ASAR Talk: "COVID-19: From Hospitals to Health System"
Association for Socially Applicable Research hosted an esteemed guest, chairman of the Maharashtra COVID-19 task force, Dr. Sanjay Oak, on 3rd July to talk about the functioning of the task force and his expertise on various hot topics related to COVID. We had over 80 participants across the country who attended the talk. Members and interns of ASAR had prepared the questions, and Mr. Siddhesh Zadey, Co-founding Director of ASAR, conducted the interview. We have transcribed our conversation with Dr. Oak, and it sure makes for an educational read.
1. Could you describe the structure, roles, and responsibilities of the Covid 19 Task Force?
The Taskforce was constituted by the Honorable Chief Minister of the State of Maharashtra on 11th April 2020. The task force included ten of the brightest minds from the public and the private sectors representing different subspecialties from varied medical backgrounds. We were given clear objectives to reduce the mortality rate, implement critical care ICU protocols, augment bed capacity, and classify some hospitals for covid and some for non-covid. We met every Monday to discuss solutions to the problems posed on the agenda. Few additions like the former director from WHO, preventive medicine specialists, and a few IAS officers responsible for executing the suggestions given by the task force. Every word that is getting printed in scientific journals like the British Medical Journals, American medical journals, or infectious disease journals was discussed, and then a distilled wisdom came out. Everything that we have witnessed in Maharashtra since last April, from the use of hydroxychloroquine to pulse oximeters in the community in pockets like Dharavi, Manpur and Govandi, every suggestion that the task force has made has proved to be valid. The outcome of the meetings should have solutions that are doable in Mumbai, Pune, Nagpur, Aurangabad but equally attainable in other interior districts. So the task force ideas were then subsequently multiplied at individual district levels with regular communication with the state task force. I write an advisory every Tuesday morning and send it to the Department of Health and medical education. They pick up the essential things which are executable and that are circulated all across the state. We have had a series of meetings with divisional commissioners, collectors, policymakers, ministers, National Task Force, think tanks, Asha workers and Sarpanch who run various villages. So I think the vertical and the horizontal penetration of concepts put up by the Task Force across the state have been highly commendable, and I'm happy to lead such an intellectual body.
2. One of the most significant interventions that we saw coming up in this pandemic was lockdown. Could you elaborate on the challenges faced concerning Maharashtra lockdowns as well as reopening economies?
I have always said that lockdown is a science and unlocking is an art. Lockdown decisions cannot solely come from the medical fraternity because a lockdown has economic, religious, and social connotations which need to be considered in the entire social fabric of your state. However, some parameters that guided us first and foremost were the case index in a given pocket, positivity ratio of the test, case fatality ratio, adherence to COVID appropriate behaviour by the populace in that particular pocket, and the amount of vaccination that has been done. An ideal situation is when the prevalence drops, the case fatality ratio is less than 1.5, and people are masking themselves. In addition, vaccination has progressed substantially; a sera survey of given populace yields at least 50 to 60% neutralising antibodies to a suitable titer are conducive situations to lift the lockdown. Unfortunately, there is no compliance with the basic requirements of the preventive aspect of COVID-19. Restrictions are still in the book due to the delayed and slowing vaccination process and poor COVID-19 preventative measures adherence.
3. The pandemic has been a test of trust for the state forces across the globe. In that regard, how do you see scope for improving that trust between authorities and the public?
If you compare India and let me restrict myself to Maharashtra, in the first wave, we did well. The various projections made, even for Mumbai, were running in lakhs. In contrast, we were not even 1/7 of those projections. People responded to the call given by the Honourable Prime Minister and Chief Minister for extension of lockdowns. The cases were few, and we had beds available in the hospital; no oxygen scarcity. This phase of complacency continued till almost December. The task force relentlessly warned about the impending worsening of the pandemic. We were reading of second lockdowns at the beginning of third waves in England, Italy, Norway, the US, and Brazil. Even countries like South Korea and Singapore claiming that COVID has gone entirely again saw cases. Based on this background, we urged not to reduce the number of testing. The virus was mutating and getting different variants, and we are not doing enough on the preventive aspect. This led to the second wave, which came with a vengeance. In the first wave, in a family of six, one person gets affected. In the second wave, all six family members were getting infected. This time, we were seeing the infection spreading like wildfire. We saw people deteriorating with astounding rapidity, leading to the non-availability of beds, ambulances lining up, and oxygen scarcity. Maharashtra was able to produce about 1300 metric tons of oxygen. And in the peak of the pandemic in the second wave, we required 1700 metric tons of oxygen. These factors led to misbeliefs and mistrust among the masses, which took time to get back on track.
4. What sustainable and long-term changes would you like to see in the healthcare system as a whole?
I have always said that COVID has done enormous harm but taught us some suitable lessons. It is up to us to not forget this and improvise the system for the better. Let me enumerate, 75 years post-independence for the first time, the public and private sectors came together and worked for a common societal good. The second lesson is that infectious diseases from here on will top the priorities of medical planning. Infectious disease hospitals in our main metropolitan cities, developed in a hub and spoke model to cater to the populace focussing on cleanliness, vaccinations, immunisations, and nutrition is an absolute need. The third thing is that penalties for misbehaving in society concerning public health need to be rationalised and rethought. The fourth lesson is financial allocation. A minuscule percentage of GDP is spent on health. Some of our neighbours like Nepal, Sri Lanka, and few others around tend to spend more. We must have a defined fractionated program that should go on in the following two or three or five-year plans to increase the GDP spending on health. We have to adopt better, faster and more efficient technology. My last point about answering your question is that we have IAS, IRS, and IFS; there is a need for the Indian Health Service as an administrative body to deal with future catastrophes like this.
