Community-led interventions are vital

Exclusive Interview/ Harsh Vardhan, Union health minister

32-HandWashGood1 Harsh Vardhan | Sanjay Ahlawat

On a busy mid-week afternoon, two weeks into the nationwide lockdown, the man leading India’s fight against the Covid-19 pandemic is dealing with an array of dizzying numbers from across the country. At his office in New Delhi’s Nirman Bhawan, Dr Harsh Vardhan, Union minister for health and family welfare, has it all on his fingertips. Every few minutes, Vardhan taps his phone screen to check the continuous stream of data, graphics and technical presentations that keep pouring in.

The minister’s schedule has been extremely demanding, and even a couple of hours of sleep is a luxury. But the efforts have paid off. “The preparations are going well,” he tells THE WEEK.

In the coming week, as the group of ministers he heads undertakes a “detailed assessment” of the situation, the health ministry’s containment strategy will hold the key to India’s fate. The precise identification of hotspots and the aggressive plans to test, trace and treat people in those areas will determine how successfully India can contain the virus. As will the participation of 1.3 billion Indians, as they follow the lockdown and practise social distancing.

None of it will be easy, but the minister is hopeful. In a detailed conversation with THE WEEK, he outlines the preparations to ramp up the health system, the risk assessment for India, its testing strategy and the long battle ahead. Excerpts from the interview:

I strongly feel that lockdown and social distancing are currently the most effective ‘social vaccines’ available to the masses.
With the help of the ministry of textiles, all potential manufacturers based in India were contacted and provided handholding support to make good-quality PPEs.
India has taken a ‘thought leadership’ role in this entire episode. Led by Modiji, we have once again established that ‘When India decides, it can do anything!’

Q/ How would you evaluate the success of the nationwide lockdown?

A/ The lockdown began on March 25 and we are on the verge of completing two weeks. India, with a population of 1.35 billion, had decided on a strategy to lock down the entire nation so as to break the chain of transmission and mount a quick capacity addition to its health care facilities. The lockdown has been an important part of our strategy to contain and mitigate the pandemic.

The lockdown is only one of the many public health measures put in place to mitigate the rise of the Covid-19 curve in India. However, the lockdown is the most critical measure that we could have taken and we took a most timely decision. The upcoming few days are critical. The experience, as is evident from the global response, tells us that even with stringent lockdowns and public health measures in place, the transmission dynamics of Covid-19 are such that it takes about two to four weeks to bend the curve.

It is vital that we initiate community-led interventions to ensure social distancing, quarantining and isolation of symptomatic persons to augment the scale of the lockdown in place. The measures are aimed at restricting this spread as much as possible.

Everything depends on our own people and their discipline to strictly follow all public health measures being outlined. Any single break in the chain can prove counterproductive.

Keeping their distance; People in a queue outside a store in Vasai, Mumbai | Amey Mansabdar Keeping their distance; People in a queue outside a store in Vasai, Mumbai | Amey Mansabdar

Although the world, including India, is striving hard to develop a vaccine for Covid-19, I strongly feel that lockdown and social distancing are currently the most effective ‘social vaccines’ available to the masses.

I have coined this term ‘social vaccine’ for lockdown and social distancing as a combined intervention strategy to not only contain, but also mitigate this dreadful pandemic.

Q/ What are the current hotspots that you are focusing on?

A/ One of the important priorities is to identify and manage the hotspots of transmission across the country. A differential strategy is being adopted for areas depending on the extent of infections being reported. While it is important to protect the districts where no cases have emerged, it is equally important to limit the spread of infection in districts where more cases have been noted.

Various measures like cluster containment, contact tracing and case-management measures are being undertaken in such areas. However, ‘community ownership’, especially for social distancing, remains the most important intervention. Unless and until there is an uptake of self-quarantine measures or self-policing by the people, it is difficult to implement an impervious lockdown. While government policies and systems are there to support all preventive efforts, it is essential for people to also take the onus.

More than 80 per cent of the confirmed cases are in 71 districts across 17 states. These are also the districts where there is significant increase

in cases in the past fortnight. Similarly, there are 31 districts that have more than 15 cases each. Here, an action plan for containment of large outbreaks is being followed. There are 76 districts with fewer than 15 cases each, where we are following an action plan for cluster containment.

Q/ How are states responding to the Centre’s call for implementation of public health measures? What are the challenges?

A/ A number of challenges are being encountered, but I would say that the states are doing well. The Union ministry of health and family welfare is coordinating with all state teams. We had issued detailed guidelines for health sector preparedness to all states on January 17 itself. The emerging situation and preparedness are being reviewed regularly with all states and Union territories. Regular video conferences are being held with health ministers. The prime minister is regularly video conferencing with chief ministers to assess the public health interventions being undertaken and the assistance required. Feedback is also being shared on the condition of patients, availability of supplies and capacity building of health staff, and on ensuring availability of all essential commodities and services to the poor.

