Covid Has To Be Fought In Communities, Not Hospitals

Mumbai: The number of cases of the novel coronavirus are surging in cities like Mumbai. In Dharavi within Mumbai, the count is higher than in entire states like Bihar and Karnataka. As we move towards the end of the lockdown, what is going to happen? Will the hospitals and the healthcare system manage the caseload that will definitely increase? How will they continue to grapple with the continued load of COVID as well as non-COVID cases, which are also now likely to surge? We speak to Nachiket Mor, who, until recently, was the country director for the Bill and Melinda Gates Foundation. He has earlier served on the boards of the Reserve Bank of India and CRISIL, and was also formerly the deputy managing director of ICICI Bank.

You are working on a concept called the ‘empowered community’ concept, which you believe is the only way to gear ourselves and not to depend on the hospital or the public health system.

Clearly, it depends on what we think is going to be the trajectory of the disease and what kind of a health system we want to build as we go forward. These are kind of twin goals that we have to keep in mind. There is one point of view which suggests that maybe India is different, things will even out more quickly, the rates we are seeing are more modest—they may well be right and I really hope and pray that is right.

Whatever I understand, though, says there is nothing about the virus to suggest that Asians, Indians, or hot temperatures are in any way doing anything specific to halt its spread. My understanding also of the idea of flattening the curve is that it does not actually change the area under the curve, it allows us more time to respond but it is entirely possible that the virus will continue its onward march and will give us the kind of numbers that we have been told about at the beginning of the pandemic.

There is some evidence from elsewhere in the world that when they tested for antibodies, a large number of people that had been infected but did not actually know it were detected. In any case, even if we actually have the experience at the end of the day, two years later, that the numbers were modest and we needn’t have been as worried, I would argue better to over-prepare and find yourself somewhat embarrassed than be under-prepared and find that you are losing lives and unable to cope because now your system is flooded.

Particularly, if that response also helps prepare a health system for a longer-term future that is separate from COVID. If I look at the experience of the European countries, particularly Spaniards, Italians—the Italians have written about this quite a bit—is that as the case load went from 10 to 10,000, even a well-prepared health system like Lombardy in Italy got overwhelmed. Not only did it get overwhelmed, the hospitals became the place from where the infection started to spread. It became the hotspot, rather than being the place where it got contained or you left after getting better. In a very passionate editorial, doctors from Lombardy write that they erred in treating every patient as an individual patient, not recognising that each patient was from a community, from a pandemic. Health workers started to get sick, transportation workers started to get sick, ambulance workers started to get sick because they were following a model that was appropriate if there was just one patient with one disease, not this larger problem.

The direction I suggest is a complementary approach to what the current approach is. The current approach is very much about hospitals, ventilators, central quarantining, trying to build social distancing with lockdowns, and such like. To build something that can perhaps survive us and last for a longer time, is to start engaging the community much more actively right away. Because communities are not homogenous entities, you have to work with them, stay with them and start to do two levels of things. One, make sure that the message you are communicating is really being heard by them. Even today surveys are showing that while we in cities with a flood of television, flood of news, are perhaps well aware of what is going on, as you go further and further away from the so-called centre, you start to see a dissipation of knowledge and information.

This disease has one particular characteristic that I think is very important to be extremely conscious of: while anybody can get infected, the mortality profile changes quite steeply once one crosses the age of 60. There is no real cure, no real possibility of keeping the virus out even of very strongly controlled environments such as South Korea, Japan and Germany. So we have to find a way that people who are above the age of 60 are protected. And rather than a diffused message to say that everybody must be protected, everybody should wear a mask, everybody should wash hands, we need a much sharper message that 60-year-olds and above need protection much more carefully, they may need protection for a longer term.

Let us talk about the number per 100,000. You say 10-20 is manageable with our existing health systems including hospitals and nursing homes, but the moment you touch 50 in any place, you are beginning to lose control and that is happening in cities like Mumbai.

Fifty is what I am seeing from the Mumbai experience, there is some anxiety that Mumbai is running out of capacity at 50. Lombardy ran out of capacity at 300 per 100,000. It is still a little bit of a distance depending on what you count as your doubling rate, etc. We could get to 300 in the not-too-distant future.

And this is 300 intensive cases, we are not saying anyone who is infected.

No, this is just benchmarked against total infection, not severe cases. Because the belief is, if you have a 100 cases, then 80 will get OK on their own without too much effort, 20 will need attention. We have to examine how those 20 are distributed, so that we are clear about what we can do with the 20, and how we can get some improvement there.

You also argue that we should not be buying expensive ventilators or investing in too many intensive care units, as that is not going to solve our problem.

We should do that as much as we can. But the evidence we are seeing is the following: A) Out of the 20 people that are needing severe attention, almost 15-16 people, or 75-80% of those 20, are going to be needing oxygen capability, not ventilator capability. And that capability of oxygen can be provided in non-ICU, non-critical care settings, not necessarily needing all other paraphernalia of the ventilator structure. Now, the four or five that do need a ventilator, unfortunately, whatever evidence again we have so far--though new data could change that--is that a very high proportion of those, somewhere between 80-95%, do not make it.