5. What is the goal for Maharashtra concerning vaccination in the remaining year? And is there an Indian vaccine hesitancy problem growing in this COVID pandemic?
There is an issue of vaccine hesitancy. I think the administrative policies have been partially responsible for this. We have changed the dosages and the interval between the doses. People somehow get an idea the reason behind this is a shortage of stock. The scientific truth of this wavering interval is the titer of neutralising antibodies that a person develops after the first dose. The second booster has to be given at the peak of these neutralising antibodies titers. It is 82 days as far as Covishield is concerned. Dosage for Covaxin has been unchanged. Pfizer and Moderna are expensive, and it’s not feasible logistically due to their storage requirements. The availability of the vaccine is happening in batches. At least 70-80% of the populace gets vaccinated, there are better chances that the community will develop herd immunity. If you take a vaccine doesn't mean that you're not going to get COVID. But at least you will not land up in the ICU or die. A pool of interrupted distribution of vaccines and reports that someone develops COVID after vaccination or death after vaccination has added to the hesitancy. These instances are far and few when you consider millions being vaccinated. The benefits that one acquires from such mass vaccination programs far outweigh the risks associated with it.
6. There is a lot of chatter also about the third wave in India. How is the task force planning for that?
It's in my nature to prepare for the worst. So, therefore, looking at the world’s scenario, there are countries with fourth and fifth waves in progress; it would be unwise to say that the 3rd wave will not hit us. Several universities, several scholars have used various mathematical formulas to confirm the third wave; it will differ in timing and tenacity. The task force has deemed the second wave to have a thick and long tail. Situations vary from week to week. We must make more efforts in terms of education, compliance, COVID-19 appropriate behaviour and conduct vaccination.
7. There is an imminent fear of the third wave hitting the pediatric group. What is our contingency plan concerning prevention as well as clinical management?
A separate task force constitutes our Honourable Chief Minister with the best paediatricians in the state. We have laid down 10 or 11 documents on pediatric COVID-19 prevention and management. The first document narrated the symptoms; we classified the cases based on the severity. The second is a document was about an ideal pediatric ambulance. For COVID-19, we have taken the pediatric age group till 18 years. You must’ve heard that the vaccination started first in 12-18 years on an experimental basis. We are now narrowing it down to about three years to 10 years. Due to the inadequacy of pediatric beds, we concentrated our effort in the last three weeks to augment beds, ICU beds, create field hospitals, create sections of mother and child, and insist on completing adult vaccinations.
8. We are starting to see case reports that COVID patients who didn't have diabetes now have diabetes, neurological problems, aphasia, stroke. So, how are our medical education and clinical management gearing up towards that, given that we have had such a colossal caseload in India?
Being a victim of long COVID, even today, one year down, if I want to run to catch a local or ascend a staircase at Dadar, I need to pause. There is not a single system in the body, which is unaffected by COVID. Neurological manifestations like Parkinsonism may precipitate or accentuate, Alzheimer's may worsen, type-2 diabetes can result because the virus directly affects the pancreatic cells, which produce insulin. Increased incidence of asthma is observed, while some may develop interstitial pulmonary fibrosis. It leads to thromboembolic episodes, and therefore you hear sudden deaths, cardiac arrest, cerebral strokes, and hemiplegia. It has even changed the mindset of people, memories have faded, and personalities have changed. Therefore, there is a need to set up post-COVID syndrome monitoring OPDs, which has been done in most of the state’s hospitals. I'm appealing to all you young people to educate COVID-affected people to return to the hospital after three months for an assessment. It is the best way to diagnose the post COVID syndrome and then treat it accordingly.
9. Do you think we need to have such task forces as a good contingency plan at a state or district level for infectious disease outbreaks or prevalent non-communicable diseases to monitor population health?
The ‘task force’ terminology comes from the military establishment. We need to convert this into a planning commission that we have in the Center. We should have a planning commission at the level of the state. You can set up better policies when planning commissions work at the grassroots level. Hence, collecting data directly from the populace, then analysing the data using research tools, converting that into strategies and action plans, and executing within a time limit. We need these decentralised planning commissions after COVID-19.
Dr. Sanjay Oak
Dr. Oak patiently and meticulously answered all our relevant questions. He also spoke about how he envisions the health system improving in India post-COVID. His charming personality and anecdotes made the conversation interesting for all attendees of the talk. His unapologetic honesty provided crisp and robust answers to our questions. ASAR is genuinely honoured to have received the opportunity to host Dr. Oak.
Edited By- Dr. Aatmika Nair
Dr. Aatmika Nair is a Medical Officer at the District TB Center in M-East ward of Mumbai. She helps out with the external management at ASAR. Her research interests include climate change and health, human resources for health and infectious diseases.
Transcribed By- Ms. Kainat Sayyed
Kainat Sayyed is a graduate in Business Management studies, specialised in marketing from Mumbai university. Her interests include reading books, writing, creating content and social media marketing.