COVID 19 – It’s too early to be complacent

The count for new COVID reported cases on 30^th May is 7964, and the total number of active cases is 86422. When you read this, another 14000 reported cases would have been added. The new cases reported are increasing every day. After every ten days the active cases will double which means by 10^th of June they will be 172844, by 20^th of June they will be 345688, and by 30^th of June they will be 691376. Most of the hospitals by 30^th of June, at least in metro cities will be exhausted. If the rate of new infections does not decrease, it would be a difficult situation for the hospitals. The testing labs in COVID hospitals are running 24 hours, the doctors, nurses and staff at the hospitals is already exhausted, as they have been working hard for the last two and a half months. 

The Ministry of Health and Family welfare issued a guideline on the eve of 30^th May, which says that religious places, shopping malls and hotels/restaurants will be open from 8^th of June. Interstate travel, passenger/shramik trains and air travel is allowed. Except for the containment zones the lockdown will be lifted in the country from 1^st of June. There is an attempt to begin economic activity, while we are reaching the most critical stage of COVID 19 pandemic. The movement of labour from one part of the country to the other has taken the infection to the hinterland, from the cities. India is one of those countries where the infection is spreading the fastest. The doubling rate of infected cases in India is 12 days, while for US its 50, and Italy 100. 

As the lockdown is lifted, we can see a rush to get back to business, even if that means taking a health risk for people. The lockdown was observed with ease by the middle and upper class. The poor faced economic hardship, hunger and malnutrition during lockdown. They lost their jobs, couldn’t pay rent, did not have cash and looked towards their villages for food and shelter.  Lifting of lockdown amidst a chaos, of middle and upper classes, vary of leaving their homes and get back to work, and the labour in a rush to get back to a place they call ‘home’, has a rationale of reviving economy from a standstill. The government has announced a package of 260 billion $, that does not provide much immediate relief. 

One of the strictest lockdown imposed by any government could not prevent the virus from reaching the most densely populated areas in the country, where social distancing is almost impossible. But what has been done cannot be reversed. What is the best strategy to deal with it right now? Epidemiological projection of numbers, estimate the reported cases of COVID 19 infections to 10 million by end of July. India’s health system will be put to test. In rural areas there are not enough infrastructures to handle the emergencies. The death rate will increase if the hospitals are exhausted.

The responsibility of personal hygiene and social distancing will be on people for the rest of the year. That is the only way the pandemic can be prevented from entering into Indian households in cities and villages. How effectively can that be done? The people will decide for themselves. An understanding of hygiene will be critical in rural areas, where there is scarcity of water, and sanitation products. Social distancing will be easier to do in the villages than in the cities. It will be impossible to do social distancing in densely populated areas of the cities.  

Complacency, on the part of government, institutions and people, will unfold another human tragedy in India. Government will have to keep efficient help lines, information systems, contact tracing alive. The hospital’s bed capacity will have to be increased looking at the conditions in the containment zones. Ambulance, medicines, PPE kits, masks, gloves and ventilators will have to be arranged. Quick actions to identify super spreaders will have to be taken. Sanitation workers, policemen, grocery shop owners and cab drivers can become super spreaders in the coming days. Regular training will have to be provided to them. PPE kits should be provided to sanitation workers. Mini-lockdowns will have to be enforced in the zones where that is the only option to keep virus from spreading, particularly in densely populated clusters of the cities. Supply chains will have to be restored but help will have to be provided on the highways – for hygienic food, clean washrooms and sanitation products. 

Institutions will have to be responsible for their employees. As offices open up, the management will have to decide, what part of work can be done from home, to restrict people from infecting others at the office. All those who can work from home, should work from home for the next six months. Industry will have to redesign shifts, and take strict measures to maintain social distancing and hygiene. New models of work will have to be evolved. Online education should be encouraged. Irresponsible, hurried decisions to open schools and colleges could be worrisome.

140 million people have become unemployed in the country, due to pandemic, as per ILO estimates. The government has doubled the outlay for MNREGA, to generate employment in the rural areas. The unemployed in the urban areas will have to get some relief package too. Hunger may lead to many social problems. There have been instances of fights and theft on the highways, when the mass exodus of labour happened. Law and order might be a cause of concern in the days to come.

