Firstpost Podcast: To fight coronavirus, states must emulate Kerala model, says public health advisor Dr Aiswarya
Are state governments putting their best foot forward in the face of the coronavirus outbreak? What do we’ve to learn from the Kerala model? Dr Aiswarya Rao takes a closer look at that and how different states are faring
All public health messages dwell on individual responsibility with stress placed on the importance of hand washing, physical distancing, and staying at home even though asymptomatic.
But the pillars on which the outbreak can be contained remains good public health practices of surveillance, screening, testing, isolation and contact tracing.
Are state governments putting their best foot forward in the face of the coronavirus outbreak? What do we’ve to learn from the Kerala model? Dr Aiswarya Rao takes a closer look at that and how different states are faring in this episode of Dr Aiswarya Explains.
I am Dr Aiswarya Rao, a paediatrician and public health Consultant, here with yet another podcast on the unfolding coronavirus outbreak in India. Today I want to discuss the response of different states, and the challenges that they face, as well as some of the best practices employed by them.
According to the World Health Organisation, COVID-19 cases have been reported from 182 countries around the world, with seven countries having more than 10,000 cases. Typically in these countries it took 2 to 3 weeks to go from 100 positive cases to 10,000 cases – that’s exponential growth. Nearly 1 billion people all over the world are confined to their homes – with more than 600 million due to government lockdown orders.
In India, positive coronavirus cases have doubled in the past three days and the tally now exceeds 315. We are now showing the same rate of growth in infection that other countries showed in their early days, followed by exponential rise in infections within a matter of weeks.
India is among the last countries to experience the outbreak, so we have a head start in preparing to meet the challenge. The next couple of weeks will be the most crucial in breaking this cycle of transmission.
So far cases have been reported from 22 states and union territories, and as expected every state has a different response to the COVID 19 outbreak in keeping with the enormous diversity that is the very description of India.
Some strategies have been admirable, while others have left a lot to be desired. This is no time to point fingers and start a blame game, but to only understand the challenges, so that we can push our policy makers to effect changes while we have the time. There is still time to act.
Look at a state like Kerala that was the first to report the infection as early as 30 January. They immediately took measures on a war foot, quite extensively and pro-actively. At the same time the chief minister of Telangana called the coronavirus outbreak as bad propaganda, and he even went as far as to call it ‘bakwas’.
Other states too were not any better, and were in denial during the initial weeks, and sat up to take stock only when the positive cases started trickling in. The good news is that all states now have realised the gravity of the situation and have begun to rise to the occasion.
All public health messages and campaigns so far have dwelt on individual responsibility with stress placed on the importance of hand washing, physical distancing, and staying at home even though asymptomatic. These measures are no doubt crucial to break the chain of transmission.
But the pillars on which the outbreak can be contained remains the good public health practices of surveillance, screening, testing, isolation and contact tracing. We have to detect all the index cases and the cluster of cases that were infected by the index case. Once someone is tested positive, depending on the symptoms they must be hospitalised and treated. Detection and treatment is also part of containment.
Kerala has some admirable best practices that must be a template for other states to follow. It started early testing of suspected cases, isolating the infected, carefully tracing contacts, shutting down mass gatherings/closing schools, shutting down the borders and restricting traffic both internationally as well as with the neighbouring states.
Kerala went full throttle and left no stone unturned in its efforts, when other states were beginning to notice the new infections. One of the reasons is because of its previous experience with the 2018 outbreak of the Nipah virus. This was an infection that spread from fruit bats into humans.
Between 5 May and 10 June 2018 – a matter of a mere five weeks they went from the first index case to halting and containing the outbreak successfully with only 19 cases reported totally. Not only that, the Institute of Advanced Virology was set up within weeks as a response to the outbreak in order to help with future similar outbreaks. So Kerala brings this experience, level of response and preparedness to the current COVID-19 outbreak.
The advantage that Kerala had was that it already has a strong health system, with very good public health networks, and dedicated health professionals. This augmented by a tested and tried emergency preparedness plan and decentralised governance, helped the administration to swiftly swing into action by coordinating multiple and interdepartmental efforts.
They set up 24-hr control rooms at the state and the district levels with single window communication. They started six phone lines at the state call centre and four fully operational state testing centres. They put into service well-coordinated HR management teams at the state and district levels with enough staff for airport surveillance, manning call centres, and for transportation, isolation and contact tracing.
They created massive outreach campaigns and public awareness in multiple languages to get the message out. Who has not seen that video of the policeman dancing and scrubbing their hands to demonstrate how it is done? They did geo-mapping for contact tracing with time, place and date mapping. People at risk or possible contacts responded with self-reporting.
They had well-equipped and secure treatment facilities and dedicated and trained staff to administer care, support and treatment. The state began manufacturing hand sanitisers, and their jail inmates began making masks to meet the growing needs. Anganwadi children who were sequestered at their homes were home delivered their mid-day meals.
Kerala thought of every possible activity to disrupt the infection and made it happen. All this massive and concerted effort boils down to one thing: leadership. Chief Minister Pinarayi Vijayan and the Health Minister KK Shalaja led from the front.
Here is a text book case study of leadership, coordination involving all stakeholders, civil society responsibility aided by effective communication. Here is a combination of political goodwill, bureaucracy, technocracy, civil society and media, who came together as if on cue to tackle an emergency situation together. The crisis is not yet over, but they know what they are doing.
Contrast that with states like Uttar Pradesh which has high vacancy rates for doctors in the public health system, where the primary health care system is not functional and there is high dependence on medical colleges and district hospitals for dealing with a situation like this. Somewhere in between the Kerala model and the Uttar Pradesh scenario are the other states such as Maharashtra, Andhra Pradesh, Telangana and Tamil Nadu.
They have functional PHCs – the basis for good health care, but the response on a war footing that is proactive and transparent has been missing so far. Though Tamil Nadu is sandwiched between two states all having more than 15 positive cases, they have only reported six cases so far sparking concerns of inadequate screening, surveillance and testing.
It will augur well for every state in India to take a leaf out of Kerala’s book to tackle the pandemic. We still have at-least another two to three weeks before the exponential rise in cases is expected. We have to learn to use available resources holistically and methodically. Now that new testing guidelines have been issued allowing testing of asymptomatic high risk contacts, all hospitalised persons with severe acute respiratory infection, and with the directive to rope in NABL-accredited private labs for the coronavirus testing, we should be detecting more index cases and their contacts.
Almost all states have done the right thing by restricting mass gathering, closing schools and colleges, and public places, restricting travel both international as well as between state boundaries. The only thing we are not hearing preparations for, from all states is their preparedness in treating persons sick with COVID-19 . Nearly 20 percent of all infected will need hospitalisation and 10 percent will need ICU care. Is our health infrastructure ready?
The onus is clearly on government doctors and health care professionals to step up to the challenge of caring and treating in the tough days ahead. The private doctors and paramedics will also need to be pressed into service when the system is overwhelmed.
As the government at the Centre and states gear up for this huge crisis, we can pressurise and urge them to work on increasing testing capacity and beds and ICU facilities for the sick. At the same time we can all listen to the clarion call of physical distancing and stay at home, and reduce their burden by taking precautions to avoid getting infected.
Finally in the words of Dr Tedros Gebresus, director general, WHO, when humanity is confronted with a common enemy like this, it also gives us a chance to bring the best of us. A unique opportunity for trity in everything. A solidarity that is more infectious than the virus itself, so we will be able to stop this virus.
This is Dr Aiswarya Rao signing off and I'll see you with the next episode of this podcast.
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