National plans need local action
As the COVID-19 storm was brewing in faraway China, and gathering momentum, national leaders were preparing plans to combat the scourge once it hit their shores. Few adopted a “head in the sand” approach, hoping it will go away like a bad dream. However, nations like Japan, South Korea, Singapore and Taiwan, who had borne the brunt of Severe Acute Respiratory Syndrome (SARS), knew what was coming, and were proactive about it. One aspect common in their proactive plans was the staunch belief that the virus could be defeated if the local governance was up to the task. Herein lies the mantra for waging a successful campaign against this insidious virus-empowering local governance at district, tehsil, panchayat and ward level to work the plan conceived at the national level.
A brief mention of the Indian disaster management structure would be relevant to comprehend how the system works. The National Disaster Management Act, 2005 empowers a National Executive Committee to issue directives to all stakeholders like States and Union Territories (UTs) on resource allocation and planning. The States and UTs are responsible for the execution of the said plan through their operational methodologies utilising their existing law and order and administrative structures.
The District Administration is the key for successful implementation of the national plan. The District Magistrate (DM) coordinates all organs of the state and those that he does not control, like the armed forces and Central Armed Police Forces, he can requisition. Under him are the departments of health care, the police, the fire service and a host of government agencies and NGOs, funded by public or private funds that can also be pressed into service. Every district has its own disaster management plan and the DM is empowered to convene a crisis group to put that plan in action. Districts that have activated their crisis management groups and the associated crisis control centres in a proactive manner, will be able to confront the developing situation in a comprehensive and organised manner.
Rolling out the Action Plan at Local Level
The national directive of COVID-19 is clear and concise; surveillance, identification, isolation and quarantine-then treat. The most effective tool is breaking the infection chain or at least, minimising it through isolation and social distancing.
The local government at the district and tehsil level, with allocations of funds and resources from their provincial capital, have to review the preparedness, identify gaps and strengthen core capacities in surveillance and isolation. These plans primarily include staying at home directives, isolation of suspected contacts, prioritising testing and supporting the healthcare system. At this stage, risk communication is critical as a large part of the population may be illiterate and unable to comprehend the stark dangers posed by this virus. This has been amply illustrated by the mass movement of migrant workers from megacities towards their rural homestead. We have witnessed local governments watching helplessly from the side-lines, making feeble attempts at dissuasion and prevention and nil at mitigating the misery of the thousands suffering from hunger and susceptible to infection spread.
The community worker is the frontline soldier in this war. He/she would be busy preparing a list of those most likely to have been exposed to the virus, and these lists are to be shared with the medical officers at the Primary Health Centres. The local populace has to be taught the basics of social distancing and home quarantine. Constant contact has to be maintained to detect symptoms as they develop. A conscientious and well-trained community worker will concurrently continue with his/her routine workload monitoring the health of expecting mothers, elderly persons, postnatal care cases and especially the marginalised section as they would be the worst affected.
The Tehsil and District governments would need to prepare for hospital care as a large number of cases will soon start flooding into the hospitals. The focus has to be enhancing laboratory support, isolation wards, and creating additional ICU beds and nursing the available ventilators in the entire district to ensure that they are available where they are most required. The DM will have to encourage the private healthcare facilities and practitioners to be available to pitch in as 20% infection amongst health care personnel should be expected. The gaps in the front line will need to be filled by private doctors.
Looming threats to the campaign against COVID-19
Lockdown creates its own set of dynamics and challenges. The entire supply chain, developed over decades of uninterrupted routine, is not attuned to such a massive disruption. Food supply, cooking gas, petroleum products and even medical supplies and medicines are now getting seriously disrupted, and prices will go through the roof if they are not restored immediately. It is here that the mettle of state / local governments is being tested in the crucible of resource shortages in every sphere-manpower, PPE, medicine and funds et al.
As per the World Health Organisation (WHO), the best practices from the success achieved by South Korea and Japan show the need to “test, test and test.” The proactive battle against COVID-19 demands that its presence in the human host be aggressively sought, isolated and treated. Instead of waiting for patients with travel history, or exposure history or serious symptoms of advanced pneumonia to fall sick , the local government has to be empowered to reach out amongst the vulnerable population and pinpoint infection through testing, testing, testing.
National Institute of Virology (NIV) in Pune is the nodal laboratory with a pan India network of 51 labs. More private labs are also being accredited but still, the testing network is far short of India's actual requirement keeping in mind our population density. The local government has to ensure that there is a well-established chain of sample collection, its timely and proper handling and dispatch to the designated testing lab. The results once received would demand an equally efficient system of dissemination to the affected individual and to the medical system to enable treatment, isolation of contacts and cordoning and fumigation of premises.
ICU beds and ventilators are vital in saving lives. In Italy, doctors faced with the horrifying situation of one ventilator for many critical patients had to make life-defining choices, akin to battlefield surgeons. Thankfully,Defence Research and Development Organisation in India has come up with a modification which enables a single ventilator to be used by multiple patients concurrently. But still, this will not be sufficient unless in whatever time is available, India procures more ventilators on a war footing, irrespective of the cost involved.
Close coordination between the Centre and the State
State government needs to expand their hospital capacity by decongesting existing hospitals and by converting public accommodations into makeshift holding areas, isolation centres and emergency COVID-19 hospitals.
There will be a critical demand for trained medical staff. The existing staff, whatever their speciality, has to undergo a crash orientation course in epidemiology. To create a ready reserve, final year trainees (doctors/ paramedics/ nurses) have to be rushed through the syllabus, provisionally certified, and imparted additional COVID specific training. They will fill the gaps in the frontline when the experienced health care workers themselves fall victim to the virus.
Lack of or timely sharing of information is hampering the fighting ability of states and local bodies. A good example is the exploding mass movement of migrants from megacities. Caught between the devil (the virus) and the deep (starvation and lack of shelter), these multitudes have started trudging home, unmindful of the risk of infection they carry with them into the extremely vulnerable rural communities. Adjoining states were totally caught by surprise by this unexpected turn of events, and for a couple of days, chaos and mayhem ensued. A coordinated effort is required to halt the migration, shelter the people in camps with safe, hygienic conditions, and ensure they do not get infected or spread it.
The country needs to adopt the best practices of other states. Kerala learnt from its past experience and quickly tracked down clusters of infections. They used Asha, Anganwadi and Kudumbashree workers to do door-to-door surveys, and with the aid of digital mapping, came up with a strategy to ‘break the chain’ of infections. Karnataka has created a Municipal Corporation War Room to track cases using mobile tracking. States have set up 24X7 helplines to guide people to the nearest hospitals.
Local governments are facing the worst of the Covid-19 crisis. Poor funding and lack of effective communication between the Centre, State and local governments is a recipe for disaster. This has to be resolved on priority, and the whole effort to combat COVID-19 has to be run as one seamless smooth well-coordinated effort.
Geo-tagging, QR codes for medical services and mapping strategies can help local governments efficiently go about conducting their operations. In these testing times, local governments must concurrently ensure the effective working of medical shops, grocery and ration ships, health centres and police stations. If these mechanisms break down, then it becomes a statewide panic, which is extremely difficult to control.
All states must constantly review their preparedness, identify gaps and strengthen core capacities in surveillance, laboratory support, infection prevention and control, logistics, risk communication and, in particular, hospital preparedness in terms of isolation and ventilator management of critically ill patients.