India’s Covid future ultimately depends on the people, state response, says top health officer

Health secretary Preeti Sudan, who retires in 4 days, gives her first ever interview since the pandemic struck, and talks about the Covid 'bubble' she's been living in.

Preeti Sudan retires as health secretary on 31 July 2020 | Photo by special arrangement

New Delhi: Six months ago, Preeti Sudan became the most important bureaucrat in India. As the health secretary, she would undertake the mammoth task of helping prepare India for the pandemic. Though due to retire in April, she was given a three-month extension to ensure the system that was put in place ran smoothly and India’s Covid-19 crisis could be managed. Now, in four days, Sudan will hang up her boots, kick up her feet and take a much needed break.

“We have come a long way, the world and India. In March, I had no clue (where we would be in a few months), we were only responding to the situation and we knew a lot would depend on how the Centre, the states and the people responded. But I would say we have done better than expected,” said 60-year-old Sudan in her first interview since the pandemic struck. She was speaking to ThePrint in her office in Nirman Bhavan where the health ministry offices are located.

An IAS officer of the 1983 batch, belonging to the Andhra Pradesh cadre, Sudan is a career bureaucrat. Before she became health secretary in 2017, she worked with the ministries of women and child development and defence. When she retires on 31 July, it will be after 37 years of service.

When the Covid-19 crisis began, Sudan was given powers under the National Executive Committee of the National Disaster Management Act 2005, through a 11 March order that came into effect retrospectively from 17 January. This meant Sudan could issue advisories to state governments.

Talking about India’s progress in these six months, she says things have changed from when the first coronavirus case was registered in the country in January. At the time, samples were being sent abroad to be tested for the novel coronavirus. Now, 1,310 labs are screening for the infection; in the past 24 hours, they conducted 5.15 lakh tests. Talks are also on with GAVI for the country to get 20 per cent of the Covid vaccines available to the global alliance. But, as the numbers rise, it will be people’s compliance and resilience of states that decide the country’s future Covid trajectory, Sudan said.

Here are excerpts from her talk with ThePrint.

The truth about community transmission

If you were to ask any Covid positive person today if they knew where they got the infection from, most likely their response will be a history of where they went and who they met, she said. That isn’t the same as community transmission, she noted.

Community transmission is defined as a situation when the virus’ transmission path is unclear and the source of the infection is unknown.

“As we have said, we have local transmission, we have some outbreaks, we have clusters. But I am not willing to say that we have community transmission.

“If that was so, 84 per cent active cases would not be in 10 states. About 54 per cent cases are in three states — Maharashtra, Karnataka and Tamil Nadu. Thirty per cent cases are in seven states — Andhra Pradesh, Uttar Pradesh, West Bengal, Gujarat, Bihar, Telangana and Delhi,” she said.

Sudan went on to say irrespective of whether there is community transmission or not, it has very little bearing on the actual disease control efforts.

“We are still at a stage when we can cut transmission. Delhi has proved that when containment zones are defined in a scientific manner, when people are following Covid-appropriate behaviour, when we are getting people to the hospital at the right time, telling people not to shy away from testing, put in place a robust infrastructure for testing, cases can go down,” she said.

The testy testing question

Results of Delhi’s sero survey that were released last week showed close to a quarter of the population in the national capital had been exposed to the virus. For a city of two crore, this would amount to upwards of 46 lakh people.

However, Sudan is not willing to question the testing strategy based on those numbers.

“I would not say we missed 45 lakh cases (Delhi has a total of 1.3 lakh cases so far). These are people who did not themselves know they had these infections. They didn’t know and we didn’t know. It is not a big deal, it happens with such viruses … 5.15 lakh tests were done yesterday, 1.68 crore done upto now in 906 government and 404 private labs. We are also asking states that wherever there are 200-bed district hospitals, they should set up BSL II laboratories. The Medical Council of India said private medical colleges should have these laboratories,” she said. The money given to states for Covid assistance can be used for setting up infrastructure in these laboratories, she added.

However, India is nowhere close to doing mass testing at the scale done in South Korea. The Asian country has emerged as an example on how to contain the virus without requiring stringent lockdown.

“Look at their population, look at ours. We are doing mass testing in containment zones. Anyway, what’s the point? Today, you are negative, tomorrow you may be positive. Mass testing for its own sake doesn’t make sense. Where you test is important,” Sudan pointed out.

