Promote people power against COVID-19

It is time to change track from a government-led but people-disconnected strategy of fighting the virus

“COVID-19 can be countered only through a unified society effort.” Healthcare workers at a medical camp in Dharavi, Mumbai, on June 10. Vijay Bate

India has a single time zone by the clock but it exists in many COVID-19 time zones. Cities with large international airports and high inflows of foreign returnees opened the door to COVID-19 and are trying to expel the unwelcome intruder. Other parts of India are trying to protect themselves against the virus which has just managed to get its toe in. These include rural India and much of the eastern and north-eastern regions. So, a pan-India defence is needed, with variations as appropriate to local contexts.

Antibody prevalence

Differences in viral exposure rates were initially observed across the country, from the RT-PCR tests. Since the testing criteria were restricted to specific indications and testing rates were variable, over time and geography, these comparisons were fallible. As reports of many persons testing positive but staying asymptomatic came in from across the world, questions arose as to the extent of virus spread in the general population. The government has just released the results of population surveys, employing antibody tests in different parts of the country. Data presented on 63 of the 83 districts reveal an antibody prevalence of 0.73% in the population. Earlier media reports of 15-30% antibody prevalence in the containment zones of large cities are yet to be corroborated, since data are still being analysed.

Some sections of the media rushed to say that the reported prevalence in the containment zones heralds an imminent arrival of herd immunity in India. The herd immunity threshold (HIT) for this virus is estimated to be at least 70% of the Indian population. Extrapolating from containment zones to the entire country is a mistake, as the district survey shows. Even the prevalence attributed to the containment zones is far from the HIT. Much of the country remains untouched by the virus. This offers an opportunity to immobilise the virus even as we move out of the lockdown.

It is clear that we need a differentiated approach in our response as we address the varied levels of infection across large cities, smaller towns and rural areas. One challenge is to stall the spread within the urban containment zones. The other is to protect the many parts of the country where the virus has touched very few but can threaten many. Despite the fatigue of national lockdown and the natural urge to get on with life as before, there are many battles yet to be fought before we unfurl the flag of victory like New Zealand or Vietnam.

Changing track

It is time to change track from a government-led but people-disconnected strategy of planning and implementation. As we open up, we need to engage the strengths of our community resources to ensure that the many components of the response, from testing and isolation to enhanced public awareness and personal protection, are successfully delivered at scale. So far, the strengths of voluntary groups and elected local bodies have been inadequately tapped across the country. There are examples of panchayats becoming excellent organisers of local community response in Kerala and Odisha, while Andhra Pradesh has deployed village and ward volunteers for symptom-based syndromic surveillance of rural and urban households and contact tracing. We need to replicate those good practices, and go beyond, as we move ahead.

Symptom-based viral nucleic acid testing with RT-PCR will have limited success, if we only depend on sick persons to self-report at hospitals. Stigma and fear of isolation in a crowded hospital impedes or delays self-referral. We need to detect all likely cases, with influenza-like illness and other COVID-19 symptoms, early in their illness and arrange for testing at home. The initial screening can be done by a school-educated community volunteer, without solely depending on the overburdened ASHA. Such volunteers can also become a family’s link with the healthcare system for follow-up of mild COVID-19 positive persons who are now being advised to isolate at home. Young volunteers can be equipped with a thermometer and a fingertip pulse oximeter. Each volunteer can visit 50 allotted houses daily, for case detection and follow-up. They should also act as the home isolated person’s link with the health system for efficient transfer and hospitalisation if symptoms worsen.

Where will we get such easily trainable, disciplined and community-oriented young persons? The National Service Scheme functions under the Ministry of Youth Affairs. Started in 1969, to commemorate Mahatma Gandhi’s birth centenary, the NSS can demonstrate its value as we celebrate the completion of 150 years of his birth. The National Cadet Corps involves college students mentored by the Defence Ministry. These youth groups can be mobilised. Young persons are at very little risk of serious illness even if infected in the line of duty. This applies also to local youth volunteer groups. Elderly individuals, people with co-morbidities and persons with physical or mental disability will need special attention and customised service, for which the volunteers can be trained by experienced NGO trainers.

Shortages in skilled healthcare providers need to be addressed, especially as there will be periodic attrition due to infection and exhaustion. The government can create a year-long short service commission under the National Health Mission to recruit doctors who have recently graduated and even attract private practitioners whose clinics shut during the lockdown. These temporary measures can lay the foundations for a larger, well-integrated health workforce of the future.

Improving awareness

We need to step up health awareness campaigns, not just through mass media but also through community leaders and local influencers. From women’s self-help groups to resident welfare associations, and trade unions to business associations, all social collectives have to be mobilised to educate their members and others. Fright and stigma, which drive the epidemic underground, must be countered while fostering social solidarity that assures collective safety.

Within the hotspots, we need to increase efforts for micro-surveillance to curb spread even as the broader containment efforts aim to douse the infection. Physical distancing is difficult in slums but masks and hand washing can be highly protective. To overcome water shortages, municipalities should arrange water tankers. Each family in a slum can also be daily provided a bucket of soap solution (water with dissolved soap) for hand cleansing. However, all of this requires the active engagement and organisational skills of local community leaders who enjoy the trust of the people.

COVID-19 threatens all of society. It can be countered only through a unified society effort. It is now time to direct people power against the virus. It requires the government to be more welcoming of NGO and volunteer participation and to create a platform for a new model of PPP: People Partnered Public Health.

K. Srinath Reddy is President, Public Health Foundation of India. Views are personal