The COVID-19 situation in India is dangerously poised. It is imperative that the health workers forcefully articulate this reality. Not doing so amounts to failing in our bounden duty.
Our purpose is not to recount what has gone wrong, but to figure out what needs to be done. The immediate redressal of the following challenges is important from the health point of view.
First, soaring hunger needs little elaboration in times of record unemployment and an economy that has all but tanked. In the absence of proven technological medical tools against the virus, the body’s innate immunity is the most reliable defence against the disease. Immunity in the face of hunger is like a promise written in sand. India’s chances of staving off large-scale COVID deaths shall depend on how effectively we can deliver food to the hungry. The princely relief of 5 kg rice or wheat and 1 kg of chana a month, for 80 million migrant families, as announced by the Union finance minister, is insufficient.
Second, by slowing down the spread of disease, the lockdown was supposed to provide time for strengthening the healthcare facilities. There is little evidence of this having happened. Claims have been made of arranging lakhs of COVID-19 beds, but these beds have been set aside from the existing hospital beds, thereby compromising the treatment of patients suffering from various other diseases.
Third, there is the problem of untreated morbidity due to non-COVID diseases. Even as we have lacked in effective planning to manage COVID cases, patients suffering from other diseases have been left to their own devices. Taking the 2017 Global Burden of Disease data as a benchmark, within the first 40 days after detection of the first COVID case in India, 50,000 tuberculosis patients may have died. Further, there are more than seven million cases of upper respiratory diseases and nearly five million cases of diarrhoea every day, besides other causes of mortality like ischaemic heart disease and strokes. Regular OPDs are still not functional in many public and private hospitals.
Fourth, there is data obscurity. The importance of comprehensive data for an evidence-based and epidemiologically sound strategy can hardly be over emphasised. But, our governments seem to be fighting “data” to suit their convenience, forgetting that “absence of evidence is seldom evidence of absence”. Even in cities like Delhi and Chennai, the system has failed to keep an accurate record of COVID deaths.
Fifth, the absence of a health manpower policy to deal with the pandemic. Historically, there has been near-absence of “managerial physicians” equipped with the social, political and technical understanding of health problems in the Indian public health system. This owes to the overall clinical orientation of our health services, implying an overbearing reliance on tools of biomedicine both for the prevention and treatment of diseases. Consequently, the epidemiologists and social scientists have almost completely been marginalised in COVID policy formulation. While sound clinical knowledge is indispensable for clinical management of patients, a grounded understanding of epidemiology and socioeconomic dynamics of the disease is foundational.
Further, the treatment of the elementary needs of health workers has been demeaning in many ways. Many doctors have reportedly been served show cause notices, suspensions and even termination of services for simply demanding PPEs (personal protective equipment). Reasonable demands like shorter durations of duty in COVID areas and regular rotation between COVID and non-COVID areas seem to have been ignored. This has not only resulted in health workers falling ill and thereby being rendered out of active duty, it has also led to many losing their lives. There are reports from the national capital of doctors working in public hospitals not being paid salaries. A disgruntled warrior is desirable in the least and the governments should deal with these issues with utmost sincerity.
In light of the foregoing submissions, we place the following actionable suggestions for consideration of the government to effectively counter the pandemic.
First, a necessary condition for formulating evidence-based and epidemiologically sound pandemic control strategy is the formation of a national committee of eminent and experienced epidemiologists, public health experts, clinicians, social scientists with background in health, representatives of pharma and medical equipment industry, biomedical scientists and engineers. Consultations should be sought with eminent citizens, activists, and representatives of the working masses.
Second, the central and the state governments should take necessary steps to nationalise all private hospitals. These facilities should be opened for one and all to provide free treatment. The doctors, nurses and other staff of these hospitals should be asked to mandatorily provide their services at remuneration as is applicable to similar staff in public hospitals.
Third, the publicly funded tertiary and secondary care hospitals in cities should be readied in all respects by improving sanitation and hygiene, provisioning of equipment, toning up of laboratory facilities, and recruiting the additional staff to meet the work load. The social work departments of public hospitals should be strengthened to ensure proper guidance and facilitation of patients. To finance all of this, the public expenditure on health should be immediately raised to 5 per cent of GDP.
Fourth, routine OPD and in-patient services should be resumed in all hospitals for non-COVID cases taking all necessary precautions to ensure the safety of the staff and the patients. To reduce crowding at hospitals, outreach clinics should be organised in communities to treat minor illnesses; OPDs should be organised in the morning and evening shifts to reduce the crowding of patients; and, hand sanitisers and face masks should be made available to all patients and their attendants.
Fifth, PPEs should be provided to the healthcare staff in accordance with the requirements of their station of work. Shorter duty hours with rotation and periodic duty offs to relieve stress should be instituted for minimising the attrition of workforce.
Sixth, primary and secondary level health facilities ought to be made fully functional and frontline health workers need to be trained and fully geared up for disease surveillance work. This onerous responsibility cannot simply be off-loaded onto them. It would require supportive supervision of senior members of the medical team including doctors. Block-level inter-sectoral teams of departments responsible for peoples’ wellbeing need to reach out to the villages to explain the nature of the health emergency, diligently register their problems, and provide solutions.
Seventh, vigorous research on the epidemiological, clinical, social, economic, and political aspects of the pandemic should be undertaken for moderating the policy to a rapidly evolving pandemic situation.
Lastly, an epidemic or a pandemic is a far greater social, economic, and political phenomenon than merely a biomedical one because the ability of people to weather the effects of ill-health is mediated through these factors. The enormous migrant crisis that we have witnessed is a testament to this cardinal truth.
Rather than exclusive reliance on medical measures, it is imperative to alleviate the conditions which imperil the ability of individuals to resist infection and prevent transmission. Ensuring the “food security” and “livelihood security” of the people are foremost priorities among these. Many suggestions already exist in the public realm and more can be formulated in consultation with relevant experts.
It is time the government opens up its purse strings for the people. The legal framework of controlling pandemics, as laid down in the ‘Epidemic Diseases Act, 1897, places the onus of controlling pandemics primarily at the door of the Central government. The Centre must not shift the responsibility of dealing with the pandemic on to the states.
Bajpai is assistant professor, Centre for Social Medicine and Community Health, JNU, and Bhatti is national president, Progressive Medicos and Scientists Forum.
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