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Wednesday, May 27, 2020

In Phase II of epidemic, states must build empirical and analytic foundations of systems of delivery

Our scientific agencies need to uncover the regional parameters of the disease, its prevalence in the community, and typical trajectories. This will help in both clinical and logistical matters.

Written by Milind Sohoni | Updated: May 13, 2020 9:14:59 am
coronavirus, gurgaon coronavirus, delhi coronavirus, gurgaon lockdown, gurgaon covid-19, delhi city news For a country which has not been able to provide drinking water to its people, containment is an overreach.

“We have to learn to live with the virus,” said Lav Agarwal, joint secretary, Union health ministry, on May 8. Hopefully, this will turn out to be a watershed moment in India’s fight with the corona epidemic. For, it marks the realisation that as the virus spreads across India, a centralised strategy of containment and elimination is no longer viable. The stage is now set to move to the states as they find effective ways to manage the epidemic. And in this, it is the community and regional institutions who must play a crucial role.

So far, the welfare costs of the measures and regulations were weighed against the infinite benefits that would accrue if we were to eliminate the virus. This provided the justification, at least in the minds of the people, for such measures. The legal basis has been extremely draconian laws: The infamous Epidemic Diseases Act of 1897 and its amendment, and a very lop-sided interpretation of the National Disaster Management Act, 2005. While the Act requires various plans to be produced at the national, state and district levels, no such documents are available.

In principle, the Act could have served to marshal our scientific institutions into undertaking useful studies. Instead, it has largely been used by the Centre to issue guidelines to the states, and to concentrate power into the hands of the elite bureaucracy and a few central scientific agencies. No reports or studies have been cited in most of the guidelines issued under this act. The most recent one, issued on May 9, on resumption of manufacturing activities, creates a bonanza for factory inspectors.

Containment and elimination is an option for small, well-governed countries with considerable technical and financial heft, and, that too, in the very initial stages of an infection. For a country which has not been able to provide drinking water to its people, containment is an overreach. It has quickly exposed our limitations, of poor testing capacity and poor access to public healthcare facilities. The logic of containment may also have been one of the reasons for the ordeal of our migrant workers. Firstly, they were forced to stay put. Now, their movement is restricted by a scientific bureaucracy which is unable to test them or move them. There just aren’t enough tests to go around. Also, the ministry of railways is perhaps overwhelmed by the logistics of operating hundreds of trains on a new schedule and coordinating with regional agencies.

Containment was also destined to fail in many poor urban neighbourhoods of our cities. Extreme densities and irregular dwellings made it impossible to maintain social distance. Little surplus at home, dependence on daily wages and frequently changing schedules caused mobility and crowding that further aggravated the situation. Finally, poor per capita availability of medical care led to delays in response. This and the collective punishment of block quarantine created both guilt and stigma that led many symptomatic patients to delay reporting to the hospital. But by then, it was too late. These are problems not of behaviour change but of poor planning and misplaced priorities.
Hopefully, we will now transition into a more systematic and scientific approach to managing the disease and improve preparedness at the level of the village and the city wards. There are several tasks which our scientific agencies need to do.

The first is to uncover the regional parameters of the disease, its prevalence in the community, and typical trajectories. This will help in both clinical and logistical matters. This must be done through careful documentation of the cases, their geographies, their socio-economic background, and their clinical response. As of now, this data is not available. Perhaps, it is not even being recorded.

This analysis would help people understand the actual risks and mortalities and make compliance and participation easier. It will provide the basis for designing village level guidelines on returning migrants, quarantine rotations and accessing common resources, for example, drinking water or sanitation, in times of infection
Today’s risk perceptions, taboos and practices have arisen from an urban salaried upper class which can work from home and not from those who need to run a shop, work in a unit or on a farm. The morbidities of the disease in rural or partly-rural societies may be quite different and behaviour change may need a different plan. The analysis would help in ensuring that procedures match risks and respect material constraints. The simplest example is that hospitalisation and testing of every case may not be feasible. Managing the disease under these constraints requires a sound empirical basis.

The other area which needs better design is the logistics of preparedness. This includes hospital beds and their distribution, ambulance services, public transport, and the provision of basic amenities and welfare services. Periodic assessments and analysis by regional institutions would ensure that obvious lacunae are overcome and any shortfalls of equipment or manpower are met in a structured manner, through the support and contributions of community organisations. A dashboard of the key parameters of preparedness and their live status would instil confidence and enable collective action.

Sadly, our central network of elite scientific institutions has largely been in a self-imposed quarantine. Their contributions so far, either in concepts or in methods, have not been commensurate with the prestige and place that they have in the national ethos. They have preferred the safety and security of their campus and old ways of working, over an opportunity to wrest a place for themselves and their mofussil brethren, the regional and state institutions, in the destiny of the nation. Their masters, the elite bureaucracy, have obliged.

Thus, as we enter Phase II of the epidemic, it is in the interest of the states to build the empirical and analytic foundation of systems of delivery and to talk to each other and share experiences. It is for us to deepen the scientific and political understanding of our people and to bring them to expect well-reasoned arguments and matching actions, and not merely hope to be beneficiaries of an expertocratic administration. The corona epidemic has once more shown the inherent inequality and instability of Big Science and the inability of the global economy to ensure welfare. It is time that we develop more regional and more convivial and vernacular models of managing our societies. The epidemic provides us a unique opportunity to move in this direction.

This article appeared in the print edition of May 13, 2020, under the title ‘Living with the epidemic’. The writer is with Centre for Technology Alternatives for Rural Areas, IIT Bombay. He is currently on deputation to IIT Goa

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