March 29, 2020

Weekly Update on Covid-19

Below we publish the Situation and the Peoples Health Movement response issued by Jan Swasthya Abhiyan (JSA) and All India People’s Science Network (AIPSN) on March 24,  2020

1. Community Transmission of the coronavirus seems to be very possibly well underway and India is now in what was being referred to as stage 3. While there were clear weaknesses in containment during stage 2, notably delays in restrictions on air passengers entering India and weaknesses particularly in effective home quarantine measures, community transmission was almost inevitable. Containment could only slow down the spread, not prevent it.

2. We are concerned that the government has not kept the public informed. Part of the problem is that they are limiting announcements of cases to those which have a laboratory diagnosis of Covid-19 disease. But since testing has been very low, the numbers of positive cases announced are also very low. India however has an influenza surveillance system that reports Influenza like illness (ILI) and Severe Acute Respiratory Illness (SARI) which continues to collect data. We believe that this system is reporting a peaking of such illness cases which, implicitly in the current context, are likely to be Covid 19. These reports were in the public domain previously, but the last report now publicly available is of February 23rd. The possible reason for this is may be to prevent panic. However, problem with this approach to data is that it leaves all health care providers across the country unprepared to protect themselves, or to ramp up preparations for the coming surge of cases. It also keeps citizens in the dark and conveys a false sense of security. As a result, we have numerous reports of suspected Covid patients reporting for testing at health facilities but there is currently no segregation or separate patient flows for them. Thus, hospitals could themselves become a major source of spread of infection. There is an urgent need to a) improve provisions for handling Covid 19 patients in the out-patient wards and bring out protocols within the next couple of days and b) re-start putting up district level information in ILI and SARI as reported by healthcare facilities through HMIS in the public domain, c) provide district level information on Covid-19 cases. This would not only help the public, but also the entire preparedness of the healthcare system.
Our working group on health sector preparedness is constituted and would be writing to the government on this. Additionally, at every district and state level we can also intervene with health department.

3. Our appeal to the government is:
Keep the public informed. We will help you with containing the panic. Please make use of all civil society organisations but especially the people’s health movements, science movements, all trade unions and working peoples organisations to help control panic and help implement what is required now- which is “ISOLATE; TEST, TREAT and TRACE supplemented by social distancing”. This cannot be done without very wide support and trust of the people. We, in the people’s health movements caution that lockdowns and social distancing while necessary, are very temporary, inefficient and incomplete solutions and should not be projected as the main approach to responding to the epidemic.

4. This week begins with news that the government has placed a large order for personal protective equipment (PPE), ordered over 5000 ventilators, instructed hospitals to prepare to deal with the expected surge and has started district focused containment action. Every one of these is a step in the right direction. We also note that the DG-ICMR has promised in his press briefing of March 22, that we would be increasing the capacity for testing to over 60,000 tests per week. We think that this should have been started two weeks back, but as they say, better late than never. Better information could have enabled more area-focused lockdowns in identified “hot spots”. However we also caution that even these numbers still appear to be too little. . At the minimum testing should include all those in whom Covid19 is a clinical differential diagnosis, as well as extensive testing in select sites (called sentinel surveillance) that would help us understand the proportion of asymptomatic, mild and severe illness in different states.

5. We are concerned that the government is still on a learning curve in many of these areas, and may recognise the bottlenecks in commodity manufacture, procurement and management only after they encounter it. We in the people’s health movements and science movements along with organisations of working people have set up a working group of those who have long struggled to convince the government to develop Indian manufacturing capacity and trade policies which are consistent with the needs of Indian health security, self-reliance and sovereignty. They know the barriers to procurement that are going to rise and how imports from developed nations are going to become very difficult and unaffordable.
This working group on testing and treating would be issuing advisories to the government, informing the public on developments in these areas, and its members are available to help state and central government at a short notice.