India has millions of malnourished children who are prone to infections. Nutrition Rehabilitation Centres will have to be provided funding to handle the cases effectively. If the schools remain closed mid-day meal will have to be served at home. Community kitchens will have to be established to combat hunger and malnutrition. All of us will have to donate food. Every Indian family should donate some money towards food, or feed people on their own every month; otherwise we will lose kids to infections. A movement needs to be generated; the sentiment of food donation should prevail for at least a year.

People will have to maintain strict self discipline. Complacency on part of people will be fatal. COVID 19 has brought a complete change in the lifestyle. We have to learn to live with essentials for the next one year. Unnecessary movement from the house will have to be stopped. The city dwellers will have to learn to maintain social distancing in densely populated clusters. Personal hygiene habits have to be maintained. Masks will have to be worn compulsorily. People will have to come forward to report infection, to save others from catching it. Family members with co-morbidities will have to be protected. The community will have to actively participate in contact tracing exercises. Disease tracked early, reduces mortality. No signs of the disease should be ignored. All this will have to be done for the next two years otherwise we will lose the battle. A very strong communications strategy will have to be implemented to prevent people from getting complacent. 

At some point of time in the next two years each one of us will perhaps catch infection. But, not all of us will have a bed in the hospital, if we land there together. If that happens, there will be personal tragedies in our families. Virus does not distinguish between rich and poor, privileged or under privileged. Every citizen in the country will have to understand that, while the nation tries to get back to normal activity. The only way to prevent ourselves is to be agile.

My Health depends upon your Health - Time for Bhore Committee 2.0

COVID 19 pandemic has done a great service to India. It has brought forth the vulnerabilities of the Indian Health System, in the fore-front, particularly for the policy maker, to think and act upon. When there was a frantic exercise done in every state of India, high level meetings being held to develop a strategy for taking on the challenge of COVID 19 pandemic, the entire calculation was done on availability of doctors, nurses, masks, PPE kits, ICU beds, Ventilators and testing labs. The health infrastructure was to be developed for a possible nation wide pandemic, affecting millions of people. The policy makers realized that the infrastructure was not adequate at all. The only way we could combat a pandemic was through preventive means. It would take time to put together whatever resources we had. The nation needed some time to prepare, and some time to see whether the preventive measures would be successful in containing the disease in some clusters. 

A disease is not just a physiological phenomenon. It is a socio-cultural-economic phenomenon too. More importantly, the health of an individual doesn't depend on him alone. It depends on the environment that he is living in. It also depends upon the other people he is with, in the community. COVID 19 has put a very important fact, that people cannot be healthy alone, to keep someone healthy, most of the people in the community, have to be healthy too. One's health also depends upon others; and thus healthy citizens are not found in a home, a nation has to be a healthy nation. Health cannot be planned at micro level, it has to be planned at a macro level. The overall benefits of health that a nation enjoys are translated into economic benefits eventually. 

Health is the most important pillar of sustainable development. Sickness tampers with human life, health is life itself. If you wish to sustain life, you wish to sustain health. Modern living has made human being healthier, but has also made him fragile, because the seasons of sickness are global now, they do not remain restricted to a geographical area anymore. Thus, health is a global goal now. The scientific community of the world has come together to fight Corona Virus. People have realized globally, that everyone in the world has to defeat corona virus, and everyone has to be healthy at the same time. 

If you look closely, that is the case with the non-communicable diseases too. The society as a whole has to fight them. It is not a person's fight alone. Lifestyle is deemed responsible for certain diseases and thus the interventions have to be planned at the societal level to fight the disease. That's where we have to rethink on our Health Care Models. It is important to have hospitals and health workers, but do you also need to plan at the national, the state and the district level, for the health of the population? Do you need qualified individuals who would assist in developing these plans? What kind of data would be required to construct these plans? Do we need to integrate the health data of every individual at the national level to be able to develop a comprehensive plan? What other variables does health interact with? Can we attain something like a national health or global health? 

Indian Health System came into being as a result of Bhore Committee Report in 1946. The committee recommended the integration of curative and preventive measures at all administrative levels. Up till the formation of National Rural Health Mission (NRHM), which was launched in 2005, to improvise primary health care in villages, the integration of preventive and curative care at the administrative level could not be done. There have been many efforts made to develop public health in India, but they remained segregated. The Mukherjee Committee in 1966 prescribed a system of targets and incentives and identified ANMs( Auxiliary Nursing Midwifery) and other village-level workers as agents for popularizing  health programs in the community. Accredited Social Health Activist (ASHA) is a community health worker, appointed since 2005, under NRHM. Ayushman Bharat operational guidelines gave a  key addition to the primary health team at the SHC-HWC, the Mid-level Health Provider (MLHP) who would be a Community Health Officer (CHO). 

