A 3D print of a spike protein of SARS-CoV-2, the virus that causes COVID-19, in front of a 3D print of a SARS-CoV-2 virus particle. The spike protein (foreground) enables the virus to enter and infect human cells. Caption and photo: niaid/Flickr, CC BY 2.0.
Public health experts caution that should the coronavirus outbreak snowball in India, the country’s weak public health infrastructure may not be able to cope. The southern states may still withstand the onslaught of demands but the northern states, and their relatively poorer amenities, will likely struggle.
“The coronavirus disease1 caused by severe acute respiratory syndrome coronavirus – SARS-CoV-2 – will impact the healthcare system of India in an unprecedented manner,” Joe Thomas, a professor of health, sustainable and inclusive development at MITWorld Peace University, Pune, said. “Though the epidemic is in its preliminary stages in India, it appears that the government’s and the community’s readiness are still not adequate.”
While the Union Ministry of Health and Family Welfare has initiated several steps to contain the outbreak, “COVID-19 demands a genuinely multi-sectoral approach and such a response is yet to be in place,” Thomas, who is visiting faculty of the school of health sciences and social work at the University of Portsmouth, UK, said.
Kerala dealt efficiently with its and India’s first three coronavirus cases, who were all treated and discharged from state government funded medical college hospitals in Thrissur and Alappuzha. Thus far, India has reported 40 cases in the country, the last six on March 8 and 9 from Kerala.
Generally, India’s southern states do well healthcare-wise “as they follow the basic principles of public health strategies to the ‘T’, and very diligently,” Sujatha Rao, former secretary of health and family welfare, told The Wire. “They invest on training and close supervision. Other states lack that eye for detail and systems.”
“The big question mark is medical facilities and preparation for outbreaks in parts of states such as Uttar Pradesh, Bihar and Madhya Pradesh, whose health infrastructure is fragmented and not in top form,” Anant Bhan, an adjunct faculty member at the Kasturba Medical College in Manipal and and visiting professor in the department of community medicine, Yenepoya Medical College, Mangalore, said.
In these states, a thorough government plan and follow-up protocols, such as in Kerala, don’t exist or are of relatively much poorer quality. Handling outbreaks requires prompt detection and identification, rapid-testing facilities, referral hospitals, cooperation between public and private centres, and transparently sharing data – and these components are currently weak, according to Bhan.
They also have lower literacy and so the people are less responsive to information, Rao added.
So if a coronavirus outbreak had happened in rural India, the situation will have been much worse. However, this isn’t to say that there has been no improvement at all. “We have better laboratory infrastructure, more manpower on the ground – for example, a million ASHAs2 – and have also experience in handling public health strategies,” he explained.
But there is a need for more investment in building public health infrastructure and rapid response systems. “The main constraint is the continued neglect of public health and notions of health security,” Rao said. “We react only when it becomes a global emergency. The moment it’s gone, and with that our attention, and we lapse back to health insurance and other populist programs. Public health needs to be a constant priority and [the subject of constant] vigil in countries like India, which are high on the vulnerability index, and should never ever be lowered.”
For Thomas, the priorities should be “early epidemiological and clinical investigations”, both critical in the early days of a viral outbreak. “The understanding of transmission patterns, severity, clinical features and risk factors for infection remains limited among the general population, for health workers and in household and other ‘closed’ settings,” he said. “Risk communication and community engagement strategy by the state governments [should] be in place. It seems clear and relevant diffusion of information is slow.”
Bhan is also concerned about India’s health priorities. “The focus of the government has been on health insurance and not on primary healthcare infrastructure. It’s a good reminder for us to approach primary health care centres with a revised perspective. This kind of reform is sorely needed.”
India spends only 1.3% of its gross domestic product on health, and the extent to which this allocation is insufficient becomes quickly apparent when short-staffed and overcrowded medical facilities and overworked personnel in many district hospitals in rural areas are faced with a higher case load.
According to the National Health Profile of 2019, India has 25,778 government hospitals and 713,986 beds in them. The country also has 158,417 sub-centres, 25,743 primary healthcare centres and 65,624 community centres.
Bhan argued that India requires a national health system, akin to the Public Health Agency of Canada, that focuses on preventing disease and injuries, promoting good physical and mental health, and providing information to support informed-decision making in response to public health threats. “A vigilant health system is not yet in place, with trained professionals, outbreak response teams and decisions on stockpiling,” he said, implying that instead of being continuously prepared, India simply responds to each outbreak as and when it happens.
In this context, the spread of SARS-CoV-2 could be the opportunity the country needs to change how its outbreak response works. “It is a good test case to learn to do better,” Bhan said.
Learning from the past
An appropriate place to figure out how is Kerala itself.
The most important aspect of the state’s response to the Nipah virus outbreak in 2018 was, according to Thomas, that the “early detection of the virus was a fluke.” That is, the virus wasn’t detected through a regular surveillance facility. Instead, an alert physician at a private hospital noticed an unusual pattern of fevers among the people who had reported to his hospital – that too from his own village – which prompted him to have their samples tested at the Manipal Centre for Virus Research (MCVR).
“The message from the Kerala Nipah outbreak is that each state should have robust surveillance facilities to detect epidemics early,” Thomas said. “There is a need to rapidly scale up national and state capacity,” in the form of identifying lacunae, assessing risk, planning for additional investigation, and executing efforts to curb infections, “to address COVID-19 since health is a state subject.”
At the moment, confirmatory testing is only possible at the National Institute of Virology (NIV), a laboratory of the Indian Council of Medical Research (ICMR) in Pune. “This can be problematic if an outbreak goes to scale,” Bhan said. “This is not a practical measure.” Instead of allowing such an obvious bottleneck, India needs a national referral chain with more next-generation labs and with wider capacity to confirm cases.
Peter Piot, director of the London School of Hygiene and Tropical Medicine, raised this issue at the annual BioAsia 2020 meeting in February; he said, “Every Indian state should have a laboratory to deal with virus diagnostics, rather than send samples to one centralised lab and wait for the results.”
Unfortunately, the MCVR that handled the Nipah virus outbreak is out of the picture now. In January 2020 the Government of India cancelled its FCRA license, suspending its ability to access foreign funds for its research and testing. Such funds play an important role in sustaining research in the country.
Earlier, the government had also terminated the Acute Febrile Illness Project, run jointly by the MCVR, the US Centres for Disease Control and the health ministry to study numerous infectious diseases with no known treatment, including the Nipah and Ebola viruses, citing procedural irregularities on MCVR’s part that have yet to come to light.
Arunkumar Govindakarnavar, the director of MCVR, has denied the charges saying his institute only used funds from the ICMR and with appropriate clearance.
“The recent controversy with regard to [MCVR] is unfortunate,” Bhan said. “The centre worked closely with government authorities in Kerala and with ICMR and other bodies to respond to Kerala’s Nipah outbreak. At this time, we need to be utilising the strength of such academic institutions to respond to scenarios, such as the spread of COVID-19.”
Indeed, SARS-CoV-2 isn’t the first viral outbreak in India and certainly won’t be the last, so the country’s preparedness is, in a manner of speaking, a timeless problem. India successfully eradicated the poliovirus, fought the H1N1 outbreak in 2009, and is constantly dealing with the spread of HIV. “India has the experience therefore of implementing public health concepts of contact tracing, etc., on scale,” Rao said.
T.V. Padma is a freelance science journalist.