1.A disease surveillance system, for the future
Diseases and outbreaks are realities and a well-functioning system can help reduce their impact
A defining moment in the history of epidemiology was the removal of the handle of a water pump. This is a spectacular story. In 1854, when a deadly outbreak of cholera affected Soho area of London, John Snow (1813-1858), a British doctor and epidemiologist, used the health statistics and death registration data from the General Registrar Office (GRO) in London, to plot on a map of the area, the distribution of cholera cases and deaths. He observed that a majority of cases and deaths were in the Broad Street area, which received supply from a common water pump, supporting his theory that cholera was a waterborne, contagious disease.
The collection of health data and vital statistics by the GRO had improved over the previous decade-and-a-half due to untiring efforts put in by another medical doctor, William Farr (1807-1883). Based upon the data on the time, place and person distribution of cholera cases and deaths, supplemented by a map, Snow, on September 7, 1854, could convince the local authorities in London to remove the handle of the water pump, which they reluctantly did. The cholera outbreak was controlled in a few weeks. It started the beginning of a new era in epidemiology. John Snow is often referred to as the father of modern epidemiology and William Farr as founder of the modern concept of disease surveillance system.
A nodal point
In the years to follow, epidemiology became a key discipline to prevent and control infectious diseases (and in present context for non communicable diseases as well). The application of principles of epidemiology is possible through systematic collection and timely analysis, and dissemination of data on the diseases. This is to initiate action to either prevent or stop further spread, a process termed as disease surveillance.
However, in the late 19th century, with the emergence of understanding that germs cause the diseases, and then in the early 20th century, with the discovery of antibiotics and advances in modern medicine, attention from epidemiology somewhat shifted. The high-income countries invested in disease surveillance systems but low- and middle-income countries used limited resources for medical care. Then, in the second half of Twentieth century, as part of the global efforts for smallpox eradication and then to tackle many emerging and re-emerging diseases, many countries recognised the importance and started to invest in and strengthen the diseases surveillance system. These efforts received further boost with the emergence of Avian flu in 1997 and the Severe Acute Respiratory Syndrome (SARS) outbreak in 2002-04.
Surveillance in India
A major cholera outbreak in Delhi in 1988 and the Surat plague outbreak of 1994, nudged the Government of India to launch the National Surveillance Programme for Communicable Diseases in 1997. However, this initiative remained rudimentary till, in wake of the SARS outbreak, in 2004, India launched the Integrated Disease Surveillance Project (IDSP). The focus under the IDSP was to increase government funding for disease surveillance, strengthen laboratory capacity, train the health workforce and have at least one trained epidemiologist in every district of India. With that, between 2004 and 2019, nearly every passing year, more outbreaks were detected and investigated than the previous year. It was on this foundation of the IDSP (which now has become a full fledged programme) that when COVID-19 pandemic struck, India could rapidly deploy the teams of epidemiologists and public health experts to respond to and guide the response, coordinate the contact tracing and rapidly scale up testing capacity.
The disease surveillance system and health data recording and reporting systems are key tools in epidemiology; however, these have performed variably in Indian States, as we know now from available analyses, be it seroprevalence-survey findings or the analysis of excess COVID-19 deaths. As per data from the fourth round of sero-survey, Kerala and Maharashtra States could identify one in every six and 12 infections, respectively; while in States such as Madhya Pradesh, Uttar Pradesh and Bihar, only one in every 100 COVID-19 infections could be detected, pointing towards a weak disease surveillance system. The estimated excess deaths are also higher in those States which have weak disease surveillance systems and the civil registration and vital statistics (CRVS) systems.
