A tale of two epidemics – Aids and Covid-19
The global upheaval created by the new strain of coronavirus (Covid-19) reminds us that communicable diseases are always a threat to public health. I look at the coronavirus pandemic with a feeling of déjà vu – with memories of the deadly spread of HIV/Aids just two decades ago fresh in my mind. It consumed more lives and left many more infected than Covid-19 is likely to before it is tamed and eliminated.
I see similarities in how countries responded to Aids then and Covid-19 now. While, in case of Aids, it was Africa and the third-world countries that were in denial and bore the brunt of the epidemic, this time around, it is the developed world that has messed up the response to the Covid-19 crisis, despite possessing the scientific and technological prowess to challenge it. During the Aids epidemic in the 1990s, African and Asian countries underestimated the spread of HIV, thanks to the lack of sophisticated epidemiological tools and responsive health systems. But there can be no excuse for the developed world’s complacency and a lack of preparedness in dealing with the coronavirus crisis; they, after all, possess the world’s best information technology-enabled epidemiological surveillance systems to track pandemics.
One common challenge that we faced then, and face still now, is to arrive at a credible number of infections. In the case of Covid-19, most countries are tailoring their responses to symptomatic cases or those quarantined for suspected infections. Infectious diseases always have a large number of unreported cases, with people either unaware or frightened to undergo tests. But there are still no organised efforts to bring out a credible number of estimated infections in countries reporting a high number of cases.
During the HIV crisis, the process to arrive at an estimated number was developed quite early with help from the United Nations system. India reported less than one lakh HIV infections 20 years after the first case was reported in 1986. But national-level sentinel surveillance conducted in 1998 yielded an estimate of three million infections. This was further refined using new data, but the number was still as high as 2.4 million, 20 times more than the reported cases. This forced the government to recognise the severity of the epidemic and invest resources into a vastly expanded and decentralised national AIDS response in 1999. In the next 10 years, the infection level was brought down by 56%, and the mortality was reduced through an expanded treatment programme covering almost 1.2 million people.
It should be epidemiologically possible to initiate national-level sentinel surveillance for Covid-19 in India, to locate if any latent epidemics are occurring in rural and remote areas outside the hot zones identified by states. The integrated disease surveillance programme (IDSP) should be given the mandate to undertake such periodic surveillance with technical inputs from the Indian Council of Medical Research (ICMR).
Testing is another important component of epidemic control. In the Aids programme, rapid kits introduced in 2,000 had enabled the government to quickly expand testing facilities across the country, which allowed people to get themselves tested and, if required, enrolled in the treatment programme.
Similarly, in the case of Covid19, India could easily overcome its initial reluctance to test large numbers. States could gradually expand testing facilities; the numbers, in case they are higher, can be partially explained by scaling up testing. The availability of rapid test kits for quick diagnosis could have enormously helped the programme, but substandard kits from China slowed down the effort. We need to quickly ramp up the indigenous production of rapid kits of standard quality to test the asymptomatic cases. Making kits available for voluntary testing at a very low price will help people access health care services during the early stages of infection.
In the 90s, stigma and discrimination associated with HIV positives greatly hindered the response. Health care providers were reluctant to treat them due to the fear of infection, and a lack of universal precautions for infection control in government hospitals which bore the brunt of the epidemic. The big difference this time around is that health care providers at the forefront of the response are being hailed as heroes.
But stigma is emerging from society due to an inadequate understanding of the dynamics of the Covid-19 epidemic. Disturbing instances of locals resisting last rites of people dying of Covid-19-related infections point towards the need to normalise the disease. Massive awareness campaigns in the late 90s, with community participation, contributed to a rise in awareness levels about HIV and Aids in the population. Similar efforts are needed now, with strong involvement of communities and persons cured of Covid-19.
Unlike HIV, which still infects about 1.5 million persons every year, the immediate threat of Covid-19 may not last more than a year or two. But its impact on the health systems and economies will be more profound than HIV, which was more of a silent tsunami causing unnoticed destruction to vulnerable communities. But even if Covid-19 is controlled, it may not necessarily vanish. Until the mass immunisation of populations becomes possible with a preventive vaccine, we must be prepared for its periodical onslaughts, even if in a less virulent form.
JVR Prasada Rao is a former health secretary and director, National AIDS Control Programme, Government of India
The views expressed are personal