She also brushed aside concerns about increasing use of antigen tests, citing the initial criticism about India’s testing strategy which overwhelmingly focussed on symptomatic people. “Even then our positivity was 3-4 per cent. We are retesting all symptomatic negatives (as determined by antigen testing) with RT-PCR now, and the strategy seems to be working,” she said.

The vaccine hope and ‘investigational’ drugs

India is in talks for entering the WHO-GAVI alliance for Covid vaccines whenever they are ready to be distributed.

“As per that, 20 per cent of the total vaccine may be made available to us. That is an indication that we will get an apportionment as per their permutations. For them also, it is an evolving situation … many vaccines are in Phase III trials and those usually take the longest (time) — three to four months easily,” she said.

Sudan added that there are hopes that the indigenously developed vaccine, Covaxin, will be ready early next year.

“I think the 15 August deadline was misinterpreted,” she added, referring to a letter ICMR’s director general and secretary of the Department of Health Research, Dr Balram Bhargava had written to the principal investigators conducting the clinical trials for Covaxin. The letter caused a huge uproar, forcing the ICMR to issue a clarification. The ICMR is the nodal medical research body in the country.

India is also periodically revising treatment guidelines looking at upcoming therapeutic options, but there are misgivings about the drug remdesivir, Sudan said.

“We are still waiting for evidence from wherever (remdesivir) is being used, but you must remember it is an investigational drug,” she added.

The trick to home isolation

Sudan had been an early and strong votary of hospitalisation for all Covid patients. India has now moved in a big way towards home isolating mild or asymptomatic cases.

“When we started with hospitalisation, we didn’t know much. We are learning and evolving … home isolation is with conditions, that’s why we keep amending guidelines as we learn. There are no yes-and-no answers. As we go along, the situation may change,” she said.

She cited Delhi as an example where more home than institutional isolation was happening. “We changed that when the home ministry took charge, and it worked. Fatality rate came down. We also discovered pulse oximetry. Home isolation is possible if people are monitoring oxygen levels, if the doctor has certified they can stay at home and health workers are monitoring on a daily basis,” Sudan explained.

‘An amazing, humbling journey’

Of the bureaucrats running India’s Covid efforts, Sudan has been the least seen. It was left to joint secretary Lav Agarwal, and now Officer on Special Duty Rajesh Bhushan, to be the faces of the government. Bhushan is due to succeed her as secretary.

But, Sudan has been at the centre of it all, working late nights, pushing the envelope and in between, even finding time to arrange meals for her team.

“My God! I have lived in a Covid bubble. I lived it, breathed it, slept it, walked it, ran it. I find it very humbling the support we got from everybody — seniors, political bosses, the Prime Minister, colleagues, cabinet secretaries — it has been amazing!” she said.

Days after the nationwide lockdown had been implemented, the Modi government had set up 11 empowered groups as quick response teams to tackle the coronavirus outbreak. At the time, India had just recorded over 1,000 Covid cases.

“The empowered groups seemed daunting initially, but how much work they have done! I don’t think we could have managed alone. My team has been amazing. I have stories about every individual, not one of them negative. Everybody rose to the challenge of saving the country, saving ourselves. That was how I used to end all my presentations in the meetings that the PM took with states — ‘We have to save the country and save ourselves’,” she said.

The key to the future is to respond to emerging situations and “reinvent”, she said.

“Cases happened in places where we didn’t expect, and did not come up in places where we expected them. Even now, look at Tamil Nadu and Karnataka. We did not think they would increase, but they did. We need a different strategy there. We need to keep learning and adapting.”

On her own future plans, she says there is a book in the offing at some point. Before becoming health secretary, Sudan had been part of the launch of ‘Beti Bachao, Beti Padhao‘ initiative as additional secretary in the Ministry of Women and Child Development, while INS Vikramaditya was acquired during her stint in the defence ministry.

“My life is divided into pre-Covid, Covid and post-Covid. I can’t disengage totally, I’m sure. I’ve been mind-body-soul into this. I need a break. I want to write stories of ‘Beti Bachao Beti Padhao’, about the National Medical Commission, e-cigarettes, the significant defence acquisitions like Vikramaditya aircraft carrier. I will definitely write,” she said.