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Public health in India: Addressing issues of politics and multiple hierarchies of knowledge

Leading Indian professional associations of public health have released two joint statements on the COVID-19 pandemic and its management in India. The central issue they raise is to ignore the technical advice of the country’s leading experts and institutions in decision-making about strategies for handling the pandemic.
What is required is to discuss larger politics of knowledge in public health and its interdisciplinary requirements, say Ritu Priya, Sanghmitra Acharya, Rama Baru, Vikas Bajpai, Ramila Bisht, Prachinkumar Ghodajkar, Nemthiang Guite, and Sunita Reddy, who teach at the Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi.
Read on:
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National responses to the COVID-19 pandemic have been shaped acr­oss countries by a narrative generated by the mathematical models of the anticipated spread of the novel coronavirus first identified in human beings at the end of 2019. Based on the Euro–American experience of influenza and influenza-like illness and China’s corona­virus experience, the models were gener­al­ised to all countries (Ferguson et al 2020; Adams 2020). The graphs generated by these models pictorially represented steep and tall peaks of cases and deaths, which were then superimposed by a flattened graph that projected the impact of strong “social distancing” measures.
The former triggered initial denial of such a threat, and then ill-planned hasty lockdowns in country ­after country as the strongest “social distancing’’ strategy. However, the epidemic curve and the responses have not been the same across continents and countries.
What has been evident in India is that, while the pandemic has affected a large number of people across various states and cities, it has not been as fearsome as projec­ted. The lockdown imposed on 24 March has slowed down but not significantly flattened the occurrence of infections and cases. While the epidemic is still evolving, it is important to review the control strategies and management of the epidemic at this stage so as to draw learnings for mid-course corre­ctions and for long-term policy ­approach.
Evident in the Government of India’s (GoI) style of governance in tackling this pandemic, has been the lack of drawing upon epidemiological and public health exper­tise available in the country. While handling the biggest public health crisis of the last 100 years, technical inputs from within the country seem to have come solely from the clinical establishment, and bureaucrats.
National institutions meant to deal with such a crisis, such as the National Centre for Disease Control (NCDC) and the National Disaster Management Authority (NDMA) too, have been ignored in the strategic planning and decision-making, brought in only to implement decisions. Even more, a matter of concern is that a United States-based business consulting firm is now known to be the technical backroom team for the Ministry of Health and Family Welfare (Jain 2020).
The ministry’s own epidemiologists and health systems teams have been bypassed, including the advice of the National Task Force for COVID-19 set up by the Indian Council of Medical Research (Sethi and Shrivastava 2020). The World Bank is the other institution collaborating with the GoI in deciding its response, with a $1 billion to back it (World Bank 2020). This is when there is a sizeable body of knowledge, experience, and wisdom embodied in the large number of individuals and institutions across the country with public health expertise and ground-level experience of managing epidemics, including the pandemic of HIV and AIDS as a novel viral disease in the 1990s, and the more recent H1N1 ­influenza.
It is in this context that we view as ext­remely significant the two statements brought out by the largest professional bodies of public health experts in the country. The Indian Public Health Association (IPHA) and Indian Association of Preventive and Social Medicine (IAPSM) came together to form a joint COVID-19 task force of their own, constituted of senior experts recently retired from leading public health positions, faculty of community medicine and community health in leading institutions (including members serving in the National Task Force on COVID-19), as well as office-bearers of the two associations. The joint COVID-19 task force put out one statement on 11 April and a second on 25 May. In the second they were also joined by the Indian Association of Epidemiologists.