6. We are also concerned with information of serious deficiencies in the way isolation and quarantine and social distancing are being practiced and imposed. In many contexts because of inability to ensure home quarantine, institutional quarantine should have been considered. There is also a major problem related to human rights. Even in non-authoritarian governments with a liberal understanding of human rights and ethics, at such times abuse of rights are bound to occur and can only be ameliorated by taking feedback and listening to civil society organisations, with a tradition of working on such issues. This is not only for ethical reasons; it is essential for effectiveness of strategies. To give a few examples – people alighting from Mumbai or Delhi airports are stamped to signify home quarantine, opening the door for stigmatisation which WHO has warned against. But they may have a full day of travel ahead to reach their homes and can often afford only public transport for that purpose. Or for example, filing FIRs against persons suspected of breaking home quarantine. Or use of unnecessary physical force for isolation or denial of healthcare by hospitals. The range and instances of such abuse multiply. If not quickly curtailed. it is going to lead to families and even communities losing their trust and confidence and lead them to hide their illness and exposure history. It would also lead to huge often panic-driven resistance. Government needs to create and keep channels open for the feedback.
Our working group on physical distancing and quarantine would be bringing out information on this in a weekly manner and sharing this with both government and civil society.

7. Even on social distancing, isolation and home quarantine, the bulk of current messaging addresses only the upper middle class and elite, the same social strata to which administrators and political leaders in decision making belong. They completely miss out and could be irrelevant to the poor and the majority of working people and their families. The messaging also conflates isolation (that only some people can pursue), home quarantine (effective only where public health infrastructure and house-to-house follow-up is strong), and social distancing (which in many situations is more a desirable than feasible solution and on which we cannot have too much expectations). Social distancing messaging should not become an opportunity for blaming the people for the epidemic in their communities, nor shift accountability to the community. And this is said without in any way diminishing the responsibility that individuals and families have in protecting themselves and in preventing further avoidable illness and deaths.
Our working group on community mobilisation would be developing and would keep updating advisories in this area to meet the needs of the different sections of working people. It would also build the largest possible coalition to take such information to the people. It would be active in organising different forms of community support and solidarity.

8. We also have great concerns regarding the lock-downs. One set of concerns is regarding ethical and rights abuses. Another is on the duration and extent of lockdowns and the lack of evidence to guide such lock-downs. Further, lockdowns were announced in many areas without due notice, leading to panic-buying and mass outmigration of unorganised sector and labourers back to their villages in far-off areas, exposing them to infection in over-crowded trains and buses on the way, and to further infection dangers in rural areas with already weak public health infrastructure. There is need for clarity by the government on the criteria for lockdowns, and assessments that will be done to open the lockdown. The overwhelming public health opinion is that we are in for a long haul and even though the disease may subside within a period, there is all possibility of its coming back. Measures such as suspending out patient departments, people not being able to reach hospitals due to shut down of public transport and so on can have disastrous consequences. Therefore government needs to seriously develop protocols for review and assessment of lockdowns. The most important concern is the huge, devastating economic consequences of such lockdowns on the lives and livelihood of the majority of the population and mostly on the poor, the marginalised and those living on the brink. The country was already going through an unprecedented economic slowdown, loss of jobs and incomes when this crisis happened. And huge degree of handouts to the corporate world and financial capital had weakened the ability of the government to respond to the crisis. Public expenditure on education, healthcare and social welfare had already been compromised and these three sectors heavily privatised. This pandemic is thus a disaster coming on top of a system that has been pushed to the brink.
Our working group in this area is working with the people’s science movements and movements of working peoples to articulate the nature of State action as well as community action that is required to prevent and mitigate the social and economic crisis that this pandemic brings about.

9. As we go to release this statement, news comes in of the 21-day nation-wide lockdown that the government has announced. We are seriously concerned that the government is promoting and pushing lockdowns and social distancing as the only effective method against the pandemic, when the evidence points to social distancing being one among many actions that governments must take, it may be necessary but in itself not sufficient. On lockdowns the evidence is far from clear, and we know that nations like South Korea and Taiwan have done well without lockdowns. We are appealing to the government to learn from the wide testing, isolation and tracing done in South Korea, and in all successful national control efforts. At best lockdowns buy time for governments to ready their health systems. It is in the latter than the government must focus. We are also appealing to the government to plan its lockdowns based on good quality data of where the disease is spreading and focus its actions in such districts or states, instead of shutting the entire country down. We are concerned at the highhanded and violent methods adopted by the police and bureaucracy during lockdowns rather than a much needed empathetic attitude. We are also most disturbed by reports that many essential health services including outpatient services and other health programmes such as TB, HIV and maternal health services could be affected by both the lockdown and diversion of all resources and attention and efforts to this one disease. Moreover there is absence of any economic and welfare measures for daily-wage earners, unorganised sector workers and out-of-state migrants. The net deaths due to all these collateral effectors of the lockdown may outweigh the limited advantage lockdowns can provide.