Public health framework and its intersections with society while dealing with the pandemic -- A conversation with a public health care specialist

Dr R Gaitonde


Can you tell us about your work as a public health care specialist?


My work involves mainly teaching and research. I teach as part of the Masters in Public Health (MPH) program here at the Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum. In addition, we guide students doing their masters or PhD dissertations as well as research work of our own. My work largely focuses on health policy, the social determinants of health and health systems. I am particularly interested in Health Inequity and  its various determinants,  with a particular focus on the institutional determinants of health inequity. In other words, we are working on exploring what are the ways in which the design of our organizations and programs themselves contribute to health inequity?

How has your average working day changed after the onset of the COVID-19 crisis?

One of the major changes in my working day – is having to spend a large amount of time dealing with COVID-19 in a number of situations. As a public health researcher, I am involved in a number of newly formed committees at the institutional as well as state levels with regards to COVID-19. Just having to read up all the new material in preparation for the work of these committees is hugely time consuming, and I need to do this along with regular teaching and research. Teaching is fully online now, however,  I find, it actually takes a longer time to teach the same concepts online, than face to face. I sorely miss the face to face interaction with students which is somehow much more inspiring and engaging than talking to a screen!
Apart from these, COVID-19 has induced a number of lifestyle changes – being forever behind a mask, not shaking hands, washing your hands every hour or two, not opening doors with the knob, disinfecting your gadgets before going home, washing your masks at home, disinfecting surfaces at home, etc. There are now so many new routines we perform that we never did in the now seemingly distant non-COVID-19 world!

Can you elaborate on the ways in which the public health framework addresses both COVID-19 and non-COVID-19 health issues?

A public health framework looks at health systems and the health of communities in a holistic manner. Not only are we interested in specific health issues per se but also in the determinants of their distribution. In other words, we are interested to know why some individuals or groups are more susceptible to diseases than others. We do this with an idea of prevention. In terms of COVID-19, a public health approach points out that while the biology of COVID-19 will be important to determine how a community is affected, we have to realize that different groups in that community have different capacities and resources to deal with this increased risk and the consequences. Thus, those in slums have very little capacity for home quarantine, or those on daily wages can ill afford to work from home. A public health approach recognizes these factors and tries to tailor interventions in order to make sure all individuals and groups are able to benefit. The inspiring work in Dharavi (a slum region in Mumbai) which took into consideration the high density of population and tailor made an intervention is a great example of such a public health approach. Here in Kerala, the opening of community kitchens recognized the fact that many people, like the elderly, in quarantine may not be able to cook the dry rations on their own. Another aspect of this holistic approach is that we cannot ignore the fact that the individuals at risk for COVID-19 also suffer from or could contract other diseases – like hypertension, renal failure, cancer etc., which need continued attention despite all the focus on COVID-19. Similarly, various public health prevention interventions like immunization and Ante-natal checks ups etc., need to be continued as these risks and issues do not disappear in the face of COVID-19! It is important to note that those presently tasked with the core COVID-19 control activities are precisely those who bear the burden of providing routine health care services.

How can scientists interface with policymakers in addressing the challenges faced by the public health care system during the pandemic?

I think it is most important for scientists to actively engage with policy makers. It is this interface that makes our research more meaningful, as well as strengthens the initiatives of policymakers with the best available evidence and interventions. While there are many reasons for doing research, with each of them being valid in their own way, I personally like to see a change as a consequence of my work. Thus to me a strong and proactive interaction with policy makers is the name of the game. Administrators and implementers are in the thick of action, and having to deal with a huge host of day to day issues that are crucial for the smooth functioning of the system, especially in an epidemic situation like now. In such a situation it is the responsibility of scientists to step back and look at the situation critically, compare the local with experiences in other settings, point out possible loopholes, point out possible alternative paths for consideration, that the front line administrators can consider as they plan future activities. In many states, including here in Kerala, there are a number of technical bodies with scientists and doctors who are providing various perspectives on the issues being faced by the governments. It is this constant interaction between the hustle and bustle of practice and the reflexivity of research that should be the foundation of effective policy direction.

Can you elaborate on your experience as a public health specialist on interacting with governments, bureaucrats for handling the epidemic?

One of the key challenges in dealing with policy makers is that scientists and policymakers speak very different languages, they are excited about different things and are driven by very different motivations. This is not being said as a criticism, but is a fact we need to deal with. While for us scientists, success or failure is defined by the method we use and the ability for us to discern a tentative truth about the system we are researching, but for a policy maker success or failure is defined quite differently. For her it is all about political goals of the government for example. Thus, it is important to realize this paradigmatic difference in any such interaction. This is certainly visible in COVID-19 too, where as a public health specialist I know that  given the nature of the disease we are going to see continuously growing numbers (given that this is a novel pathogen with no pre-existing immunity among humans). Thus to me the issue is not about the numbers being affected, but whether we can  prevent vulnerable individuals from getting affected, and whether we can reduce numbers to those that the health system can handle. However, for bureaucrats whose performance is unrealistically measured solely in terms of “number of cases” it is very difficult to be removed and see things from a distance.

In such interactions there is a need for patience, humility and the ability to see the different places from which different individuals are approaching the issue.
Could you elaborate on how the public domain data (testing, infection, recovery, etc) can be used for actionable solutions during an epidemic?
I am a great supporter for making all available data public to researchers who are interested in looking at it. In a situation of such uncertainty, we can certainly do with as much help as we can get.

On another note, this is data from the public, funded by taxpayers money, and so there is no reason for this not to be made public. It is well known that the more the transparency there is in the management of the epidemic, the more there is trust between the government and the people. In an epidemic like COVID-19, where so much depends on behavioral changes being made by people and sustaining them over long periods of time, this trust and the necessary transparency is absolutely crucial.
Having said this, I must say that as of now the data available is difficult to use and incomplete. Definitions are not clear, underlying denominators are not always available and in general there are many assumptions we are left to make. Much of this is usable, but not as good as would have been with a more open policy on data transparency.

What are some ways in which the community can actively participate in addressing the issues in public health care?

Communities are key stakeholders in the management of COVID-19. Much of the so-called flattening of the curves depends on the various behavioral changes brought about by communities and their sustenance. Successful campaigns of physical distancing, masking and washing hands and not having mass gathering is known to significantly reduce the risk of infection.

Community solidarity is well known to fill in the gaps – some large and some small – in the outreach of the government to those who really need this support.
Community volunteers can play a major role in increasing the effectiveness of quarantining, for example, by supporting elderly individuals living alone and helping keep a track of them during the long lockdowns etc.

Various communities and their organizations like residents' welfare associations, and other associations and unions can play a key role in identifying various gaps in the programs / implementation and helping in filling them.

However for all this to happen, the government for its part has to recognize individuals and communities as key stakeholders and active participants in their own right and invite them into decision making spaces too.
Dr. Rakhal Gaitonde is a Professor at the Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, Department of Science and Technology, Government of India.
Interviewed by Meena Kharatmal, Scientific Officer and a PhD Student at the Homi Bhabha Centre for Science Education, Tata Institute of Fundamental Research, Mumbai.