By KR Antony
Today we are discussing the lessons learned from the Covid-19 pandemic, the most severe health crisis in more than 100 years. The coronavirus was like an X-ray film or a CT scan report that exposed our health system. It made us realise what is our requirement and where the health system stands today. We have to use the lessons we learnt during the polio eradication programme – focus on who are untraced and marginalised.
The Covid-19 outbreak exposed the vulnerability and fragility of our public health system. It is the cumulative neglect of decades — underfunding, understaffing, poor infrastructure and the need for technology upgradation. All this led to the decimation of the system in various parts of India. But all the same, it proved its relevance when the nation, and the poorest 40% of its population, needed it. We cannot think of no dismantling it or going in for alternatives. We cannot rely on the private sector that is way too costly for most Indians to afford.
In any pandemic or crisis, there will be inadequate preparedness. The whole world was not prepared for the Covid-19 outbreak. There were a lot of errors and delays in decision making. And there were a number of misfired strategies and faulty implementations. WHO made mistakes — it initially suggested droplet infection and said hand washing / use of sanitizer was good enough to check the spread of coronavirus. But by June 2020, there was evidence of air transmission and then WHO said the use of masks is the most potent defence. But all these mistakes are pardonable as they are part of a learning process. The virus was new, treatment methodologies were new, and the world was figuring it out.
Covid-19 response: Learning from mistakes
Refusal to learn from mistakes, however, is a tragedy. Science is never perfect; it grows by advancing day by day. Science should prevail, not politics. And if you have to make political decisions to govern, that should be during a calamity like a pandemic. It should be strongly guided by technical advisors, sound scientific principles and technical advisory bodies.
Now, what are the lessons learnt from the Covid-19 pandemic? In February, we should have closed all the airports as the virus was coming through airports and those who can afford air tickets. And it came from China, Italy, Saudi Arabia, and Iran. We didn’t do that on time. We wasted a whole month before training health workers, starting monitored home quarantine / domiciliary isolation of positive cases, and active contact tracing. All of a sudden on March 23, there was a broad national lockdown. It was not guided by any technical decision or based on any epidemiological evidence of virus transmission.
In a huge country with 736 districts, only 75 districts in Delhi, Maharashtra, and Kerala had infection. So, this unnecessary lockdown of the whole country was not justified. That was the first mistake. The second mistake was unnecessary locking up of migrant workers and urban poor in their settlements. And gave fertile ground to the virus that came from abroad. It is not a virus that originated among the urban poor or the migrant workers. The other lesson is that we can’t enforce pandemic control using police or administration.
Need a community based system
If we get a community-involved system of contact tracing, surveillance, and Covid-19-appropriate behavior would have worked better. This we saw in Dharavi slum area, where one officer prepared community-based or slum-based planning. There is also the lesson of Kerala where all 14 districts have the district committees down to 956 Gram Panchayats and 65 Municipal bodies making plans. The other thing is in a pandemic, though we are dealing with a virus, the human element is very important. Addressing hunger is as important as cash transfers. Kerala’s example of running community kitchens, giving dry ration kits, and running Janata hotels for subsidised food are excellent examples of how to address hunger during a pandemic.
Post-Covid, the non-communicable diseases, mental illnesses, and palliative treatment should get priority. It is inhuman to stop regular services for maternity, medical / surgical emergencies, curative care of acute illnesses, blood transfusion for thalassemia patients, and chemotherapy for cancer patients. Neither can we ignore TB or malaria that kill lakhs of people every year. We cannot shut our eyes and say we’ll deal with it tomorrow. We cannot lose the advances we made in HIV AIDS control because of Covid-19. If there is an epidemic, we need alternative arrangements beyond what the regular system.
We found that we need dedicated hospitals to treat Covid-19 which is a highly contagious disease. We also need separate ICUs and civil Covid-19 isolation hospitals and community-based quarantine centers. We found that even strong public health systems will need elasticity and mobility. For example, Karnataka had a good setup. They were very confident with 740 ventilator supported beds. There was only 2% occupancy in the first week of May and everybody thought there won’t be any need of more arrangements. By September, there was a shortage of beds.
Flexibility key to effective response
We had 27,000 beds in India of which health minister was very proud, and we had only 4% occupancy. But the scenario changed in August and September when Delhi started suffocating. There were shortage of oxygen, lack of beds, and people were running helter-skelter. In January 2021, Delhi administration reduced Covid-19 beds. Nobody expected that by April cases would rise and it reached 90% occupancy which led to oxygen shortage. So, what we need is an elastic system.
