How to Prevent the Next Pandemic
Coronavirus pandemic has revealed the disastrous flaws of India's healthcare system. What are the steps required to battle the next pandemic, and what are the factors that decide the success and failure of a health response in a low-income setting? A HE report.
"Pandemics emerge as surprises and cannot be prevented by design. Since all recent pandemics were zoonoses turning pandemic, watching for earliest signals can help in responding rapidly and effectively," says Dr T Jacob John, prominent virologist and former professor of CMC Vellore.
Is prevention Unrealistic?
A vociferous advocate of public health surveillance, Dr John points out that H1N1 pdm 09 flu emerged in February, detected in February and the world geared up to face the pandemic by April 2009. "To pick early signals, all countries must practice public health surveillance and "one health approach. COVID-19 had emerged in September or October but was recognized only in December. It became pandemic by early February, but WHO misread signals and declared a pandemic in March second week. More than four months lost. Public health surveillance failed in China. India does not practice public health surveillance because we have a poor surrogate called Integrated Disease Surveillance Programme, which does not fit as public health surveillance. It is the responsibility of the WHO to ensure every member country practices public health surveillance. Data from One health and public health surveillance will provide early signals. Prevention is unrealistic; mitigation is possible," explains Dr John.
Lessons from the Past
Are there any lessons from how India handled Polio, which can be used in our battle against pandemics?
"For polio eradication, the goal was set by WHO, one-disease surveillance fitting definition of public health surveillance was designed and implemented by WHO through National Polio Surveillance Project, in which our MoH was a junior partner. Without surveillance, both clinical (AFP) and virological, polio elimination programme would not have succeeded. Polio is an ancient disease. A country that is unable to address existing 'endemic' diseases will hardly be able to address 'epidemic' diseases, especially newly emerging ones. No legacy was institutionalized after smallpox eradication or after polio elimination," explains the renowned virologist.
India needs a Health Management System
So, which are the areas/measures, where India needs to invest in the post-pandemic world immediately?
Dr John adds that India must design a "health management" system, which must include "public health", universal health-care and research. "We have token research, not substantive, to impinge on policy-making. We have a most unsatisfactory health-care system that must be built upon as universal and quality assured. India must rebuild, from scratch, public health that was abolished soon after independence. Government and medical profession collude in painting "public sector health-care" as public health to hoodwink the people and avoid building public health. The consumer of public health surveillance is public health; no public health, no public health surveillance needed. The present fragile health-care consumes <2% GDP, and Universal health-care will require about 3%. That is a guesstimate. Public health will require another 2% at least," he explains.
Reduce Inequities
Dr Sushil Shah, Chairman of Metropolis, has a different take on the issue.
"The novel coronavirus pandemic has hit us almost a century after the Influenza pandemic. India relatively remained safe from the SARS and MERS epidemic as compared to the scale of COVID-19. A good example is Vietnam, where the SARS outbreak forced the country to start community infection centres in every town, and this has come as a boon during COVID-19. In India, the incidence of infectious diseases is many. Yet, our municipal corporations are not entirely equipped to handle or even conduct basics of a pandemic such as contact tracing," explains Shah.
Dr.Shah notes that India has a long way to go before achieving universal health coverage, but we can take some definitive steps to reduce inequities. "One of it would be to considerably increase spending on healthcare, encourage more public-private partnerships, ramp-up health-care infrastructure in our towns, villages and districts. Building an interface that has active community participation in healthcare is very important. The pandemic is a grim reminder of the state of health-care in the country, and if we do not act upon the inadequacies, it would be a gross disservice to the future generations in India," explains Shah.
Strengthen Grassroots Healthcare
Shah also points out that there are a lot of lessons to take home from the current outbreak. "Even in India, we have seen that different states have responded differently to the pandemic. If you take Kerala, for example, their strong public health strategies and involvement of volunteers worked greatly in the social behaviour of the population, which is very important to tackle a pandemic. Mizoram, the only state to not have recorded even a single death so far also has used their community efforts and used their time during the lockdown to plan a response and ramp up their resources."
So, is a more equitable healthcare coverage the solution?
"We have seen that countries with more equitable health-care coverage have responded better to the pandemic. We can look at South Korea, Vietnam, and Singapore who have demonstrated considerable success in their response to the pandemic. The objective of Universal healthcare coverage is to ensure that no one is left behind. Countries that have made little progress or have done very little in the past to strengthen their health systems have been affected to a large extent. The list includes some wealthy and developed nations."
Refocus on Public Health
There are important lessons from this pandemic that will help us better prepare to tackle future health emergencies; one of the most important one being that there is an urgent need to ramp significantly up our health-care facilities and resources. Controlling Infectious diseases like Malaria, tuberculosis and viral infections will be very critical in the future. It is now time to motivate and encourage Indians to adopt healthy living and lifestyle by putting norms on the quality of food we ingest, bringing in stricter norms on quality of medication, treatment and diagnosis are all critical," he adds.
Address Inequities in Testing
So, how can testing be made more affordable in a country like India?
The chairman of a multinational chain of pathology centres based in Mumbai, notes that in India, the diagnostic industry is unregulated, and this has created a price disparity amongst different laboratories. "We have seen that a large percentage of labs in India have no accreditation and certification of their lab practices and because of no minimum standards, there is no real way to know if the test results are reliable. One big step in making testing more affordable would be to bring in regulation and put minimum standards in place. Often, we have seen that as volumes increase, the test of the price can be brought down. Additionally, developing more indigenous testing kits whose standards are on par with US FDA will help bring down a lot of costs," he adds.
Pioneering newer technologies in India that make use of artificial intelligence and other advanced diagnostic methods that change the way testing happens can bring about a significant turn-around in testing prices. But one key thing to remember is that testing must be 100% reliable as human life and wellness are dependent on diagnosis. It is important to remember that even today, 70% of clinical decisions are made based on laboratory reports.
Additionally, removing custom duties on reagents needed for critical tests, bringing in uniform regulation can cut down the leakages in the system and ultimately cut down the cost for the patient," he adds.
Coronavirus has shown that cities are more prone to a pandemic, what measures can be adopted by Mumbai and Delhi to prevent the next pandemic?
Dr Shah notes that it is not possible to entirely prevent a pandemic as emerging diseases will cross international borders. However, it is possible to improve our response to a health emergency in the future. The Zika and Nipah outbreak in India's Kerala proved that it is possible to build a health-care system that allows systemic detection of an outbreak and prepare a rapid containment response. We witnessed that both in Mumbai and Delhi, health-care systems were overwhelmed during a period when infections were steadily on the rise. Many deaths could have been avoided if our health-care infrastructure, our ICU capacity, and ventilator support were larger in number and easily accessible to everyone who needed it.
In India, over the decades, there has been a trust deficit between the public and private health-care industry, and we need to look at a participative approach in the next few decades to bring a balance in the healthcare systems. There need to be more avenues for PPPs that will make health-care more affordable and accessible and also ensure quality in services. Additionally, there is a dire need to invest in community interventions and ramp up infrastructure to a great deal in our towns and districts, Shah concludes.