 Good evening everyone and welcome to a new episode of the COVID Connect series. USP COVID Connect is an online interview space where we speak to various leaders in the healthcare sector to get fresh insights on the impact of COVID-19 as we all navigate this crisis together. As we look at official numbers today, they paint a very grim picture. Globally, as of today, it looks like we have lost about 1.34 billion people to COVID and in India, the numbers show that we have lost 135,000 people. We are also hearing about resurgence of this virus in several parts of the world and in India in some cities. So we are today very fortunate to have with us Mr. Ajit Sadanathan to talk about how governance is a role in preparing for and handling this crisis. Mr. Sadanathan is the former additional secretary of health in Kerala. He is currently the CEO of Health Systems Transformation Platform, a not-for-profit organization incubated under the age of Tata Trust. Mr. Sadanathan played a key role in controlling the situation during the 2018 NEPA virus outbreak in Kerala. With his hands-on experience and expertise in managing pandemics in the state, he was appointed as the Chief Minister's advisor to combat COVID-19 pandemic in the state of Kerala. Welcome, Mr. Sadanathan. Thank you so much for your time. Thank you, Siddish. Thank you for having me on this. So I will start off with the first question. I think it was January 30th when the first COVID case in India was reported in Kerala. And when you began to plan to tackle this crisis, there would have been a set of hypotheses, some assumptions that Kerala may have gone in with, given your past experience. Now, many months down, maybe we are about halfway through this pandemic, which of those hypotheses have come out to be true? And what may have been surprises that you're seeing? And how are we doing against expectations you may have had in terms of controlling the spread of this virus and in terms of saving lives? You mentioned NEPA experience. The crucial difference was in NEPA. We were caught by surprise. But here the advantage was that if you're tracking international health events, you knew about this epidemic in China. And since the epicenter of the epidemic is known, all you had to do was to watch for the possibility of spread from that epicenter to wherever you are. And that's what Kerala did, watching people who came in from China. And as luck would have it, they got three cases and they were managed. What Kerala, for that matter, the whole world didn't prepare for was that new epicenters spring up in no time and create fresh areas of problems. And then we had Europe, Italy, UK, France coming up as epicenters. That wouldn't have affected Kerala very badly, but Iran came up as one from Iran. It's spread to all of the Middle East countries. And Kerala has a very close link with the Middle East countries. And then as this epicenter started coming in, the cases started coming in. But even at that time, because the people were coming in from known destinations that we could manage. The advantage Kerala had was that thanks to our experience of managing the NEPA crisis, our health workers were trained on how to track trees and do the contact tracing, prepare the route map and then watch people who were likely to be infected, put them on quarantine, test them and so on. And then that went on. And if you remember at one time, Kerala had the largest number of cases in the country. But that was because Kerala was doing a better job of picking up the app. Then the lockdown happened. A lockdown meant that Kerala would be turned into something like New Zealand, an island in which you would not get infected in other places. Then the strategy was full to full use and then the whole situation was brought under control. That's the time when Kerala earned a lot of attention. But even at that time, people like us were saying, everybody was saying that the moment this protection is taken off, the epidemic people would come in, the whole thing would go up and community spread would start and so on. Even at that time, what was, and there was this whole question of would Kerala welcome the migrants back? And the answer was yes, there are people who will take care of them. Even at that time, the aim was Kerala has a depth of health capacity. Our spike should never cross the surge capacity that the state had. And I think it's to the credit of the Kerala health managers that even at an unexpected spike that we had after Onam, the surge capacity was never exceeded. So more or less the assumptions I would say have held till now. Thank you. So there has been a recent talk about did Kerala celebrate the success a little too early? When Kerala was hailed as the success model for having been very prepared and now having seen a lot of cases in October and November, you're talking about how it did not exceed surge capacity. Could you add a little more detail to why the perception that Kerala's success was celebrated too early or it's not really succeeding right now? Why that may not be true based on what you just said? No, what was celebrated in Kerala, even I had written about this. What was celebrated was that in a certain condition, the public health strategies of contact tracing testing works and that was demonstrated. But remember, a viral epidemic with a virus to which the population is naive will go through a certain course till the herd immunity is achieved, either through a vaccination