So really, the question that you have to ask yourself is: if you are planning an overall exercise of where to invest resources, certainly the ventilators are going to be important for a portion of the people. But investing in creating a far wider and much cheaper oxygen capability; now I understand that from the people that need oxygen, a reasonable proportion, maybe about half need simple oxygen capability. They do not even need complex machines. Put a cylinder, put a valve and give people a modest amount of oxygen. There will be a group that will need more oxygen, more attention but while I am not saying that I can do it in a street corner, you do not need heavy infrastructure. More importantly, you can do it closer to where the patient is, rather than transporting them to locations where, on the way, they have the risk of infecting a number of people and exhausting the resources of the hospital that are needed for intensive care cases.

Right, that is something else that other epidemiologists have been pointing out. What is going to happen as we start lifting the lockdown because we will see a surge and then in the Western part of the country and cities like Mumbai you will have the monsoons coming and that brings its own set of diseases. So, tell us about empowered communities. How will an empowered community work?

I will give you a concrete example. I have been in dialogue with the Ambuja Cement foundation. They have a fairly big reach, they are a mature NGO working for years in various catchments with a fairly large catchment population. In my view, what they have done is almost textbook. They have gone out there and made sure that they have fully counted everybody that lives and works in their catchment area. They have identified the high-risk candidates with co-morbidities, old age, etc., and targeted them for special attention, special phone calls, making sure that they are OK, making sure that the families are aware what their issues are, they are well supplied with protective gears, so that they can make sure that the senior citizens are well taken care of. Then they have gone out there to assess their resources, their preparedness in case the crisis gets out of hand. Are there isolation capabilities?

I was talking to somebody else in Odisha in the tribal belt, another primary care provider. She is working towards making sure that there is an isolation hut in every village. Now that is something that the empowered community can do. In crowded areas there is another group that is working to figure out how you do that in Mumbai slums or villages that are densely populated.

This disease does not transmit through the air or through mosquitoes, it transmits through droplets. What you can do is build collaborative arrangements. Four families get together; one of the rooms is identified as an isolation room or one kholi as an isolation kholi, and the other members are in the rest of the homes/space. Because this disease has a unique characteristic that is different from others that allows if you have a simple wall, you can manage. We have the tradition, in many parts of India in the summers, to sleep outside on the roof; see if you can use that as a way to manage your isolation.

Another very important step that they are trying to take is to identify the healthcare providers in the vicinity and assess their preparedness. What is their phone number, what is the setup of the clinic, do they know how to manage all the various kinds of protocol?

The patient comes in, I do not know if he is a COVID patient or not, he is coughing, maybe he is not even coughing, maybe he has shown up with fever. So how do I organise my clinic so that there is a preparing section, there is an upper respiratory tract infection section, how do you manage the queues in the open air, outdoors?

And then a conversation about what would these primary care providers like to do as they move forward? Particularly smaller clinics, nursing homes, maternity homes—would they be interested in upgrading their capabilities to add on some oxygen capacity, simple oxygen capacity with cylinders and such like, adding an oxygenator—is that going to make sense? There is an organisation called Basic Healthcare Services in rural Udaipur. They have gone ahead and kitted out their clinic with oxygen capabilities because they do not know whether the person has COVID or not. If they see somebody getting hypoxic, they can start to respond fairly quickly. Some people might be willing--small, maternity homes may say they want to go one step further, to build and install a Rs 90,000-95,000 machine called the High-Flow Nasal Cannula machine with a helmet to prevent the transmission of the disease. That will of course need permissions from the government and all of that. I think this is a useful kind of investment to make for the future of the primary health care system. So, in my mind, that is what an empowered community approach would look like, in which in community after community, you are identifying community leaders or community-based organisations who can follow a checklist of four or five things to do in the neighborhood and to really take charge of the people working there. Because this crisis is not going away soon, it may be 12-18 months even when you are still grappling with it. You will have to return to normalcy, but there will be things that you have to do differently.

How can this be replicated in a highly congested city like Mumbai, where you have a population of 20 million and maybe one apartment complex has 400 families?

Clearly there are limitations, I am not saying everything can be done. But finding ways in which you are bringing care closer, building isolation capabilities closer, trusting communities to work—this is what the Italian experience was. The doctors say in so many words. Do not transport these people, treat them in place, stay there, bring treatment to them rather than shift here and there, because we do not have capacities in a central place and the central place is becoming a source of infection. And people feel more comfortable if they are with people they recognise and understand. The disease is going to spread anyway, no matter what you do. The sense that we have that somehow, we can contain it, is not consistent with the nature of a respiratory virus and the kind of social distancing that is feasible for a country like ours. Which means we have to be mentally prepared that the infection will be there. What we have to decide is what we want to do about people that need attention.

The empowered community approach is trying to do this in collaboration with the community, not in conflict with them, not by forcing action on them that they are not comfortable with. Something that they feel much more satisfied.

What can an individual do? How can one contribute to the creation of this empowered community?

My understanding is that the community is an amorphous idea and somehow in our mind we think lakhs and lakhs of people. In your own housing colony, can you sit down and take simple steps about what to do with senior citizens? What is the action plan if tomorrow something goes wrong? Do I know where to go? What happens when the hospital that I am supposed to be sent to does not have capacity? What is my plan then? Do I know a local primary care provider, do I know a local facility that can do this, can help me out? Am I well-equipped to understand all the pieces that are necessary? Housing societies are doing it but somehow the emphasis seems to be on preventing people from coming in and going out, etc., rather than sitting down together and seeing what is the action plan as things move forward, when the situation requires attention and support from neighbours and the community.

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