For want of a vaccine, the HIV epidemic raged for 25 years taking over 35 million, mostly young, lives.
In its early years HIV created fear, panic and extremely irrational behaviour, such as excommunicating an infected person from the village, to denying healthcare services.
Cuba, one of the earliest countries to diagnose a HIV case, took the public health principle of social isolation to the extreme – quarantining anyone infected with HIV into sanatoriums for two months where they were provided food and intensive preventive education, followed by life imprisonment if caught indulging in risky behaviour upon release.
The WHO public health experts called these sanatoria ‘prisons’. Though this model was successful in bringing down prevalence levels to less than 0.5%, it was not replicated as it was seen to violate individual privacy and criminalised the sick.
Though India discovered its first HIV case in 1986, it was in denial for close to 15 years. In 2005, while India reported 5.1 million infected persons, modelling done in US universities seemed to suggest a caseload of at least 25 million people. Interestingly, however, in depth analysis showed the number to be 2.3 million.
However, in its defence, India developed its own strategy of working with the infected and key populations who are vulnerable to the infection. It rapidly expanded surveillance, divided districts and states as per burden of infections, took up intensive targeted interventions among the high risk, decentralised and expanded testing and treatment manifold, and scaled up information campaigns.
Though there is still no vaccine, the HIV incidence was contained through the rigorous implementation of policies aimed at behaviour change.
India’s battles with the other two viruses – polio and H1N1 – also have similar unique features. While polio is an example of exemplary political support and a never again to be seen community engagement, coping with the H1N1 pandemic, that resulted in 44,000 infections and 4,000 deaths (against a total of an estimated 60.5 million persons and about 3 lakh deaths) within the year August 2009-2010, utmost concern was paid to ensure economic activity was not affected and panic contained.
Relevance to COVID-19
COVID-19, also a virus, is however not comparable with those that caused HIV, polio or H1N1, calling for new approaches and strategies.
Many times more virulent and fatal, the speed with which it has raced across the globe, affecting 185 countries, infecting over 2.7 million persons and causing nearly 2 lakh deaths within two months, is unmatched to any in recent memory. Yet, notwithstanding these fundamental differences, I see some lessons that can be learnt in coping with it.
First, is not to panic with estimations provided by modellers. For any sound and rigorous modelling, there must be available adequate data over time, behavioural and economic characteristics.
It is for this reason there is a worrying concern about how we could have taken the estimates of modellers who came up with astounding numbers of 300 to 600 million people getting infected with COVID-19 so seriously. Hyped by the media that suspended all reason, there was panic, resulting in the imposition of a national lockdown with a four-hour notice on March 24 – a lockdown that has entailed massive suffering of unimaginable proportions catching even the prime minister unawares.
At that time, it may be recalled, India had a caseload of less than 500 and 10 deaths.
Second, similar to HIV, the national lockdown and COVID-19 have at once brought out in open glare India’s underbelly, pointing out the utter fragility of the lives of the millions who have sought refuge in urban cities from the ravages of poverty in their villages.
All daily wagers were, with the stroke of a pen, denied their very means of survival. Facing hostility, lakhs, with their meagre belongings on their heads and children swung on their arms ,walked back to the comfort of their own homes that suddenly seemed a better option.
What hurt most was the stark display of the moral contagion sweeping us the urban middle class. While some came forward and helped, most turned away their maids, refused to allow anyone to enter apartment complexes, insisted payment of rent on pain of eviction, ran off without paying the wages due and so on.
We also began to avoid contact with the migrants as they were now seen as carriers of the coronavirus, even though the persons responsible for bringing the coronavirus were the middle class tourists and students, specially flown back in our planes with their virus intact.
A more stark irony is difficult to find.
The icing of such a moral contagion was yet to come in the steady and cruel manner in which the epidemic was communalised.
Blame for the disease now shifted squarely to the Muslims. In reality, the Tablighi super spreader was as much due to the stupidity of the Tablighis as the utter failure of our public health system and the immigration authorities.