There is a unique opportunity at present in India. The digital footprint that the nation has been able to create, can give Indian Healthcare System a unique shape. Digital technologies will help the nation leapfrog to advance health systems. It is time for making organised efforts to redesign the healthcare systems in the country by developing comprehensive health systems, that take care of socio-economic components of health too. The rationale given for introducing the new cadre of community health officer at HWCs is to:

1)Augment the capacity of the Health and Wellness Centres to offer expanded range of services closer to community, thus improving access and coverage with a commensurate reduction in OOPE.

2)Improve clinical management, care coordination and ensure continuity of care through regular

follow up, dispensing of medicines, early identification of complications, and undertaking basic

diagnostic tests.

3) Improve public health activities related to preventive and promotive health and the measurement

of health outcomes for the population served by the HWC (Health and Wellness Centre).

But this is not enough. In order to develop executable national plans for people's health we need to extend this cadre at block, district, state and national level. This cadre has to be integrated with the curative care infrastructure too. Doctors and community health officers have to work hand-in-hand to attain national healthcare goals. 

It is time to have a national consultation on the vulnerabilities of the Indian Healthcare system, and design a robust public health system. In principle, the community health officer posted at Health and wellness centre would be the nodal workforce to prepare a report on health status of the population served by HWC. This would be made possible by creating a digital health eco -system 'National Health Stack', where digital personal health records captured at the PHC level, will be stored in a national database, under a unique identity number (UIN). National Digital Health Blueprint (NDHB), 'which is more than an architectural document', as it provides an implementation plan of 'National Digital Health Eco-system' has been released on 15th of July, 2019, by Ministry of Health and Family Welfare, Government of India. 

The cadre at the block district and state level is also to be designed. The curricula for such public health officers is to be designed and be aligned with his role and responsibility under a broad planning structure. COVID 19 year will be a good time to initiate the process. Goals and objectives decided at the national level have to be converted into executable plans according to the need of the community, with the help of this workforce. Countries like Cuba and Sweden have achieved a lot, by having a robust public health workforce. It has been reinforced during COVID 19 times also. Nation's health needs attention. 

Time for Bhore Committee 2.0?

Why is the migrant labour being sent back now?

When it was time to bring the migrant labour back, they are being sent back to their villages. The government has arranged for buses and trains to send them back safely to their villages. One political voice is debating that the expenditure of their journey should be borne by the state, while the other voice is expecting the people to acknowledge their efforts of getting the labour back to their homes and to appreciate their welfare measures. Not long ago, we were talking about cluster containment strategy to combat the corona virus pandemic.

The official government guideline issued by the ministry talks about it in detail. A Containment Plan was released by the Government of India, which laid out a ‘cluster containment strategy’ to contain the disease with in a defined geographic area by early detection, breaking the chain of transmission and thus preventing its spread to new areas. This would include geographic quarantine, social distancing measures, enhanced active surveillance, testing all suspected cases, isolation of cases, home quarantine of contacts, and social mobilization to follow preventive public health measures. As a result of this strategy a nation-wide lockdown was enforced for 40 days. It brought successful results as largely the disease spread was limited to 13 urban clusters in the country. We had received this information just three days ago.

A 40 day lockdown period, had its impact on the economic activity. Certain sectors like Travel and Tourism, Aviation, Retail and MSMEs were majorly hit. It was estimated by many agencies and economists in the country that the economic growth rate in the country could be 1.5 % in the current fiscal year. It was also estimated that there could be three scenarios of the productivity loss for the country. 

In the first scenario, of the disease spread is contained by May end, the epidemic curve was expected to turn, which would mean a lockdown of about 2 months, or a productivity loss of one quarter. The economy was expected to revive, however, very fast in the third quarter, when the production activity was to be resumed. The suppressed demand was expected to revive and bring back buying in the markets. There is a phenomenon of revenge buying, explained in economics, where, if the consumers do not get an opportunity to buy for some time, they flock to markets to do revenge buying, when they get an opportunity. A short term lockdown period was not expected to hit the economy much, as productive activity was to be resumed in the third quarter and the economy was expected to generate a new investment demand in the fourth quarter. Government spending will replace domestic consumption spending, and the economy could be soon put to track, was the theoretical premise on which it was based. 

