under COVID-19, given the gravity of the epidemic, the PM is himself leading the fight. But I find the political commitment at the state level to be varied, a situation that needs to be avoided. This was ensured in the previous years with the Union Minister personally reaching out to the state Chief Ministers and Health Ministers. I am glad that the PM has himself talked to the state Chief Ministers. But I still feel that the Health Minister must meet the state Health Ministers and ensure a more coordinated approach. What is most important to note is that in matters of infectious diseases we must have one strategy, one approach, and one focal point of leadership. If each state does what it wants, the situation can get chaotic. There is need for a guideline of who and when lockdowns should be enforced, and what preparatory work needs to be done, because at all times balance needs to be maintained. One cannot lock down totally as there are always human needs that could be of equal priority. Balance and a humanitarian approach are needed. I would have preferred a graded approach to what is turning out to be a total approach. But experts need to deliberate and advise govt.
There is a need to recall the Spanish Influenza in the last millennium as a case. But the 21st century has seen viral epidemics too. The 2009 H1N1 crisis, how was it handled, say at the very top? What kind of a centralised mechanism was in place?
As you know, infectious disease control is in the concurrent list of the VIIth Schedule. That means that the Union government lays down the strategy, the protocols and the standards for implementation. The states are only to implement. It is a centralized activity with little room for variance or innovation at the state level. This is essential, and you might have seen this in polio (that we eradicated), HIV/AIDS (that we brought down the incidence by 67%) or TB (that we are trying to eliminate), etc. So in H1N1 too, it was the Ministry of Health that led the battle — and provided all logistical and financial support to the states to carry out the implementation that was also closely reviewed and monitored.
How was the state mechanism coordinated with the Centre’s, and with the district level then? As health is something for which all are responsible?
Health is something that all are responsible for. As per the Constitution that divides powers and responsibilities between states and the central government, infectious diseases comes under the Concurrent list. In all such programs, the central government provides support both in cash and kind – funds and equipment, drugs, personnel, etc. in kind along with standardized treatment protocols, testing guidelines, training curriculum etc. The actual implementation is that of the states through the health infrastructure that they have.
In the case of Corona too, India has had a window and the cases are just picking up now.
Specific lessons learned at the time which may be useful now?
When I compare H1N1 with Corona, both being pandemics, I can say we were lucky at both times. Before swine flu ( H1N1) hit us, we had the bird flu ( H5N1) that helped us to ramp up our public health infrastructure for disease control. So when H1N1 hit us, we had our drugs and machinery in shape.
In the case of Corona too, India has had a window and the cases are just picking up now. By this time we have the advantage of the experience of China, S Korea, Japan etc. to study and adapt our strategies.
Having said that, I feel that in the light of our own experience, we should have followed the testing strategy that we followed in H1N1 and also without time lag. Second lesson is to have a much tighter grip on states so the response is standardized and caliberated and after taking people into confidence so there is no panic. People must understand and trust policy. That is critical for infectious diseases. Uniformity in approach helps as variations in responses can be taken advantage of by the virus.
Any specific lessons from 2009?
Unified command. All agencies must only work to support the Ministry of Health and there must only be one voice so as to ensure no confusion and have clarity. Be it H1N1, polio or even dengue epidemic during the Commonwealth Games time and so on, it was the Ministry of Health that laid out the strategy and explained the government policy. Here I find far too many actors — NITI Aayog, ICMR, GOM, and several people giving different views to the media.
There is need for a guideline of who and when lockdowns should be enforced, and what preparatory work needs to be done, because at all times balance needs to be maintained.
The second, I would say from my HIV and polio experience, is the need to more intensely utilize data analytics to formulate a strategy. We must at all times look at global and country evidence. I think that is an area where focus needs to be paid and urgently.
Thirdly, there is a need to institutionalise response mechanisms for coping with such outbreaks. We cannot afford to reinvent the wheel every time a new epidemic hits us. Such institutionalization down the line can only happen when there is an institutional mechanism for it such as having a Department of Public Health. Having such a mechanism then keeps the priority high at all times and not get buffeted with shifting global and local agendas.
Former US President Barack Obama put a mission on pandemics in place which Donald Trump got rid of. Did we have a Mission/Protocol in place for future viral epidemics?
No. I don’t know if there is one now. Given the frequency with which these viral epidemics are hitting us, we need to have a Mission approach to viral epidemics, the way we have for natural disasters.
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What are the crucial things that we need to do in secondary and tertiary care, which would prevent or limit an outbreak in India?
Tertiary and secondary care cannot prevent an epidemic, as prevention and limitation is to be done before the patient gets into treatment from secondary or tertiary hospitals. These levels, however, can play a major role in limiting fatality by providing effective treatment and good patient care. Keeping and adhering to infection control practices can help limit spread of infection.
In this context, the coronavirus is more challenging, as there is no standardized treatment available. Yet our mortality is low. The credit for this goes entirely to our highly competent doctors and nurses.
Dr Sujatha has represented India on the boards of the WHO, Global Fund and UNAIDS. She is currently the first Gro Harlem Brundtland Senior Leadership Fellow at Harvard School of Public Health.
What are the three top constraints in how to battle a pandemic in a country of India’s size, density and type?
Funds, as prevention is not cheap. Second, well trained human resources available at all levels and equitably spread out, since portability of patients from the north to the south may not be an option. And third, primary health care based on the principles of Public Health.
We have to invest in building public health discipline and infrastructure. We have a strong knowledge base and expertise built for tackling SARS, Nipah, H1N1, swine flu, polio, HIV/AIDS etc. It seems to be getting lost with non-communicable diseases taking over the agenda. We need to realize that India has a dual burden, and our vulnerability to infectious diseases is very high and so under no circumstances can we let down our vigil. Infectious diseases do not respect class, caste, or geography. Neglecting health and neglecting public health is not an option for India.
How important is international partnership at a time like this? Have we seen enough of it in play?
Absolutely crucial, particularly our relationship with WHO. Yes, I think India has done very well and leveraged that well. But then every country is bogged down with their own problems. Despite that we helped China in its early stages and countries are helping our stranded citizens.
Never has, not just India but the world, since 1918, witnessed anything so devastating in terms of speed, fatality, and spread.
It’s early days still, but what would be the key takeaways from this crisis?
If we get away lightly now, we need to thank our good luck and our stars. The key takeaway from this experience is the urgent need to build our public health infrastructure — personnel trained in public health, laboratories, surveillance systems, standardization of responses to disease outbreaks, and building systems that keep a vigilant eye on infectious diseases at all times without a break.
It is for this that NCDC was strengthened and set up. It’s nowhere now. This must change, and public funding has to be increased without further delay. But this is for the future. For now, we need to expand testing sites and test more people so as to identify the carriers. It’s not enough to test only those with symptoms as increasing evidence shows that it is the asymptomatics that are the drivers of this epidemic. We need to very quickly get a grip on this issue before it gets late and we lose our window of opportunity.