Where the world stands today, a lower-middle-income country like India has a lot more to do to prepare for the peak of COVID-19 and its aftermath. So, let us look at what went wrong and what can start the discourse on course correction, writes Prof R.P. Gupta.
Today is World Health Day. When I look back at the events (scare of COVID-19) that have unfolded in the last few weeks, my routine, habits andoutlook towards many things has changed. It has also given me a reason to look back and at the same time think about the future – the next few weeks. Look at the crisis and the number of countries fighting this pandemic, it’s greater than the number of nations which were involved in WWI & WWII.
We never really got warned after Ebola, SARS, or NIPAH outbreak. The World Health Organization (WHO) operates in a reserved mannerand it failed to prepare the world for the coronavirus outbreak.
Where the world stands today, a lower-middle-income country like India has a lot more to do to prepare for the peak of COVID-19 and its aftermath. So, let us look at what went wrong and what can start the discourse on course correction.
Chronology is crucial for us to consider future steps and preparedness.
• China first informed about the COVID-19 outbreak to the WHO on December 31, 2019.
• China locked down 50 million people on January 23. This was the first warning sign. Clearly, it would not have ordered a complete shutdown on January 23 for a few hundred deaths. Perhaps, this is where WHO’s role comes under suspicion.
• By January 20, 2020, COVID had already spread to 25 countries
• The WHO declared outbreak as a Public Health Emergency of International Concern on January 30, 2020
• On January 30, India reported its first case
The killer was not ordinary. When Chinaordered the world's factory shutdown, it still did not shake the global community. The global response to COVID-19 reconfirms the failure of systems, science and strategy. As much I would have castigated the WHO for its initial failures in China, I still think it did a fair job through its daily bulletins. Yes, it would have been great had it suggested specific steps rather than 'keeping countries updated'. The WHO should have prodded the countries to take steps for containment and reversalwith specific action points for each country. More so,when the WHO SEARO hired an additional secretary official recently from the Ministry of Health and Family Welfare (MOHFW).
In India, the cases started adding up and spreading beyond Kerala, from just one case on January 30, three cases on February 29 to 34 cases in the first week of March. The trajectory points towards an increase of more than 11 times in the first week of March. The warning was not just severe, but unambiguous. India should have stopped flights from major global transit hubs like Dubai, London, Paris, Munich, and New York as well as entry of people with a travel history to these places and other affected countries immediately. Also, it should have kept adding countries to its list as per the daily WHO country spread bulletin . According to the WHO daily bulletins, the following was the trajectory:
Date |
Countries Impacted
No. of cases
Deaths
January 01
1
44
January 20
4
282
January 31
20
9826
213
February 15
26
50580
1526
February 29
87
85403
2924
March 07
94
101927
3486
Source: WHO Bulletins on COVID-19
On January 22, WHO stated that the risk was 'high' at the global level. On January 24, WHO, in its bulletin, said 'the New epidemiological information reinforces the evidence that the 2019-nCoV can be transmitted from one individual to another'.
Clearly, the trajectory was scary between February 15 and February 29, and WHO was clear when it raised it to 'Global – High-Risk' on February 29. We should have been pre-emptive in our approach and initiated'international isolation' by March 01.
On March 01, WHO situation report no 41 stated that the disease had spread to 58 countries, and the risk assessment was 'Very High' at the global level. Even if we had stopped all international flights by March 08, Indiaprobably wouldn’thave to announce a lockdown for domestic flights. Joint Secretary, International Health and Secretary, Health should have been more realistic to inform the PMO that the situation was getting worse and suggested steps but clearly, they failed in their basic responsibility. Also, by March 15, the cases had increased to 112, an increase of over 37 times from March 01. So lockdown was needed in key states with mass transit and slums a week earlier than it was actually announced.