After all, the hundreds of foreigners were to have been screened and watched – their addresses indicated to the local public health authorities who in turn were to have tested them to trace signs of infection and quarantine them for 14 days.
Besides, when the Delhi government issued orders against gatherings of 50, the police authorities should have swung into action. So while the system failed to enforce its own guidelines, the Tablighi Muslims who have suffered the infection and spread it to their community members are being blamed for having brought in the infection.
The media, as has been its wont these past few years, went berserk highlighting the Tablighis as the cause of COVID-19 in India, injecting the communal virus that in several pockets of the country, resulting in Muslims being denied treatment, relief, food and social boycott in towns and villages.
Situation deteriorated to such an extent as to invite a rebuke from the elites of Saudi Arabia and UAE that partly oil our economic engines, forcing the PM to issue a statement not to discriminate on grounds of religion and call up the middle east governments to assure them of non discrimination of muslims.
With the Tablighi contribution to COVID cases and deaths less than 10% and 1% respectively, the deliberate apportioning in the official briefings and media has stopped. However, social attitudes have been poisoned and will take time to heal.
To me as a former civil servant and former secretary of the Union health ministry, it was galling to hear the communalisation efforts in official press briefings. India is a founder member of WHO. WHO founding values rest upon and state that the WHO vision and mission is:
“…to promote health, keep the world safe and serve the vulnerable…selflessly defend everyone’s right to health…show compassion for all human beings…make people feel safe, respected, empowered, fairly treated and duly recognized”.
It is this vision that guides all policy formulation in the Ministry of Health and is reason for not agreeing to the earmarking any of its budget on grounds of caste or religion.
Violating these values then raises the question of whether we are a responsible nation. Rightly, we invited a sharp rebuke from the WHO Geneva reminding us that disease knows no religion and not to communalise this fight against the COVID-19.
Never has India ever been found wanting on this score ever before.
Considering that India is going to be the chair of the Executive Committee – the highest policy making body reporting to the World Health Assembly of Health Ministers, it is crucial that we conduct ourselves in accordance with the values that guide health policy, lest some countries object to India’s chairmanship on grounds of being unfit.
The fact that India has to manage the charge of communalising efforts to contain a disease is unfortunate as it is India that has demonstrated to the world its openness in engaging with and coopting of criminalised, socially discriminated groups like sex workers, gay people and drug addicts in our fight against HIV, based on the principles of human dignity and right to health.
In addition to non panicking and non discrimination, the third lesson from past experience is to formulate policies based on evidence. This helps in providing specific solutions to a local problem than having a one size fit all approach.
Accordingly, under the HIV/AIDS control programme, the district was taken as a unit and based on the disease burden, categorised into four groups – A to D, with A having the maximum number of caseloads and D having none.
Such categorisation helped in the disproportionate allocation of resources – human, material, funding – and policy attention to A versus D.
The scale, intensity and design of policies differed as per the category. As much as 70% of the funds and resources went to the A districts. Similarly, 25% of the budget was provided to civil society and NGOs, to help the key population groups access services and reduce societal discrimination against them. Such engagement was the cornerstone of the success of the HIV/AIDS control strategy.
For COVID-19 too a similar approach is necessary. While a graded lifting of the lockdown will be imperative, partnering efforts with the community, civil society organisations and NGOs would be foundational for achieving the balance between saving lives and minimising harm to the economy.
It is not the government fiat but the peoples organisations that can ensure social harmony, reduce fear, increase acceptance and adherence to the preventive messages for behaviour change, etc. This is the only sustainable solution in the absence of a vaccine.
Any strategies that are developed need to be based on the reality that it may be over a year before COVID-19 is normalised and all people are protected with a vaccine or herd immunity. But till then we need to protect ourselves with a sense of human solidarity and compassion towards one another.
K. Sujatha Rao is a former Union health secretary.