by Jan Swasthya Abhiyan (JSA) and All India People Science Network (AIPSN)
Two weeks after the imposition of the 21-day countrywide lockdown, India has seen a sharp rise in the number of COVID 19 positive cases and deaths, with multiple clusters of cases emerging across different parts of the country along with substantial local or community transmission (refer the recent ICMR study on patients with SARI). While efforts are being made by the Centre and different States to prepare the health system for the larger number of cases that are expected in the coming weeks, discussions are underway on whether the present lockdown should be extended, perhaps till the end of April.
In this context, a detailed review of the present lockdown, its achievements and weaknesses, particularly regarding implementation, is called for. Any review should take into account both the health outcomes of the epidemic, and the socio-economic impacts, without approaching it as a trade-off of the former aspect against the latter. Decisions on extension of the lockdown in any form should be based on such an evidence-based review.
Humanitarian Crisis Experience of the past two weeks clearly show that the sudden announcement of a nationwide lockdown with no notice, and poor planning for support mechanisms for the vulnerable and even for the general population, has resulted in a humanitarian crisis of enormous proportions. There is a serious threat of widespread hunger, unemployment and poverty, which will, in turn, worsen the health impacts of the epidemic.
The travails of migrant and unorganized sector workers are too well-known to need reiteration, but it needs emphasis that they face multiple, mutually reinforcing challenges of exposure of infection in overcrowded shelters and surroundings, hunger and malnutrition, and complete lack of cash for daily needs. Desperation of migrants in different parts of the country is becoming increasingly evident, including through mass expressions of anger and frustration, with reports of unrest breaking out over food, violence from shelter staff, and even deaths as a result of the conditions of shelter spaces.
Shutdown of Essential Health Services
Essential health services have been suspended in the name of COVID 19, leading to a threat of increasing morbidity and mortality from other conditions. OPD closures at major public hospitals are continuing, instead of triaging of those coming in with suspected COVID 19 symptoms and channelling their care needs through a separate stream. The lack of public transport to get to hospitals or ambulances for non-COVID 19 patients is now resulting in deaths. Gaps in access to NCD drugs, access to anti-tubercular drugs, access to dialysis services, cancer chemotherapy, pregnancy care, abortion care, contraceptive services continue to be reported. Attempts to convert existing and already overburdened public health facilities into dedicated COVID facilities without alternative arrangement for existing patients is endangering lives of non-COVID patients already admitted in these facilities. Many are not being provided ambulance services to other facilities or even admission at other facilities.
Disruption of Essential Services
Agricultural operations and the entire supply-chain from farm to retail including agroprocessing, impacting hundreds of millions of farmers, farm workers, other workers, transporters and consumers, have been severely impacted, with grim portents for the future. Other essential commodities including medicines are in extremely short supply.
Transportation bottlenecks despite exemptions from lockdown restrictions are strangulating all supplies and the economy in general. Local transport is not available even for basic requirements, especially for the elderly.
Broadly speaking, the main approach of the Central Government and that of most States, has been to deal with the epidemic through a law-andorder lens of enforcing restrictions, leaving all other aspects to work themselves out. It is evident that the supply of life saving commodities whether it is food, water or medicine, or care for stray and abandoned animals, is overwhelmingly being carried out by NGOs and CSOs in several places.
The home delivery of life saving HIV medicines is being done by networks of people living with HIV, often traveling hundreds of kilometres across States. All these underline the need for a re-look at the costs and benefits of the lockdowns, from both epidemiological and socio-economic perspectives.
Health Systems Preparedness
WHO has clearly stated that a lockdown, on its own, cannot be successful in addressing the COVID 19 pandemic and needs to be accompanied by actions to strengthen health systems preparedness and to increase testing, isolation and tracing mechanisms. While some efforts seem to have been made to strengthen health systems capacity in a few states, there is evidence that these actions may be inadequate and belated. For instance, a substantial percentage of orders for PPE, masks, ventilators etc have been placed after the lockdown was imposed, more than two months after onset of COVID 19 in India, and even here, domestic manufacturers face supply-chain and transportation constraints due to the lockdown.
Many doctors, health and ancillary workers have been facing serious shortages of personal protective equipment (PPE), placing their own lives at risk and further lowering the capacity of the health system to respond to the COVID 19 crisis. It is noted that number of tests being conducted has increased after periodic but limited enlargement of criteria on who can be tested, but these still leave the scale of testing far below requirement.
Again, a major constraint is availability of testing kits for both molecular and anti-body tests, with the latter having been ordered from abroad, but not yet arrived in India for roll-out. Controversy over meeting costs of tests by private labs so as to ensure free-to-patient testing has also not been resolved; attempts are being made by the private sector to challenge the order of the Supreme Court for free testing from private laboratories.
There is no transparency on stocks of medicines currently required in COVID 19 treatment protocols, including the availability of sufficient oxygen or indeed of treatment for non-COVID illnesses.
Social Stigma, Police Excesses and Violation of Rights
Stigmatization of many categories of people has become widespread, largely due to the lawand-order approach being taken and severe problems with the public messaging on the COVID 19 epidemic which has only aggravated fear and aversion of ‘the other.” Daily reports of the violations of rights by governments and law enforcement agencies continue.
There have been multiple reports of police using lathis to inflict injuries on persons found on the roads. The use of shame and humiliation by the police such as publicly making people do squat or jumps have become routine, particularly in areas that are ‘sealed.’ Despite the tokenism of calls by the PM for people to clap or bang plates, or to switch off lights and light candles outside to express support for health workers and others in the frontline of the struggle against the epidemic, doctors, nurses and other health-sector workers are increasingly being socially ostracized, stigmatized and even criminally assaulted.