or such a number of people getting infected. Now, if you have a huge epidemic in the beginning, you have some kind of advantage because a lot of people develop immunity. On the other hand, if you keep your initial numbers low, you are exposed to an adverse event at a later stage. So, this is something that all of us knew and were ready for. What kind of exceeded our estimation was the speed at which the reproduction number shot up. But that was quickly brought back to, it kind of reached its peak on the weekend at September 25th and it was brought back to less than one as of last week. So, all of this that led to being able to control this in an efficient way, the systems behind that cannot be built during a pandemic, right? So, could you share what the states can do or what Kerala has done over a period of time to actually be so prepared and so ready so that even at the worst unexpected time, like after Onam when the case is surged, you haven't exceeded your surge capacity. It's not the situation like in other states where you're out of ICU beds, where you're out of beds. And I think we're still talking just the government hospitals that have not been exceeded capacity. We're not yet even talking about the private hospitals. So, what over a period of time has helped Kerala be in this state today? I think you have given me one hour, isn't it? I don't know whether it will be sufficient to cover all the topics that I think led to this access. One, of course, the health system is what is obviously the strength. But I would go slightly behind that. I would say, what's the philosophy of the state? The philosophy of the state that the state follows is similar to what is there for the SDG goals, leave no one behind. Every human life is important. So, once that is your philosophy, then not only for this, but for practically every mobility, you invest adequately so that you are able to meet the demand. This does not happen overnight. There is no point, anyone of the current dispensation claiming credit for it. It dates back to the pre-Kerala, the Prince Lee kingdoms that invested in it and kept up by the successive state governments that have happened. And the health system was built up over time. The number of vacancies were considerably less compared to other places. More than that, there's always a demand for quality health systems in Kerala and it's a political issue too. If you don't deliver on health, you can be sure that you are going to be dragged over hot coals in this state. So, that helped. Now, more than that is the philosophy of social justice that the state has. Again, because of the egalitarian system over here and this is not unique to Kerala. There are many states in India which are characterized by an egalitarian approach to society and they are likely to have done well in various other issues. What I am saying is this is not about disease alone. The response to the disease has caused social disruption, loss of livelihoods, empowerment and so on. Now, let's assume that you had an excellent health system but did not have a social welfare system that took care of people who were out of the safety net or didn't have an adequate good safety net to take care of such people. More people would have died of starvation than from the disease. So, having that kind of a system was also important. The third thing is what happened with the migrant workers? Now, I don't want to go through all the unfortunate suffering they were put through but this is something again that the Kerala government recognized and took care of the migrant workers and ensure that till the lockdown was lifted, they were supported to continue. There is another aspect. We are talking about the system capacity. But there is another aspect which we know from the 2014 Ebola epidemic in Africa. A very important thing in responding to an epidemic is trust that people have in government. In Liberia, government officials who were trying to quarantine population who were trying to stop funeral rites were attacked because they did not believe in government. Similar coercive measures where similar kind of quarantine, that kind of thing had to be used if the success that I mentioned before had to be achieved in Kerala. The good thing was that people have had that kind of a trust in government and were willing to comply with the request that was made on them. Even in some of the advanced, so-called socially advanced countries, we have seen populations rising against this and we have had some very unfortunate events in some of the countries. But this is again, I would say, a very important thing that played a role in Kerala's success. Here I'd like to highlight something else that is actually, should have been given in public health, but is generally ignored. That is, since SARS of 2002 in China, most of the people working in public health know that it is very important to be transparent about the state of the epidemic. China, unfortunately, tried to hide that in 2002 with disastrous consequences for their own people and for the countries around them. During NEPA, we realized in fact that if unless we were totally transparent, we would not have the community, the society working with us. So we co-opted the media, there were some problems in social media, we countered that through social media and we were absolutely transparent during the NEPA crisis and that's become a kind of tradition that you have to be transparent with the data. And