The coronavirus epidemic was a major crisis in China even before the news came out on 10 January and alerted the Chinese leadership. The illness by then was no longer localized. In fact, it had even travelled abroad. China’s rigid bureaucracy discourages local officials from raising bad news with central bosses.
China’s health sector is so heavily compartmentalized that officials in the public health division, the disease control department, in hospital administration and drug procurement seldom speak to each other. This makes it harder to manage, or even see, a crisis in the making. Those systemic flaws appear to have played a role in the pace at which Chinese officials responded to the outbreak, and the country’s inability to address the health risks from its so-called wet markets, which are stuffed with livestock living and dead, domesticated and wild.
The real bad news is the coronavirus, which comes from a family of viruses that affect the respiratory tract, seems to be far deadlier than before. In 2002, when the SARS (Severe Acute Respiratory Syndrome) virus hit China, it took more than 90 days to mutate and take its new deadly form. But the coronavirus seems to have achieved the capability of transmitting among humans within the first month.
The World Health Organization (WHO) has clarified that the disease only spreads from animals to humans and is not communicable between human beings. However, now questions are being raised as some among those affected claim not to have been near any animals recently.
That is why the panic within the public health machinery in China is palpable, even as human resources are being mobilized and sent to the epicentre in Wuhan, the capital of central China’s Hubei province, by the thousands.
The fact that this is happening during the Chinese New Year, when massive numbers move across the country to visit relatives, is unprecedented and will have a huge economic impact.
The big question is—how long before the coronavirus reaches India? There are already reports of a couple of suspected cases being quarantined in the country. While there is no confirmation as yet of any live cases in India, is the country battle-ready to identify, isolate and prevent the spread of this new virus? What steps do the public healthcare authorities quickly need to take to tackle this crisis on a war footing?
Truth be told, the steps India needs to take do not require rocket science. Surveillance mechanisms have to be improved—detection has to be strengthened at all major airports and along the border with Nepal. Of course, one also needs to maintain quarantine facilities at key points where adequate stock of medicines and fluids is stocked. Finally, awareness campaigns have to be launched on precautions to be taken; the public has to be made aware of the symptoms; information helplines have to be set up; and travel advisories have to be issued to the afflicted countries.
While the Indian government has already moved on some of these measures, what can on-ground experience with past crises tell us about the ground reality—and the challenges ahead?
Lessons from Nipah
Like the Chinese health bureaucracy, in India too there is remarkable time lag before diseases get identified and before they get notified, if at all. India’s medical bureaucracy is often loath to report bad news. We see that happening in case of dengue and chikungunya outbreaks in most Indian cities, where news only emerges after a few people have died and several seriously taken ill.
No wonder India ranks high globally in the burden of communicable diseases, a burden which causes approximately 10% of deaths in the country. The issue is serious considering the phase of rapid urbanization the country is going through—raising challenges to an already beleaguered and cash-crunched healthcare system.
Human resources and healthcare infrastructure are woefully below the WHO standards. The risk from communicable diseases increases manifold when other factors—environmental, socioeconomic and demographic—are considered.
The Nipah virus outbreak of 2018 in Kerala has several lessons for today’s emergency. This epidemic showed how the Indian infectious disease management infrastructure could be severely challenged. After its discovery in a small Malaysian village in 1999, the virus emerged in Kerala in May 2018, claiming 17 lives. The seriousness of the public health threat was underscored by the lack of a vaccine or even targeted treatment. This allowed the virus to spread unchecked initially.
Soon after the National Centre for Disease Control was alerted by the state, the ministry of health and family welfare along with local, state, and national agencies collaborated on a response to contain the virus. A multidisciplinary team was deployed with the main aim of preventing and controlling the infection.
This coordination and data-exchange from multiple stakeholders helped to rapidly detect infected cases, treat the patients, and helped in controlling and containing the spread of the disease. It also helped safeguard the front-line health workers who were most at risk. Also, campaigns for information dissemination and education of the public led to reducing panic and fear among the people.
The Nipah case study highlights the fact that the response worked primarily because of the infrastructure available in the state. The only other state where this is possible is perhaps Tamil Nadu. Across the country, there are major gaps in the public health system. Poor surveillance mechanisms and lack of public awareness are again in the spotlight with the re-emergence of the Nipah virus in Kerala and the persistent outbreaks of acute encephalitis syndrome, seen recently in Bihar.
The situation is compounded by healthcare facilities without equipment, doctors and drugs, not to mention the poor nutritional status and poorer sanitation status of the population. A speedy local response is crucial in infectious disease management.
