From AIDS to COVID-19 – Whither Public Health

While the world is grappling with a runaway epidemic of Covid19 which is defying all projections on its progress, it is time to take a hard look at the reasons for the collective failure of governments and multilateral organisations to check its spread.

First, we can rewind and recollect how the HIV/AIDS epidemic which was threatening to overwhelm the countries was finally brought under check in both incidence and mortality. The global AIDS response was successful in adopting a public health model to halt its spread and brought into focus the importance of public health in containing epidemics.

Public health is not just public sector health. It has a wider connotation and should essentially rest on four pillars of public health. First, prevention should be in the forefront of disease control and other health interventions. And populations who are most vulnerable and at risk of contracting the infections should be central to the response. Second, treatment programmes should be carried out at the lowest level of primary health care with emphasis on awareness, counselling and follow up. Third, civil society should be a strong partner with governments in policy and implementation. And last, national and global responses should be evidence based. Strong and focused epidemiology should drive programmes.

Many new viruses like SARS, Ebola, H5N1 and H1N1 emerged in the last two decades and exposed the weakness of the health system and lack of preparedness of countries and UN agencies like WHO in quickly mounting an effective response. We did not see adoption of any of the approaches explained earlier which are people centered and could have minimized the damage in terms of morbidity and mortality.

And this happened again in Covid which has completely thrown the health system out of gear in a short period of 6 months. We are just chasing the epidemic and are nowhere near getting ahead of the curve. And in very few countries do we see a successful application of sound public health principles outlined above.

Prevention focus in Covid has to be around universal use of masks and social distancing. We see that shortage of good quality masks and lack of awareness around social distancing are the basic causes for the explosive rise in new infections. But we don’t see people’s involvement in getting these messages across.

Covid treatment is highly centralized in tertiary care hospitals and facilities lack at primary health care level resulting in migration of people to urban areas in search of treatment. Failure of governments in strengthening systems of primary health care has been seriously exposed in Covid crisis. And the poor and under privileged are the biggest sufferers.

The entire response is government driven and enforcement oriented. Police and law and order machinery have been brought into the picture for enforcement of lockdowns and closures without any involvement of local communities. Involvement of Covid warriors in countering stigma and generating awareness has been minimal unlike that of HIV positive networks in AIDS programmes.

Most important, the national responses are not driven by sound epidemiological evidence. Barring few exceptions we do not have a credible estimate of Covid prevalence in many countries. We see the country and global leadership in a denial mode refusing to bite the bullet to make the people aware of the high percentage of population who are already infected with the virus.

Reasons for decline of public health as a strategy are not difficult to find. For many governments in the developing world, health is synonymous with medical care. Health policies world over promise higher investments in primary health care but do not deliver in practice. Prevention and health promotion with strong focus on hygiene and nutrition do not figure high in government priorities. And the big difference is absence of community involvement in Covid management which is just a top down model of medical interventions with overworked health care personnel.

Let us again rewind to 2001.We had seen great leadership at global level within countries and UN organisations like UNAIDS who could inspire the country leadership for launching an effective global AIDS response. Do we have such global leadership today to take charge of Covid response? While there are many areas where global action is found wanting, the most glaring of all is the failure of leadership in the rocky drive of public health from AIDS to Covid.