even if it is bad news, you have to share with them, you have to bring in people as partners and which is also very important for the successful management of a pandemic. I think these were some of the elements that helped the state. So that's interesting. You mentioned investment that goes back decades or maybe hundreds of years, even before the state governments were formed. Investment in health and also the fact that there was so much demand and continues to be demand for focus on health from the public. So both the supply and the demand side of importance of health is what is really distinguished about Kerala and trust and transparency being very key. So today, yes, we see a lot of misinformation, a lot of information, misleading information across social media, across that is creating maybe confusion or what people should believe in, should not believe in. How is Kerala handling this issue of information, misinformation and getting the right data to the people, right information to the people? All of us who have been dealing with epidemics know that every epidemic will be followed by infodemic where the false information will start flying over the place. Now, if you work in the area of communication, you know that communication does not tolerate a vacuum. So in during when we had a human, in fact in COVID it was much less compared to what we had to deal with during the NEPA crisis. The only counter to misinformation is proper information from trusted sources. So every evening, which is something we continued in the COVID response also, every evening all the data about the current state of the epidemic and the response, including number of samples that were tested, number of people that have expired, all this would be revealed to the press in an open press conference and the press would carry it. And we were active also on the social media. The moment there is a counter information, your Facebook, somebody or the other would post it on the Facebook account and say, look, we this is circulating on social media, what is what is the fact? And since that source was trusted, the message that we would share would then get picked up by the social media networks and would continue. So the best way to counter an infodemic is to give accurate information from trusted sources. Now that source is generally the, it should be the government, but we have seen situations in which they were not there in some of the situations in some other places where they were not government. Sometimes it is professional organizations, faith-based organizations, but the only way to counter misinformation is through counter proper trusted information. Thank you. So all of these elements are speaking to governance, right? How governance is really the core central aspect and managing pandemics as a pandemic with epidemiologists informing versus managing the pandemic as a disaster management. Different states in India have handled this differently. So I think there are elements of governance here that are really helping Kerala. One of the other elements, so you mentioned investment in health, trust and transparency and information. One of the other elements of governance in Kerala is decentralization. Could you talk a little bit to how decentralization has really helped whether it was with the Nipah virus or with the COVID pandemic? I would say one, I remember governance is just a reflection of the social norms. So it is not possible to have good governance in a vacuum. That aside, it is wrong to assume that decentralization was a factor only in Kerala's response. I think it was Mr. Dekundan who wrote that because governments, central and state were far away due to the lockdown, the local communities mobilized themselves. And we've heard about, you know, we've heard about quarantine senders being arranged by local people. We've heard about social support being provided by local community. We've heard about support given to the affected populations. Only thing is that it never got mainstreamed into the formal response. But decentralized response has been one of the hallmarks of this pandemic, especially during the lockdown. The advantage Kerala has is that it is kind of formalized. The Punjab Raj system that is rural and urban local bodies in Kerala are fairly well, very democratic and highly politicized, of course. But the way the system is structured is that they have access to independent funds which they can use and also have access to delegation of powers and control over institutions which they can use. Now in Kerala, all the health institutions from sub-center up to district hospitals are under the Punjab Raj system. Again, it's not unique to Kerala. Maharashtra has a similar structure. Gujarat has a similar structure. But the difference is that they also have money that can be used in improving the systems, you know, in improving the condition of these hospitals. As I mentioned before, if there is a lot of demand for health or education, a politician, an elected group of people who would like to do something popular would invest in areas that would earn them brownie points, that would be education and health. If you look at the primary health centers after they were handed over to the Punjab Raj institution that happened in 1996, their quality has really improved and many of them now have been certified under the NQA system. In fact, the largest number of primary health centers have been certified in areas where the Punjab