Epidemiologist throws light on healthcare management

(Over most of April and May, as the Covid-19 pandemic unfolded in India, growing from just a handful of cases to take region after region in its grasp, Dr T Jacob John, India’s foremost virologist, epidemiologist and researcher, spoke daily with Jagdish Rattanani, journalist and editor of Foundation of The Billion Press, to build what we call the COVID-19 diary.)

Here, Dr John talks about how, with little direction from the Centre, states early on took the pandemic situation into their own hands, turning the Constitutional provision for division of health duties between the Centre and states on its head;   about how there is hardly a squeak about the Director General of Health Services and the National Centre for Disease Control at this crucial juncture; and about how a phased lifting of the lockdown, with the district as the unit, could bring about an administrative revolution.

JR: What are the thoughts you have about India’s management of the Covid epidemic? Does it have a machinery in place?

Dr John: I thought rich epidemic management is possible, in part by the Indian Constitutional division of jobs between the Centre and states – the Centre in charge of epidemic control, and the states in charge of healthcare.

JR: Has it worked like that during this pandemic?

Dr John: When the Covid epidemic broke out in China and other countries, Kerala took the lead, quite apart from any directive from the Central government, which amounts to actually flouting the Constitutional stipulation that testing quarantining, preventing further spread, are all epidemic control and therefore the Central government's responsibility.

Whereas treatment is state responsibility …  healthcare. But the Kerala government went ahead, and they did things right. Thereafter, our states are tackling the epidemic independently, doing whatever they want. And they are making use of this central facility of the NIV for testing. So, in the states, samples are sent to an NIV, and NIV has to test.                                                

So, the roles have been reversed. Mamta Banerjee’s complaint is that the Centre is not giving enough kits for West Bengal; I will not know whether it's true or not true. However, my point is, the division of epidemic control by the Central government and healthcare by the state governments is not working well.

JR: Very clearly it has not worked in this case. But where did Kerala get its testing kits so early?

Dr John: By that time, the National Institute of Virology was ready with a test kit. There is an NIV presence in Kerala, a field station.

JR: So, NIV had already come up with a testing kit.

Dr John: Yes. See, the Chinese announced the gene sequence for primers by 11 January or so, so all virologists would synthesise those gene sequences and be ready. Christian Medical College was ready, but was told explicitly not to test. So they obeyed orders, till they were released from this, well, constraint.

JR: How much later were they given permission to test?  

Dr John:  That came much later. I think it came towards the end of March or beginning of April . . . I’m not sure. But it came later. So, they (the government) have not taken the lead in this coronavirus episode. But the Kerala government did. Apparently, in the case of the first tests they did, 30 January or so, the flight that came from Wuhan or from somewhere in China either had a stopover or a transfer of passengers from one plane to another in Kolkata. The girls who came from Wuhan faced no test or inquiry in Kolkata, but the moment they landed in Kerala they were taken off, tested and quarantined. So, the lead was taken by one state. Medical students from Wuhan also came to Tamil Nadu and to Andhra Pradesh. But these states had not done any homework, the Central government had not done any homework.

Then, gradually, different states began thinking about the infection and were doing something here and there; Tamil Nadu, Karnataka, Telangana, Andhra Pradesh, Delhi . . . little by little, many states began doing their own thing. And it's only in end of March, beginning of April, that the prime minister seemed to become the leader.

By about April 7, I think he had convened empowered groups and assign them tasks.  

21 March is when he came on national television and said, I'm leading in from front. So, I think his tactic was to wait and see. Let states play their game. Then he appeared again on 24 March and announced the lockdown. And thus he asserted his leadership. Thereafter, he seemed to be the leader. But there was a long delay . . . in his response to the problem.

JR: Has Centre-state coordination on health matters always been like this, or is it a new phenomenon?

Dr John: In the past also, when I went for lychee investigation in Bihar (there were mass deaths among children in the state during the lychee season), there was a little a bit of a muscle flexing from the Central government saying, who are you to investigate it? It's our right to investigate. There was posturing. Again, what the Bihar government did was Constitutionally not right. To have their own independent investigator when the Central government was actually investigating it from 1995 to 2012. And then I went there in 2013.

JR: You were appointed by the state government in 2013?