Big hospital is immovable, but whatever is movable must have been moved like some equipment, medical supplies. We have got a good example. Union minister Nitin Gadkari requested oxygen regulators from Andhra Pradesh and Odisha for Nagpur region and these states obliged. The other movable thing is patients who could have been moved from where there is high caseload to places with better infrastructure. We cannot say Delhi is only for only Delhiites. Patients from adjacent states like Punjab, Haryana, and UP went to Delhi.
Another lesson learned is that health is not necessarily a wealthy city. For example, Bombay, Delhi, Pune, and Calcutta saw public health systems failing miserably. especially for urban poor and migrant laborers who account for 40% of the population. These people are the builders of the Indian economy. By transmitting virus to them, we are putting the whole city in danger. So, if we are doing something for them, it is not for charity, bit for our own interest. So, think about that portion of basic services like water, sanitation, clean night shelter and drainage. It is good for everybody.
Role of Asha workers
Another lesson. What we learned is in floods or in calamities. There should be some safe areas that could be community centres. They can be used for community meetings. And I’ve seen these types of community centres built by community, governing bodies in states like Manipur. We had a major pandemic. About 9 lakh women, Asha workers.
They were the backbone of the entire surveillance activity in our community, helping contact tracing, isolation, and getting suspects tested. Now, my question is if Asha workers are an inevitable intermediary between health officials and the community then accept them as regular contributors to India’s health system. Pay them the right wages and get that fund to be spent from the national health commission. That is one way of spending money usefully.
Currently, there are 2,75,000 contract workers. Well, that is a misleading term, they are consultants, and technical hands. I have two or recommendations at the state level and national level. In every state, telemedicine can replace a lot of personal consultation. Do it in a regularised way.
Post-Covid, the non-communicable diseases, mental illnesses, and palliative treatment should get priority. Now we need only one virology lab to diagnose the coronavirus from there. But there are so many labs now. So, every state has a regional virology research lab, and that could also be a co-production center for vaccines for newly evolving viruses. So, we need vaccine production units as well. We could have oxygen generation plants in every state. And from these medical oxygen production centers, we need to move oxygen in tankers. The irony is that all our oxygen production is where the coal and steel plants are. Then, we need oxygen in Haryana and Bihar. So, we need oxygen transportation.
Need a national communicable disease centre
Now, another thing is to have a national communicable disease centre. What we lacked in the last epidemic is the leadership of two agencies, the National Centre for Disease Control and ICMR. Their technical advisors were overshadowed by political considerations. Some blunders were made. There were no uniform treatment guidelines, and consensus building.
We need enforcement of the Clinical Establishment Act and regulation of the private sector. We can pay the money, but profiteering should stop. That’s why the courts intervened in resolving the issues of ICU beds in private hospitals in Bangalore. Kerala High Court intervened in the pricing of the PPE kits and per day charges of ICU beds got into the detailed billing. So, do we need to do that?
Another lesson learned from Kerala is to transfer a part of development funds to the local self-government corporations. This should be done for planning, delivery, and monitoring. The most important thing is to do the categorisation of districts where the pandemic is high, heavy, or minimal. The district which does not have a medical college must be having a district hospital, which will be the centre for tertiary care. So, it must be like a medical college hospital. It should have everything from a burns centre to plastic surgery, from dialysis unit to cancer treatment.
Then you need to prioritise these institutions. For example, even in this pandemic. 45 districts were contributing to 50% of the caseload, 145 districts were contributing to 75% of cases. So, they need saturation of equipment, investment, and deployment. It should be a flexible plan. Every district hospital has a 50-bed isolation ward for communicable diseases. And with 10 ICU beds and a minimum of five ventilator beds or dialysis units are essential for life support. The one good example of Kerala is that all 14 districts had medical oxygen plants with 150 tonne production capacity. This can be done and replicated in all states in the country.
Accuracy of data is important for pandemic control. Responsibilities and accountability are passed on at present. For data, what they get from their own system triangulate with other events like journalists exposing excess deaths. So, there is increasing number of deaths. In a pandemic, epidemiological data is very important for forecasting what would be the action. I would say we must have a float assembly of reserve medical staff which is deployable on short notice. We then need a volunteer blood donor list. Meticulous planning and flawless execution can help us neutralise the third wave.
(Dr KR Antony is an Independent Monitor with National Health Mission. This article is the reproduction of his presentation at a webinar organised by policycircle.org.)