The critical link here was the success of cluster containment strategy. A tragedy of sorts happened in between. Migratory Labour, that amounts to about 300 million people in the country, wanted to return back to their homes, and they decided to make that journey on foot. Future uncertainty, fear of starvation, lack of daily employment and a fear of contracting the disease, were some of the factors that triggered that behaviour. It was fair for the government at the beginning of April to provide transportation to these migratory workers, so that they could reach their homes. Some facilitation was done but still there were many who made that journey on foot. There was lack of coordination between the states, when the effort was made. The Prime minister and many Chief ministers appealed to the migratory labour to stay back where they were, and promised to take care of them. Many philanthropists came forward to help, food was distributed to daily wage earners, camps were organised and ration, money etc. were transferred.

The efforts were segregated though. There was a lack of a systematic approach. It was difficult to trace who was staying where, those who needed help and those who did not. There were some people who were left out and they starved. There is a lack of a state sponsored social security net in the country, so identification of vulnerable people in a given situation is difficult. The poor, the weak and the old cannot be easily identified in a country of 1.3 billion people. There are BPL card, MNREGA card, BOTC card, Jan Dhan accounts to track those who are in need, but there are many who are still left out. The mechanism of identifying beneficiaries under various schemes is segregated, and thus it is difficult to create one system around relief measures, which covers all. We have a unique identification number - Aadhar Card, but it is not linked to other schemes. Not everyone has Aadhar too. There has always been problem with migratory workforce regarding Aadhar. 

At the end of 40 days of lockdown, there is a clarion call made for economic revival. The productivity loss has been realised in a month. There is a pressure from the industrial lobby to allow them to resume production. The retail sector wants the transportation to be resumed to get the benefit of new demand. The government does an exercise to identify clusters where the viral spread is high and the entire country is classified in red, orange and green zones. The states prepared their exit strategies. The common man assumed that the government will take rational decisions to keep them safe, and at the same time gradually bring back activity. 

4th May was the date decided to lift the lockdown partially in the country. Same time, the state governments were making efforts to arrange transport for the migratory labour, to send them back to their villages. There are two implications of such efforts. One - the labourers are being transported at a time when they are required in the production activity. In a country that focuses on labour intensive processes, labour is the most important factor of production. The entire exercise of lifting of lockdown would be futile, if there is no labour to restart the production activity. Two - It has been statistically established from the data being received from all parts of the world that the ratio of asymptomatic carriers of virus to symptomatic carriers of virus is 70:30. The risk of developing new clusters in the villages is high, when we decide to support the reverse migration of labourers to villages, after 40 days of lockdown. 

The containment plan of Corona Virus spread may go for a toss if the migratory labour takes the virus to every nook and corner of the country. Ministry of Heath and Family welfare, and research agencies like ICMR, should have made an estimate of potential risk involved in state supported reverse migration, from identified clusters to remote areas after 40 days of lockdown. If this kind of effort was to be made for the welfare of the labour, it was to be done in the early days of lockdown. This was the time to bring back the labour, from their villages after getting them duly tested. To and fro movement to labour in the country, when the epidemic curve doesn't seem to flatten, might be responsible for many new clusters created in the country. 

Last two days have seen a large surge in the Covid 19 positively reported cases, the highest so far, since lockdown. States like Chhattisgarh, which were not having any case for a large part of lockdown have reported cases. North-eastern states are also reporting cases. All those countries in the world, who had not had a complete lockdown in the initial stages of virus spread, saw a huge surge in the cases, be it Italy, Spain, UK, US or very recently Brazil. The benefits of 40 day lockdown might be lost, if exit strategy is not planned well in India. There might be a dreaded situation of overwhelming of hospitals, in the country. India doesn't have enough capacity of generating a proper health system response to a pandemic is well known. We had chosen a preventive strategy, with a purpose. 

Reverse migration of labour after 40 days of lockdown will defeat the purpose. States are building up screening, testing and quarantining protocols. Rajasthan has prepared a database of migrant workers district wise, to identify outbound workers and where they need to be transported. Who is this effort helping? The labour? They were helped better by resuming their employment, while preventing them from the infection. It will not help the economy either. Coordinated efforts of health systems, workplaces, people and the government were required. An imminent thinking and action needs to be taken, otherwise the situation may turn explosive.