has taken responsibility. Then during the 2018 flood, since then, they have also been made in charge of disaster management. The Punjab has systems to deal with disasters. They can take social support measures and a lot of them did by opening community kitchens, by taking care of migrant workers, by helping people, the elderly people who are reverse quarantined, ensuring that they had access to supplies and so on. So the advantage, and I believe it's not unique to Kerala, anywhere that you empower a local community, they will be more responsive to the local needs and the local response. Let me give an example. At a time when Kerala had divided the management system into four levels and the lowest of them was called the COVID first line treatment centers, which was set up by Punjab Raj institutions and supported by the local primary health center. But then some of the Punjab said, why are we setting up such large institutions? Why do we ask local people to render small houses where the asymptomatic people could be quarantined? And that was an innovation that the Punjab came up with and the state government adopted later, which considerably improved the quality of life who were institutionally quarantined. So you trust the local decision makers who have an interest in ensuring that they are acceptable to the people who put them in control, they will find ways of doing their job well because they know that their job is at stake. And I think that was the rationale of why Punjab Raj institutions and urban local bodies should be at the center of this response. Of course, this will work only if you have a good primary health care system because if you put people on in a quarantine center, they should be monitored and there must be a good referral system along with transportation system which can transport them to upper centers if there is a crisis. Without that, it won't work. So in this management, a lot of focus have been on ventilators, on tertiary hospitals. What people forget is that more than 80% of people will not need these kind of facilities, but they will need to be monitored, they will need to have access to quality care. So the I would submit that the emphasis should actually be on strengthening your primary care system and your secondary level system and not the way it is being done now, not focus on tertiary hospitals. Thank you. So decentralization and the empowerment with local bodies really helps because also you're kind of saying that it is not just that they can execute at the local level. They actually have funds to make the decisions they need to make at the local level that are immediate and required and they have a better visibility to. So that kind of empowerment is probably what's driving the success and the results. I'm going to switch gears a little bit to quality and we, you know, how improved governance can keep a check on whether it is falsified medicines, falsified or substandard medicines or products. So the market was flooded in during the COVID pandemic with substandard PPE kits or face masks or sanitizer for pulse oximeters, maybe even medicines. So a strict kind of quality check needs to be done and how can improve governance help with something like this? At the beginning of this interview, you said that, you know, systems have to be in place before the pandemic, you know, epidemic starts. That's not fully correct. We've seen cases in which after the epidemic started, people have kind of scrambled and forces and have mounted good response. But what you just mentioned, like systems of quality control, it's a way of life, it's a way in organization functions. That is something that has to be in place. It should become a kind of ingrained trait of an organization if this is to be maintained. One, you need efficient procurement systems along with the, which is, which is a transparent procurement. In fact, in many countries, there are allegations of wrongdoing in the cover of the epidemic and at some stage it's going to be examined. So it's important that you have a, you have a robust procurement, robust and transparent procurement system that ensures that you follow the procedures and picking up things even in a crisis. Secondly, you need to have a, this procurement system should have assets component, a quality control mechanism, which ensures that substantive stuff will not come up. Having said that, remember, when, during the initial days of the crisis, we did not have enough PPE. So we did end up buying lots of stuff that might have been substandard under a duris under, you know, because we are an option at a high price. That I'm sure, I mean, that, that did happen. But once that is passed, if you have a quality control system which is ingrained in your normal work, that would get taken care of. The other part is, is that you mentioned about equipments and medicines, but how about the quality of treatment? We know that when we started, or even now, we do not have a definitive cure for COVID. The only thing that is possible is supportive care. The quality of supportive care becomes extremely important in ensuring that, you know, we, we, we, we prevent mortality. Now, having supervisory systems, having well trained staff, who would deliver good quality care during normal times, again helps you maintain quality of treatment during the, during a man, when managing a crisis like this. So, what are the lessons that this pandemic along with lots of others is teaching us is