Strengthening primary and community health care, combined with vastly expanded testing, will be key to overcoming the pandemic that threatens to rage through the country
The fight against COVID-19 has been likened to fighting a war with an insidious, dangerous, but invisible enemy. We need to carefully chart out the strategy to emerge victorious. While no formal strategic plan has been issued by the government, the broad parameters of its strategy can be drawn from the series of actions it has announced. This includes closing of all schools and colleges, and imposing a 21-day lockdown, with only essential services allowed to function.
What is not clear is the level of preparedness of other components of the containment or mitigation strategies. This includes steps such as expansion of testing to include all those who show symptoms and their contacts, and arrangements for managing large numbers of cases, should the epidemic grow. What is emerging, however, is the economic and social costs to a large number of marginalised people in the immediate run. While the lockdown provides an immediate respite from the growing epidemic, there is an urgent need to ameliorate the adverse economic and social impact of the “battle” itself, and fine-tune the strategy to address the “enemy”.
The lockdown in most states and Union Territories is causing a medical and a humanitarian situation. Thousands of migrant labourers are returning home from different cities and towns, as workplaces shut. They are mostly stranded at state and district borders or on highways, without any money or food. Simultaneously, the number of people affected by COVID-19 is increasing, as are deaths, though absolute numbers are still low. Massive restrictions on movements and difficulty in accessing basic amenities and healthcare, especially when away from home, can have significant adverse effects on the basic right of every citizen to life and survival. While these are extraordinary times, the State must provide basic amenities of food, shelter, humane treatment and timely repatriation back home.
Allow people to return home
The central government has done a remarkable job in bringing back hundreds of students and other Indian citizens stranded in foreign lands, with due precautions to ensure that they do not become carriers and disseminators of the virus in the country. Having done that, we cannot leave behind labourers and migrant workers on our highways to fend for themselves, when all shops, establishments and services are closed. This will create a crisis that may be worse than the one we seek to fight, as we try to fend off the COVID-19 pandemic. In view of difficulties faced by these thousands of internal migrants, and the fact that, as many scientists
have warned, the transmission of the virus is unlikely to stop anytime soon, the Central and state governments must make arrangements to bring them home safely.
All symptomatic people can be tested at the borders, and, if found to be negative for the virus, should be repatriated immediately. If found positive, they can be kept in isolation, as was the protocol followed when repatriating people from overseas. This will not only give the government a truer and fuller picture of the extent of the COVID-19 threat in India’s interiors, but it will also send a signal that will get many more to seek help and report their condition to the authorities. In the absence of this, we run the risk of the threat slipping underground, leading to a slow but more severe spread of the disease.
The number of people currently being tested is small, while the number under lockdown is huge. While providing a respite for a short period, this is not sustainable, and as many experts have pointed out, may lead to a resurge after the lockdown is relaxed. We need to progressively reverse this situation: Have much more expanded testing (with rigorous promotion of social distancing) and fewer people under lockdown. Currently, only about 100 laboratories, almost all located in large cities, provide testing facilities for COVID-19.
We would urge the government to follow the example of South Korea (as recommended by the World Health Organisation and many experts), and urgently expand testing facilities, with sample collection facilities being opened outside hospitals and laboratories. This will have to be through home collection, walk-ins and drive-through centres, to facilitate access and restrict exposure. For this to work the test must be free for patients, or cost very little. A test for Rs 4,500 — the current fee in Mumbai — will not work.
Strengthen primary health care
We need to prepare ahead to provide health care to large numbers of patients requiring it. As revealed by a review of about 160,000 patients from China and Italy, 90-95 per cent of patients would be managed at home or in primary care settings, and only 5-10 per cent would require in-patient care. Of the latter, about 30 per cent would require critical care, while 70 per cent would require supportive care and oxygen. Even in the best of health systems, the mortality rate among those who require critical care is upwards of 50 per cent. So, it is clear that primary care would be extremely critical in providing care to and preventing deaths of large numbers of patients through providing supportive care and oxygen.
A lot of attention in the media has been focused on increasing the capacity for critical care and the number of ventilators, which will address only 30 per cent of severely ill patients, and would, in the best of situations, save only 50 per cent of the severely ill. The government should urgently review and strengthen primary health care (PHC) centres, community health centres (CHCs) and district hospitals, to enable them to provide supportive care, isolation and oxygen to the 70 per cent who would require in-patient care, almost all of whom can be saved.
An analysis based on data from 2012 to 2014 showed that no oxygen is available in about 30 per cent of PHCs and 10 per cent of CHCs. Small private general practices, nursing homes and hospitals must also be roped in for this fight, with controls on the charges they can levy. This would mean the supply chain of oxygen, which is now highly inadequate, will have to be quickly reactivated if we are to claim that we are truly prepared to fight the threat of COVID-19.
Mohan is a paediatrician, public health expert and co-founder of Basic Health Care Services. Rattanani is a founder of The Billion Press and a faculty member at SPJIMR. © The Billion Press