Three ways to combat coronavirus

The fight against COVID19 has been likened to fighting a war with an insidious, dangerous but invisible enemy. As in any war, 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 that have been announced in recent days. This includes closing of all schools and colleges, and imposing of the 21-day lockdown with all services except essential services allowed to function. However, what is not clear is how much is the preparedness for 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 arrangement of 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 populations in the immediate run. While lockdown provides us an immediate respite from the growing epidemic, we should see it as a window on which there is an urgent need to ameliorate the adverse economic and social impact of the “battle” itself, and of fine-tuning the effective strategy to address the “enemy”.  

What we can see clearly is that the lockdown in most States and Union Territories of India is causing a medical and a humanitarian situation. There are reports of tens of thousands of labour-migrants returning home, coming back from different capital cities and towns as workplaces shuttered. These workers are mostly stranded on State and district borders or on highways without any money or food. Entering Rajasthan are people who are returning from Gujarat State, some having walked some 300 kilometres. While this is happening, the count of numbers of people affected by COVID-19 is increasing as are deaths, though absolute numbers are still low. We know that massive restrictions on movements and difficulty in accessing basic amenities and healthcare, especially when away from home, can have significant adverse effects on basic right of every citizen to life and survival. While these are extraordinary situations, all measures need to be taken to ensure that the State provides basic amenities of food, shelter, humane treatment and timely repatriation back home.

While these are extraordinary situations, all measures need to be taken to ensure that the State provides basic amenities of food, shelter, humane treatment and timely repatriation back home.

Allow people to return home

We must acknowledge that the Government of India has done a remarkable job in bringing people back home from hundreds of students and other Indian citizens stranded in foreign lands, with due precautions that they do not become carriers and disseminators of the virus back home. 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 COVID19 pandemic. In view of difficulties faced by these thousands of internal migrants, and the fact that, as many scientists have said, the transmission of virus is unlikely to stop anytime soon, the Central government and various 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 coronavirus, should be repatriated immediately. If positive, they can be kept in isolation in safe conditions, as was the protocol followed up when repatriating people from overseas. In doing so, the government will not only get a truer and fuller picture of the extent of the COVID19 threat in the deep interiors of India but it will also be sending  a signal that will get many more to seek help and report their conditions to the authorities. In the absence of this, the threat runs the risk of slipping “underground”, as it were. It will lead to a slow but more severe spread of the disease.

Expand testing

At the moment, the number of people being tested is small while the number of people under lockdown is huge. While providing a respite for a short period, this is not sustainable for long periods, and as many experts have pointed out, may lead to resurge after relaxation of the lockdown. We need to progressively reverse this situation: have much more expanded testing (with rigorous promotion of social distancing) and lesser number of people and populations under lockdown. At the moment, only about 100 laboratories, almost all of which are located in large cities are providing testing facilities. We should urge the governments, as recommended by WHO and many experts, and followed by South Korea, to urgently expand the testing facilities widely, with sample collection facilities being outside the hospitals and laboratories. This will have to be through home base collections, walk-ins and drive through centers to facilitate access and restrict exposure. The cost of the test to the patient has to be free or very low for this to work. A test for Rs 4,500 as is the current fee in a city like Mumbai, is unacceptable and will not work.

Engage and equip primary healthcare services

We need to prepare ahead to provide healthcare to large numbers of patients requiring healthcare. As shown from a review of about 160,000 patients from China and Italy, a large number of patients (about 90 to 95 per cent) would be managed at home or in primary care settings and only about five to ten per cent would require in-patient care. Of those who would require in-patient care, 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 would require critical care is upwards of 50 per cent. So, it is clear that primary care settings would be extremely critical to provide care and prevent deaths to large numbers of patients through providing supportive care and oxygen.

Unfortunately, a lot of attention in the media has been on increasing capacity for critical care and the number of ventilators etc, which will address only 30 per cent of severely ill patients, and would be in the best of situations, will save 50 per cent of those severely ill. The governments should urgently review and strengthen functionality of Primary Health Care  (PHC) centres, Community Health Centres (CHCs) and district hospitals, especially for supportive care, isolation and oxygen to almost 70 per cent of those who would require in-patient care, almost all of whom can be saved. An analysis based on data from 2012-2014 showed that no oxygen is available in about 30 per cent of PHCs and 10 per cent of CHCs. The small private general practices, nursing homes and small hospitals must also be roped in for this fight, with control on the charges they can levy. Working backwards, 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 COVID19.