that we have to ensure that quality of, of materials, quality of systems and a learning system that makes it possible for you to learn as you go should become a necessary part of, you know, of the health system. And the learning system you're referring to is learning both from a governance standpoint and also from health workers and all the way through the chain that there is an ability to pick up and learn based on new information. Very well said. And then what really struck me was a learning system that's based on feedback from the frontline that comes from evidence that they are seeing on a daily basis, being the foundation for all of this learning and putting that into a system. That's great. Thank you for that. I'm going to switch to technology and how can we use technology for containing COVID, how has it already been useful for public health in India in reality? And what do you see its role for future governance of healthcare? Technology actually has come in as it's a necessity being the mother of invention. For example, we've never been very friendly and the medical profession has never been very friendly to telemedicine. But when the lockdowns happened and when people needed to consult both government and private device systems by which people could remotely consult. For example, in the past we had developed a system by which cancer patients on routine chemo would be routinely managed, would be managed in decentralized centers. It's a system that we developed actually for decongesting the tertiary care centers. But when the pandemic struck and people couldn't move, these centers were repurposed to actually become management centers where the trained physicians who are anyway managing the routine chemo now started becoming the eyes and ears of the specialist and then reporting back to the specialist and prescribing in partnership with on a collaborative mode. Let's assume that going forward this is something that we need to work on and but we also need to have supporting systems to take care of this. For example, the quality of remote management would have been considerably improved if we had adequate number of point of care diagnostics where things could have been fed back to a place to read and prescribe. There have been effort at remote reading of CTs for diagnosing stroke to prevent the time to treatment. There have been cases in which massive screening of diabetes cases through fundus photography and remote reading either by a trained optometrist or AI have happened. But these are sporadic ones. Going forward, once we realize that we may have to live with, we may need to reconfigure the system for technology, we may have to invest adequately in point of care diagnostics, validate them, we have never taken them seriously. Remember when a clinician moves from face to face meeting to a remote management, he or she is letting go of a lot of information that comes otherwise. Now that has to be made good by technology, point of care, remote diagnosis are one method. But the other one is to have longitudinal data on the patient available to the clinician, to the doctor. How does that happen? You will need to have dedicated primary care doctors who continue to deal with patients continuously or you will need to build up electronic health records that are available to the clinician and better still have backend algorithms that can analyze this data and prompt the clinician saying look boss, I think you should be looking at this or you should be looking at that. Which will kind of compensate for the loss and information that will happen when a clinician manages things remotely. But we are talking about change of mindset, we are talking about change of systems, we are talking infrastructure. But I think going forward it was imperative that we start looking at this seriously. Thank you. And do you think there's a role that technology can play in dissemination of vaccine given the big challenge of vaccine distribution that we will have on our. Sadly, I don't think there will be a major challenge because if you look at the availability of the front runner now that is the Oxford or the AstraZeneca vaccine. The amount of vaccine that will be available may not pose a major challenge of distribution. In fact, the supply chain is unless we get all the ones that India is kind of signed up to even then the I believe this is something that will be managed that can be managed by the current system and the central government is I mean all governments are stepping up the influence and I do not anticipate major delivery constraint in vaccine delivery. But in terms of generating datasets who should get it prioritize and all that. Yes, technology could be extremely useful. Thank you. And some folks joined a little later so in a quick summary of what really led to Canada success we talked about investment in health that has happened over a long period of time in Canada both from a supply side and from a demand side. Trust and transparency that the state government has built with the public has really helped in getting information out there and making sure that even bad news is conveyed so that there is trust and when the government is making certain suggestions that the citizens take it seriously. We also talked about efficient systems such as procurement systems quality control systems HR material systems and also having an earning system and these cannot be built maybe everything during a crisis but having some of