The South Delhi Municipal Corporation public health department field workers arrive with a team of doctors and inspectors, Defence Colony, New Delhi, April 6, 2020(Burhaan Kinu/HT PHOTO)
The South Delhi Municipal Corporation public health department field workers arrive with a team of doctors and inspectors, Defence Colony, New Delhi, April 6, 2020(Burhaan Kinu/HT PHOTO)

Covid-19: Here is what India needs to do now

Expand testing; protect the medical fraternity; and emphasise on better science and transparency in data
By Prabhat Jha
UPDATED ON APR 07, 2020 09:03 PM IST

The Indian government’s decision to impose a 21-day lockdown to fight the coronavirus pandemic (Covid-19) was a bold one. But now more remedies are needed to help citizens whose lives have been upended by the lockdown. It’s worth restating the main goal of the lockdown: Prevent a sharp rise in Covid-19 cases that could overwhelm the health care system, and wreak economic and social havoc. Global evidence, including from Asia and Europe, points to three priorities over the next few weeks: Test, protect health care workers, and produce better and open scientific data.

First, India’s testing rates, while better than 10 days ago, are still far too low. India can use innovations such as drive-through testing to achieve an unprecedented rapid expansion of free testing through public and private labs (a ~5,000 bill will deter too many from testing, and so it needs to be free). The Indian Council for Medical Research aims to raise testing capacity to 10,00,00 a day in the upcoming months. But this will need to be done faster.

Thousands of mobile testing sites placed away from health care facilities must be created, along with limited random testing of communities. The National AIDS Control Programme offers replicable lessons to ensure the quality of testing and reporting. All positive samples must be archived in national bio-repositories, paired with basic, confidential information on each person.

For those testing positive, self-isolation effectively means quarantine (and testing) of their whole family. Hence, all those who test positive, and who need it, should be given immediate cash or credit to organise self-care and compensate for the loss of family wages. Each case must also be assigned a community chaperone to help meet basic needs. Most cases are mild and can be managed at home. To care for those too sick to be at home, the Indian Army can construct temporary field hospitals, as the Chinese did. India’s innovative information technology companies can connect people with local testing and treatment sites and to community support workers, even let patients rate their care. Covid-19 re-infection appears unlikely. Positive patients, after isolation and a second negative test, can be put to work (including as chaperones). These steps would also reduce the stigma of a positive test.

Second, Covid-19 transmission must not occur in crowded hospitals and clinics. Hospitals must focus on treatment, not testing. Physical partitions and separate teams should manage presumptive or possible Covid-19 cases, apart from non-cases. Health care workers became infected too often in Italy, Spain and the United States (US). Sick nurses, doctors and other health care workers reduce valuable human resources. Moreover, providers without symptoms can infect older patients or those with existing conditions who are at greater risk of death from Covid-19. A major industrial push is required to ensure that the World Health Organization’s recommended protective personal equipment list is available for every frontline health care worker. Excess stocks at private hospitals need to be bought or conscripted. Indian industries must be tasked to crank out millions of masks, gloves, sanitisers and lakhs of ventilators. Whatever is unused in India can be sold or donated globally.

Third, India must emphasise better science and transparency in data. Collection of core demographic and risk details (age, sex, travel, contact with other Covid-19 patients, existing chronic conditions, current smoking) is a priority. Singapore is a model of exemplary reporting and contact tracing. A follow-up phone call at three weeks can establish if the infected person is alive, dead or hospitalised. Antibody tests in random populations and among health care workers can establish the true proportion infected, but needs to start very soon before immunity wanes. The above, paired with testing in morgues, can provide a plausible estimate of the infection fatality rate — a key parameter that is inadequately documented worldwide.

If Covid-19 deaths are going to rise sharply, daily reporting of the total death counts by age and sex by each municipality would help track if there is a spike in presumed Covid-19 deaths. The registrar general’s verbal autopsy studies are useful, but must be reactivated to review deaths occurring in 2020, as the last published results are from 2013. Collectively, simple denominators of infected and rates of death would help provide a true “GPS” to control the epidemic. Unfortunately, mathematical models make too many assumptions. We need actual data.

To their credit, Prime Minister Narendra Modi, health minister Harsh Vardhan, and most chief ministers have begun to speak as one. Honest, calm and daily communication of science can explain each citizen’s role in flattening the trajectory of the epidemic and build public confidence in a stronger response.

Prabhat Jha is university professor, University of Toronto, and leads India’s Million Death Study
The views expressed are personal
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