In the process, there are some exemplary ‘best practices’ by states.

Water warrior: A sanitation worker cleans a locked-down Bengaluru | Bhanu Prakash Chandra Water warrior: A sanitation worker cleans a locked-down Bengaluru | Bhanu Prakash Chandra

Q/ There have been concerns that India might be testing fewer people than required. What is the rationale behind India’s current testing strategy and how is it adequate?

A/ Testing for Covid-19 is being scaled up in a sustainable manner. We are making sure that the quality of the testing kits and the biosafety of the testing labs are maintained so as to avoid any issues related to unreliable results or iatrogenic transmission (illness caused by medical examination or treatment) in health care or laboratory staff.

The current iteration of the testing strategy is customised based on the transmission typology in India. The testing has been extended in a manner to prioritise individuals who are primarily at risk. Given the population of India, we need to scale up in a manner that can be sustained while we build up capacity for testing and management of positive cases.

With the impending scaling up of testing, it is envisioned that we shall reach optimal levels of case detection. In addition, we are also considering scaling up of rapid antibody tests, which is easier to do and takes less time, but is not recommended as a diagnostic test.

We have increased our testing facilities across India. At present, 136 government labs and 59 NABL-accredited (National Accreditation Board for Testing and Calibration Laboratories) private laboratory chains are involved in testing. The number of collection centres have also been increased to 16,000.

As of April 8, we have done 1,04,764 tests. Our present capacity of testing is 20,000 a day.

Q/ Based on the rise in the number of cases, what is the strategy for ramping up public health infrastructure?

A/ We have worked round the clock to ensure sufficient capacity addition in terms of medical personnel resource availability as well as infrastructure. Every state has prioritised capacity addition such as adding new beds, increasing capacity of intensive care units, requisitioning portions of private hospitals, ordering lifesaving ventilators, recruiting medical practitioners on contract, weighing in on extending services of retiring doctors and nurses and earmarking select government hospitals for Covid-19 patients.

Q/ A key issue is the paucity of ventilators. How is the government addressing this? What preparations are being made to train personnel in operating the ventilators?

A/ Data suggests that 80 per cent of the infections are mild or asymptomatic, 15 per cent are severe, requiring oxygen, and 5 per cent are critical, requiring ventilation. The more important thing is oxygen supply. Not all will require a ventilator, but 20 per cent of the cases will require oxygen support through masks or cannula. I can assure the country that around 17,000 ventilators are available for isolation beds set apart for Covid-19 management. This number is gradually being increased.

In addition, many medical colleges and hospitals have postponed their routine planned surgeries, thereby adding more ventilators to available capacity. Every effort is being made to [get another] 48,538 [ventilators] in the coming weeks, which we are hopeful of achieving as per schedule. For this, the health ministry is continuously in touch with a number of domestic manufacturers and importing companies.

All health care workers are being given appropriate training. Workshops are being continuously conducted. Doctors, nurses and paramedical workers posted at intensive care facilities are being trained to operate the ventilators.

Q/ Doctors across the country are concerned about the shortage of personal protective equipment. How is the ministry planning to augment PPE supplies?

A/ Availability of PPE has been a problem worldwide. The problem was even more acute in India because they were not manufactured locally. With the help of the ministry of textiles, all potential manufacturers based in India were contacted and provided handholding support to make good-quality PPEs.

The health ministry, along with the external affairs ministry and the textiles ministry, has identified several other foreign sources also. Orders have already been placed for 80 lakh PPE kits from one foreign supplier and other suppliers are being evaluated. A total of 1.57 crore PPEs have been ordered or pledged already.

Furthermore, several foreign suppliers have been roped in through philanthropic contributions from the Indian corporate sector and the Red Cross. They have promised supplies of around 20 lakh PPEs soon, of which 1.9 lakh have already been received.

The health ministry has also taken a number of steps to strengthen the supply of such items. States have also been directed to prevent hoarding of PPE, masks and gloves, if any, and to monitor the availability of such items. Exports of these items have been banned to ensure continued availability in the country. We hope there will be a steady supply available in the immediate future, in phases. As of now, hospitals across the country have around 4 lakh PPEs with them. We are aiming to achieve 10 lakh a week by the end of next week.

Q/ Apart from private laboratories, how is the government planning to involve the private health care sector in managing Covid-19?

Private sector players have a major role in responding to this national crisis. They have helped scale up the testing capacity in the country. The private sector will have a major part to play as the epidemic leads to more demand for tertiary health care.