Highlights of the Statements

In the first statement (IPHA and IAPSM, 2020), the joint task force recommended a 10-point action plan for control of the pandemic, including a review of the lockdown and its replacement by “cluster restrictions.” It states that
“An interdisciplinary team of public health specialists along with grassroots political and social leaderships and volunteers should continue raising awareness about COVID-19 modes of transmission and methods of prevention in the community by adopting emergency risk communication methods and broad-based community engagement strategies while acknowledging multi-cultural and multi-linguistic realities.”
The statement recommended that “social dis­tancing” should be replaced with phy­sical distancing and enhanced social bonding, to slow down the spread of infe­ction while at the same time taking care of those socially isolated by lockdown. Measures should be taken to avoid social stigma, discrimination and fear of isolation and quarantine, by making people aware and treating them with respect and empathy.
It recommended extensive sentinel and active surveillance
“...for Influenza like Illnesses (ILI) through ASHA/ANMs/MPWs, and Severe Acute Respiratory Illness (SARI) through clinical institutions (including private hospitals), daily repor­ting to identify geographic and temporal clustering of cases to trace transmission foci (hot spots/cluster events). This must be supported by trained epidemiologists from local medical colleges and public health ­institutions.”
The statement further went on to emphasise the importance of limited hospitalisation of only those needing intensive care, the necessity of strict infection control and adequacy of supplies of protective materials to prevent occurrence of hospital spread of the virus, affecting patients and the healthcare providers alike.
Long-term recommendations included:
“Local health authorities, municipal bodies and panchayats should be sensitized to enable policy makers and planners not to be instrumental in creating a 'pandemic of ­human misery' by advocating impromptu public health decisions not supported by epidemiological data and evidence based scientific reasoning. Rapid scaling up (five times) of public health, clinical and related social care—both services and research—should be done on a war footing with an ­allocation of about 5% of GDP.”
Noting the ecological approach required to prevent recurrence of such pandemics in the future it ends with the observation that
“Nature has once again reminded us of our tenuous situation in the wider universe. It is high time that humankind takes note of the warning signals and undertakes mid­course corrections urgently and now. The “One World One Health” approach should be central in ensuring optimal harmony amongst all humans and animals of the world based on principle of “Vasudhaiva Kutumbakam” (The world is one family).”
The second statement (IPHA, IAPSM and IAE 2020) takes note of new evidence that has become available since the first one, as well as draws on interactions with public health professionals working at national, state, and district levels. It reiterates all the earlier recommendations, and further notes that though the lockdown had “blunted the rapid progress of the infection,” the disease burden had got
“...coupled with a humanitarian crisis that encompasses an estimated 114 million job losses (91 million daily wage earners and 17 million salary earners who have been laid off), across 2,71,000 factories and 65–70 million small and micro enterprises that have come to a standstill.”
It goes on to assert that
“Had the Government of India consulted epidemiologists who had better grasp of disease transmission dynamics compared to modelers, it would have perhaps been better served. From the limited information available in the public domain, it seems that the government was primarily advised by clinicians and academic epidemiologists with limited field training and skills. Policy makers apparently relied overwhelmingly on general administrative bureaucrats. The engagement with expert technocrats in the areas of epidemiology, public health, preventive medicine and social scientists was limited. India is paying a heavy price, both in terms of humanitarian crisis and disease spread. The incoherent and often rapidly shifting strategies and policies, especially at the national level, are more a reflection of 'afterthought' and 'catching up' pheno­menon on part of the policy makers rather than a well thought cogent strategy with an epidemiologic basis.”
It, therefore, recommends:
“A Public Health Commission with task-specific Working Groups may be urgently constituted to provide real-time technical inputs to the government,”
as also
“...constituting a panel of inter-disciplinary public health and preventive health experts and social scientists at central, state and district levels to address both public health and humanitarian crises.”
Pointing to a critical lacuna, it urges for correctives:
“...each country, and regions within the country, have to adapt the larger general model to its own specifics. Open and transparent data sharing with scientists, public health professionals and indeed the public at large, which is conspicuous by its absence till date, should be ensured at the earliest. This will strengthen pandemic control measures, build bottom-up consensus, and evolve an ecosystem of engagement, faith, and trust.”
It states a considered view that
“Clinical, epidemiological and laboratory kno­wledge for control of the novel corona virus indicates that humankind will have to “live with the virus” and operational strategies rapidly need to be recalibrated from containment to mitigation. The emerging evidence unequivocally indicates that COVID-19 worsened the health inequities, and public health measures need to make that concern central.”

