April 29, 2021 7:01:53 pm
Junaid Nabi and Monalisa Padhee
For the past four days, India has continually registered over 330,000 coronavirus cases per day, smashing the world record for the highest number of infections recorded since the pandemic started. For perspective, the highest number of cases recorded per day was 300,000 in the United States in early January 2021, a country that has suffered the highest death toll globally. The current situation in India is alarming because of limited health system capacity, a large concentration of the population in the rural areas, and ongoing socioeconomic constraints.
At the same time, a disturbing narrative is developing in the country. Instead of organisations being held accountable for severe failures in policy-making, blame is being thrown mainly at people’s behaviour. All this is happening in a country that has historically been highly successful in vaccination campaigns for highly infectious and lethal diseases, including polio. The current COVID crisis in India is a direct consequence of severe political complacency, lack of thoughtful policymaking, and conflicting or absent mass communication.
Instead of blaming people, governments at the central and state levels need to work together and develop a cohesive COVID containment strategy, that is based on three core actions: effective leadership, breaking the chains of transmission, and immediate investment in developing health system capacity. These strategies need to address issues as per local needs (culturally competent) and designed distinctly for the urban and rural populations.
First, political leaders and bureaucrats need to demonstrate effective leadership by focusing on clear and consistent communication. WhatsApp and social media have, unfortunately, become major sources of information for people across India, leading to unscrupulous entities co-opting these platforms to spread misinformation and disinformation. To address this, local and central governments need to proactively start comprehensive marketing campaigns that clearly, and repeatedly, underscore that public health measures (such as masking) and vaccines can reduce transmission and severity of viral infection.
In urban areas, this messaging effort can be carried out through television and radio advertisements. Influencers — including movie actors and cricketers — need to get involved and highlight these messages repeatedly on their social media. In rural communities, local health workers, teachers, and grassroots political and religious leaders need to continuously campaign on this consistent messaging. In these areas, leaflets, posters, wall paintings, and loudspeakers can also be used to create a counter-narrative that vaccines and public health measures work.
Second, policies need to be implemented that can break the chains of viral transmission. The most effective strategy to achieve this would be to vaccinate as many people as quickly as possible. The government’s recent steps on waiving import duty on vaccines and collaborating with international partners to increase supply are the right actions to take. However, given the burden of disease and the current supply of vaccines, increased focus should be placed on providing high-filtration masks to as many people as possible. In cases where high filtration masks are not available, double masking needs to be promoted effectively. Masking should also be included in the counter-narrative strategy described above.
Additionally, COVID testing capacity should be increased, and those testing positives should be traced and isolated as soon as possible to break the chains of transmission. Proper training should be afforded to technicians/nurses who are carrying out the testing, to reduce false-negative rates. Since national lockdowns have become politically untenable, the government should use COVID testing to develop targeted lockdowns in areas that have high case positivity rates. Worryingly, it is unclear how much the coronavirus infection has penetrated rural communities, which have a much lower healthcare capacity than metropolitans that are currently struggling to contain the spread. Mass gatherings, in the form of religious or celebratory events, must be suspended.
To achieve this, local leadership in towns and villages needs to be activated for campaigning on these issues and raising awareness. Social connections of local NGOs should be utilised, as these workers are often familiar with local needs and customs and can deliver culturally competent guidance. To boost the update of strategies, social recognition of those who comply with public health measures should also be considered.
Third, immediate investments in enhancing health system capacity and building temporary medical infrastructure should be a priority. China was able to build a hospital in five days at the peak of their initial surge in cases. India should learn from this example or collaborate with other countries that can provide expertise and support in developing field hospitals to care for patients with mild illness and for isolation. Another technique to build capacity quickly is to convert major sports stadiums into temporary health care delivery facilities, as was done during infection surges in Nigeria. The advantage in building these facilities is that the burden on traditional hospitals is reduced and patients who do not need immediate complex care (such as ICU) can be taken care of, with oxygen supplementation and conservative therapies (for fever, pain, etc.), instead of patients languishing outside the hospitals, as happened recently in Delhi.
Letting patients suffer on the roads increases the chances of their untimely death and can potentially increase the spread of the infection. In addition, makeshift isolation facilities should be built for people who may not have separate rooms for isolation. This would be particularly effective in isolating people who have been actively exposed to coronavirus positive patients and reduce the risk of contracting and transmitting the infection. Simultaneously, efforts need to be taken to destigmatise the usage of such facilities with proper awareness, care, and service.
To further reduce the burden on hospitals, clear and consistent messaging efforts need to be pursued on patient triage. We know that not all patients need to be hospitalised, but lack of clear communication results in people panicking and heading for the nearest hospital. To prevent this, there should be clear guidelines on how to isolate at home, which patients need oxygen and ambulatory care, and how local primary care centres should handle mild cases (including techniques on patient positioning). Additionally, capacity can also be increased by enabling patients to seek care online via telehealth services.
Online networks of volunteer doctors, such as Project StepOne should also be part of such collaborations. Regulatory barriers that are preventing the implementation of telehealth services could temporarily be suspended. Information on how to access these programmes should be broadcast on every news and social media platform, repeatedly.
The current humanitarian crisis in India will be an example of policy making in history books — either one of sheer failure or one of bold decision-making. The strategies that political and healthcare leaders pursue in the upcoming days will define that status. Implementation of evidence-based and human-centered strategies that can help India overcome this unprecedented crisis.
Nabi is a physician and public health researcher working at the intersection of health care reform and innovation. He is a senior fellow at the Aspen Institute in Washington DC and serves on the Working Group on Regulatory Considerations for Digital Health and Innovation at the World Health Organisation. Padhee is the programme head of the women wellness initiative at Barefoot College International focusing on women’s health in rural India. She is a current Gender Lab fellow at Swedish Institute and a Senior fellow at Aspen Institute and an Atlantic fellow for health equity at George Washington University.
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