As India records the second-highest number of positive Covid-19 cases, and still records the highest daily rate of rise in the world, there is a concern that the runaway train of the pandemic is beyond capture or control. Will we soon rise to the number one spot in the world, with the economy proceeding in the opposite direction? There is some comfort in the fact that deaths per million population are still much lower than in high-income countries, despite probable undercounting, which is not unique to India and cannot by itself account for the low mortality rate in South Asia.
However, India needs a course reset, with a GPS that provides temporal and locational adaptability in responses rather than a rigidly pre-set roadmap we are using to navigate through the coronavirus crisis.
Where India stands now
A SWOT analysis will help India configure the future course.
Our strengths have been: a nationally coordinated response; step up in national capacity for production of medical equipment, drugs and test kits; ramp up in testing capacity; expansion of healthcare facilities for quarantine, isolation, intermediate and advanced care in hospitals; adoption of home care model for mild cases; expansible laboratory capacity across public and private sectors; ability to develop, evaluate and mass manufacture vaccines; extensive mass media engagement for messaging on Covid-19 prevention.
Our weaknesses have been: inadequate primary and secondary healthcare infrastructure and staffing in many areas; absence of organised urban primary healthcare in the cities and towns that started and spread the epidemic; lack of public health expertise at various levels of the health system; inadequate contact tracing in many areas, leading to high rates of viral spread; excessive dependance on rapid antigen tests, which have a high rate of false negative results; data collection systems not providing complete, timely and accurate data in the public domain, on newly tested persons, ratio of nucleic acid tests like RT-PCR to rapid antigen tests, Covid-19 related deaths (in hospital and out of hospital), co-morbidities, antibody surveillance studies and hospital bed availability; inadequate citizen and NGO engagement; limited use of local community networks and influencers for case identification, contact tracing, risk communication and health education; stigma and fear that inhibited case and contact identification; poor adherence of many citizens to public health advisories on wearing of masks in the right manner, physical distancing and avoidance of large gatherings.
Despite the rapid spread of the coronavirus so far, there are several opportunities that we must utilise to control the pandemic. These opportunities are: preventing or markedly slowing down the spread of the virus to and between villages in rural India will contain the epidemic, because low crowd density, short commutes to work and more open spaces yield a lower ‘R’ (reproduction factor) than in urban areas; shielding of the elderly and persons with severe co-morbidities will reduce rates of severe morbidity and death; home care for mildly affected and asymptomatic persons with infection is now a well-accepted modality of care and will reduce the load on hospitals; available evidence that ventilators are needed only in a very small fraction of infected persons and that secondary care facilities, which can provide free-flowing oxygen, can treat many sick patients; potential for using now well-recognised clinical symptoms for syndromic household surveillance and early detection of suspect cases for prompt testing, isolation and contact tracing; domestic production and wide availability of drugs, which have so far shown benefit in large clinical trials (steroids and Remdesivir); many of the primary care functions can be performed by trained, young citizen volunteers or groups like National Service Scheme (NSS) or National Cadet Corps (NCC), and an energetic civil society can mobilise community resources for active citizen engagement.
The threats that need to be guarded against are: non-adherence of people to public health measures such as physical distancing; unrestricted travel between urban and rural areas; lack of firm action by local administration to prevent large gatherings; high crowd density in urban areas, especially in slums, many areas of indoor employment and in public transport; lack of threat perception among many citizens and even some policymakers, with trust in an imminent arrival of ‘herd immunity’ as a sure saviour; neglect of the essential needs of non-Covid-19 health services, which will superimpose a secondary public health emergency on the primary health emergency we are battling now.
Summer of 2021
Despite the rising case count, there is no scope for a fresh national, state or city-wide lockdown. As economic, social and scholastic activities resume in carefully calibrated stages of relaxation, caution must be the watchword for policymakers as well as the public. The resurgence of the coronavirus in parts of Europe and Asia is a warning that the virus is not caged though it may have become less virulent.
We have to maintain vigil and practise self-restraint until the summer of 2021. A year may seem too long for those who are uninfected and impatient, but a lost life is many years irretrievably cast away in carelessness. The coronavirus will change its behaviour only when we change our behaviour.
India can and should quickly take stock to mount a defence through disaggregated data analysis and contextualised local responses at the sub-district and district level. These should be supported by extensive citizen and NGO engagement. We can still turn the tide through political will, professional skill, data-driven decentralised decision making, and people-partnered public health.
The author, a cardiologist and epidemiologist, is President, PHFI. He is the author of Make Health in India: Reaching a Billion Plus. Views are personal.
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