Pro-people Perspective

Reading these two thoughtful and fairly comprehensive statements encourages us to flag some further issues. One is the lack of comment on the initial delayed response of the GoI, when it let the entire month of February lapse with lack of strict measures for quarantine of international travellers and without much action in preparation for the epidemic. Timely intervention could have saved India’s millions from the lockdown and its consequent misery. Second, an assessment of the public health capacities and medical infrastructure available in the country (public and private), with strategies for their optimal utilisation, would be useful for a planned health systems approach during the rest of this crisis. Third, the role of the central and state governments needs to be clearly delineated. Centre-state relations, that are influencing how responses to this epidemic unfold, needs to be analysed. Fourth, because of the known immune-modulatory effects of traditional health practices and their widespread default utilisation in all parts of India, there has been a debate on ­incorporation of AYUSH and local health traditions in the anti-COVID measures. A public health perspective needs to be generated in this complex domain. It is to be hoped that the forthcoming joint statements in this series by the public health associations will address these ­issues.
In the context of public health expertise in the country, there are people even outside these professional associations who have been immersed lifelong in the thinking and practice of public health, epidemiology and ways of strengthening healthcare systems, especially from a bottom-up people’s perspective, and who have been active on COVID-19 (Muliyil 2020; Kollanur 2020; Ghosh and Qadeer 2020).
The Jan Swasthya Abhiyan (India chapter of the global People’s Health Movement) and the All-India Peoples Science Network, the Medico Friend Circle, the Right to Food Campaign, and their member organisations and individuals, have been studying, discussing and debating issues, and putting out statements of concern periodically since 16 March (phmindia 2020). There have been suggestions for how the epidemic management needs to incorporate lessons from past experience as well as voices of the most adver­sely affected—the migrant workers and slum dwellers, women, Dalits, reli­gious minorities and rural populations (rather than implement only upper middle class-oriented containment stra­tegies, with even large sections of the lower-middle classes facing the brunt of the lockdown) (Dasgupta and Mitra 2020).
Despite the lockdown, younger members have been intensively engaged on the ground, with providing transport and basic necessities to migrant workers stran­ded on the highways at state boundaries, procuring personal protective equi­pment for healthcare workers, all through crowdfunding (Yumetta Foundation 2020; ­Nagaraj and Suneetha 2020). They have creatively designed protective practices that the workers can adopt even in their crowded surroundings in urban and rural dwellings at low cost. Networks of researchers and practitioners of systems of medicine other than conventional biomedicine too have been extremely active and generated appro­aches to COVID-19 based on their sciences (Working Group 2020). All these experiences and ideas need to be tapped for rigorous evidence generation and detailed planning. 
Public health responses to the present situation need to take a long-term view even while we engage in firefighting during the pandemic. Reflecting on the severe constraints being experienced at policy and field levels in producing an effective response to COVID-19, we need to remind ourselves of how we got here. The last four decades of liberalisation, privatisation and globalisation have com­promised the importance of the public sector by supporting policies that further commercialisation. Across the globe, in both developed and developing countries, the uptake of economic reforms has been evident, including health sector reforms that led to the weakening of public systems, rising inequalities, and heightened insecurities and uncertainties for the working and middle classes.
A fairly strong critique of these reforms had emerged that found voice through public health academics, civil society organisations, health movements, advocacy groups and international non-governmental orga­nisations. The experience of this pandemic demonstrates how reliance on private systems (through insurance or otherwise) is of little value in dealing with public health challenges. The lack of public services and primary-level provisioning is being widely recognised today in both developed and developing countries when stru­ggling against the COVID-19 challenge.
The pandemic calls for a complex systems understanding for policy and programming. Deeper social science evidence and insight need to be built into the public health knowledge base. This necessitates use of interdisciplinary app­roaches in epidemiology and health systems research, with nuanced understan­dings about social structure and inequa­lities, cultural meanings and resources that communities draw from to deal with ill-health, epidemics and death (illu­strated by a set of recent articles at CSMCH 2020).

Knowledge Hierarchies

However, there is a politics of knowledge in public health that needs to be addres­sed. It relates to the multiple hierarchies between the various kinds of knowledge that are essential for the ­domain of public health. As one kind of knowledge gets priority and power, and others tend to be denigrated or ignored, public health evidence suffers. In the long term, it is necessary to develop a public health cadre in all states and union territories, that moves from primary to higher levels with ground experience, and is capacitated to study, analyse and operation­alise the biomedical, social, cultural and managerial dimensions of public health (Priya 2013).
The point is not to be adversarial to any form of knowledge, but to bring them together in an optimal combination: the medical, clinical and the epidemiological public health; mathematical modelling and shoe-leather epidemio­logy; social sciences, epidemiology and health systems research. The issue is whe­ther we adopt monolithic approaches or openness to plural options that are best suited to the problem as located in its context.
This pandemic provides us with an opportunity to rebuild healthcare from the comprehensive perspectives provided by the Alma Ata declaration (1978) and the Astana declaration (2018), with universal access, inter-sectoral linkages, self-reliance and centring of community level interventions (Qadeer et al 2019; Priya et al 2018). Therefore, it is incumbent on governments at the centre and state levels to recognise the various kinds of knowledge inherent in public health and draw upon all the contextually rooted expertise to design interventions that can be most effective in mitigating people’s suffering. In what is a difficult and uncertain situation by any standards, ignoring such experience and knowledge available in the country during the pandemic and in the post-pandemic period, can only further imperil the lives of millions.

