[Long Read] Apprehending A Third Wave: Lessons From The Present And Building Resilience

To face a question paper which can throw new questions, we tell our kids that they need to get their fundamentals in place, else they can’t get past the creativity of the teacher who set the paper. Same applies to every state, every society.

Political executives come and go, but it is the fundamentals of the infrastructure, of governance systems manned by bureaucrats which unquestionably constitute the spine of societal resilience.

Only when society places an equal weight on the creation of this resilience as it places on the evaluation of people they vote for, can one can expect the political executive to be aligned with the expected outcomes (on resilience).

Sizing up the Nation

On a typical day, a government hospital overflows with patients. On any typical day, getting a bed in speciality hospitals like AIIMS in New Delhi or SGPGI in Lucknow means one has to pull in all contacts one has. This is on any given day.

While India has a doctors to population ratio 0.77:1,000 , beds available for Indians is estimated at 0.55 per 1,000 (Brookings Study published in Mar 2020), whereas a WB study quoted in this study reports 0.7 beds per 1000 for India for year 2011 (which includes inpatient beds available in public, private, general, and specialised hospitals and rehabilitation centres).

ICU beds have been estimated at a level of 35,699 to 57,119. In a widely circulated video of Dr. Devi Shetty, this figure is put at 75,000 to 90,000.

The second wave is perhaps our Pearl Harbour moment—not because it hit without warning, but because, like in Pearl Harbour, the warnings could not be processed and sized up in time.

For all governments, this was a 'Titanic' moment. The steel we depended on to declare the ship as unsinkable became brittle in freezing cold waters.

Sero surveys, epidemiology models—there is lot of ground to be covered.

It is sobering that 7.7 billion people on the planet face something which weighs about a kilogram and the best of the brains are struggling to understand and contain it.

As I had argued in earlier pieces (this, this), our broken urban architecture meant we generated or stored our own electricity (diesel generators and inverters), we hired our own security, dug our own bore wells, had our own septic tanks, had private tutors for our children.

The reality of the massive rural-to-urban population flow (estimated above one crore a year) hit us hard when the last national lock down was imposed in March 2020.

This was temporarily reversed and people streamed back to their villages-process which happened over several years just got reversed in few weeks. The size of the possible reverse migration, hence, is staggering.

Facing Uncertainty

Facing a virus has always been a challenge- starting from HIV-AIDS, Ebola, Swine Flu, Avian Flu, MERS etc. We now have yet another zoonotic virus which has brought humanity to its knees.

These all have been in the wild since time-immemorial. Reckless human behaviour has made these jump to homo sapiens.

At the same time, the older economic models where developed countries delegated dirty work to the third-world countries to keep themselves safe and clean has given way finally. Disease, like climate change and terrorism has become global.

From the time in early 2020 when COVD-19 was taken note of, the disease has now overwhelmed India in what is called the second wave.

Contrary to what was understood, the virus has mutated to emerge stronger in its ability to spread faster and in the damage it causes (this Forbes article is very informative).

Immunity escape or the ability of the virus to evade defences is also reportedly increasing.

Despite the scale of devastation, we are still in the process of understanding this virus (WHO’s views on 23 January 20 can be seen here).

Even the most basic facts like how it gets transmitted or what organs it attacks is part of the evolving understanding.

A recent discovery says that the virus is not just transmitted in larger droplets which will drop down and settle (reason why shoes had to be kept outside and after touching any public surface there was a need to sanitise hands), but that it lingers as an aerosol.

So, the mere act of breathing after an infected person has left the space can possibly cause infection.

This also puts a question mark on the efficacy of our primary line of defence-social distancing and type of masks (do gaj doori, mask hai zaroori).

The second wave of the disease struck a state which did not have an election or religious gathering. This accelerated in the last week of March elsewhere and the pace of spread has just overwhelmed almost every family.

This time around, more infected people are needing oxygen support, including young persons.

Though a lockdown is deemed to be a measure of last resort, diversion of industrial oxygen for medicinal purposes will dramatically slow down economic activity, even without a formal lockdown.

The Government and the bureaucracy is wired to respond at speeds which can not tackle events needing real-time response.

Creation of NDMA (National Disaster Management Agency) was a step in that direction. May be we need an equivalent for pandemic management-general public health systems have proven inadequate.

Building resilience

Planning of physical infrastructure is done on statistics. Black swan events usually go unaccounted in planning process.

A pandemic demanding higher hospitalisation will hence be overwhelming, no matter how many beds we create in hospitals. Can optimistic estimates of about 90,000 ICU beds be sufficient for a nation of 1.3 billion?

There is a need to have a graded response to reduce infection numbers that will eventually need a bed in the hospital; a need to create a modular and scalable hospital architecture of which the cot in one’s home becomes an extension.

Our understanding of electricity grids can help us look at possibilities. A grid does not end at the wall socket any more but interacts with our domestic equipment.

This model can help us to create needed resilience and ease demand on hospital beds.

To be able to gain this level of resilience, we can leverage many initiatives which have been implemented.

These will align our fundamentals to meet the targeted objective. The Aarogya Setu framework, CoWin, Aadhaar, Ayushman Bharat need to be aggressively integrated to be able to create framework where every citizen can be taken care of. Connecting every panchayat on broadband gives the needed bandwidth to serve health the needs of every citizen.