Dr John: Invited, not appointed. During 2013, the outbreak period. I went and did what the Central government could not do from 1995 to 2012—seventeen years. I took one week to sort it out. I had to create supportive evidence, which we did in 2014 and 2015, while preventive modalities were given to the Bihar government. They took action and the disease virtually disappeared until 2019, when things fell apart, for various reasons.

The point I am making is, epidemic investigation control is the Union government’s responsibility, and it is the National Centre for Disease Control that should be doing it. And if they goof up, then the state government has to just watch children die. That was when I was invited. And when I went there, I was fully supported by the health secretary, National Rural Health Mission agency.

Then things were sorted out by a Bihar government order issued directly to me.

My point is about the Centre-state equation in health management. I'm using the term health management because epidemic detection, prevention and healthcare are all to do with managing human health. The interface between the Centre and the states needs to be re-engineered. That has not happened with Covid, and I was explaining to you that Kerala government took its own lead. They just ignored the Central government. And then various state governments began working Delhi to get the Central government to test people coming from foreign countries. You know who ordered it—the civil aviation ministry. The director general of civil aviation is the one who passed orders. That is very interesting.

JR: That is very interesting.                                                               

Dr John: Anyway, we need to revisit the health management scenario and re-engineer the Union government’s and state government's responsibilities . . . otherwise accountability will fall between two stools.

To come back to the lychee incident, NCDC brought CDC Atlanta into the picture.

So, they had an extensive investigation and they reconfirmed everything we had said and published already. We were publishing too for the sake of the Bihar government; they wanted a peer-reviewed scientific publication so that they can defend themselves if anybody asked them questions. For that purpose, we published in the Current Science, a poor man’s Nature coming from Bengaluru, Indian Academy of Science’s official publication. But in 2019, 294 children died during the lychee season after withdrawal of all the preventive measures applied in 2015, 2016, 2017, 2018, when numbers were below 10.

JR: But why would the government withdraw that preventive measure?                

Dr John: I had a word with the health secretary who said it was not a deliberate withdrawal. It was by default, the health education staff . . .  they were all on election duty. The primary health centre doctors . . . I trained 32 of them in 2013 and 2014 . . . they were transferred to other places and new batches had come. Nobody told them what to do. It was simply easy to call an ambulance and send the kids to the medical college which is three to six hours by road from the rural areas, and so they goofed up badly on the biomedical advice. The senior paediatrician did not follow the instructions given by me. So altogether 294 children died. The health staff had to be simply given the necessary health education. And what was that? Give a meal to the children before they go to sleep.  

JR: That’s all? How is that linked to lychee disease and how does it help?

Dr John:  Kids often go to bed at 6 p.m. in the hot months of April, May and June, having got exhausted playing during the daytime. During the lychee season, they binge on single lychees that fall to the ground, which are not saleable. By the way these incidents were in Muzaffarpur district, the largest producer of lychees in India. The children go home and sleep for straight twelve hours until, say, 5.30 am the next morning. That means they are fasting for 12 hours and their blood sugar goes down. Usually, the liver kicks out its glucose stores to keep the blood sugar level above 70 to protect the brain. But the liver does not have sugar storage in the case of chronically undernourished children. Then you cannot correct the hypoglycaemia.

Usually, the body goes through an alternative mechanism to synthesize glucose, burning fat to create blood sugar. But this is what lychee blocks. So, if your liver storage of glucose is minimal and you have prolonged fasting and you have had lychee, you die. Children who do this go into early morning brain disease, and if you don't treat it quickly then they die.

The easy intervention is one evening meal or cooked meal. No child dies if the child has a cooked meal by about 7.30 or 8p.m.

In my definition, the 2019 deaths are homicide by neglect. Public health is the government’s responsibility, and when 200 children die because of a problem between the Central and state government, then they are victims of homicide by neglect. I'm not pointing fingers at anybody. But there are two other instances in which I have got involved in outbreak investigations where there was a tussle between the Centre and state. Anyway, the re-engineering is essential.

JR: We have seen a lot of politics during this epidemic too. A central team was sent to Mumbai, and they predicted more than six lakh cases for Mumbai by May 15 and shortage of beds and oxygen. Some BJP people said the state government is inept and you need the army here. There was sparring when a Central team went to West Bengal too. There was a Centre-state dimension in both the West Bengal and Maharashtra episodes.

