“The safaiwallahs are not being allowed to move out of their colonies and garbage is accumulating.”
∼ Panicked message on the WhatsApp group of a housing society
There is a concept in medicine called ‘essential medicines’. Its roots lie in the basic tenets of medicine, which the World Health Organisation has articulated as patients must receive the right medicines, in the right doses, for the right duration and at the lowest cost to patients and the community.
Achieving this is not as easy as it may sound. A physician may prescribe the medicine appropriately, but it may be too expensive for the patient to afford, may not be available nearby or may be available but of poor quality. One of the ways to achieve the rational use of medicines was the concept of ‘essential medicines’.
In 1977, the WHO came out with a model list of essential medicines, defining them as medicines “that satisfy the priority health care needs of the population”. The first list of essential medicines contained 208 drugs, and the WHO proposed that these “could provide safe, effective treatment for the majority of communicable and non-communicable diseases”.
Since then, this concept gained widespread acceptance, and more than 150 countries developed their own National Lists of Essential Medicines (NLEM). Not only that, NGOs and agencies like UNICEF have used these lists to improve their work on medicine supply. The WHO website states,
“Essential medicines are intended to be available within the context of functioning health systems at all times in adequate amounts, in the appropriate dosage forms, with assured quality, and at a price the individual and the community can afford.”
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This is a dynamic process, and the WHO list is revised every two years. The first Indian NLEM appeared in 1996, and the latest 2015 edition has 376 medicines on it. The list is currently being revised – a huge task in which multi-disciplinary teams of specialists evaluate the evidence for inclusion or exclusion of each medicine. Most experts agree that such lists help in improving quality, access, procurement and distribution of medicines, besides resulting in cost saving for patients.
Can we apply this strategy to the ongoing coronavirus pandemic to prepare a list of essential workers?
First, a bit of history. “New York in peril of epidemic from garbage”, ran a headline on July 1, 1907, as garbage collectors went on a strike. Within a couple of days, the city was in a horrible state of filth and stench, expectedly.
Contrast this with the bankers’ six-month strike in Ireland in 1970: people made cheques by writing on toilet paper and the backs of cigarette boxes, with a surprisingly modest adverse impact on the economy.
According to the International Labour Organisation (ILO), essential services are those, “the interruption of which would endanger the life, health or personal safety of the whole or part of the population.” Some typical examples are health services, sanitary services, fire services, water services, electricity services, and telecommunication.
However, in each of these services, there will be some employees who are “essential” or “core” and some who can be called “complementary”. Again, this is borrowing from the WHO essential medicines concept – the list is divided into core and complementary items, a major difference being that complementary drugs require additional infrastructure (trained healthcare providers or special equipment), whereas core medicines can be used without additional requirements.
Take the example of healthcare. If I ask someone not associated with healthcare, they are likely to say doctors and nurses are essential workers. Some would also add lab technicians – after all, they process and analyse patient samples. Others would use the generic term ‘paramedics’. Let me give three examples. A dialysis or an X-ray technician, coming to the patient’s bedside; a physiotherapist clearing secretion from a patient’s lungs; and a ward attendant changing the patient’s soiled clothes are all essential.
Nevertheless, it would be inappropriate to say that all the staff in a healthcare facility are essential. For example, staff in the administrative section, or the academic section of a teaching hospital, or the accounts department may not be needed in the “core list”, and some of them may be added to “complementary list”.
On the other hand, there are some who are not healthcare workers but are no less important – suppose a ventilator malfunctions, or the Hospital Information System breaks down and the physician is unable to access patients’ reports online. An engineer and/or technician will be needed. They will be essential. Furthermore, a hospital attendant who cycles 10 km to work may require repair of a punctured tyre, but the roadside bicycle repairmen aren’t there. Surely, they must be included in at least a complementary list.
Then there are many people involved in the process of supplying medicines from manufacturers through dealers to the hospital. Are they essential?
The WHO prepared its model essential medicine list after consultations across specialists, super-specialists and other stakeholders; the list contains medicines from all disciplines. Similar lists of essential or core workers as well as complementary workers can be made in each of the essential services before the next pandemic.
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Event 201 was a simulation of the coronavirus pandemic by the Johns Hopkins Centre for Health Security with support from the World Economic Forum and the Gates Foundation on October 18, 2019 in New York. Although the Event did not predict the pandemic, they did discuss how various agencies should react if such a situation arises so that socio-economic consequences can be minimised.
PREDICT-2 was a US Agency for International Development Emerging Pandemic Threats programme; it supported major work related to pathogens, ecology and epidemiology around the world, with more than 60 countries participating in capacity building and strengthening surveillance of pathogens. Unfortunately it was closed, ironically just prior to this pandemic, probably making predictions even harder.
This pandemic will pass. But another one may be around the corner. Let us be prepared. Let us have a list of essential workers, nationally, worldwide. The WHO model of essential medicines provides an excellent benchmark. The ILO or the UN have the means to do this. Individual countries can tailor the list to their own requirements, much in the same manner as the essential medicines list. Global solidarity and collaboration are required, especially for future epidemics, as Yuval Harari points out, preparing a List of Essential Workers can be one such effort.
But then there is the equally important question of who need not be part of the essential list of workers. Take a moment to imagine who can be left out. Now, go back to read the historical comparison of the strikes of garbage collectors and bankers. Now, think of more examples of who can be left out of the list and jot them down. Finally, in your thoughts, compare the salaries of essential workers mentioned above in the context of healthcare and non-essential workers you have jotted down. Should be an interesting comparison!
Samir Malhotra works at the Post-Graduate Institution of Medical Education and Research, Chandigarh.