What has happened is behind us, and now we have to brace ourselves for the new reality. Whether we call it local transmission or stage 3, it really doesn't matter. What is important, how we deal with it, and some of the steps we need to take are mentioned in my previous article. Here's what we need to consider:
Though the world is asking for extensive scale testing and isolating, we need to use our existing capabilities and create an online, mobile-enabled risk assessment tool. It is easy to create a tool with a set of questions backed by an algorithm that evaluates the risk level. Those who are at high-risk need to move into home isolation, and only these people and their immediate family members need to get the screening done. So, like Chennai, we don’t have to screen the entire population.
Now is the time that the government starts funding COVID-19 testing kits for high-risk individuals and not just those covered under PMJAY. It would be impractical to expect people to pay Rs 4500 per person to get themselves and families tested in a private lab. Also, government must negotiate the testing rates. So, India'sstrategy to consider should be:
COVID Clinical Management through a ‘Population Health’ Approach |
No.
Steps
Covering
Applicable
1.
Homemade masks for all
Entire population
When moving out of house
2.
Health Risk Assessment tool (HRAT) as per case management tools – defined clinical protocols
Entire Population
Done weekly – Self-reporting
3.
Screening
High risk individuals and their families
As per HRAT
4.
Self-quarantine at home and isolation
High risk individuals, people with comorbidities and senior citizens
Eight weeks
5.
Treatment
Testing positive
Till confirmed negative as per Protocols
6
Random screening from households across the nation
Randomly picked pin codes and households
Daily basis for eight weeks
Also, the calibrated and staggered uplifting of the lockdown would be a good approach.
Citieswhich are – a) densely populated, b) have a mass transit system, and c) have slums should continue with the lockdown with a focus on 'high-risk areas' being 'sealed' for another month.
|
Additional steps and lifting the lockdown
Steps
Applicable
Timeline
Remarks
1
Banning all chewable products(Tobacco, Bubble gums, pan masala)
All India
Eight weeks
NA
2
Shut down public transport, shopping malls, restaurants, religious places
All India
Four weeks
Review after four weeks
3
High density population catchments, slums and transport hubs like interstate bus stops as high risk and be kept under lock down
All India
Four weeks
Review after four weeks
4
Total lockdown
Delhi -NCR and Mumbai Metropolitan region.
Also, high spread areas across districts be ‘sealed’ for containment PAN-India and not the entire districts
Four weeks
Review after four weeks
5
Start lifting lockdown for a few hours every day
Low incidence areas or where the numbers are coming down
From 15th April
Only people with low risk allowed to go out with homemade masks.Also, lock down being relaxed from four to eight hours and so on based on decrease in incidence
6
Train services and domestic flights resume for low risk individuals
Pan-India
30th April
Reviewed daily
7
International flights be put under lockdown
All flights
30th June
Global situation reviewed every week
8
Investment in development of Point of care testing toolkits and manufacturing
DST – MOHFW
Ongoing
9
Investment for R & D
DST – MOHFW
Ongoing
10
Mass production of prophylactic treatment for 20 % of the population and PPE for entire clinical staff + export
PMO
Till ready
Daily review and production to be spread in four zones
It should be mandatory for individuals to do a symptom-check through self-assessment (feed-in through an interactive SMS based central system or an app-based tool) every week for the next two months.
Those under medium risk category should check their SPO2 through handheld devices on a weekly basis. This will ensure that there is no chance of recurrence. The capability for this app exists within the MOHFW. During my tenure, we had created a stress identification and management app('No More Tension'); such a platform can be used for COVID risk assessment.
Also, it would be prudent that India does not export any products related to COVID management till we have buffer stock. Planning must be donekeeping the worst-case scenario in mind. Managing COVID-19 outbreak is the test of our understanding, system's strength, resilience, solidarity and national leadership. India will certainly win this sooner than the rest of the world with a bold leadership at the helm
(Prof. Rajendra Pratap Gupta is a leading public policy expert and former advisor to the Union Health Minister, Government of India. He tweets @rajendragupta. Views expressed are personal.)