these in place so that they can be used when the crisis happens. Givens and I've probably missed a few that we just talked about. Given all of these elements Mrs. You are probably also watching what's happening across different states in the country right now and not everybody has the same success or the same surge in cases. Maybe the same level of investments in health have not been done definitely Kerala has a higher percentage of investment in health compared to the national average for a I think for always. So what I think that certain states can do right now amongst all these in this moment of crisis if the pandemic is getting out of control what might be maybe the low hanging fruit that states can immediately act on. Well, if you start with what happened Wuhan the funk and hospitals that is the Greenfield hospitals being set up. So if the state has adequate depth in terms of HR and most states, many of the states are richer than Kerala is they can repurpose existing institutions but the important thing. I mean, many of the places which repurposed indoor stadiums and the hospitals found the real shortest was HR. So if adequate HR is available, you know, these can be they can be recruited. My request is this crisis is also an opportunity so don't go for please don't go for temporary contractual employment. Create those posts you're going to need them and then you know, right from multipurpose health workers, the nurses, the doctors recruit them because the you're training them and that's that that is a that's a resource that should not be lost. And I think the an immediate, you know, expansion of capacity, building capacity and some bit of task shifting. For example, there is no reason why, you know, asymptomatic or even mildly symptomatic patients cannot be managed by by by nurses if you're short of doctors, train nurses, give them confidence, give them support. So, so if saving lives is is an important thing for the state, then there are ways in which can be done and each state can develop on its own. One of the resources that have not been used remember 70% of the capacity is in the private sector. Unfortunately, government and private sector have not developed ways of working together. So both go their ways, each accusing you know, each other of lots of things. But I think it's time to cut that kind of nonsense and get together and decide to work together. We need to understand the compulsions the private sector private sector needs to realize that because they have lost money in the initial days of the epidemic, you know, you can't be greedy about it. So arrive at an understanding of how this can happen. And that could be the other way of using existing capacity that is available in the private sector to deal with the crisis. Having said that, I think considering the we have a few zero prevalence studies that have come out and some of them point to the fact that it may not before long we would have overcome the plateau. So I hope that in most parts of the country, we will be seeing it coming down. But as I mentioned before, never waste a good crisis. Use it as an opportunity to build up your systems and even if you get past this pandemic, there is one around the corner coming and there's no point, you know, flailing your arms around when that hits you. Please get ready for it. This is what this pandemic is teaching us. So create employment, not temporary employment. So you can train and retain those resources. Public private partnership, both have to both private sector and the government have to kind of find middle ground to leverage that and building systems and getting ready for the next one using this as an opportunity. Great news. Thank you. I'm going to ask about another topic which is impacted by COVID, which is the non COVID related healthcare. So how has that been affected by the COVID pandemic in Kerala and what how is Kerala planning to ensure that it is not too effective that the other busy states and other health systems don't fall apart because everything is open. Everything is focused on COVID. Thank you. This is something that was anticipated in the beginning and I mentioned about the changes we made in cancer. But some of the areas that have been affected like child immunization, pharmacological management of non communicability, hypertension, diabetes, more importantly, you know, COPD management, then and something that's been badly hit is the diagnosis of and treatment of tuberculosis. All these have taken a hit. But what what was done in the initial days of the hypertension and diabetes case was mailing, you know, ensure distribution of house to house distribution of drugs and so that they take it forward. Of course, the review wouldn't happen. A similar thing was tried in tuberculosis that mostly people who were on tuberculosis, you know, medications have remained, but the hit has been in diagnosing new cases. Kerala had a target of, you know, of bringing the infection down to elimination level by 2025 and was aggressively moving towards it. That has taken a hit. NCDs detection of new cases have taken a hit, but the management is going on. Childhood immunization, the outrage in outrage immunizations have come down, but facility immunizations are going up, but I'm afraid that also would reduce it to some extent. So, one of the learnings from this is that we need to firewall these to ensure that the health system is resilient enough to manage them. And again, having