Wisdom and intuition might see us through routine situations in our lives but they are counterproductive for public health programmes.
It is scientific evidence which should guide the decisions which ultimately save lives in a public health crisis.
Last year, India went into a national lockdown when it had 500 cases. In retrospect, the public health response was a wise decision as the effective reproduction number (RT) — the number of people infected from infected persons — was its highest (3.75) on March 23, 2020.
A year later, despite a lower RT of 1.65, multiple super spreader events and poor compliance of appropriate behaviour, have resulted in the ongoing devastation we see around us — Covid cases which touch a new high each day, increasing deaths and a shortage of medicines and oxygen.
I want to think that the decision to go into lockdown in 2020 was based on evidence. Even if it was intuitive, it did help avert a major national health crisis.
Cut to February 2021: there was the red flag of rising RT quite early in the month.
Even as cases rose sharply in Kerala and Maharashtra, the country failed to prevent mass gatherings at a time when it should have gone into war mode.
This inability to use data at this crucial juncture saw us obliterate our chances of restricting newer variants of the virus to a few areas.
India has some of the best minds and research laboratories to study genomic sequencing and detect new variants of Covid-19.
When the The Indian SARS-CoV-2 Consortium on Genomics (INSACOG) — a grouping of 10 National Laboratories — was established by the Ministry of Health and Family Welfare, on December 25, 2020, it had a mandate to test 5% of positive samples from all states and 100% of positive samples from international travellers.
However, the government’s press release from March 24 this year indicates that just 10,878 samples were shared by the states and UTs in three months, the same day when the country officially saw over 50,000 positive cases.
Today, India ranks 102 when it comes to genomic sequencing of Covid (See table), even falling behind smaller countries like Australia and Denmark when it comes to the absolute number of positive samples sequenced.
This is mostly due to the poor resource allocation by the Government and lack of prioritisation to identify the role of newer variants in the earlier outbreak in Maharashtra. Much of the crucial time was lost when the state was undergoing through the surge in cases. As a result of the delay, the variants might have spread to other areas.
From March 27, the test positivity rate of India has jumped four-fold, from 5% to 21%.
Similarly, there has been a 12-fold increase in the daily deaths per million of the population, from 0.2 on March 28 to the current levels of 2.7.
Based on what we know about the RT and health system capacity, some cities, districts and states need to halt the speed at which the virus is spreading through a focused lockdown and aggressive containment.
Instead, we are ignoring scientific data when it comes to evolving a response to the second wave.
The national centre for disease control (NCDC) is a powerhouse of field epidemiologists; the National Institute of Epidemiology (NIE) at Chennai is the nucleus of laboratory surveillance and training health workers for epidemiology.
Ideally, the country would have benefitted from our own Anthony Fauci — someone from the ICMR or NCDC, given the autonomy to run a combined response against Covid-19.
But any attempt at reviewing state performance using data is hampered by the silent or poor reporting of figures.
The states that test at higher rates and have better reporting systems can also attract the necessary attention required for getting more resources.
States like Kerala, Punjab, Karnataka, Haryana and Gujarat are seeing an increase in RT compared to the previous week. Incidentally, these states also have the highest tests per million (TPM > 1600).
In contrast, states like Uttar Pradesh and Bihar, which are showing a decrease in RT, are directly correlated to having a relatively lower TPM when compared to earlier in the week.
Using the data-based approach promotes equity as detecting more cases by better testing strategy ensures that many vulnerable people get into the ambit of services.
And this absence of an evidence-based approach is not just found in the public health response. The current clinical guidelines also contain hydroxychloroquine, which has no evidence of being beneficial as a prophylaxis against Covid-19.
In contrast, it was extremely confusing to see the endorsement of the Coronil for fighting against the COVID disease. Also, some of the medicines in the health ministry’s management protocol required evidence to be cited from the randomised control trial or published studies. Combining non-evidence based guidelines as part of the clinical management has only confounded the provision of quality care.
The country could also benefit from a data-driven approach when it comes to vaccination.
The speed with which India started the vaccination programme even ahead of the results of phase-3 from Covaxin and Covieshield without bridging study was not matched with the speed of coverage subsequently.
The results from phase 3 of Covaxin were announced recently with vaccine efficacy of 78% (95%CI: 61-88) against mild, moderate, and severe Covid-19 disease. The best time to fight against the virus was when the transmission was low in India while the other countries were witnessing second and third waves.
Instead of ramping up the vaccination pace, the country did not take extraordinary measures in facilitating the foreign firms from outside to collaborate with Indian manufacturers.
While the supply constraints still exist, more confusion is created by expanding the age group to younger people without setting up a clear date by when the process can start.
Indians are prone to cardiovascular diseases at least a decade earlier when compared to patients in the west. Young people with comorbidities should be included in the vulnerable group for vaccination. The government should have prioritised vaccinating them along with the existing 45 years and above.
India’s response to the pandemic has relied on an unscientific approach, relying on a system that was never built to address the health needs of crores of its citizens.
For example, one in three adults has hypertension. Yet, neglecting its detection and treatment, the focus has been on increasing government expenditure in footing the reimbursements of complications resulting from high blood pressure.
Similarly, more than 60% of the healthcare needs are met by the private sector. Yet, there are no efforts to shift the patient base by building reliable and stronger public health systems.
By neglecting all the data suggesting growing out of expenditure and treatment costs in private hospitals, the curative services are mostly outsourced to private health systems.
In a health emergency such as Covid-19, the private health care system is demonised, while the government’s inability to prioritise public health is rarely questioned.
The way forward
For starters, the country has failed to use the full potential of those at the NCDC and NIE in managing the Covid response. The scientists and public health experts should be entrusted with complete autonomy to manage the pandemic.
The office of the principal scientific advisor has enabled data access only yesterday (May 1). The data from NCDC and ICMR, when made available to Indian researchers, can provide useful analysis and valid inferences to guide our Covid policy.
India takes pride in computation skills, data analysis and is home to some of the best scientists in the world. Epidemiological evidence should be aligned with genomic sequencing results to halt the onslaught of the virus and prevent the spread of newer variants of concern.
India is a global leader in vaccination due to the strengths in micro-planning and mobilisation efforts. The expertise of WHO-NPSP and UNICEF, which was used to fight polio, measles, and rubella, should be used as part of the coalition to expand vaccination coverage swiftly.
We can have specialists at every block of India and create fully functional intensive care units with sufficient oxygenated beds in every hospital at the block level.
Isn't it time to convert all block-level hospitals into 250-500 bedded hospitals according to population and permanently hire all the required qualified and trained staff? Also, isn’t it the time to provide them with amenities and salaries that of the private sector or what is comparable to the West?
Using evidence-based practice and guidelines and having well-trained workers are not a luxury but a dire necessity in catering to the public health needs of the country.
(Giridhara R Babu is a professor of Epidemiology at the Indian Institute of Public Health, PHFI, Bengaluru)