In a well-functioning disease surveillance system, an increase in cases of any illness would be identified very quickly. An example is Kerala, arguably the best performing disease surveillance system amongst the India States, as it is picking the maximum COVID-19 cases; it could pick the first case of the Nipah virus in early September 2021. On the contrary, cases of dengue, malaria, leptospirosis and scrub typhus received attention only when more than three dozen deaths were reported and health facilities in multiple districts of Uttar Pradesh, began to be overwhelmed. The situation is not very different in States such as Madhya Pradesh and Haryana, where viral illnesses, most likely dengue, are causing hospitalisation but not being correctly identified or are being reported as mystery fever. This is a bit concerning as 18 months into the COVID-19 pandemic and a lot of political promises of strengthening disease surveillance and health systems, one would have expected a better performance. It raises the question: if the pandemic could not nudge the governments to strengthen the disease surveillance system, then what will? Or is it that difficult to strengthen the disease surveillance system?
What should be done
A review of the IDSP by joint monitoring mission in 2015, conducted jointly by the Ministry of Health and Family Welfare, the Government of India and World Health Organization India had made a few concrete recommendations to strengthen disease surveillance systems. These included increasing financial resource allocation, ensuring adequate number of trained human resources, strengthening laboratories, and zoonosis, influenza and vaccine-preventable diseases surveillance. Clearly, it is time all these recommendations are re-looked and acted upon. At a more specific level, the following should be considered by health policy makers.
First, the government resources allocated to preventive and promotive health services and disease surveillance need to be increased by the Union and State governments. Second, the workforce in the primary health-care system in both rural and urban areas needs to be retrained in disease surveillance and public health actions. The vacancies of surveillance staff at all levels need to be urgently filled in. Third, the laboratory capacity for COVID-19, developed in the last 18 months, needs to be planned and repurposed to increase the ability to conduct testing for other public health challenges and infections. This should be linked to create a system in which samples collected are quickly transported and tested and the reports are available in real time. Fourth, the emerging outbreaks of zoonotic diseases, be it the Nipah virus in Kerala or avian flu in other States as well as scrub typhus in Uttar Pradesh, are a reminder of the interconnectedness of human and animal health. The ‘One Health’ approach has to be promoted beyond policy discourses and made functional on the ground. Fifth, there has to be a dedicated focus on strengthening the civil registration and vital statistics (CRVS) systems and medical certification of cause of deaths (MCCD). These are complementary to disease surveillance systems and often where one is weak, the other is also functioning sub-optimally. Sixth, it is also time to ensure coordinated actions between the State government and municipal corporation to develop joint action plans and assume responsibility for public health and disease surveillance. The allocation made by the 15th Finance Commission to corporations for health should be used to activate this process.
Check the right pump
The emergence and re-emergence of new and old diseases and an increase in cases of endemic diseases are partly unavoidable. We cannot prevent every single outbreak but with a well-functioning disease surveillance system and with application of principles of epidemiology, we can reduce their impact. Sometimes, the control of a deadly disease could be as easy as the removal of a handle of a water pump. However, which handle it is to be can only be guided by coordinated actions between a disease surveillance system, a civil registration system and experts in medical statistics, and, finally, informed by the application of principles of epidemiology. Indian States urgently need to do everything to start detecting diseases, which will prepare the country for all future outbreaks, epidemics and pandemics. This is amongst the first things, which Indian health policy makers should pay attention to.
2.A climate change narrative that India can steer
The Glasgow COP26 meet offers New Delhi a chance to update its Nationally Determined Contributions to meet targets
In a keynote speech on September 8 in a seminar organised by a think tank, R.K. Singh, Union Minister for Power, New and Renewable Energy stated, “Environment is something we are trustees of and have to leave behind a better environment for our children and great grand children.” However, a recent report, “Assessment of Climate Change over the Indian Region” by the Ministry of Earth Sciences (MoES) reveals that India has warmed up 0.7° C during 1901-2018. The 2010-2019 decade was the hottest with a mean temperature of 0.36° C higher than average. Heatwaves continued to increase with no signs of diminishing greenhouse gas emissions despite lower activity since the novel coronavirus pandemic. Prolonged exposure to heat is becoming detrimental to public health, especially the poor unable to afford support for coping with the heat. Assessment by the MoES shows that India may experience a 4.4° C rise by the end of this century.
