The corona virus disease (COVID-19) pandemic continues to challenge the way the world has viewed and managed public health, everyday bringing new solutions and challenges. The pandemic has led to what is a “first” for civilization – a simultaneous lock-down of nearly 3 billion people across the world. India was coasting along with relatively fewer cases until the end of March, but is staring at a health, economic and humanitarian disaster if the situation gets worse. Hoping that it doesn’t. While many have praised India’s policy response, there are questions to be asked. This article reflects on India’s response so far and summarizes a few key focus areas.
India reported its first case of COVID-19 on 30th January 2020, the same day the WHO declared this a public health emergency of international concern (PHEIC). As of 31st March, India reported over 1400 confirmed cases, with about 40,000 tests conducted, amounting to a meagre 30 tests per million population. India’s response remained mostly watchful until 11th March, when the WHO declared COVID-19 a pandemic. The Indian government has taken stern measures and acts such as The Epidemic Diseases act, 1897 and Disaster Management Act, 2005 have been invoked.
The most significant measure – a country-wide lockdown which started on the 24th of March – is widely considered one of the harshest measures. This was cited as the ‘only’ way to avoid the looming disaster, despite a repeated denial by the government of community transmission, a move which has raised multiple questions.
I reflect below on the overall preparedness and response of India and what the options look like:
Lockdown appeared to be the only option, because of losing on the critical lead time, lack of preparedness, testing, capacity and confidence to generate an adequate surveillance response. Nearly 90% of India’s workforce are engaged in the informal sector with limited access to social and financial security. Urban India depends on the labor of daily wage workers, coming from distant villages. The lockdown has forced hundreds of thousands to lose wages, go hungry and live in overcrowded shelters which are vulnerable to COVID-19 and other disease outbreaks. By the 4th day of the lockdown, heart wrenching pictures of a mass exodus of millions of Indians, from bigger cities to their villages appeared. Most walked on their feet, many without food, with hundreds of miles to go. This can have huge economic and humanitarian costs, if it continues for a long time and is not supported by other measures. This mass exodus of workers from cities, reflects a lack of planning and implementation.
This contrasted with converging opinions of experts towards the need of ramping up the testing to identify COVID-19 cases and build strong, locally required surveillance, isolation and treatment strategies. However, despite a lead time of at least six weeks from the first case reported, there were only 51 labs conducting tests for the virus. The capacity has, however, improved later and a total of 160 labs were supported by 29th March, inclusive of 47 private facilities. Nonetheless, only about 30% of the testing capacity was utilized according to the ICMR until end of March. The government maintained that they had adopted a rational testing strategy to not to exhaust the testing capacity and would use it on right time.
Essential support and supplies for healthcare workers were scarce and were mobilized late. Several reports have indicated that hospitals face an acute lack of personal protective equipment (PPE) and healthcare workers in many areas have threatened to strike. As a partial relief, however, an insurance for all health care workers for up to INR 50,00,000 was announced. Also, as the total number of ventilators in the country remains under 40,000, the procurement of about 10,000 ventilators has been initiated and additionally, about 30,000 will be built by the public serving units. The process is however going to take time and scarcity of PPEs for a few weeks can make things worse, especially so if the outbreaks occur in healthcare settings. Despite this scarcity, India continued to export certain protective medical supplies, such as gloves to other countries as export of a consignment was reported for Serbia.
What can be done from here?
India would need an escalation of response and adjustment of strategy for different areas from here. As the speculations rise, that the rural India could be the next hotbed of infections, some of the vital measures could be:
First and foremost, the food and safe, appropriate shelter would have to be provided to the poor, so that the looming danger of hunger and economic devastation and an imminent humanitarian crisis can be prevented.
Second, India should look beyond the complete lockdown and a differentiated lockdown strategy should be developed, based on cases and contact tracking, and lockdowns should be prioritised for the identified hotspots of the virus spread. The universal lockdown in the whole of the country may not bring the active cases to zero for many weeks and can have devastating costs to the country.
Third, community level surveillance to rapidly identify and isolate areas is needed, if the lockdowns were to be adjusted and further spread of the virus to be contained. A door-to- door symptom screening and contact tracing should be considered. To be able to execute this, the community health workers will have to be oriented and mobilized. They should be protected with PPE and supported with proper incentives. The testing needs to be more liberal against the current 30% utilization and all symptomatic cases, symptomatic contacts and high-risk asymptomatic contacts should be tested. Random community level testing is also a must and can be done based on area mapping and can help revising the lockdown strategy.
Fourth, in the time of crisis, the healthcare system should not give up its original responsibility of providing care to all, for all type of health conditions. While the non-emergency care can be catered to with innovative thinking, services such as nutrition, pregnancy, childbirth and new-born care, non-communicable diseases, mental health and care of elderly need to be maintained.