Major Fault Lines In COVID-19 Intervention Program In India?
To envisage that COVID-19 is just not a health issue but a bigger developmental challenge is missing somewhere in the line.
On my way to the medical clinic, I came across a couple of youth whom I found guarding a barricade put up in front of a lane by the Kolkata police. I stopped for a while and engaged in a conversation with the two. When I asked them about the objective of the lockdown, within no time they responded in a chorus 'to stop corona' and going a little further they added: "We would make Kolkata Corona free through ensuring effective lockdown."
The common perception is that lockdown is a panacea through which pandemic would be stalled. However, they can't be blamed for their incomplete understanding. The objective of lockdown which is to flatten the pandemic curve and buy some more time to bolster our existing healthcare system is not very clear to many even today. To address the pandemic we chose a readymade and a quick fix solution and lockdown suits the best.
Fractured Vision, Lack of Comprehension
The COVID-19 intervention strategy and approach in our country is primarily pivoting around the lockdown which appears to be the one and only solution. We failed to capture the broader dimension of the epidemic as a result of which our discourse has hardly gone beyond the implementation and plausible outcome of lockdown.
There is no comprehensive strategy to address COVID-19 pandemic. Ideally, the strategy should have incorporated both medium and long term plan in which lockdown could be considered a very short term intervention embedded in the overall strategy of containment. To envisage that COVID-19 is just not a health issue but a bigger developmental challenge is missing somewhere in the line. This is perhaps the biggest gap in the national response.
It appears that policymakers in our country suddenly sprang into action after getting some inputs from the modelling exercise conducted in India and abroad. The Indian Council of Medical Research scientist, based on their statistical model, had predicted that in mid-March that there could be COVID-19 cases ranging from 40 lakhs to 1.1 crores only in Delhi, and that too will happen within fifty days provided there is no intervention. Similar projections were made for other metro cities as well.
Predictors did suggest that if lockdown is undertaken the curve will be flattened and cases could be spread over for a period of three hundred days. Keeping in view the population density of metropolis and other obstacles they assumed that lockdown could be successful only by half of its efficacy resulting in flattening of the peak of the epidemic by 26 per cent. However, they also added that if lockdown is aided with adequate testing followed by isolation of cases and home quarantine of contacts the outcome could be as high as 71 per cent.
We know by this time what is the capability of our country in ensuing testing in sufficient numbers even after the completion of the third phases of lockdown spreading forty days. In contrast to another European country who could carry out testing among one per cent of their population, we could do roughly three per lakh of population
No Homework, No Plan of Action
The most disturbing aspect of the lockdown is that the government did not do basic homework and there was not even slightest preparation on their part to lay down the process of lockdown for a country which is so huge with high population density and all kinds of diversity.
Sooner the lockdown declared; it opens up the pandora's box, the plight of migrant workers is one such which shows not just the lack of imagination on the part of the program implementers but also the level of ignorance of the health ministry.
The ministry possesses relevant information related to interstate migrants as part of their HIV intervention program. However, migrant labours were invisible until they hit the streets. This is just the tip of the iceberg, the innumerable lateral damages impacting multiple areas of humane are social life is yet to be unfolded. It is not just the slowing down of the economy which is the forte of the economists.
How many people have already lost their lives for not getting timely intervention due to non-COVID related illnesses is not known to us. It is almost certain that there would be perceptible negative consequences impacting other major health intervention programs namely TB, HIV or MCH to mention a few.
How many new cases of TB, HIV will flare up is yet to be known and worst of all the increase in the number of newly developed resistance cases of TB and HIV which will further complicate already stretched TB and HIV intervention program. Had there been a planned lockdown with appropriate preparation in hand some of these negative outcomes of lockdown could have been averted. One should have a developed model projecting collateral damages of lockdown with planned and unplanned implementation.
It is difficult to explain the conspicuous move on the part of the government to avoid wider consultation in deciding for such a disruptive strategy either at the political and or at the societal level. No discussion was held even with the heads of respective states who will implement the program the Ministry of Health and Family Welfare did not bother to consult with wider scientific communities belonging to different disciplines.
Even if we accept the modelling data as the gold standard (which is not) one needs to think twice before endorsing such a strategy which could bring about just 20 per cent of its capacity and at what cost? Where there any other alternatives to lockdown? Or could we think and implement different kinds of lockdown keeping in view existing social and structural barriers?
