June is the auspicious month for unlocking in India, it appears. After 68 days of hard lockdown, we began lifting curbs on businesses and activities in June 2020. Now, in June 2021, we are moving towards similar easing of restrictions that were imposed with the onset of a brutal second wave of Covid-19. However, there is a greater sense of caution this year, as the second wave caused infections and deaths in much higher numbers and at a much faster rate than the first wave.
Even politicians, who had triumphantly but mistakenly proclaimed the arrival of ‘herd immunity’ several times before April 2021, now guardedly favour reopening in stages. Delhi announced an opening of industrial and construction activities, while asking others still in confinement to await their turn for early release on grounds of good behaviour. Will it prove to be a short-lived parole, if the cases spike again, or will we move through 2021 with a growing sense of confidence that the term lockdown is permanently relegated to the past?
As we begin to unlock, we need to identify priorities and pathways for continued action to contain Covid-19. There is a lurking danger of post-release laxity in people’s behaviours and reduced rigour of enforcement of regulations that would still be needed. We saw cases go up during June-September 2020, after the lockdown ended and before decline of the first wave began. It is still too early to declare a definite departure of the second wave. For that reason, several steps need to be taken to resolutely end the second wave and prepare for possible future waves. The agility and cunning with which the virus is evolving to hurl more villainous variants at us makes future waves a distinct possibility, if we do not stand steadfast and smart in our defences.
As we transit from a lockdown to a more open society, priorities for action relate to: containment of transmission; early detection of cases and contacts; improvement of healthcare facilities for timely and efficient delivery of needed care and acceleration of universal vaccination. All of these actions are important if we are to avoid a repeat experience of the distressing damage inflicted by the second wave, both in the immediate future that is evolving as we unlock and in the more distant future that awaits us. We need to be guided by the recognition that only an efficient and effective health system can create a strong and swift surge response, to competently counter a public health emergency.
Should we unlock in stages? It would be wise to do so, but not delay it too long lest we suffer severe economic and social damage. So, we need to make it clear to the public that the policy on unlocking is like a frozen carrot — it can serve both as a carrot and a stick. People would be able to enjoy the longed for freedom of movement and socialisation, only under conditions of continued good conduct for several months more. Otherwise, we would create conditions for the virus to regain dangerous dominance. Discipline must be maintained on always masking when out of home. Masking would be needed even at home, if there is anyone else who is clinically suspected or test-proven to be Covid positive and is isolating at home. Low income families must be supplied masks free of cost, by municipal, district or state authorities. Guidance on proper use of masks, their cleaning and disposal must be provided by the authorities, with the help of community based organisations.
Importance of home and workplace ventilation must be emphasised. Crowding in public places must be prohibited. Offices must try to operate with minimal staff on location and a function with a high proportion continuing to work from home. Offices and schools can function in shifts, with restrictions on numbers of persons and attention to wearing of masks and good airflow. Open markets should get priority over malls for early reopening. Cinema halls and swimming pools will have to wait a while. Indoor restaurants too should be eligible for opening later, after at least four weeks of observation provides assurance that unlocking is not leading to a rise in infections and evidence that active cases are decreasing steadily.
Identification of infected cases cannot be left only to the persons self-reporting for testing. While testing rates need to be high, availability of timely tests will be uncertain in small towns and villages. Further, tests of viral detection are known to have false negative results, depending on timing of the test and the technical competence displayed in the collection, transport and lab storage of the nose or throat swab samples. Primary healthcare teams, supported by citizen volunteers and community-based organisations, should conduct regular household surveillance to check for history of suggestive symptoms, contact with a diagnosed or suspected case, and recent travel to places under containment.
Tests should be performed on the basis of these eligibility criteria. Since Rapid Antigen Tests (RAT) are now being preferentially performed for speed of processing, repeat tests may be needed over a few days if the initial tests are negative. This is because of the lower sensitivity of these tests than the RT-PCR tests, which have a longer processing time. When tests are negative in a person with high clinical probability, the rationale for advising isolation on other diagnostic criteria must be clearly explained. The weekly mean growth rate of cases (rise or fall) must be one of the trackers in the population, as test positivity rate is vulnerable to time-to-time variations in testing rates, repeat testing in same individuals, use of different testing methods and prescribed eligibility criteria for testing. Genomic analysis of at least 5% of all positive samples must be performed in every state to track the spread of known and emerging variants.
Timely and assured health care provision is the legitimate expectation of any infected person. The obligation to provide such care does not fade even when cases are falling. Mildly ill persons must be provided monitored home care. Primary health care teams, of Accredited Social Health Activists (ASHAs) and Anganwadi workers, must form the frontline team. Citizen volunteers can add strength to these teams, after a short period of training. Checking for fever, pulse oximetry readings and symptoms must be performed by these teams. Tele-health services, by doctors and trained medical students, can provide support directly to families and to the frontline health workers for monitoring progress and guiding care. Emergency transport services must be available on call, with fit-for-purpose ambulances stationed in close locations. Persons showing clinical features of severe illness or impending deterioration must be transported to a hospital where assured admission will be available for advanced care. The government of Haryana has recently launched the Sanjeevini Pariyojana in Karnal district, incorporating these features in an integrated framework. Kerala already has a well-functioning system of integrated health services.
Hospitals must be well-equipped to deal with Covid cases that will continue to demand care even as the second wave is declining. Temporary hospitals that have been recreated during the second wave should not be dismantled till we can confidently assess the timing and severity of a third wave. These hospitals may be kept in a functional state by treating other conditions as Covid cases decline. Paediatric care facilities, including intensive care, would need to be enhanced to handle possible increase in younger patients in a third wave. Though severe Covid illness in children is infrequent, a surge in total cases can still swell the numbers of those who need hospitalisation. Augmented paediatric care facilities would be useful for other childhood illnesses too, even when Covid ceases to be a threat. Shortages in oxygen, medicines, equipment must be avoided through better planning and procurement than we saw in the second wave. The speed with which states unlock will also depend on their confidence in the ability to meet the home and hospital care requirements, should the cases spike again.
Vaccination must pick up pace across the country. Vaccine production and procurement must be ramped up. Cost and technology should not become barriers for universal adult registration and vaccine administration. Vaccines must be provided free, by central and state governments. Persons who do not possess smart phones, or are unskilled in their use, should be assisted for registering and receiving vaccines. Vaccine confidence must be built by engaging community networks as trusted counsellors.
Even as states start to unlock while keeping a vigilant watch on Covid resurgence, they must turn their attention to the task of meeting the many other health needs of the population. Many of them were neglected due to the focus on Covid in the past 16 months. Recognising that public health and healthcare systems are crying out for greater investment and strengthening, states must commit to increasing health financing for augmenting infrastructure and expanding the health workforce. Health promotion, disease prevention and integrated surveillance systems must become high priorities of health policy. Public health expertise must be promoted, for both field level action and problem solving research. Creation of state-level public health cadres is a long-pending action that must not be deferred further.
As we unlock in stages, we must ensure that the needs and concerns of the vulnerable sections of the people are addressed with unwavering commitment to equity and social justice. These include several groups, ranging from the poor and migrants to disabled persons, tribal populations and minority groups. We must unlock our social solidarity, while expelling prejudice, discrimination and indifference to fellow human beings. When we leave our homes and re-enter the social collective, it is not just our lungs but also our minds that must breathe fresh air.