Dr John: The whole point is, what is the role of the federal ministry of health or the Central government? Their role should be to seamlessly work with the states to fight the coronavirus. If you say, you do your work, we will come and check, investigate and decide how many marks out of 10 you get… that is not right. You have to ask: What do you need?  How are you doing? We know Mumbai has problems because of housing. You tell West Bengal: We know your problem because you are one of the highest population-density areas in the country and you have cholera . . . this should be the attitude.

But there was little cooperation. Karnataka decided to seal its borders with Kerala. And Kerala went to the Supreme Court and then some compromise was arrived at. States are now closing their borders to neighbouring states, and that leaves an unpleasant taste in the mouth.

JR: Because of Covid?

Dr John: Only because of it. Karnataka saying, we don't have any Covid, Kerala has, so its people don't should not come here. Travel between states is almost prohibited. If a Tamilian comes to Kerala, the police will immediately quarantine him for fourteen days. That's the rule. And we have a wall that was built between Chitoor district in Andhra Pradesh and Vellore district in Tamil Nadu.

JR: So, there is little synergy between the Centre and the states, and between states themselves. You mentioned the NCDC, but we don’t hear much about it though we have an epidemic on.

Dr John: Yes. When Modi addressed the nation on the lockdown, he did not go into any of the peripheral issues which are as crucial as the lockdown. I did not expect him to say anything technical of course, but the technical head in health matters is the Director General of Health Services, and this head is missing. When I mention the post, people ask me, oh, is there one like that? Man or woman? That is the kind of ignorance among the people, even about the existence of a person in that position.

People have learnt about Balram Bhargava (DG of Indian Council of Medical Research), about Dr Raman R Gangakhedkar, head of epidemiology and communicable diseases at ICMR. So we all know the research chiefs, but not the chief of health management, namely, the DGHS or the director of NCDC. That is a disappointment, because I was hoping for a briefing on what doctors should know and do, not do and how hospitals have to be run at this time. Yesterday, a doctor called me in great agitation and said, ‘What do I do, my wife and I work here.’ He said he had closed his hospital yesterday. That’s because hospitals have become the new sources of infection. I did not expect such details from the prime minister, but I want it from somebody.

JR: Anyway, overall, you feel there will be an extension of the lockdown, I suspect?

Dr John: Absolutely. The state governments wanted it. And I think the state governments have understood one more thing—that they need time to prepare for the post lockdown period.

JR: But would you say the lockdown was a success.

Dr John: The answer is, only partially. It was very, very, very leaky. In some places the lockdown was good, some places not good, and in some places it could not work like in Dharavi.

So, the lockdown as a government administrative procedure was a failure; not a complete failure, but not as successful as it could have been if it was planned and done well. Therefore, you have to scramble and find out if the curve has been flattened. The numbers don't show success.                                                                                                                         

JR: Correct.

Dr John: One thing that I want to say about the lockdown’s success is, if a prescription is not followed, you cannot look at the efficacy of a medicine that you have prescribed. The medicine has to be taken, swallowed on time. And then only can we see whether the disease was treated. So here, we have a prescription and we are looking for the effects of the treatment when the prescription has not been followed fully.

For example, it is not yet time to allow large crowds, even with masks, because we don't want even that, you know, 5 per cent chance of infection in spite of everybody wearing masks. So, we have to wait and see how things develop. Assuming that lockdown is the only way of flattening the curve, then you have to think in terms of lifting the lockdown in a staggered manner . . . Not all of a sudden.

JJ: How do you suggest this is administratively done?

Dr John: The district idea is not a bad idea. Some districts lift the lockdown, but other districts do not, based on the level of infection within the district. They have already classified red, orange and green (zones) . . .  the greens could be let out, and the problem is when a green is adjacent to a non-green and when the non-green seeps into the green. District borders are not like country borders that you can close them. Then you have to think in terms of what needs to be taken care of centrally . . . for schools and colleges you can make centralized decisions. But state-wise decision-databases—on small industries, local industries, any local major industry, if it is a transport hub, all those kind of things . . . district by district, somebody must sit down and make a list and then see what should be done for each of them.        

Every district should have a taskforce—medical officer, district collector, civil society, industry and a few others can go through all the rigmarole for lockdown withdrawal in their district. And then the task force makes sure that every establishment, institution and agency has standard operating procedures to reopen business and maintain infection control.