surplus capacity in the system will make it possible for us to, you know, to manage them. The other thing is, of course, technology. Now, how do you ensure that the remote management of, you know, remote monitoring of hypertension or diabetes cases are done, remote management of tubal treatment. In fact, one of the reasons, one of the causes that helped better treatment of tuberculosis was the use of technology by the National Tuberculosis Control Program. Similar measures will have to be developed for hypertension, diabetes, but the programs will take a hit and the best thing to do is morphage up as soon as the crisis is over. So, the planning itself assumes a little bit of the hit can only be addressed once we have post-COVID-19 pandemic or is there a slow, I mean, is it a slow pace, but we are addressing non-COVID treatments at the moment or some of these things have to pause? Only the pharmacological management of those diagnosed treatments is going reasonably well. Immunization, because there's a huge demand for it, will be maintained even if it is at the facility level. But the progress towards detection of larger cases, for example, our hypertension management was boasting of a 60% compliance level. We are now down to 38%. But this is something that has been recouped as we come over to the crisis. The next question is about some of the complexity around managing a crisis in health comes because health in India is a state subject, but there's a lot of coordination that has to happen with the center as well. So, how does that work usually and how is it working during this crisis? Well, while health is a state subject, the managing the spread of infection between different states is a central subject. I mean, the central can do it. So, but in this pandemic, what has happened, what has been disturbing is that instead of an epidemic or a public health act, it's a disaster management act that is used. I hope we will never have to do that in the future because that is, I mean, that is just not acceptable. So, one of the things that need to happen is we need to develop a public health act and states have to modify that to see their purposes. Health has made a state subject not because of any other reason. The health has always managed closest to the population. So, there is no way that a national, you know, pan-national strategy can work and that is why many of the states have led on this and that's the way it should be. But the major problem is there in the federal fiscal relations. Again, it's not related to health, but most of the subjects that need elastic investment that is advancement, more important investments are with the states, but the elastic revenues are with the central. So, and you know the crisis that hit the federal fiscal relations during this period. So, going forward it will be important to ensure that that is also taken care of. But there is no escaping the need for states to pull up their socks and start investing on it. Center and none of the states in India are currently fiscally capable of putting in that kind of investment and center will need to support the states fiscally to increase investment in health. So, you brought up a very good point that what India needs is a public health act and currently we don't have that act and what we are using is a disaster management act which isn't fully appropriate, but that's all we have at the moment and that's what we're using. So, that's a great point for policy as to what needs to happen for the future. As you mentioned, the next one might be around the corner. You mentioned financing. So, as economy shrinks is depending on the center, pretty much all that the states have left to be able to finance what's required whether for continuing support or even for vaccine distribution for other health investments that need to be made. Well, this is not an area of my expertise. The lots have been written by economists on the best way forward. So, I would rather pass this question because I'm not competent to answer how well the finances of the center and the states can be best managed. All I know is that as a person who works in a sector that needs resources, unless there are adequate resources, all that we talked about will not happen. So, the other part I would rather pass. Sure, no problem. So, I'll switch to the next question I received on vaccine supply that we've never had to so far ever supply so much vaccine so much quantity to all of the citizens. So, how is Kerala planning for supply and distribution of vaccine assuming that vaccine will be made available whether it is the vaccines produced outside of India or the other vaccines and trials in India that might become available a little later. If you look at the pipeline that is available for vaccine, I expect there will be three supply chains and right now I don't want to go into which of those right now AstraZeneca looks to be the front runner. And fortunately serum institute is a major manufacturer and and India will get a certain amount of vaccine for distribution government. I also expect that serum institute will make the vaccine available in the private sector so they will be another channel that is possible. The third channel would be that many of the states might invest in buying the vaccine themselves so there could be three sources of vaccines that will that might be available but please don't get your hopes very high. The supply chain is very constrained and we did an