Health care
What the pandemic has taught us?
A pandemic stretches health systems to the limit. Luckily, this Covid-19 pandemic has spared India the worst. We have had fewer infections and deaths than anticipated. What can we learn from the current pandemic?
The Covid-19 outbreak was first detected in China in December 2019. In the first month, it was limited to the province of Hubei. If China had worked closely with the WHO and the international community to stop all travel, into and out of Hubei, the spread could have been contained. For the response to be effective the action taken has to be quick, firm, massive and globally coordinated. A massive response, early in an outbreak, when the seriousness is still not apparent is a hard decision to take. The collateral economic damage and panic triggered by a lockdown compels health authorities to delay firm action till it becomes too late. In the case of China, the political compulsions embedded in the statecraft of an autocratic communist state were an additional factor that delayed the response.
Pandemic prevention pact
Through global multilateral organisations, we need to create a mechanism – Pandemic Prevention Pact (PPP) – to cushion the economic shocks of early pandemic interventions. The political price of not complying with the PPP must be so heavy that countries, in their self-interest, should rush to cooperate with the international community when they detect a disease outbreak. In normal times, such international cooperation would seem unrealistic. But we are just winding down from a pandemic that has caused incalculable losses of human lives and economic activity. This should be sufficient proof of the need for a strict multilateral alerting and response mechanism.
indian response to the pandemic…
Analysing the Indian response to the pandemic is useful to understand what could have been done better. The sudden lockdown was effective because a charismatic and popular prime minister used the media to good effect to communicate the gravity of the situation. But it was brutal for millions of migrant workers. Overnight, daily wage workers lost their jobs and were compelled to trudge home to their villages.
Government reaction to the unfolding tragedy was slow and inadequate. This human disaster could have been mitigated with a better planned and phased lockdown. Government should have instituted mechanisms for supplying free grains and financial support to ensure that no one was deprived of food and other essential supplies during the lockdown.
Aarogya Setu App – a good initiative
Government did a good job providing a steady diet of news and information during the pandemic. The Aarogya Setu app was a good initiative, limited only because public use of the app was not at a scale for the data to generate actionable insight. Daily press briefings were designed to buttress the story of the government rather than to inform and allow critical discussion. India must count itself among the few major democracies that did not muster a panel of reputable scientists – virologists, immunologists and epidemiologists – to stand up and take questions from the audience at these public briefings. Indian media continued to play to the ratings. It was especially disheartening how a religious group was singled out for adverse commentary. Fortunately, it did not spiral out of control at a time when such news had a combustible quality.
Despite the weaknesses in India’s public health infrastructure, we seem to have dodged the pandemic bullet. Therefore it is important to examine and strengthen India’s pandemic response mechanisms and not leave the outcome of a future pandemic to chance.
Governance during a pandemic…
This can be looked at in three parts. The first is the quality of governance when a pandemic happens.
A key aspect of governance is leadership. India needs a standing Pandemic Response Committee (PRC) that can be made operational at short notice. It should have representation from the scientific, medical and administrative cadres, as well as political representation from the states.
Since health is a concurrent subject, each state has its own unique set of policies and regulations implemented during the pandemic. The response to the pandemic across different states was patchy, consistent with the strengths of their respective public health systems. In some states contact tracing, testing and quarantining was diligent and in others, it was a perfunctory ritual. A pandemic transcends state borders and therefore no individual state can customise pandemic rules ignoring what is happening across its borders.
A pandemic calls for strong top-down governance. The coordination between the Centre and states and among states has to be rock solid. A pandemic is not a good time for Centre-state bickering. Rules should be laid down by the PRC, but the implementation of the rules can be left to state governments.
SOP for handling pandemics…
The 19th-century Epidemics Act, which has been continuously tinkered with, needs to be rewritten from the ground up as a coherent document that addresses all aspects of pandemics. One of the tasks for the PRC should be to build a play-book for a variety of different pandemic scenarios. The current pandemic is caused by a respiratory virus. The next one could be an antibiotic-resistant plague. All likely scenarios, including some outlier possibilities, should be studied by the PRC and play-books and models created.
The Epidemics Act needs to define the responsibilities and rights of private hospitals. It should provide fair and equitable compensation for their role in the pandemic so that they are not permanently driven out of business by ham-handed enforcement thrust down their throat.
A key role for the PRC should be a communication plan that ensures clear lines of communication, frequent updates and monitoring of media to suppress rumours. It would be good if an embedded media team within the Pandemic Response Committee attended the meetings or received the meeting minutes promptly, to ensure that reportage directed at the public is accurate and up to date.
Surge capacity
The second aspect that needs attention is to ramp up health care services in response to a surge in demand created by the pandemic. Since it would be too expensive in terms of fixed costs to maintain the PRC permanently, it is necessary to ramp up only when the demand arises. To some extent, this is possible to do so by shifting beds from routine elective care that can be postponed to meet the exigency needs of the pandemic. Besides, mobile capacity (beds and medical equipment) can be kept as standby and airlifted to places where the demand for care during a pandemic threatens to overwhelm locally available capacity. Since space is in short supply it would also be necessary to create and deploy modular pre-fab hospital bed units to places where such demand arises. It is essential to have trained medical staff, cross-training doctors, nurses and other paramedical staff in intensive care, so that they can be redeployed during the pandemic from their routine duties to caring for critically ill patients in acute care environments.
Enable a quick science and technology response
The third aspect of a pandemic response is to curate and build carefully science and technology capabilities. We must build national capability to collect and analyse clinical data from patients real-time during the pandemic. Treatment to be provided in designated centres connected digitally (even if this is only via a smart phone). This will take care of centralising the patient records, at least for all patients needing hospitalisation. This data will be key to understand quickly the behaviour of the new pathogen and using this knowledge to design diagnostic tests and treatments. The governance of product development and approval under these exigent conditions must be pre-determined as part of the play-book for the pandemic. Exceptions can be made for emergency use of tests and treatments.
We often hear on the need to spend more money on health care. We certainly do but the budget for health care should be tailored bottom-up and not top-down. Simply fire-hosing health care with money will not lead us anywhere. Infact mindness spending can have negative consequences. For example, installing expensive imaging equipment in a hospital: this can lead to doctors ordering imaging tests to use the machine to capacity even when the result has marginal utility. Or creation of hospitals in cities where there are already too many of them. Finally even as we plan increases in bed numbers, we must plan for increased numbers of trained staff. This may require training nurses and paramedical staff in basic intensive care so that they can step in when there is a surge in demand during a pandemic.
Redesign of health care must be within the context of the sad fact that millions of Indians do not have access to even basic health care. Thus public health that prevents disease, avoids wasteful expenditure and improves the quality of care for every single Indian is of paramount importance.
– Dr Swami Subramaniam is a physician, clinical pharmacologist and neuroscientist.
