Interview: Dr Naman Shah

‘Regional lockdowns would have been better’

Print edition : April 24, 2020

Dr Naman Shah.

Interview with Dr Naman Shah, infectious disease epidemiologist.

Dr Naman Shah, M.D., PhD, is a family medicine physician and infectious disease epidemiologist at Jan Swasthya Sahyog (JSS), a community-based health system in rural Chhattisgarh. He has worked in the areas of pandemic influenza planning, disease-control research and programme management with health departments, the Indian Council of Medical Research and the World Health Organisation. Speaking to Frontline on the COVID-19 outbreak (SARS-COV-2) in India and the aspects that need to be prioritised, including health preparedness, Dr Shah believes that cases will grow exponentially in India and that there is an acute need to centre-stage institutions such as the National Centre for Disease Control which was set up for research in epidemiology and the control of communicable diseases. Excerpts from his interview:

While the COVID-19 outbreak has been a wake-up call for public health systems all over the world, it has affected the developed world more than the developing countries. Are there any epidemiological lessons in this? Or is the worst yet to come?

The outbreak is indeed a wake-up call. At a time when social and international relations feel increasingly fractured, I’ve found it amazing that colleagues all across the world are preparing for, or responding to, the same disease now. Cases appear higher in developed countries, but that is a function of their higher international connectivity—as imported cases drive the epidemic in the early stage—and their increased testing. Our worst is yet to come; cases are growing exponentially and we now have virus transmission that is community-based rather than related to travel. We’ll be able to make more meaningful comparisons with time.

In recent years, we have seen a shift of emphasis from communicable diseases to non-communicable diseases. Despite the shift, there have been several outbreaks such as Ebola, Zika, Nipah and so on. Do you think the shift distracted policymakers from focussing on communicable diseases?

You are correct. Infections will not be going away. India has both non-communicable diseases and communicable diseases. We have just been ignoring the latter, including our frightful tuberculosis burden, among others. One thing that has struck me in this outbreak so far is the relative absence of the National Centre for Disease Control. The NCDC should be India’s nodal agency for responding to epidemic disease, especially communicable ones. They were set up for this purpose and have an extensive history of contributions. NCDC is our equivalent of the United States’ famous Centers for Disease Control and Prevention, but only in name. Unfortunately, it has lost what scientific edge it had to bureaucratisation, and like many public institutions, we have allowed it to bleed away its talent and resources. They [NCDC] have been working against COVID-19, but not leading [the campaign] as we would expect.

The government claims that India is not in the stage of community transmission. The government has also placed some very limited testing criteria, confining it to those who have a travel history abroad and those who have come in contact with them. No symptomatic person needs to be tested. Do you think the low testing is a mechanism to keep the numbers low?

This is silly word play by the government. If we have insufficient testing and testing criteria which excludes the community, we won’t have the necessary evidence. Some very limited sampling, from a while back, does not answer this question. We know the disease is here; we know it is very infectious and spreads exponentially. I do not understand what the government thinks they gain by denying this when we are already taking action against community transmission. And yes, the testing strategy needs a complete overhaul. Although our case numbers are low, that is not the goal of our limited testing. Here, I would invoke the old adage to not assume malevolence when ignorance will suffice.

In any event, does testing for an outbreak like this involve prohibitive costs, and could the technology be developed at a reasonable rate so that there is widespread testing?

This is a good question. While our current testing is far too low, I do not believe extensive testing is desirable either. We have to ask what the purpose of testing is. For the patient, testing does not currently change their treatment as mild cases do not need treatment; in severe cases, it would be reasonable to treat based on a clinical diagnosis alone. For public health purposes, testing assists with isolation in the early stages, but won’t be workable as the numbers rise. We cannot carry out widespread facility-based isolation. In both cases, testing increases inter-person contact and the risk for spread. Many people with symptoms will have other viral illness and gathering at health facilities exposes them to COVID-19. As you indicated, extensive testing will also be expensive and those funds could be better used elsewhere. Now, the tests cost over Rs.1,000 (compared with Rs.20 for malaria) and have limited sensitivity, that is, they miss 20-30 per cent of positive samples. That rate, along with the price, improves in blood-based rapid tests, but the rationale for testing doesn’t change.

The primary benefit of testing is for surveillance, where we need a more modest number of tests to understand our trends and to target interventions such as economic and physical restrictions for reducing spread.

Was a complete lockdown called for in India? Should it have been a graded lockdown?

We were unprepared, and still are. A national lockdown was extreme, and its side-effects are even more severe in a society where many citizens already live precarious lives and social support mechanisms are weak. These very citizens are also the most vulnerable to the virus. So the situation was grave, and while the lockdown has given us critical time as it will slow down community transmission, note that a lockdown will not reduce cases in the long run. Cases will rise rapidly as it is lifted.

Regional lockdowns would have been a better approach, but we would need adequate data to know where to apply them. Certainly, it was poorly planned.

With even 48-72 hours of warning and preparation, we could have decreased many of its harms. The other open question is how long the lockdown is needed. I think we should be able to prepare faster now and end it before the full 21 days.

The virus’ trajectory is another matter of discussion. For instance, it has begun to taper in China.

I think a sustained decline after the initial peak is unlikely, based on past similar epidemics. Most have secondary peaks, if not more. It depends on the spread of the coronavirus within a community and between communities, and how many people remain susceptible, among other factors. We also cannot take into account the impact of uncertain, but not uncommon, developments of key events such as an effective vaccine, new treatments, or mutations in the virus, which can radically affect the course.

Globally, there is a shortage of health infrastructure, especially in the provisioning of public health. Do you think any lessons will be learnt from this worldwide or will it be a case of business as usual once the situation normalises?

Crises are a wonderful opportunity for change. I am hopeful that citizens and their leaders will take stock of these events towards three ends: 1) to build meaningful universal health coverage, 2) to make sure we support each other through adequate social safety nets, and 3) to restructure and rebuild our disease control infrastructure. Traditional public health measures, that is, surveillance, outbreak response and hygiene, are often overlooked as their successes are not visible, but they prevent events from happening.

Do you think that the fact that the Indian population is younger means it is at a lower risk? What is the likely implication of the poor health situation of the Indian population?

It is hard to predict our population risk. On the optimistic side, we are a younger population and our rate of some co-morbidities, diabetes and heart diseases, is lower. Undernutrition is embarrassingly common but its contribution to risk in COVID-19 is not yet known. In our work at JSS in rural Central India, undernutrition is rampant and is a major risk factor for complications and poor outcomes in many other diseases.

If the virus spreads to rural areas, does the health system have the necessary wherewithal to track it and deal with it?

Not where we work. Here many routine health services still struggle for simple tasks. This includes the care of many acute fevers such as scrub typhus or leptospirosis, or managing birth emergencies, or the administrative aspect of reporting notifiable diseases. I believe a new illness that is widespread and which invokes fear of contagion will be very difficult to tackle. Additionally, social trust is low, with many caste divides and a history of overlooking the needs of tribal residents. Our best hope is equipping people with enough support, food, transport, and access to medical centres for at least basic treatment. We should make good but achievable plans as our history is largely one of repeated implementation failures.

How big is the likely gap between the need and the availability of PPE for health care workers?

So far, because the cases are just starting, the situation is okay. At JSS, we are adequately stocked at this time and have even received additional supplies from the state. The real test will be a month or two from now, when cases peak. I hope we can make enough PPE and distribute them well.

The views expressed here are of the doctor only.