initial assessment of the of the capacity that is needed. Frankly, it will less than it may not even be as much as what we had to do with the when the MR vaccination campaign started. Having said that several government is heavily investing in in the cold chain. I mean large number of walk-in coolers have been ordered. States have been asked to identify locations. Iceland refrigerators have been ordered. Thermal packs have been ready. So, so if and when the vaccine is available, the if the if all that is currently being planned is in position, I do not expect a constraint because forget about the the Pfizer vaccine which reads minus 90 degrees Celsius. We are not going to see that. We will most probably seeing vaccines that require a cooling up to from minus 4 to minus 8 which which India is quite capable of managing. So, apart from the fact that the vaccine supply is going to be constrained. I do anticipate a major problem in distribution. Now, who will be eligible to receive it? That's a different question altogether. Right now we are clear that health workers will get priority. But after that what will happen? I think we will be seeing the issue unfolding as we move forward. But the we need to be I think we need to be prepared for three channels that would come up. But as I mentioned before it is going to be a long while before the vaccine induced herd immunity comes in. So, till that time we we need to remain in this present state of alertness and ensure that our other social vaccine like mask and social distancing and etc. are kept in place. So, let's not let's not worry too much about the infrastructure constraints for vaccine. I think that will be handled but the issue is the availability may not be as much as people seem to think. So, given what you just said, how long do you think in India we might be having to follow the norms to keep ourselves safe, whether it's social distancing, masking, all of the precautions washing hands, all of these precautions we're taking right now. How long do you think we might be in that mode? Sirisha, one thing I've learned about this pandemic is never make a prediction because you'll end up eating your words. So, I would not hazard that. But let's look at what we have now. We have AstraZeneca that is on the last stage, we expect the results to come in anytime now, which means the vaccine should be available after March, even though earlier expectations are there. But realistically, March is when we should see. Now, the Sputnik 5, the trials have just started. If we do it well, we should be able to do it within the next three months. And if the Indian counterpart is able to manufacture them, that should be coming in, let's say, June, July or something. The other one we have a large contract with, which is Novavax, that is yet to get, I believe yet to get into the phase three trial. Even in the US, the phase three trials are nowhere near where the other front runners are. So, I think this, again, I mean, I'm breaking my own injection here. I think this will go on. Again, there's another mode of herd immunity that will happen, which is the level of infection. So, we are looking at the middle of, at least the middle of 2021, before it will not go back to normal, but at least the current panic I think should be coming down. Again, don't hold me to my prediction. Thank you. So probably one of my last questions is, do you think it should be free for everybody in the country? And do you think it might be free or subsidized? What I expect is the government will find it difficult to charge. So the government supply will be free. I mean, it's difficult to think of it being done. But as I mentioned before, there will be other supply sources, the private source certainly is going to be paid for, I don't know how much that will be there. But if your question is, will government vaccine be charged? The answer, I would say, I don't think government has an option of charging. So, yes, I expect that to be free. One last question was, what is your opinion on the new death rate in India for COVID compared to maybe some of the other countries? See, there are two death rates that we talk about during the epidemic. One is the case fatality rate. The other one is the fatality rate of infection. Now, the good measure would be the fatality rate of infection. Of the total number of infected, how many died? Unfortunately, that denominator is not available for us. So your case fatality rate is indexed on how many patients actually report to hospitals. So, when Kerala claims that the case fatality rate is low, the question will be that are their denominator larger than the other states? And is that why they're reporting a lower case fatality rate? On the other hand, you have a state in which the people do not go to hospitals and die at home. The case fatality rate again will be less because they are not captured by the system. So, I would be very skeptical of making any claims based on case fatality rate, so long as you're not put in place a surveillance system that will help you estimate the prevalence in the population. Until that is there, I would treat it with a lot of skepticism. Thank you. We are right on time and Mr. Sadanand, and this was very, very useful to us. A lot of good tips for other states as well and an understanding of what led to Kerala being able to successfully manage the pandemic to the best that it can be. Thank you so much for joining us today. Really appreciate it.