Stigmatization is also heightened by publicly identifying positive cases or even suspect cases under home quarantine. The rush by the Centre and many States to develop and deploy mobile Apps to track positive and quarantined cases, inform others nearby about proximity of such persons etc will not only increase this stigmatization, and possibly even promote vigilantism. It also exposes citizens to dangerous intrusions into their privacy, including far beyond the epidemic, with explicit provisions in many of these Apps to empower the Government to use personal data collected in any manner whatsoever!
Communalization of COVID 19
This public health crisis has unraveled the injustices and inequities that underpin people’s lives, including more recently the extremely communal undertones given to it. While some states have emphasized the importance of not stigmatizing communities on the basis of religion, other states, as well as non-state actors, have used this pandemic to aggravate prejudice based on religious identity and vigilantism against the Muslim community. Any 4 attempt to shift accountability of a pandemic of this magnitude to a congregation of persons is deplorable, and also counter-productive to public health efforts.
Vulnerability of women and children to violence
One of the most worrying aspects of the lockdown in India is the alarming increase in calls reporting domestic and sexual violence. These calls represent the tip of the iceberg, as women trapped in homes with their abusers may not find any opportunity to call and ask for help. Child sexual abuse cases are slowly coming to light. Given the extreme curtailment of movement, girls and women find no respite, affecting their physical and mental health further.
Violence – verbal, physical, psychological and economic – against women and girls within homes and institutions are reported to have worsened due to the lockdown, also leading to adverse physical and mental health outcomes. The National Commission for Women reported a sharp rise in number of cases of domestic violence against women and against children. Reports indicate that the police is even more unsympathetic and resistant to registering or acting on complaints. The safety and security of women in shelters, isolation wards or institutional quarantines needs serious attention, with a recent report of rape in one isolation ward highlighting this.
Recommendations Several States and numerous districts, perhaps as many as half the total, have witnessed low number of cases over an extended period. Several States are also increasingly concentrating their efforts on select hotspots or clusters, and imposing even more extreme forms of lockdowns such as complete sealing even for essentials, again with poor preparation. These trends indicate that a geographically more localized focus may be beneficial. Many states have also asked for a phased withdrawal, with harsh restrictions limited to districts and regions which are more affected by the epidemic. Going by reports of the tele-conference of the Prime Minister with Chief Ministers on 11th April, the country seems set for another 2-week extension of the nationwide lockdown. Unfortunately, this approach has been pushed by several States as well, including those with very low number of cases, apparently motivated more by fear, aversion to risk, and an implicit admission of lack of administrative capacity to handle a calibrated, district-wise easing of restrictions.
JSA-AIPSN strongly urge against extension of a one-size-fits-all nationwide lockdown, and recommend that measures for easing containment restrictions should be based on available data on disease spread, be context specific and based on a real judgement of administrative, logistic and health system capacity in different settings.
We strongly recommend that localized and graded responses to containment based on pre-defined epidemiological criteria must be the norm, rather than universal lockdowns with banning of all socio-economic activity. How the country proposes to deal with the situation after 30 April should also be built into the overall approach.
In order to improve quality of such data for periodic review, surveillance for COVID 19 infections in the community needs to be substantially improved including by institutionally combining it with the existing Integrated Disease Surveillance Programme (IDSP). A COVID 19 surveillance programme can be put into place immediately by reporting presumptive cases from all facilities and extending testing to symptomatic cases irrespective of contact history. If testing kits are a limitation, such surveillance could start with sentinel sites.
Along with this, vigorous identify, trace, test, isolate, treat strategies must be the foundational principles of future control strategies.
Central and State governments should further compile and transparently communicate to the public what control measures are being put in place in different locations, and the data based on which such decisions are based. Sufficient notice should be given before instituting any future control measures so as to allow people to make arrangements for the same. Calibrated easing of restrictions in presently locked down areas should have at its core a humane and people-friendly approach.
These should all be done while maintaining physical distancing and should include
: Gradual restoration of socio-economic activity especially for daily-wage workers, the self-employed and the unorganized sector
Expansion of relief measures to those who are not able to regain full earning capacity
Restoration of essential health services and manufacture related to essential health commodities
Restoration of all other essential services including transportation services Central and State governments must ensure that they deliver on their responsibilities to citizens in a manner respectful of their rights and addressing the needs for essential goods and services, especially the needs of the poor, the elderly and disabled, and other vulnerable sections of the society.
All OPD services of hospitals need to be resumed immediately. An emergency review of the impact of the disruption of health services needs to be done and a plan 6 in consultation with health groups and experts must be expedited for the care of non-COVID 19 patients.
The government response must be framed as a public health response and not as a law and order response for the further successful handling of the COVID 19 outbreak. Excessive police powers must be curtailed and mechanisms for accountability for police violence and abuse must be put in place immediately
Respecting rights and building trust in public agencies and the public health system is the only way that any plan by the government will succeed. Privacy and confidentiality must be maintained whether in lockdown or not.
Immediate action must be taken against incidents of discrimination, and communalism. The advisory from WHO and GOI on this should be followed.
Safety and security of women and children vulnerable to abuse and violence must be ensured. Calls to the phone helpline should be responded to immediately; a local response team including for providing first aid, counselling should reach the survivor and coordinate all necessary steps and requirements as per the needs of the girl/woman.
Facilities of shelter and food provided to migrants stuck in various cities and states requires urgent review and accountability. Measures to repatriate migrant workers and their families to their native villages, in a safe and supportive manner should be expedited.
For further information, please contact: Subha Sri Balakrishnan – 9840260715 T. Sundararaman – 9987438253 D. Raghunandan – 9810098621