Private health care facilities will need to supplement the government efforts in providing care to the patients, especially those who need isolation and intensive care. At the same time, they have to ensure that the health care workers involved are protected adequately. We envision that even at the district level, private health care facilities can play a major role.

Q/ What treatment protocol is being followed for those admitted to hospitals?

A/ Covid-19 does not have any specific treatment. Management is mostly symptomatic and supportive. The ministry has issued guidelines for the management of cases, which have been posted on the ministry website. These guidelines must be followed for all Covid-19 patients admitted to hospitals.

Q/ What key lessons from previous outbreaks have helped you design the strategy this time?

A/ We have a lot of learnings from previous outbreaks and epidemics, which can be replicated in the Covid-19 response. However, we need to keep in consideration the fact that this is a unique pandemic, and it poses a different set of challenges.

First, we need to build community-based approaches, where the interventions are not only accepted by communities, but also owned by communities, to ensure that they are sustainably scaled up.

Second, developing the infrastructure to deal with the challenge on a sustained basis. For example, we have invested in scaling up our testing capacity, detection and management of cases, and developing quality-assured management guidelines.

Third, developing a system to provide informational support through sharing of data on an open platform through the ministry site or portals. This has been important to quell the infodemic of misinformation that has accompanied the rise of the epidemic. Providing correct information is an important intervention to ensure that there is no panic or unrest among the lay population.

Fourth, we have built on the policy and intervention experiences of other countries in shaping the Indian response. Scaling up testing, moving towards community-owned interventions, dedicated health care facilities at the district level for case management, and the current lockdown, all have been calibrated to Indian needs based on the experience of various countries.

And finally, there is a need to provide surge capacity responses, both for mild/asymptomatic cases, which may be managed in domiciliary settings, or for more severe cases, which need to be managed in tertiary care settings.

Gear-ed up: Workers in Kolkata make PPE for the health department | Salil Bera Gear-ed up: Workers in Kolkata make PPE for the health department | Salil Bera

Q/ What is the future course in terms of progression of the disease?

A/ There are several theories that explain the future progression of Covid-19. It is not clear which of them will eventually play out.

In the short term, this is likely to play out like an epidemic, which inevitably follows a pattern of going up and then coming down to a baseline, over three to six months, depending on the intensity of interventions put in place.

If herd immunity develops in the community, there is a possibility that the infection will fizzle out in the medium term, over the next few months.

There is a third possibility, which states that in the long term the novel coronavirus will mix in with the seasonal flu virus, and have seasonal trends, much in line with the current influenza patterns.

Finally, there is also the consideration that like the 2003 pandemic of SARS, this new infection will also fizzle out and eventually die out.

The development of vaccines and therapeutics is also likely to impact the way the infection plays out in the long term. For now, we need to focus on limiting the deaths and raising a concerted effort to reduce the impact of Covid-19 in India.

Q/ What has been your overall experience in handling this pandemic and how hopeful are you of being able to contain and mitigate it? Do you have any message for the nation?

A/ Today the world acknowledges that India was extremely proactive in handling this entire crisis. With my fingers crossed, I can say that so far we have a much lower incidence of confirmed cases compared with other countries. However, we are not complacent. On the contrary, we are burning the midnight oil to ensure that we are able to mitigate this virus. Given all the constraints, I would think India handled this maturely—with speed, scale and determination. I have been using this terminology because it explains exactly how we have worked. The speed with which we acted was praised by none less than the World Health Organisation, the capacity building scale that we ensured was commendable for a developing nation like ours, and the determination of our medical personnel and everyone who was involved in disease management has been exemplary.

In fact, I would go a step further to say that India has taken a ‘thought leadership’ role in this entire episode. Led by Modiji, we have once again established that ‘When India decides, it can do anything!’

I thank our political leadership for taking quick decisions. Modiji inspired the entire nation to follow stringent disease-containment strategies like the Janata Curfew and later the complete lockdown. He showed the benevolence to pledge $10 million as a voluntary contribution for our neighbouring SAARC (South Asian Association for Regional Cooperation) nations and created a ‘SAARC Covid-19 Emergency Fund’. Under his leadership, India offered rapid response teams of doctors, specialists as well as testing gear as part of our collaboration with SAARC nations. While battling our own cases within India, we carried out online training of SAARC nations’ emergency response staff and shared integrated health information with them.

I am hopeful that India will soon come out of this crisis. I also hope and pray for the entire world. I shall take this opportunity to express my gratitude to the frontline health workers across the country, who are constantly at risk. Their sacrifice is exemplary. We must strive to show more compassion and love towards them and their families. Some recent incidents have come to our notice and we are taking adequate measures to ensure the safety of our health workers and their families.