Kanuru Sujatha Rao served as the secretary of the ministry of health and family welfare from 2009 to 2010. Prior to that, Rao was the director general of the National AIDS Control Organisation, a division of the health ministry that is at the apex of the HIV/AIDS control programme in India. She has represented India on the boards of the World Health Organisation and the Joint United Nations Programme on HIV/AIDS. Rao is also the author of a book on healthcare in India, titled, Do we care?:India’s Health System.
In an interview with Tushar Dhara, a reporting fellow at The Caravan, Rao spoke about India’s response to the COVID-19 pandemic and the country’s current protocol for testing. “By not doing tests we may be under reporting or missing out on cases,” she said. “The more you increase access to testing, the more robust the strategy and greater the control over the epidemic.”
Tushar Dhara: Where does India stand currently with regards to the spread of COVID-19?
Sujatha Rao: If you go by government figures, it’s doing well. Compared to other countries, we seem to be containing the infection. We now have 315 cases, which for a population of our size is not bad. [According to health ministry figures at 8 pm on 22 March, India had 329 active COVID-19 cases.] Given that around the world, nearly three lakh people are infected and the fact that we are a highly populated country with not much of a public health system, we seem to be doing well. This is good, if these figures are right. But, there are doubts on these figures as there has been inadequate testing—about 10 per million population.
TD: The Indian Council of Medical Research,the nodal agency framing India's policy for COVID testing, says that there is no evidence of community transmission. Does this claim hold up?
SR: India is following a policy of restricted testing confined only to those having a travel history and people who have come in contact with them. This has since yesterday been extended to include two more cohorts, all hospitalised patients with severe acute respiratory illness, shortness of breath, fever and cough; and two tests— one on the fifth and the second on the fourteenth day of all asymptomatic direct and high-risk contacts of confirmed cases.
Besides the Indian Council of Medical Research has tested 826 samples on a random basis and found them all negative. The sample methodology is unknown and so it is hard to say anything. But then such testing of populations not connected to persons with travel history needs to done regularly and in a structured manner. Maybe it will be useful to also establish sentinel sites, as some experts feel that this infection may not be a one time affair but be erupting in surges throughout the year. A sentinel site is one where a similar sample of tests are conducted at set intervals from the same site or place. Overtime, it provides information on changes, if any. We need such data and information to help us analyse and understand the trajectory of the virus, who is getting infected and where? In short the epidemiology of the virus. I haven’t seen any good analysis of that yet.
TD: What does the low count of infections and deaths at this moment indicate?
SR: The fatality rate of COVID-19 in India is very low. That could be because the current strain could be a mild one. The low number could be because of high temperatures, though there is no scientific evidence that shows hot climates have a deterrent effect on the virus. Thailand, Malaysia and Singapore have the type of climate we have in south India and yet cases are climbing up there too. They have more cases than south Indian cities have. All these intuitive and counter-intuitive factors and variables have to be knocked out and we have to do much more analysis to come up with quantitative projections. I think the government is being cautious, but they are not doing enough testing, and that worries me.
TD: Could it be that the low count is because not enough testing is being done?
SR: That is a possibility. We have to step up testing, but it doesn’t mean that everyone has to be tested. One need not, and cannot, test 1.3 billion people. However, there is some information on the types of people who have got infected and based on that we can have a good random sampling exercise. The second reason I am a bit worried is because of press reports that in Chennai, patients with a travel history and symptoms are being denied testing. If that is true, then we have missed out cases. The Chennai authorities are reported to have told the patients to return only if the symptoms get worse. The point is that even if one has mild symptoms and so may not be fatal, yet one could transmit the infection. They should have been tested for epidemiological reasons. Likewise, Kerala also seems to be discouraging patients with mild symptoms to be tested and instead asking them to self-quarantine themselves. By not doing tests we may be under reporting or missing out on cases. Even a mild case needs to be tested as he can infect the entire household and the infection can turn fatal if that household has elderly persons.
TD: What is the current protocol for treatment and testing of COVID-19 in India?
