Delhi was one of the early entry points for the COVID-19 virus. With international and domestic travellers pouring in by air, rail and road, the virus could hitchhike its way into the city, eluding the screening measures that were set up. Since it is now known that many of the infected persons could remain asymptomatic while harbouring the virus or infect others in the pre-symptomatic phase, screening tests for fever would, in any case, have been ineffective as a failsafe barrier.
The nationwide lockdown was the first major move to stall or slow down the dissemination of the virus. As the long lockdown eased in stages and the imperatives of resuming some economic and social activities were acknowledged, the virus found fresh opportunities to spread. The first three weeks of June saw the daily case count mount sharply. However, containment and care measures initiated by the Delhi government started demonstrating their impact by late June and a steady decline in the case count in July is providing the promise of overcoming the threat soon. It must be remembered that there is a lag time between infection and clinical symptoms and a further time lapse before some infections turn fatal. So, public health measures intensified in early June will show an impact on tested case count only after some days, and after an even longer period on the COVID-19 death count.
The consistent fall in the daily case count since the last week of June is reassuring. Especially since the testing rates have gone up. While the recently-introduced rapid antigen tests are more likely to miss some infected persons than the RT-PCR tests, the fall in test positivity rates cannot be attributed to that alone since both methods are being regularly used now. A genuine decline in the infectivity rate appears likely and signals a slowing down of virus transmission. A steady decline in the daily death count will be further evidence of effective epidemic control. This trend too has commenced recently.
Even as diagnostic testing was being scaled up, capacity was ramped up to provide care to infected persons. The initial preoccupation was with the shortfall in ventilators and advanced intensive care. Media reports from Europe and the US focused on such care as the dominant pattern for COVID-19, leading to concerns about inadequate capacity against projected needs, in Delhi and the rest of India. It turned out that the proportion of seriously ill COVID-19 patients who required ventilatory care was a small fraction of all cases. Many had very mild clinical manifestations and even those who had more severe illness did well on oxygen, not requiring mechanical ventilation. Oxygen production and supply chains were strengthened. A Plasma Bank was set up to provide the potential benefit of passive immunity from antibodies of convalescent patients to very sick hospitalised patients, as a part of approved experimental therapy.
The change of strategy resulted in an increased capacity for providing beds with assured oxygen flow. Large buildings were converted into such hospitals, with augmented capacity ranging from 1,000 to 10,000 beds. Hotels too were converted to isolation facilities. Private hospitals were asked to reserve beds for COVID-19 patients. Though there were concerns initially about affected persons having to move around in search of a bed for admission, coordinated information technology and citizen guidance systems emerged to address this problem.
The most important change in the care of COVID-19-infected persons came through the state government permitting home isolation for all who had mild symptoms. This enabled about 80 per cent of the virus-positive persons to be cared for at home without being mandatorily moved to a hospital or a designated isolation facility. It provided the infected person with the social and psychological comfort of being cared for at home, while permitting the available hospital beds to be used for moderately or seriously ill persons. It was estimated that around 80 per cent of all COVID-19-infected persons could be provided home care.
Visits by primary healthcare teams and provision of finger pulse oximeters for home monitoring ensured that those who were receiving home care were recovering safely, with an assurance of transport to a hospital when needed. This policy also reduced the inhibitions of people to report symptoms and seek testing, overcoming the fear of being mandatorily transferred to an isolation facility. Emergency medical transport services too were strengthened, with ambulances and designated cabs being made readily available for faster response and transfer times.
Stigma and fear are major barriers to an efficient public health response. Public communication was strengthened greatly over time, to assure people that the epidemic is not the mass killer that it was apprehended to be and could be countered through a combination of public health measures and accessible hospitalised care when needed. Unfortunate incidents of stigma and discrimination, directed at healthcare workers, minorities and persons from the Northeast were reported early on, but destigmatisation was achieved through sustained public messaging. Voluntary organisations played a great role in countering stigma as well as in providing social support to vulnerable groups. In this regard, the Sikh community set an admirable example of selfless voluntarism.
Where can Delhi do better, not only to overcome COVID-19 but also to build a stronger health system that can respond to any future public health emergency? The effort must begin with the recognition that the health system must be functioning well in a non-emergency steady-state to be capable of generating a swift and strong surge response in an emergency. Linking medical colleges to different urban zones to support the government health system will help improve health monitoring and coordinated care. A public health cadre must be created as a priority, per the National Health Policy 2017. Capacity building for disease surveillance, outbreak investigation, epidemic control and effective delivery of national health programmes must become a budgetary and administrative priority. Household visits by primary healthcare teams must become a routine function for performing symptom-based recognition, testing and early management of infectious as well as non-communicable diseases. The mohalla clinics, a powerful innovation for delivering urban primary healthcare, must be expanded and strengthened. The network connectivity of public and private hospitals, initiated during COVID-19, must be systematically reviewed and guided to optimally and consistently serve public needs.
Preventive efforts through effective public communication must be a priority. Information dissemination is most effective when mass media communication is repeatedly reinforced and contextualised through local organisations and influencers. Apart from billboards at local markets and outside places of worship, engagement of women’s groups, youth organisations, RWAs, traders’ associations, parent-teacher associations, trade unions and other civic groups will help to amplify the messages. This will also deter sporadic vigilantism, which feeds on misinformation.
Citizen engagement is pivotal to public health. Every city ward should have identified citizen volunteers who support the primary healthcare teams. From syndromic surveillance to contact tracing and support for home-isolated persons, such volunteers can be a great asset. They can also be the catalysts and coordinators for promotional activities in the community. The urban volunteers’ programme of Iran, which has won praise from international public health experts, can serve as a model. Delhi can become the national and global role model for people-partnered public health.
The writer is president, Public Health Foundation of India. Views are personal
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