Covid-19 crisis: Handling the second wave in rural areas

With rural cases accounting for almost half of the daily cases currently, large-scale decentralised mobilisation of district health resources is the need of the hour

It appears in hindsight that the first wave of the Covid-19 pandemic let us off relatively lightly, hotspots being largely urban areas in some parts of the country. With over 3.5 million cases, the second wave has overwhelmed hospitals and cremation services to tragic proportions, even in the most privileged cities.

Several modelling results for the country as a whole tell us that the worst phase has already set in, shall increase for some more time to reach the peak in a week or two, and decline well into August-September. However, the aggregate national curve hides within it the staggered roll-out and peaks of the epidemic across different geographies. The urban areas where it started early are seeing declines (such as Mumbai and Delhi).

Reported data from 243 districts in the Backward Region Grant Fund (BRGF) scheme show a four-fold rise in cases and deaths compared to the peak incidence last year, and this needs to be multiplied severalfold to reflect the reality on the ground. Bodies floating in rivers suspected to be Covid deaths reveal a horrific story of distress. Predictably, much of the second wave ahead will likely be concentrated in rural and peri-urban populations. Given the lack of supplies, any protective vaccine effect is, in any case, not possible for this second wave. Saving lives is presently the biggest public health challenge.

The courts have stepped in, passing orders and advisories. The Supreme Court’s National Task Force has been mandated with fixing oxygen and medical supplies and the health system’s pandemic response. Its choice of eminent clinical specialists and hospital heads reveals dominance of the image that the saviours are only the high-end tertiary care hospitals. However, data shared by the union health minister shows that only “1.34 per cent of the active caseload is in ICU, 0.39 per cent of them are on ventilators, and 3.7 per cent of them are on oxygen support”.

Besides ramping up these hospital services, how can pressure on them be decreased, and rational care be provided to reduce people’s suffering closer home?

We attempt to set out broad contours of the systems required to get all-hands-on-deck for facing the present challenge of saving lives. An epidemiological and health systems approach, not merely a hospital-drugs-ICU centred one, is crucial. With rural cases accounting for almost half of the daily cases currently, large scale decentralised mobilisation of district health resources – public, private and voluntary – is the need of the hour.

About 85 per cent of the cases have mild to moderate symptoms. Their needs entail basic information, monitoring and psychosocial support through telephonic or physical consultations, an issue requiring attention on a war footing. Despite the huge numbers, it is possible, through ensuring home and community level care for all, especially in slums and rural areas, with referral to appropriate institutions for isolation or hospitalisation as per need. Each district and block needs to be mandated to map and mobilise all its healthcare resources, public and otherwise, supplemented by training teachers and volunteer teams from civil society and community members. Resident welfare associations in cities are increasingly organizing private care at the community level, and such facilities need to be developed on an emergency scale for all. Medication and oxygen hubs at strategic points in blocks and districts can take care of the 15 per cent who move from mild to moderate.

The five per cent who are severe cases can be moved to hospitals. This will mean ramping up all CHCs (community health centres), sub-district and district hospitals and upwards, setting up field hospitals where necessary, with adequate supplies of PPEs, oxygen and respiratory support.

Secondly, popularising rational protocols and evidence-based guidelines can cut down much of the prevalent unnecessary use of medicines at all stages that can be counter-productive as well as financially draining. Clinical information gathered over the past year has provided much improved and simplified regimens.

Thirdly, syndromic diagnosis and treatment of cases, with epidemiological/clinical evidence-based protocols, can be another game-changer. Testing, considered the backbone of a COVID response system, has to be recognised as an impossibility to cover the numbers at this stage. Given the low availability and challenges of accessing testing, with overwhelmed laboratories, and the false-negative results in at least 30 per cent of cases, the fetish about testing has to be given up. Most of the states have laboratories at district towns but nearly none at the sub-district level. For surveillance data and public health planning, positivity rates can provide the basis for making corrective estimates on their testing data.

To operationalise these three measures, a judicious combination of central decision making and operation, as well as decentralisation to local levels, is required. Centralised decisions made in good faith have proved counterproductive without the encouragement to local administrations to interpret and practice rules with contextual flexibility and without fear of repercussion. The decision to restrict industrial use of oxygen resulted in stopping work in the one unit producing a majority of oxygen cylinders in the country when they were the one thing needed on an emergency scale!

Oxygen supplies dropped off the agenda since last year despite the government’s task force itself flagging it, costing many lives. How it happened may have at least two explanations. One, that there was no industry push, as there was for vaccines or drugs and ventilators. Another, that the first world countries did not face it as an issue; thereby it did not become part of the global pandemic control discourse. We have to learn from this fiasco that we must examine our own health systems situation and find our own solutions, not get blinded by international or industry-led priorities.

Transparency with Covid data and communicating all the limitations of available technology is another imperative as it will allow people to realistically understand what we are up against. A wider base of researchers can also delve into the data and come up with innovative solutions.

Three sets of media reports indicate that early warning signals on key areas – epidemic forecasting, genomic surveillance and AEFI (adverse events following immunization) – did not receive the prompt attention and response that they deserved.

The centre should focus on ensuring emergency finances for state-run healthcare, supplies and inter-state movement as also knowledge and research for strategic planning. Decentralized decision making, down to district and sub-district levels, has worked well in states, using a continuum of primary/secondary/tertiary level services, such as Kerala and Chhattisgarh. That provides the way to go for an all-out response. Building such systems will serve us well in the present and future crises as well as in normal times, thereby be the wisest investment right now.

Ritu Priya is a medical doctor, Professor and former Chairperson, Centre of Social Medicine and Community Health, Jawaharlal Nehru University (JNU), as well as former Advisor- Public Health Planning at the National Health Systems Resource Centre, GoI.

Rajib Dasgupta is a medical doctor, Professor and current Chairperson at the Centre of Social Medicine and Community Health, JNU.

Disclaimer: The views expressed above are the author’s own. They do not necessarily reflect the views of DH.