Districts should be units of lockdown, rather than states the units of lockdown.  When it comes to Mumbai, the units would be different. Slums would be units unto themselves, and in Mumbai certain wards would be units. It might be very messy though, to have one unit under lockdown and an adjacent one free.

JR: I guess Mumbai will have to continue under lockdown, given the situation.

Dr John: Well, there is a price to pay for continued lockdown and we don't know what the price is because nobody seems to be actually keeping a tab on what's happening under the lockdown. When I look for pneumonia, there is no current data on pneumonia; similarly, we don’t know current data on death . . . what people are dying of … and whether they are dying of preventable diseases that could have been prevented but for the lockdown.

Somebody wrote in the newspapers about impending stroke being a medical emergency; the patient must reach the hospital immediately, lockdown or no lockdown. There may be a heart attack, chest pain; just observing a lockdown is no good for a person with acute chest pain. We don't know if people are dying like this or not. So, the issues of feasibility, advisability, of going beyond the May 3 deadline is being discussed. It’s cruel on people to take it further. Wherever it can be unlocked, we must unlock. Though the priority must be to see how to do it in the best way.

If you do that, district by district withdrawal is not a bad idea. So, state by state is not as good as by district. So, there are ways of staggering withdrawal of the lockdown. Otherwise, you can go on with the lockdown for a very long time . . . but this is very unnatural.

JR: Right.                                                                                                      

Dr John: This way, the district becomes a hub of administrative leadership, administrative thinking and execution of a plan of action, defining its own best interests. That could be a great model, if the districts actually do this. And if it is done really well, it could be a social revolution.

JR: What would you say is the optimum time for a lockdown.

Dr John: First, they locked down for three weeks, from 25 March to

14 April. It was three weeks. Looking back, I feel three weeks was the right time and extension was not necessary. Mask wearing should have been necessary. So, three weeks of universal mask wearing and then gradual lifting of the lockdown in a staggered fashion. We haven't got IGG antibody testing yet. If we do, we can certify who are positive and can release them . . . they can wear identity passes saying they are free to go anywhere, do anything they like, the police should not stop them because they have this badge …

JR: But can’t they still infect?

Dr John: No. If they have IDG antibodies they will not get infected and the virus will not grow in them, and therefore they cannot infect others.

JR: Between antibody tested and testing for Covid, which should we prioritize?                                                                                      

Dr John: They're both necessary. Because we need as much information as we can get about the crisis.

JR: What antibody test we are talking about? Which antibodies, IGM or IGG?

Dr John: IGM is a surrogate for PCR. The PCR will be positive from day one through, let’s say, day 21. It will be incubation-period positive, illness-period positive; during recovery time it may become negative, but you have to assume that for three weeks it will be positive. The IGM antibody test will be positive only after the symptoms develop. Incubation-period IGM antibody test will be negative.

So, IGM antibody as a diagnostic test can only be applied for a person who has had fever, coughing, breathlessness for at least—I am just pulling a number from my hat—three days. Before that we cannot expect the rapid IGM test to be positive. It's not a good test to know the infection load, but it's a good test if you have somebody with fever for three-four days and you don't know what it is. So, a quick test is this idea of antibody test.

The IGG is not necessarily to identify Covid-recovered people. For those people whom you know have recovered from Covid, you already know, so you don't need any more intervention. The IGG is essentially to test for those who can go about their activities without risk to themselves and to others . . .

JR: The ones who will carry a pass and can move around, according to your plan.

Dr John: Exactly.

JR: You can't test a lot of people with that . . .

Dr John: Why not. It's a finger stick . . . just like a testing glucose. You need not test everybody; you don't need to test old people for that. You need to get active the productive age group, who are now stuck because of inability to move out because of the lockdown. So, the crucial people, they should all be tested. And that testing should be very well designed by statistical experts.

So, you start in one place. You say which age group you will test. You select that age group and you test and then come back and test another group so that you can add more and more people who are allowed economic activities. Let's say the test costs 30 rupees, and that is well worth it because you are returning people to economic activity.

JR: So, that’s positive, two tests with two different purposes. Both are needed.

Dr John: Yes, they're both rapid tests. It only takes ten minutes to show up the antibody if you you're doing it as a rapid test method.