Cornering the coronavirus

The Ministry of Health and Family Welfare has been diligently reporting the spread of the Novel Coronavirus 2019 (Covid-19) cases on its website, providing a daily update on the number of cases by state and Union Territory, those cured and the deaths. On Thursday morning, it showed that there were 602 cases in India (and it rose to 649 by the afternoon, as per news reports), across 26 states and UTs.

The first case of Covid-19 in India was reported on January 30, 2020, in a person who had travelled back to the country from Wuhan, China – the origin of the pandemic. The following weeks were fairly quiet, with single cases being reported. Until March 6, there were 30 cases identified across the country. Since then there has been a steady rise in cases.

There are those who take comfort in the low count – 600-plus cases in a country of 1.3 billion people! Surely, the shutting down of schools and colleges and malls and everything else under the lockdown must be an over-reaction! There are fantastic notions doing the rounds that somehow Indians are immune to the virus, with no evidence to back that claim.

One reason for the low number of known cases is the low level of testing: there are 50-plus testing centres for the whole country, and less than 20,000 people have been tested so far. The testing criteria are also narrow: if you are displaying some of the symptoms (cough, cold, fever) and if you have returned from a foreign country, or if you have pneumonia. This flies in the face of what we already know: that infected people can be asymptomatic and yet spreading the infection. For comparison, China had tested some 3.2 lakh people in just its Guangdong province by February 28. Even the US, which has faced severe criticism on this front, has conducted over 1 lakh tests so far. Testing is the only way to prevent, detect and arrest community spread.

Under the circumstances, it is premature to presume that community spread is not already a reality in India – we simply don’t have the data to back such a claim. It is more a prayer than a presumption, because if the coronavirus were to spread through our crowded urban neighborhoods and poorly served rural hamlets, the ill-equipped and under-resourced Indian public health system will be the most spectacular victim of the pandemic.

The chronic under-funding of the health sector in India is well-known. Stagnating at around 1.2% of GDP, healthcare (both out-patient and inpatient) is largely financed by people out of their own pockets. The government has recently launched Ayushman Bharat, which aims to cover the costs of curative, hospital-based services for millions of people below the poverty line. This is necessary, since catastrophic illness is a major cause of poverty. Even without a looming epidemic, it was estimated that about 55 million people got pushed below the poverty line due to health expenditures (2012); 38 million fell into poverty due to the cost of medicines alone. However, if insurance for catastrophic illness, and that too at secondary/tertiary level, is expanded while neglecting primary preventive care, we face a grim scenario.

What we need urgently is to make ‘Health for All’ not just a slogan but a reality. A basic requirement for this is a strong public health network, with a sufficient number of full-time trained and equipped health workers who could undertake preventive actions (including health education), early detection, testing and self-quarantine if necessary so that such epidemics could be contained and dealt with at low human and systems cost.

Additionally, dealing with Covid-19 has had to enlist other departments: airport authorities (for screening passengers), police (for contact tracing) and so on. Clearly, we have to recognize the inadequacy of a siloed, medical approach to public health and move beyond it with ‘inter-sectoral collaboration’ and society-wide approaches. An important part of this would be to bring the private sector fully on board. Stringent reporting mechanisms need to be in place so that cases which present themselves in private facilities do not fall through the cracks. Most dangerous are those who lack access to a credible public health system and cannot afford private healthcare: by delaying seeking care, they might go unnoticed and contribute to community spread.

Simple, cheap measures that prevent early onset of serious diseases are underfunded. If we instead focus on funding quarantine facilities, respirators and high-end equipment at secondary and tertiary hospitals to deal with the most critical cases, we have already lost the battle. Not that they are not required – they are. But not at the cost of robust primary preventive care. Emergencies like the Covid-19 pandemic should be used as opportunities for systemic strengthening, not just for crisis management.

(The writers are professor and guest faculty, respectively, at Azim Premji University, Bengaluru)