India has also suffered two of the 10 most expensive climate disasters in the last two years. Super-cyclone “Cyclone Amphan” that hit India in 2020, cost more than USD13 billion even as the country was just recovering from “June-October Monsoon Flooding” that cost USD10 billion and around 1,600 lives. It was India’s heaviest monsoon rain in the last 25 years and the world’s seventh costliest. In early 2021, India suffered two more cyclones: Cyclone Tauktae hitting the west coast and Cyclone Yaas from the east.
India’s rising IDPs
According to the Internal Displacement Monitoring Centre, India’s Internally Displaced Populations (IDPs) are rising due to damaging climate events. Uttarakhand residents began deserting their homes after the Kedarnath floods in 2013 due to heavy precipitation that increases every year. Within 2050, rainfall is expected to rise by 6% and temperature by 1.6° C.
To make things worse, India lost about 235 square kilometres to coastal erosion due to climate change induced sea-level rise, land erosion and natural disasters such as tropical cyclones between 1990-2016. About 3.6 million out of 170 million living in coastal areas were displaced between 2008-2018. Recent figures are more alarming with 3.9 million displaced in 2020 alone, mostly due to Cyclone Amphan.
India’s Deccan plateau has seen eight out of 17 severe droughts since 1876 in the 21st century (2000-2003; 2015-2018). In Maharashtra and Karnataka (the heart of the Deccan Plateau), families deserted homes in 2019 due to an acute water crisis. Hatkarwadi, a village in Beed district of Maharashtra State, had as few as 10-15 families remaining out of the previous population count of 2,000 people.
Good policies, weak practices
India held the top 10 position for the second year in a row in 2020’s Climate Change Performance Index (CCPI). The country received credit under all of the CCPI’s performance fields except renewable energy where India performed medium.
India vowed to work with COP21 by signing the Paris Agreement to limit global warming and submitted the Nationally Determined Contributions (NDCs) with a goal of reducing emissions intensity of GDP by 33%-35% and increasing green energy resources (non-fossil-oil based) to 40% of installed electric power capacity by 2030.
India cofounded with France at COP21, in 2015, the International Solar Alliance (ISA) — a coalition of about 120 countries with solar rich resources— which aims at mobilising USD1 trillion in investments for the deployment of solar energy at affordable prices by 2030. Despite leading ISA, India performed the least in renewable energy according to the CCPI’s performance of India. The question is, are these global alliances and world-leading policies being practised or are merely big promises with little implementation?
Experts agree that India can achieve the 2° C target of COP15 Copenhagen in 2009. But it also observes that the country is not fully compliant with the Paris Agreement’s long-term temperature goal of the NDCs and there are still risks of falling short of the 2° C goal. According to India’s carbon emission trajectory, the country is en route to achieve barely half of the pledged carbon sink by 2030. To achieve the Paris Agreement’s NDC target, India needs to produce 25 million-30 million hectares of forest cover by 2030 — a third of current Indian forestation and trees. Going by the facts, it seems India has overpromised on policies and goals as it becomes difficult to deliver on the same.
Why COP26 matters
The Glasgow COP26 offers India a great opportunity to reflect on the years since the Paris Agreement and update NDCs to successfully meet the set targets. India is expected to be the most populated country by 2027, overtaking China, contributing significantly to the global climate through its consumption pattern. India is in a rather unique position to have a significant influence on global climate impact in the new decade.
Alok Sharma, President of the COP26 met Minister for Environment, Forest and Climate Change Bhupender Yadav in August to persuade India to deliver a more ambitious NDCs for 2030 to which the Minister responded by stating, “India believes that climate actions must be nationally determined… UNFCCC and the Paris Agreement for developing countries should be at the core of decision-making….”