We knew that there are differences in the implementation of lockdown across countries. On the other hand, most of the Asian countries like South Korea, Taiwan, Hong Kong, Singapore, Srilanka etc did not implement lockdown but they came up as victorious. Keeping in view the high population density in cities (it ranges between 60,000 to 70,000 per square mile in the metropolis), and where around 40 per cent of households live in slums and another twenty per cent or more live on streets we could have developed a stratified and calibrated strategy to contain transmission of COVID.
There should have been at least a national level forum to promote debate and discussion on issues of public health interest in a country which is gifted with so many scholars, intellectuals, social scientists, activists of repute. Lastly, no system is yet to be instituted to establish accountability of the program and the program implementers.
Encouraging Stigma and Discrimination
It appears from various actions and approaches of the government officials that they are rather promoting stigma even though Prime minister lately shared that COVID does not respect class, caste or religion. Respective government departments recklessly published names and address of individuals who are in isolation or quarantines as if they are criminals. Epidemiological reports developed citing names of mosques and religious sites and identifying various outfits as a spreader of COVID-19.
Social media took the cue from these reports and intensified it further. This kind of profiling does not subserve any interest of the disease control program neither it follows the basic principles of public health interventions. WHO and other UN agencies repeatedly suggested respecting individual's privacy and confidentiality while implementing schemes and not to use terms like super spreader' or similar coinage tagging one or other community.
People, in general, do not give much importance to stigma. Our experience in connection to HIV epidemic could be an eye-opener. One of the three major global indicators of HIV which are followed across countries including ours is the reduction of stigma. It is recognised that without the reduction of stigma, the transmission of disease and death out of it could not be achieved.
Officer sitting at the helm of the affairs must know these guiding rules to get success and sustain health interventions. The stigma which was initially restricted to health care providers now inflicting individuals, groups communities based on religion, occupation and so on. This approach has already alienated a large section of the population. Stigma going to be the major roadblock in COVID intervention program. Sooner we recognize it the better.
Repeat Lockdown Out of Repeat Desperation?
There is strong evidence that keeping physical distance, washing hands with soap and putting mask reduces transmission of COVID-19. However, whether lockdown could add extra mileage in the prevention outcome is still a debatable issue.
The exponential growth of COVID could not be averted in many countries even after the introduction of lockdown; countries which introduced lockdown earlier did not do better either. Projections made based on those models appear far from reality. One needs to understand that models are made to fail but it does provide essential inputs to help an intervention.
Centre took decision thrice to extend lockdown further without any assessment of the strategy. No rigour could be observed to analyse, reflect and triangulate various finding obtained from different sources to assess the contribution of lockdown, how far it worked, what are gaps and so on.
Data which are presented as an indicator of the success of lockdown are doubling period [the number of cases doubled over a period], in addition to quick recovery and death rate among the infected individuals. The fact remains that the doubling period started increasing since March 23, i.e two days before the lockdown. No doubt It has increased further during the lockdown phases. The question is whether it is due to behaviour change or due to lockdown? The other two indicators have nothing to do with the lockdown. There is over-dependency on the model, and having no long term plan to address COVID-19, it appears the ministry out of desperation opt for an exit route through extending lockdown.
No Success Without Community Engagement
There is no quick-fix solution for COVID19. We have to live with the virus till and until an effective vaccine is made available and people get vaccinated irrespective of their purchasing power. It will take years and COVID 19 has to be dealt with the implementation of the behavioural change program.
The science of behaviour change model and its success depends on the active engagement of the community. Fortunately, we have rich experience in implementing behaviour change in achieving success in HIV transmission which could add value to COVID intervention program.
Giving due importance to the community and respecting their perceived needs and challenges, one can effectively engage communities and ensure their 'role model' in the COVID intervention program. The top-down approach does not work in behavioural change interventions.
There are many vulnerable GROUPS like migrant workers, sex workers, slum dwellers, etc. who are capable of making change through developing more effective and innovative interventions as has been well established in HIV program. Communities showed be enabled and empowered to play their role not just as a service recipient but as an implementer and as a gatekeeper of the program. The implementation of a strategy based on 'one size fits for all' will not work.
The earlier our policymaker recognize and respect communities' role the better. We have to change our' gear' from police and administration led approach to bottom-up community-centric programming. Without adopting community mobilization approaches there is hardly any option to address COVID transmission and mitigation of its impact.
(The author is a part of the expert committee set up by the NITI Aayog to help the government develop strategies to prevent and control the outbreak. He has been credited with starting one of the most successful intervention programmes to stem the spread of HIV in India.)