The rapid spread of the zoonotic (transmitted from animal-to-human) coronavirus infection in Wuhan in China — several hundreds every day — in December 2019 and January 2020 was a clear signal that COVID-19 is drastically different from its nearest relative, the Severe Acute Respiratory Syndrome (SARS) coronavirus, and its distant relative, the Middle-East Respiratory Syndrome (MERS) coronavirus. The former spread slowly among humans in 2002-2003. It was checked globally within nine months by screening passengers and quarantining travellers from infected countries. There have been no cases since July 2003. MERS coronavirus is, by and large, an inefficient spreader — it has been confined to the Middle-East.
In contrast, COVID-19 has assumed a pandemic form. In less than three months, it has reached more than 180 countries and claimed more than 10,000 lives. The disease has claimed more people in Italy than in the country of its origin. Travel bans, screening travellers and quarantines are necessary to slow the spread of COVID-19. However, there is a limit to the utility of these measures. When the infection becomes widespread, screening procedures will become inefficient — the virus will spread stealthily. Indigenous transmission — the virus spreading within communities — has begun in many countries. This is typical of viruses that spread from human to human through the respiratory system.
How should India’s health management system minimise the disease burden and deaths due to communicable diseases — endemic or newly emerging? How do other countries address epidemics? Countries like China, Japan, Sri Lanka, Thailand and Malaysia have transplanted modern medicine, a European cultural product, without any local cultural misgivings. Medicine consists of three components — universal healthcare, public health, and research to constantly contextualise solutions to local problems. Many of us in India believe that disease is a matter of fate or karma and disease prevention is not always in human hands — we only react after falling ill. So therapeutics and surgeries — healthcare interventions — are valued much, but not disease prevention and control.
Attitudes and cultural beliefs do matter. If victims are somehow regarded as responsible for their maladies, universal healthcare is perceived as an optional service — not mandatory.
There are good reasons for such thinking to change. Every person who contracts a communicable disease stands the risk of spreading it to others. At the same time, the state, too, is responsible for the spread of diseases by not mitigating the environmental and social risk factors or determinants. Prevention of disease is the state’s duty.
Healthy people create wealth. For example, every year, uncontrolled tuberculosis drains India’s economy of the equivalent of the GDP of roughly 2 million people. Investment in health, therefore, can have implications for the country’s economy. But Indians have never really demanded an effective public health system. Healthcare has never become a political slogan. That’s one reason for the sorry state of India’s public health system.
The country does have international obligations to control TB, malaria and leprosy, and eliminate polio. In the absence of an effective public health system, the country has depended on fulfilling these obligations through ad hoc measures that are targeted towards one disease. Robust public health systems are needed to prevent typhoid, cholera, dysentery, leptospirosis, brucellosis, water-born hepatitis and influenza.
The absence of an effective preventive element means that healthcare services in the public sector are over-burdened with uncontrolled communicable diseases. This encourages private sector healthcare providers to step in, which brings in problems related to unregulated profits. Questions are often raised over the quality of service. Moreover, uncontrolled communicable diseases vie with the non-communicable ones for the healthcare provider’s attention. The COVID-19 outbreak could compound the system’s problems.
The SARS and Nipah virus outbreak in Kerala in 2018 were crises that required short bursts of professional activity. Our healthcare systems coped with them. But endemic diseases, even influenza, that has a vaccine, require sustained interventions. Herein lies the test for the country’s healthcare system. It has often been seen that the system is not able to sustain its initial momentum. There is a possibility that COVID-19 could follow the path taken by the HINI influenza – after the epidemic died down, the disease became endemic. The country’s healthcare system has to prepare for that. In other words, it has to be one step ahead of the virus.
Every district hospital must be equipped to diagnose infections caused by serious communicable diseases — these affect the lungs, brain, liver and kidneys. The system should also ensure that healthcare personnel do not get infected. The country needs to allocate 5 per cent of the GDP to the health budget to have a health management system that can take care of public health emergencies such as the COVID-19 outbreak — and its aftermath.
A unified command and control machinery, under the prime minister’s guidance, to control the spread of COVID-19 is overdue by at least six weeks in the country. The tasks of the Directorate-General of Health Services, National Centre for Disease Control, Indian Council of Medical Research, National Health Mission and state health ministries must be clearly defined. Most importantly, a mechanism for coordination between these agencies should be set up to deal with the COVID-19 threat.
The COVID-19 pandemic has repercussions beyond the biomedical sector — it impinges on industry, transport, finance, banking and education sectors. All of them must act in unison.
The writer is a former head of the Indian Council for Medical Research’s Centre for Advanced Research in Virology and an emeritus professor at the Christian Medical College, Vellore