Building on Aarogya Setu

Aarogya Setu has given a framework in which almost every citizen can be reached individually. Its integration with CoWin has effectively dealt with vaccine delivery.

Sale of prescription medicines and creation of its log on this platform can go a long way in arresting black marketing of oxygen and specialised medication for COVID-19 as seen in recent weeks.

Handling diseases like TB, for which the government is running a big programme, can also be done on the Aarogya Setu framework. This will integrate the resources better.

Resilient Body

Research shows that immunocompromised individuals are at great risk to these viruses which are not going away in hurry. Building up of long term immunity is perhaps the only answer when we look at the aggressive mutant versions emerging.

Anecdotal evidence reveals that people with healthy levels of zinc and vitamins-B, C and D are able to endure infection better.

Folic acid and iron is given to every expectant mother in the country and fortified food served as part of several mid-day meal schemes—can a similar arrangement be worked out for these nutrients?

This will become our first line of defence.

Communication on the Aarogya Setu platform on the outbreak of diseases, schedule for nutrients etc. can be a value addition to this.

PHC framework and testing/diagnostic framework

The Indian health infrastructure is just not geared for pandemics of this nature. This means, rural India must move to towns and cities to get even basic heath care, further stressing facilities available in urban India.

What Exists

India has about 23,000 PHCs (Primary Health Centres) and 1,46,000 sub-centres catering to about 72 per cent of country’s rural population. Further, India has 1.4 million anganwadis, which are run by 1.3 million anganwadi workers and 1.2 million anganwadi helpers .

Investments have already been made in PHCs and anganwadis. The government is further embarking on major skilling initiatives and reaching every panchayat through broadband internet. These can form the kernel of last-mile health care.

What can be done

Citizens can be given video consultations and prescriptions stored on the Aarogya Setu framework. This can ease lot of pressure on a typical day in government hospitals.

Use of AI and skill-upgradation at PHCs can tackle typical health issues better.

Low cost sensors, AI-enabled robotic diagnostic tools can perform several tests and avoid travel of sick citizens.

Jan Aushadhi Kendras have made access to generics better, may be we expand their reach.

Under AI initiatives of the government, let DST and university research labs create diagnostic tool kits which get taught to our last-mile workers. These tools ideally should be built as an extension of standard mobile phones.

What needs to be done

Testing technology needs further research as rapid antigen testing tends to give many false negatives and RT-PCR in several cases failed to detect COVID-19. Further, in face of such an aggressive disease, RT-PCR has emerged as a very slow test to be of much practical utility.

Complications arise when COVID-19 starts to affect the lungs. It is said that a simple chest x-ray is powerful tool to assess the extent of disease and this along with other symptoms can enable quick diagnosis-faster than RT-PCR.

Mobile/portable x-ray units linked to cloud can perform detailed analysis even with the current state of technology, and can aid in basic classification or first order diagnosis.

Those who can afford can be encouraged to invest in oxygen concentrators and simple Bi-PAP ventilation machines, nebulisers, equipment for measurement of blood pressure, blood sugar and blood-oxygen levels.

With existing technology, their readings can be monitored and assistance given. Essentially, a hospital bed can sit in the house of those who can afford.

Making high quality medical equipment accessible

ICU hospitalisation is a nightmare for many just because of the formidable costs involved. In many cases, a simple BiPAP machine, oxygen and access to medical supervision is all that is required.

This facility can be delivered with the current state of technology to the masses using platforms the nation is already investing in aggressively.

These tools in the hands of a skilled person and guidance of a doctor can manage the cases better and avoid the need of an ICU bed in a hospital.

There is case of encouraging auto industries to scale up production of these machines and reduce the cost.

Similarly, the same industrial ecosystem can be tasked to deliver on intelligent medical equipment for the PHCs and sub-centres. These diagnostic equipment should be linked through BharatNet to one of the Meghraj services. This would be a jewel in the crown in rurban concept.

Connecting the last citizen

Giving portable equipment like mobile phones to ration card holders can be a starting point. A threshold for eligibility can be worked out.

Mechanism for its linkage to data services also can be figured out (something like Amazon Kindle’s global connectivity or ability of a mobile phone to reach out to emergency services).

This device can enable video consultation, track medication issued, help arrest pilferage as the device holder can check medicines issued on his name.

Resilient Tomorrow

Upgraded and integrated PHC-Anganwadi Infrastructure can provide local support in diagnosis, building immunity at hyper-local level, and in surveillance of infectious diseases.

This framework can take care of the State’s outreach and provide superior medical care.

In the event of being hit by a public health emergency, the public health administration can reach out to individual citizens with correct information better, can track issue of medicines and ensure its availability, allow a citizen have access to sound medical advice, enable treatment such that a hospital bed is not needed to the extent possible, and also assist in the management of medical care in the confines of a house.

We have time to prepare for the impending third wave. The temporary structures we prepared in first wave were dismantled as the case load came down; now they should be kept and maintained in place for not less than a year from the pandemic getting over.

As a nation, we need to now inculcate a habit of doing exercises, taking nutrients and constantly remind ourselves that we are adopting COVID appropriate behaviour. May be Aarogya Setu can give that reminder to us daily in an engaging manner.