Importance of diagnostics
While epidemiological research is absolutely critical to understand the manner in which diseases emerge and travel, it is also extremely important to identify and track all neglected and communicable diseases. Here, diagnosis almost always suffers from lack of availability of stock, of pathologists and medical equipment.
Existing diagnostic practices are time-consuming and expensive. Innovations for diagnostics, detection, testing, notification and treatment have always been significant variables that make a difference. Till very recently, tuberculosis (TB) diagnostics were cumbersome. Dengue and Chikungunya are fraught with danger primarily because it costs upwards of $15 (upwards of ₹1,000) to get tests done.
Till recently, most diagnostic tests required large amounts of equipment and stocks of chemicals. The lab needed an electricity connection and the samples had to be carried long distances within refrigerators or in ice boxes. Remote areas and rural health centres simply could not provide these facilities—in fact they still cannot.
All this has been replaced in various parts of the country with health ATMs— private, walk-in medical kiosks with integrated medical devices for basic vitals, lab testing and emergency facilities, and staffed by a medical attendant. Instead of large machinery and human resource requirements, most diagnostics now only need a pinprick. To detect deadly diseases like TB, for instance, the person needs to give just some sputum.
Technology has helped to some extent. Most diagnostics can now be done using smartphones and simple apps loaded on them. Health workers with very little training can now reach patients in the most remote places. With cheaper diagnostics and quicker procedures in laboratories, it is possible to hugely improve access to healthcare and a timely cure.
It is prevention, however, that is always better than identification, diagnostics and cure. Hygiene and sanitation play a huge role. The huge burden of morbidity that exists in India is related in part to unsanitary conditions and practices, unsafe and unclean drinking water, and lack of awareness and information.
Role of vaccinations
Vaccinations are among the most efficient and effective instruments for preventing diseases, operating primarily by providing acquired immunity and thereby preventing the easy spread of infectious diseases among large populations.
However, developing vaccines, especially for new and mutated strains of diseases, can take a very long time. Coupled with the time and the resources needed for mass production and delivery, vaccines cannot be seen as the only solution during fast-spreading epidemics.
India successfully repeated its success against small pox when it fought off polio with another massive immunization drive 12 years ago. From being the polio capital of the world in 2009 to one with no new cases in 2011, the Indian public healthcare machinery showed that it can fight well when it wants to.
Still, there’s a lot of work to be done. The healthcare sector needs inputs from the public and the private sectors to conduct research on improved drugs and tests to help make it easier to treat people quickly. Front-line health workers need modern supply chains and equipment as they already have the tough job of delivering medicines to the hardest-to-reach regions of the world. And importantly, medicine stocks must be maintained and supplied to all vulnerable areas on time.
In China, there is now a travel ban on 16 cities in the epicentre Wuhan province. Wild animal sales have been banned. Three new 1,000-bed hospitals are being built at breakneck speed in areas where the health infrastructure is rather poor. The sale of face masks has shot up and there are enormous shortages, especially problematic because medical supplies are also falling short as manufacturers rush to meet the new demand.
All overseas group tours from China have been banned by the Chinese tourism ministry and all domestic tour groups have been suspended too. The capital city Beijing has stopped all buses from entering or exiting the city. The US, Japan, France, etc. are chartering flights to evacuate their nationals from Wuhan. The gravity of the situation can be estimated by traffic managers blocking, and in some cases even destroying, roads to prevent people from travelling to vulnerable spots.
This is thankfully far removed from the situation in India, which for now needs to have a strict surveillance and monitoring mechanism at its airports. The sensitive border this time is the one we share with China and it is important that a new enemy in the form of a deadly virus doesn’t come in.
Very few tourists—just about 350,000—come from China every year and double that number visit the country from India. This vulnerable million needs to be treated with care and attention. Travel advisories would need to be issued with immediate effect to contain the spread of the infection.
The Indian diaspora (mostly students) who are stuck in Wuhan due to the travel ban by China need to be evacuated quickly. Remember, the doomsday scenario that accompanies any virus outbreak is never as bleak as it seems initially. Deadly pathogens that could cause a global pandemic have been pinging at humanity’s defence at least for a thousand years.
It is important that India—which accounts for approximately 18% of the world’s population—steps up to take responsibility, by ensuring that the spread of infectious diseases is contained. This, more than anything else, is the true mark of a superpower in the making.
Amir Ullah Khan teaches economic policy at the Indian School of Business and the Nalsar University of Law. Saleema Razvi is senior researcher at the Copenhagen Consensus Center.