Hardly any healthcare system in the world can handle the surge in COVID-19 cases, such as we are seeing in India. The country is reeling from a daily burden of over three lakh cases and over 2,000 deaths. The projections of various modellers indicate that India will touch nearly two crore cases by May 1, with four to five lakh cases each day. The reproductive number, which suggests the number of people who can acquire it from the infected, is rising unabated in most states, suggesting a trajectory of higher cases in the next few weeks.
What led to the second wave? There is a strong case that newer, more contagious variants of concern are resulting in rapid transmission. There could be more variants of concern, both imported and indigenous. Studies have shown that the cases infected with the Indian variants are doubling every week in other parts of the world. However, the second wave could occur only after a country accumulated a pool of susceptible persons and crossed a critical threshold level. This is aided by a conducive environment for transmission, with leaders, the learned, and laypersons mostly disregarding COVID-19 appropriate behaviour.
There is a severe strain on the health systems in states witnessing a surge. Even a state such as Karnataka, which substantially ramped up the number of oxygenated beds during the first wave, cannot bear the case burden.
The immediate steps to be taken are mitigation and containment. The rate of spread should be mitigated to levels of cases that the health system can reasonably handle. Although it is the last resort, states should not hesitate in imposing complete lockdowns at the city or subregional levels with a higher case burden. Aggressive containment efforts should be pursued in parallel to ensure that most people with the illness are identified, isolated and do not spread the disease. These measures will help in minimising unfortunate deaths. Early detection of people with respiratory distress, referral and timely provision of oxygen have to be universally hastened. All available supplies of oxygen should be diverted to areas reeling from a higher burden. This should be supplemented by faster procurement and transportation of medicines for the patients. We should upscale capacity at the district levels for oxygenated beds and ICUs.
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Although beds can be put up overnight by converting trains, halls, temples into care centres and oxygen can be flown in by industries, it is not the same with healthcare workers. Without them, these resources have no value. Governments have to resist the temptation to hire temporary staff. A temporary workforce cannot be the mainstay as the country will have to tackle multiple such waves and pandemics. This is an opportunity for governments to build strong and resilient health systems. The first requirement is to hire doctors, nursing staff and frontline workers. ASHAs are the backbone of health services in rural areas. Similar volunteers should be hired for operating in dense urban pockets where primary healthcare is ignored the most. The country can avert future disasters if health workers are recruited, trained and well taken care of. In peacetime, they can take care of primary care services, including chronic disease management.
Vaccination is the eternal solution but is effective mostly to minimise the adversities of a third wave. It is a welcome move by the government to open up vaccination for all those aged 18 and above. The proportion of post-vaccination breakthrough COVID-19 infection is 0.03-0.04 per cent after receiving a second dose, as per authorities. This is promising. However, the speed of vaccination should increase many folds to reach at least 10 million doses per day over the next few months. This cannot be done without strengthening micro plans and mobilisation efforts. Micro plans focus on bottom-up planning.
Frontline health workers map households and match beneficiaries to designated health facilities. It is easier to plan with decentralised mechanisms for units of 10 to 20,000 population so that the teams can ensure each individual is vaccinated.
Future pandemics can be averted by prioritising public health, especially by strengthening primary and primordial disease prevention. The health and wellness centres, designed for every 5,000 people, need strengthening. The health practitioners should be able to provide the first level of primary health care services. These include awareness generation in the community, mobilisation and ensuring that all health care services are brought to people nearer to their homes. For long, we have ignored strengthening the public health system. We are obsessed with spending more money on curative services. The pandemic is a grim reminder that it is high time we shift the focus on preventive services and health promotion. Hiring public health practitioners, promoting data transparency and evidence-based planning is essential.
It is not that the COVID-19 second wave has caught us completely off-guard. The wave has only exposed the existing vulnerabilities of the health system. The country is in a state of shock with this massive blow of the second wave. This is due to chronic apathy, with bare minimum allocations over decades and lack of resolve to strengthen public health. Public health systems have to be strengthened for any reasonable accomplishments or growth in any other sector.
It is evident that all sectors are intertwined; every single wave across the globe has washed away most aspirations, be it economics, education or service. The second wave has reminded us of the costs and casualties of ignoring public health services. When can this change?
This article first appeared in the print edition on April 26, 2021, under the title “Second wave is a wake-up call”. Babu is a professor and head, life-course epidemiology, Indian Institute of Public Health, PHFI, Bengaluru; Deepa is a research fellow at Indian Institute of Public Health.
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