References

Adams, D (2020): “Modelling the Pandemic: The Simulations Driving the World’s Response to COVID-19,” Nature, Vol 580, 16 April, pp 316–18, https://media.nature.com/original/magazine-assets/d41586-020-01003-6/d41....
CSMCH (2020): “COVID-19: Inter-disciplinary Public Health Perspectives, Articles Related to COVID-19 Pandemic, Centre of Social Medicine and Community Health,” Jawaharlal Nehru University, http://jnu.ac.in/csmch-event-reports.
Dasgupta, J and S Mitra (2020): “A Gender-responsive Policy and Fiscal Response to the Pandemic,” Economic & Political Weekly, Vol 55, No 22, 30 May.
Ferguson et al (2020): “Report 9: Impact of Non-pharmaceutical Interventions (NPIs) to Reduce COVID-19 Mortality and Healthcare Demand,” 16 March, https://spiral.imperial.ac.uk:8443/bitstream/10044/1/77482/14/2020-03-16- COVID19-Report-9.pdf.
Ghosh, S and I Qadeer (2020): “Significance of Testing for Identification of COVID-19: A State-level Analysis,” Economic & Political Weekly, Vol 55, No 20, 16 May.
IPHA and IAPSM (2020): “Joint Statement on COVID-19 Pandemic in India: Review of Current Strategy and the Way Forward,” Indian Public Health Association and Indian Association of Preventive and Social Medicine, 11 April, https://www.iapsmupuk.org/journal/index.php/IJCH /article/view/1464/986.
IPHA, IAPSM and IAE (2020): “Second Joint Statement on COVID-19 Pandemic in India: Review of Current Strategy and the Way Forward,” Indian Public Health Association, Indian Association of Epidemiologists and Indian Association of Preventive and Social Medicine, 25 May, https://www.iphaonline.org/wp-content/uploads/2020/06/Second-Joint-State....
Jain, S (2020): “US-based Consulting Firm’s ‘Mystery’ Role in India’s War against COVID-19,” NDTV.com, 28 May, https://www.ndtv.com/india-news/coronavirus-us-based-boston-consulting-g....
Kollanur, A (2020): “Where the Governmentt Erred with the Coronavirus Response,” Deccan Herald, 20 May, https://www.deccanherald.com/amp/opinion/main-article/where-the-govt-err....
Muliyil, J P (2020): “Epidemiologist Dr Jayaprakash Muliyil Speaks on India’s Fight against COVID-19: CNN News18,” 5 June, https://www.msn.com/en-in/sports/sports-index/epidemiologist-dr-jayaprak... Cxg.
Nagaraj, V and A Suneetha (2020): “Covid-19 Crisis: Caring for the Migrant Worker,” Financial Express, 28 May, https://www.financialexpress.com/opinion/covid-19-crisis-caring-for-the-....
Phmindia (2020): “Statement and Background ­Paper on COVID-19 (Corona Virus) by JSA and AIPSN Jan Swasthya Abhiyan,” People’s Health Movement-India, http://phmindia.org/page/3/.
Priya R and A Chikersal (2013): “Developing a Public Health Cadre in 21st Century India: Addressing Gaps in Technical, Administrative and Social Dimensions of Public Health Services,” Indian Journal of Public Health, Vol 57, No 4, October–December, pp 47–52.
Priya, R, R Gaitonde, M P Gandhi, A Sarkar, S Das and P Ghodajkar (2019): “The Alma-Ata Declaration and Elements for a PHC 2.0,” Medico Friend Circle Bulletin, No 380, pp 1–8, http://www.mfcindia.org/mfcpdfs/MFC380.pdf.
Qadeer, I, K B Saxena and P M Arathi (eds) (2019): Universalising Health Care in India: From Care to Coverage, Delhi: Aakar.
Sethi, N and K S Shrivastava (2020): “No Action Has Been Taken: Frustration in National Covid-19 Task Force,” Article 14.com, 24 April, https://www.article-14.com/post/no-action-taken-frustration-in-national-....
Working Group (2020): “Ayurvedic Diagnostic and Management Protocol for COVID-19—A Proposal,” Working Group of Ayurvedic Clinicians for COVID-19.
World Bank (2020): “India COVID-19 Emergency Response and Health Systems Preparedness Project (P173836), Environmental and Social Commitment Plan,” Fast Track COVID-19 Response Program, 27 March.
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This article has been distributed by JanVikalp. It was first published in EPW, Vol. 55, Issue No. 32-33, 08 Aug, 2020

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