Being one of the observer states of the Climate Vulnerable Forum (CVF) as well as an influential member of COP26, India has the ability to improve its global positioning by leading a favourable climate goal aspiration for the world to follow. The country has the opportunity to not only save itself from further climate disasters but also be a leader in the path to climate change prevention.
Key Points
- This visit will happen in the aftermath of India putting pressure of declaring a net zero emission goal.
- Instead, India called out countries on their carbon neutral intent announcements and termed it meaningless.
- UK is committed to work closely with partners in India to ensure successful outcome at COP26 in Glasgow in November 2021.
- Earlier in 2021, COP26 President Designate, Alok Sharma, also visited India and met PM Modi.
About COP-26
COP-26 is extended as “The 2021 United Nations Climate Change Conference”. It is the 26th United Nations Climate Change conference, which is scheduled to be held in city of Glasgow, Scotland. It will be held from 31 October to 12 November 2021. United Kingdom holds presidency of the conference. Conference will also incorporate the 26th Conference of Parties to United Nations Framework Convention on Climate Change (UNFCCC), third meeting of parties to Paris Agreement (CMA3) and 16th meeting of the parties to the Kyoto Protocol (CMP16). During this conference, Parties are expected to commit to enhanced ambition for first time since COP21.
Venue of COP 26
Venue for the conference is SEC Centre in Glasgow. Originally it was to be held at same place in November 2020. But the event was postponed for twelve months because of COVID-19 pandemic in Scotland.
3.‘CoWIN adheres to WHO specifications’
R.S. Sharma says U.K. has not expressed any concern on the certification process of the platform
No concern whatsoever has been expressed by the government of the United Kingdom on the certification process of CoWIN, R.S. Sharma, Chairman of the Empowered Group for COVID-19 Vaccine Administration, told The Hindu on Thursday.
He called reports that the U.K. had agreed to recognise Indian-made Covishield (COVID-19 vaccine) and add it to the list of recognised vaccines, but refused to recognise vaccine certificate issued by India for Indian travellers a “baseless controversy”.
“There has been no communication from the U.K. about the COVID-19 vaccination certificate process. The recent talks were about the U.K.’s interest in the CoWIN platform. The technical teams of both the countries have been in touch since early September,” Dr. Sharma added.
CoWIN was an open-source platform, Dr. Sharma said. The External Affairs Ministry had been in talks with countries that were interested in this platform. “Talks are at various stages and I will not be able to give specific details. But yes, several countries have shown an interest in the platform,” he added.
WHO standardisation
Responding to a query whether the Indian COVID-19 vaccination certificate conformed to the World Health Organization’s (WHO) specifications, he said India was adhering to the specifications.
“We have looked at our certificate while keeping in mind the WHO standardisation. There is a minor technical rectification where India uses year of birth, while WHO prescribes date of birth. For those wanting this change for travel needs, the same can be rectified,” said Dr. Sharma.
‘No concerns raised’
On Wednesday, U.K. High Commissioner to India Alex Ellis had said that his country had no issues with the Covishield vaccine, but the question was on certification.
On Thursday he tweeted: “Excellent technical discussions with Dr. R.S. Sharma. Neither side raised technical concerns with each other’s certification process. An important step forward in our joint aim to facilitate travel and fully protect the public health of the U.K. and India.”
Dr. Sharma responded to the tweet. “Echoing his excellency @AlexWEllis’s views, this will be instrumental in resuming socio-economic activities between India and UK. We also look forward to deepening ties between @AyushmanNHA and @NHSX, as we collaborate to build a digital continuum of healthcare services.”
To a query on the controversy, Health Secretary Rajesh Bhushan said on Thursday at a press conference that India and U.K. officials were in a dialogue. “And we are hopeful that the issue will be resolved soon. We stand by the External Affair Ministry’s position on the issue. This is discriminatory and we have the right of reciprocity,” he said.