SR: There is, as yet, no standardised treatment protocol. Some doctors have, however, claimed that anti-retroviral treatment given to HIV patients is working in the case of COVID patients as well. These claims need to be tested and treatment protocols developed.
As for testing, as already said, India, is being very conservative and has a highly limited testing policy—testing only those with a travel history. This is being changed now. For testing, swabs are taken from the throat and sent for a Polymerase Chain Reaction Test. If that test is positive the sample is sent to the National Institute of Virology in Pune for a confirmatory test. But now the ICMR is allowing state level labs to do the confirmatory test as well. When their testing sites are too few; they cause two problems—one, deter people from actively seeking tests and two, delay. For instance, Andhra Pradesh has three or four testing centres but not evenly spread out. Given the large size of the districts, access becomes problematic. Given the vastness of our country they have to decentralise testing. Now they are opening up some more, I believe. ICMR is notifying some more public and private labs, which is good. The more you increase access to testing, the more robust the strategy and greater the control over the epidemic.
TD: Would decentralisation also involve private labs?
SR: With regards to the private sector, the quality of the laboratory has to be certified. Today you have all kinds of labs and not all of them have the capability. The test for COVID-19 is sophisticated and expensive. Poor testing will give wrong results and create more confusion. They have to be accredited, maintain standards, and need to have well trained technicians. Standard operating procedure’s need to be laid down and strictly enforced.
TD: Is the Indian healthcare sector equipped to tackle a full blown epidemic?
SR: Full blown like China or Italy? No way. Maybe Kerala and Tamil Nadu could perhaps handle it, but Uttar Pradesh and Bihar will collapse. The health system in the northern states—both public and private—is weak and will get overwhelmed if the case load increases exponentially. It is for this reason that the strategy is to contain and flatten it out so that the case load is in keeping with the health system’s capacity to cope. The issue also is that things like social distancing are not uniform across the country. They are state specific. Andhra Pradesh does not have social distancing, but Telangana has. So, for instance, if a person comes from Iran and passes through Hyderabad on his way to Andhra, what happens? We need to have uniformity and coordination in the implementation of the preventive strategies as the next two weeks are crucial for us.
TD: Are the steps announced by various governments enough?
SR: Not really. As I said there is no uniformity in terms of extent, depth or timing. Social distancing by shutting down schools and population aggregating places is a good first step. But enforcing a total lock down is not easy. [On 22 March, the centre and state governments decided to completely lockdown 75 districts across the country where COVID-19 cases have been reported.]
What therefore is also key is information dissemination: The dos and don’ts for COVID-19 have to be promoted vigorously by governments. Every one hour they should have advertisements on all mass media channels, as it is ultimately individuals that need to take responsibility through awareness and right knowledge.
TD: Health is a state subject, but the money comes from the centre. Can you explain the financing of healthcare in India?
SR: Hospitals are a state subject, but infectious disease is in the concurrent list of the Seventh Schedule of the Constitution. That is the reason the government of India has such a dominant role on programmes to contain HIV/AIDS, tuberculosis, measles and polio. Both centre and states have a role to play. The centre must provide funding support to the states to come up to the standards and guidelines that they are laying down. They need to work together. For instance, the Chhattisgarh health minister has requested the central government to scale up testing. There has to be alignment of thinking and work and the centre has to be aware of the states’ problems. The centre on the other hand has the convening power and can get knowledge from the World Health Organisation and other international organisations. But the implementation agencies are the states, so it is a two-way street. There has to be a concerted approach.
Though the prime minister had a video conference with chief ministers the other day, it is inadequate. There must, sooner or later, be a full fledged half a day face-to-face meeting to drive home the importance of the crisis on hand. There is an urgent need for the chief ministers to understand the gravity of the situation and the likely social and economic consequences and need to prepare for it. The health minister needs to likewise convene a meeting of all state health ministers to understand the thinking behind the containment strategies being proposed. They need to also be ready with measures in the event of the infection exploding. I find it inexplicable as to why the union government is not harnessing political attention of state governments to this issue. Its essential to have states on board. At the center too there is a need to have one focal point—we have too many people taking policy decisions and formulating strategies giving room for confusion and lack of clarity.
This interview has been edited and condensed.