The national lockdown announced by the prime minister must be unanimously supported, even if a country of 1.3 billion will be inconvenienced. Frankly, some inconvenience should be endured as a necessary price, given the scale of the catastrophe that other countries are already facing. Measures should be taken to ensure that essential services continue unabated, especially for the disadvantaged and disenfranchised, who suffer the most during such times. While relief through economic stimulus packages will be announced, often the implementation of such interventions invokes considerable distress among the most vulnerable. The Indian people need to recognise that we have gained some time to arrest the spread of the pandemic that we cannot afford to squander. Urgent steps need to be taken, so the caseload does not explode soon after the lockdown is lifted.
During the lockdown
Protecting health workers: India has a diminishing healthcare workforce. Our human resources for health and their disparity across the country have been a concern for a long time. Goa has 41.6 doctors per 10,000 people but Chhattisgarh 3-4 times fewer. Based on 2016 numbers, Bihar has only 4.8 nurses per lakh people while Kottayam in Kerala has 396.6. These disparities will translate into differential outcomes. These problems may not be fixed soon, hence protecting the existing workforce is imperative. As testing becomes more readily available, there has to be a national ordinance that makes it mandatory for all healthcare workers to be tested, not just once, but regularly. Cumulative exposure has been cited as a reason for increased mortality among health workers around the world. All health workers who test positive should be promptly treated and quarantined. Besides individual testing, we should explore pooled testing, which has been validated for testing up to 60 subjects at a time in Israel. The results should be updated online, and technology should be used liberally. As the government is working to create better access to PPE (Personal Protective Equipment), industry leaders around the country, irrespective of their expertise, should come forward to work with the government to scale up manufacturing and supply of PPE, ventilators, and other resources for the frontline health workers and hospital systems.
Creating healthy pockets: We have operationalised the single-largest quarantine in the world’s history. The coming weeks will throw up two developments: One, the silent spread of the disease within pockets that are created by the national shutdown from asymptomatic carriers and two, existing patients will show up in hospitals around the country, increasing the utilisation of services related to COVID-19. Our caseload, as of today, stands at 1,251 and is constantly growing. Given the population density and the timeline regarding India’s first case, one can assume that the spread has been less virulent compared to Italy or the US — both countries had their first case only days before India. While rational thinking would point to a lack of testing as an explanation, we have also not witnessed patients flooding our hospitals with mortality rising, as in the US or Italy. However, we are also around the time when an explosion of cases, both mild and severe, has been witnessed in other countries. Having said that, it is possible that the current social distancing efforts have resulted in the contagion still being within our control. Concerted efforts can mitigate the risk of explosive growth. It is, therefore, imperative to expand testing capabilities during the lockdown to identify and isolate the exposed, particularly pre-symptomatic cases, to create health pockets within society. This will substantially reduce the risk of explosion of cases when the lockdown is lifted.
Establishing safe houses: Safe-houses need to be reserved for those who test negative, especially if they cannot exercise safe social distancing. Quarantine houses at the district level should be reserved for those who test positive so they can be safely monitored. District hospitals or community health centres can be used for quarantine while public schools can work as safe houses. Seventeen states are planning to establish hospitals specifically for COVID-19 patients. This needs to be expanded to all the states through the Essential Services Prevention Act (ESMA).
Addressing psychosocial consequences: As we brace to protect the elderly and those with co-morbidities, it is important to recognise that they are also at a very high risk of getting isolated without access to essential services. Pharmacies will have to ensure that the elderly have an unabated supply of medications. State governments should ensure continued provision of mid-day meals through their existing network of public schools. All employees in the organised sector should continue to receive a paycheck. Landlords should be given a subsidy by the government to facilitate a rent-free period of up to three months, banks should waive off interests and/or EMI on housing payments for at least a month, groceries should be supplied at a subsidised cost and so on. While no interventions will completely address the gaps and concerns experienced by the common man, the overarching need of the hour will remain the preservation of human life, with mitigation of social and economic consequences.
Ending the lockdown
As we approach the end of the lockdown, the aim is to have identified clusters of individuals who are exposed and separate them from the non-exposed. It seems like many other countries have deployed the use of technology to track and enforce quarantines using GPS tracking. While this may seem an invasion of privacy, it is only temporary and will serve a much higher common good. The government should quickly overcome any barrier for testing and make it easily available across centres. This will significantly reduce any chance of resurgence soon after lifting the lockdown. State-wise command centres will gather important data on viral caseload, spread, utilisation of services and other state-specific metrics. This will facilitate the movement of resources from states with larger healthy pockets to ones that need them the most.
After the lockdown
Preparation will be key. The large-scale hysteria around the virus with the panacea still elusive brings about uncertainty and fear. The government should hold daily press conferences by designated health care providers to alleviate stress and not reinforce sensationalism. There will not be a better opportunity for interdisciplinary collaborations between private and public entities with equal regard for the people as stakeholders. This will be the greatest challenge that this generation has faced and it is now up to all of civil society to come together to show the world that the whole is greater than the sum of its parts.
New norms will be created for every sector including health, education, IT and public works. In times when we are quick to criticise the government, troll people on social media, take sides based on political ideologies or religious conventions, let us not be overcome by pettiness. We must remain true to a larger purpose. Let us not be divided by language or religion, but be united by our indomitable will to fight. Let us not be divided by prejudice and bias. We will no doubt be inconvenienced, some of us will fall sick, some even die, but there is no doubt that the human race will prevail. I hope that we can look back and see that even at the height of this adversity, we stood steadfast alongside each other, where everyone mattered equally.
This article first appeared in the print edition on April 1, 2020 under the title ‘How to make lockdown succeed’. The writer is a public health scholar and a psychiatrist at Veteran Affairs Medical Center, St Louis, USA.
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