A medical worker, carries an oxygen cylinder on his shoulder while a COVID-19 patient is carried to the ICU a hospital in Bhagalpur, Bihar, July 27, 2020. Photo: Reuters/Danish Siddiqui
The second wave of COVID-19 is currently rampant in India. A temporary dip in the number of new cases in January and February this year led to an inflated and erroneous sense of triumph. The quest to bring the economy and lives back to normal was extremely rushed.
In Bihar, one of India’s poorest states and which has a very fragile health system, the number of cases dipped to as low as fewer than 50 a day in January. Even before that, the state had surprisingly been spared the worst of the first wave, except for two months of chaos in July and August. At various points during the first wave, experts repeatedly said something worse was around the corner, but somehow that never came to be.
The surprise is warranted because of how many systematic opportunities Bihar presented, and still presents, for an infectious disease spread to blow out of control. The state was one of the biggest hosts of migrant workers due to the countrywide lockdown last year. The first major election in India during the pandemic was conducted in Bihar, and the election rallies that followed stumped the experts and observers threw caution to the wind. Next came Chhath Puja.
There were concerns about the integrity of the data that the state was sharing and whether peripheral health facilities were misreporting or underreporting the extent of the ground situation. Nevertheless, life started to return to normal earlier this year, with economic and educational activities being restored.
In the wake of this miracle, experts (and non-experts) began advancing theories about what could have protected Bihar – including higher immunity due to repeated exposure to many infections in the past, herd immunity, lower vulnerability due to its younger population and the extent of its rurality. Whatever the reason, the Bihar paradox seemed to be real, and invited further investigation.
Then came the second wave, and submerged the paradox. The number of new COVID-19 cases daily surged to more than 12,000, plus more than 50 deaths. The actual number of cases may be much higher, thanks to the fact that test results have been delayed. The trajectory of cases in the last few weeks indicates the spread is expanding at an alarming velocity. The limited capacity of the health system and perennial issues like leadership, management, skills and centralised decision-making together make this fightback more challenging. So exceptional planning and action is required, and the state must at the same time focus on prevention and control.
Prevention and control activities need to be scaled up. The challenges of managing crowds is easier in Bihar due to limited industrialisation and economic activity; but the focus in particular should be to restrict activities in hotspots. Next, to prevent the spread of infection in rural areas, the government should ensure compliance with restrictions in rural markets as well. The quarantine of incoming migrants from higher caseload states needs to be robust and efficacious. Strict enforcement of COVID-19 appropriate behaviour and ramping up of mass education to educate people on right behaviour should be urgently addressed. The existing strong network of field-level workers and Self-Help Groups should be mobilised for this key initiative, but only after proper orientation and by ensuring an appropriate standard operating procedure.
Vaccination drive in the state should be undertaken at war footing. Bihar was the first state to announce free vaccination for all, so the focus should now be on universal coverage of eligible population. The state machinery must leverage the long experience of mass vaccination campaigns, such as polio eradication. The experience of engaging multiple non-health system stakeholders in mass vaccination planning should also be harnessed to ensure equity and risk stratification in a vaccine.
Management of COVID cases would essentially require focus on minimising the three major delays. First, the delay in detecting, isolating, and contact tracing should be addressed urgently. Strengthening lab capacity, deputing adequate human resources, and providing them on job online training are reliable options in this direction. Second, minimise the delay in patient’s transportation to an appropriate place of care. Decentralised health care by strengthening COVID treatment centres in each district, deputing adequate human resources, and on job capacity building training of health workers are some of the actions which should urgently be prioritised. This is ideally a time to reinforce the referral transport by making them readily available and easily accessible is equally vital.
The third most important concern is minimising delay in delivering necessary and adequate treatment. This one is the most critical challenge and requires a radical approach for effective resolution. Here, the focus should be on optimising the limited resources by acting upon them judiciously. A big challenge is to ensure the continued trust of health workers working in the system. Bihar has witnessed unprecedented cases among healthcare workers leading to fear of infection among them, thus optimisation of their services, facilitating appreciation, and more importantly allowing them a protected environment at work should be the utmost priority. We should not forget that dispirited warriors cannot win a war.
To ensure these solutions, an urgent mini system reboot is required. Decentralise the decision making by constituting an empowered COVID-19 action group with a multidisciplinary team of experts at the state, regional and district levels. Similarly, an exclusive group should be empowered at larger health facilities. These groups should be authorised to take rational decisions. And given the limited resources, the state must actively seek support from the Centre to organise financial and other resources.
These are just a few quick fixes. In the long-run, the state must prioritise holistic health system reforms.
Dr Vikash R. Keshri is a medical doctor, public health and health policy specialist. He has long experience of working with Bihar’s health system. He tweets @docVRK. The views expressed here are the author’s own.