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COVID-19 Control in India: Where are the Public Health Experts?

COVID-19 Control in India: Where are the Public Health Experts?

Illustration: Satwik Gade for The Wire.

India has the second largest number of COVID-19 cases in the world, and the country’s epidemic is still on the rise. Some of the health-related control strategies developed and implemented by the Central and state governments do not have a scientific basis. This begs the question: did decision-makers not seek the opinions of public health experts, or were these opinions ignored?

The first case of COVID-19 was reported in India on January 30, 2020. Since then we have faced a rising epidemic, with the total number of cases exceeding 5 million in mid-September. The Centre developed measures for disease control and which also provided overall guidelines to the states. One of the main strategies was a total lockdown in the initial phase (from March 24) followed by an incremental unlocking spread over several months. The states also devised additional activities to address more local situations – such as intense contact-tracing and testing in Kerala, the ‘Dharavi model’ for containment in slum areas of Mumbai and monthly rounds of seroprevalence survey in Delhi.

However, some strategies being used at both national and state levels do not have a scientific basis. Consider the crucial one about testing persons with relevant symptoms and asymptomatic contacts of confirmed cases. Two types of tests are being used: the reverse-transcription polymerase chain reaction (RT-PCR) and rapid antigen tests (RATs). While RT-PCR is regarded as the ‘gold standard’, RATs are less expensive and faster – but they typically miss almost half of all positive cases. Despite this well-known fact, an increasing fraction of tests are RATs.

The decision to use RATs could have been in response to the need to quickly ramp up testing or for financial reasons. Recently, responding to a public interest litigation, the Delhi high court has asked the Delhi government to increase the capacity for RT-PCR tests to the extent possible – a welcome ruling.

Also read: Why Experts Are Calling ICMR’s New Advisory on Antigen Tests Unreasonable

Another inexplicable strategy is the weekly lockdown that some states have been implementing. Lockdowns in the initial phase of the pandemic are used to slow down the spread of infections while health systems for contact-tracing, testing and treatment are being put in place. Thereafter, periodic lockdowns over a period of time – such as several weeks or months – may also be used to slow down the virus’s spread to avoid overwhelming locally available health facilities, like the one announced in Chhattisgarh recently.

However, lockdowns for one or two days in a week may only postpone infections for a day or two, and will not help in disease control. Such lockdowns will also disrupt routine services and bring on economic losses, particularly for daily-wage workers. There has even been a debate in scientific journals about the suitability of extended strict-lockdowns in low- and middle-income countries that can lead to various problems, including widespread loss of livelihoods. In India, we have witnessed chaotic scenes of informal-sector workers losing their jobs en masse, trying to return to their villages from cities, resulting in deaths due to various causes and spread of the virus into rural areas, where health facilities are limited.

It appears that COVID-19 control has been driven primarily by politicians in power and by bureaucrats. Scientific inputs on the health aspects mentioned above were either not sought or ignored by policymakers. We cannot expect public-health experts to be in policymaking or regulatory roles for a national emergency. But during a pandemic, they should be included as essential members of decision-making committees to analyse data and advise the government on disease-control measures.

At the national level, we did see public health experts from the Indian Council of Medical Research (ICMR) in the initial stages, particularly at the daily media briefings. But this coordination mechanism is not so visible at present, with only officials from the Ministry of Health conducting periodic press-briefings and discussing pandemic-related data. Some states have involved eminent clinicians who are specialists in other branches of medicine as advisors. But if you had an earache, would you consult a cardiologist? In similar vein, why would one approach a non-public-health medical professional to design a public-health programme?

Also read: Coronavirus: The Lockdown Has Caught Us Between Expertise and Common Sense

We would like more involvement of public-health experts and epidemiologists to ensure that all decisions have a scientific rationale. Disease-control strategies, while drawing upon proven practices from other parts of the world, need to be tailored to the local situation. This is a good time to identify and promote a leadership role for state government institutions, such as bodies affiliated with the ICMR and the public-health departments of reputed medical colleges. India desperately needs to improve its public health systems to meet the needs of its people and the best time to begin is now.

Dr Anjana Das is a medical doctor and public health specialist who has worked in the fields of reproductive health, HIV and sexually transmitted infections for over three decades.

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