In response to the COVID-19 outbreak, the Indian prime minister called for an early and total lockdown of the country on March 25th, 2020. The early lockdown in India was a promising step because a similar lock down in China had managed to control the outbreak of the COVID-19 virus. The lockdown began to be partially relaxed in phases after May 2020. However, contrary to the expectations, the infections continued to rise unabatedly in India. Our shoulder surgery team operates in two major cities of India: Mumbai (metropolitan city with a population of 20 million), one of the largest Indian cities and Agra (around 200 kilometres from New Delhi with a population of 3 million), another important city that is known for its heritage value and tourism. Our experience with the patchy response by the local authorities to COVID-19 at the community level showed us that we, as a nation, can potentially learn and improve further.
Indian council for medical research (ICMR) is the national body which is responsible for introducing guidelines regarding testing, prevention and treatment of various endemic diseases and pandemic outbreaks. The initial notifications read that asymptomatic patients could not be tested for COVID-19 unless they had been in contact with an infected patient. The limited testing capabilities in the early phases of the pandemic, may have been the reason behind these restrictive notifications. However, in any endemic area, from a surgeon’s and a hospital’s perspective, all semi-urgent pre-surgical patients had to be mandatorily tested for COVID-19. Reportedly, there were risks for a flare-up of an undetected infection and also risks for the infection being passed on to the health care workers. In Mumbai, these initial notifications provided a hindrance in our testing protocol of the pre-surgical patients.
In the months after July, the initial restrictive notifications were not strictly enforced by the authorities, and the hospitals began testing the asymptomatic patients as well. However, the prevailing local diktats in the city of Agra presented severe additional problems. The local administration’s (Agra) instructions dictated that no asymptomatic patient could be tested for COVID-19 from a private lab (only 2 labs for the entire city) unless the patient was already admitted in a hospital. Additionally, the results of the test were available only after 4-5 days as the tests had to be transported back and forth to New Delhi, where the actual testing was performed. This meant that we could not test the pre-surgical patients on an outpatient basis, as was routinely practiced, but instead, they had to be admitted 5-6 days ahead of the surgery, only to get their RT-PCR swab testing for COVID-19, and then sent home immediately after the swab test. Later, the patients would be admitted again a day prior to the scheduled surgical procedure. Intermittently, the labs were even ordered to shut down for political reasons, further complicating our efforts to investigate the patients. For those patients who resided 100-200 kilometres away from Agra, this whole process was a big ordeal.
Finally, we discovered that all hospitals in the region had resorted to a rapid antigen test instead of the RT-PCR to work around these roadblocks. In the smaller cities the problems are compounded by the unresponsive local systems. In essence, these confusing and uncoordinated recommendations are just one of the examples, of how the pre-existent inequities in the socially disadvantaged group, have revealed themselves. At the local community level, the community response depended on the prevailing local culture and understanding, which was out of sync with the broader international norms. Additionally, in the absence of a central co-ordination, each state was laying out their own unsupervised, insensitive and unscientific diktats. Eventually all these missteps may have a potentially negative influence on the community response and their participation.
India needs more locally sensitive, and scientifically guided solutions at the local community level and the small rural city level. Community level working generates local feedback about the disease outbreak pattern and about the prevailing misconceptions and this, in turn, influences policymaking at the federal level. A community level workforce can implement guidelines for self-care and for following preventive measures, by building trust between the various communities and the civil society organisation.
We have an excellent example of how the Centres for Disease Control (CDC) of China with a community level surveillance under a centrally coordinated effort, was successfully able to control the COVID-19 outbreak in Wuhan. The current pandemic should therefore serve as a catalyst for much needed health reforms in India. It’s high time that India should form its own CDC, such as the one in China and in Republic of Korea, which is politically neutral, and which can set up centrally coordinated district and community level CDC offices to enforce the relevant measures and to guide policymaking. In a country as vast as India that has several diversified communities with wide ranging local culture, only a CDC type body would be able to coordinate and effect an active case-finding and surveillance at the community level. India has an extensive network of primary and community (secondary referral) health centres that can be expanded for disease surveillance through real time internet-enabled-system, by enhancing laboratory testing capacities and by manpower training. However, healthcare funding currently is only 3.6 % of the country’s GDP, and health and sanitation is on the state list. Re-structuring the existing organisations will entail massive costs and will also need state support. Local governments support and non-interference is crucial to its proper functioning because we have seen that any political meddling is usually inimical to its purpose.
CDC of United States (US) has been guiding and helping India in its efforts to control various endemic diseases and can help to set up a public health body. However, a pandemic such as COVID-19, needs a pre-existent machinery and an organised community level network in place to manage the countrywide outbreak, because as we know this was not the first pandemic and it won’t be the last.
Dr Dipit Sahu
Dr Dipit Sahu is a Consultant Shoulder Surgeon in Sir H.N. Reliance foundation hospital, Mumbai and Jupiter Hospital Thane. Earlier he has worked, and fellowship trained in 4 different medical systems of the world: USA, France, South Korea and India.
Declaration of interests
I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.