A BBMP worker fumigates a building, May 9, 2020. Photo: PTI/Shailendra Bhojak.
I am a proud Bengalurean and take pride in everything that went well and not in the Bengaluru Model, which has been lauded for successfully implementing its lockdown. More than anyone who claimed it, the success belonged to the people of Bengaluru. This is why many people are wondering what had to have happened for the city’s health to take so quick a turn for the worse. Having been in the field, I offer some inputs and potential solutions to prevent mortality as Bengaluru’s novel coronavirus cases surge.
(Editor’s note: The author is a member of the technical advisory group for COVID-19, Government of Karnataka, and a member of the ICMR Task Force working group on surveillance and research.)
First, no city in this world is immune to a surging coronavirus case load. It is also only natural that epidemics in different parts of the country will peak at different times. So a surge was expected in Bengaluru as well. Instead, the timing surprised everyone, and only 10,000 active cases sufficed to trigger panic.
But the surge is not a freak occurrence. There were several systematic problems with surveillance, testing, contact tracing and tracking, which resulted in several missed cases and the virus’s continued spread. The city has fewer diagnostic technicians than are required, so people often wait for more than three hours to be tested.
Next, there is a delay in analysing and reporting the results, often up to five days. In this time, people keep moving around freely, and potentially spreading the disease. Till date, there is no data on how many samples have been collected on each day and on clarity on whether people undergoing can be quarantined until the reports are available.
These issues could be resolved by tracking at the laboratory-level, and sharing information between the Indian Council of Medical Research (ICMR), the Government of Karnataka, state health authorities and urban health centres as soon as a sample is collected.
Teams at urban health centres could then track down the contacts for all persons with both positive and negative reports by distributing the list to each health centre as soon as tests are conducted. This will limit the ongoing unchecked transmission in Bengaluru.
Second, the model that Bengaluru claimed as its own is a micro-version of the Karnataka model. Exemplary leadership by the health department at the state-level led to efforts such as reverse contact-tracing, enhanced testing, survey of influenza-like illnesses and other similarly innovative activities. However, though they worked hard for four months, the public health workers, medical officers and officers in the state health department also had – and have – limited autonomy, fatigue and frequent distractions in the form of reactive measures proposed by the senior administration.
As a result, by virtue of not having strengthening public healthcare mechanisms and workforce, the Bruhat Bengaluru Mahanagara Palike (BBMP) has now having its administrative model tested. The state has designated eight ministers and several senior bureaucrats to coordinate Bengaluru’s COVID-19 response strategy. However, these well-meaning ministers and officers are outside the corporation system and will need some time to learn how it works.
So in the meantime, BBMP should put its in-house expertise to better use, and work against compartmentalisation. Instead of wasting public health professionals’ time by forcing them to report to multiple bosses, BBMP should have them report to a single decision-making entity.
Third, urban local bodies should be helped and empowered to tackle the local epidemic by themselves. All urban areas in India have one thing in common: negligence towards public health. While the coffers of these civic bodies are fed by property taxes, they usually spend little on health-related activities. For example, BBMP spends only 2% of its budget on health and education combined. Therefore, it is ambitious to expect that urban areas will by themselves develop and implement a successful health-delivery mechanism through the course of the epidemic.
In Bengaluru, link workers who were working for public health services earlier were shifted into solid waste management. They should be repatriated to the health department because these workers know everyone in their community. They can be very useful to mobilise people for testing, contact-tracing and tracking. Getting more of them on the ground instead of more ministers and IAS officers to BBMP would be better.
Fourth, while we know the state health department constituted a technical advisory group to generate inputs, it’s not clear where BBMP is getting its public health expertise from. It is unfortunate to see that the corporation spent nearly six crore rupees to set up a ‘war room’ when its own IT wing and a team of public health professionals could have set it up at a tenth of the cost.
I say this with confidence because I’ve seen a wonderful real-time surveillance platform that BBMP public health professionals developed. It inspired the WHO as well as the National Centre for Disease Control to develop theIntegrated Health Information Platform (IHIP), which in turn has streamlined data collection and analysis in India.
Also, it appears the BBMP didn’t consult its own public health team, or other expert groups, before implementing any of its projects. At a time like this, the entire implementation programme should be handed over to the public health department, which also currently handles health surveillance. BBMP also needs to constitute an expert group like the state did.
Fifth, in the face of a surge, the BBMP has to ensure manpower and a logistic action plan is ready by liaising with the state health department and private care facilities. BBMP started responding to the initial surge in cases with poor coordination and by shifting public health professionals away from contact-tracing. On the other hand, the state health department prepared more than 20,000 beds to have centralised oxygen supply and prepared a plan to ready and maintain nearly a lakh beds in the state. The BBMP needs to undertake similar actions.
Six, any city’s success depends on how many deaths are prevented due to both COVID-19 and other diseases. Mumbai has India’s largest urban slum but mounted an inspiring response to the epidemic through hard work, with several course corrections. Delhi had the benefit of being managed by the home ministry. Chennai has been experimenting with transient, alternating lockdowns, and other containment strategies. Right now, Bengaluru doesn’t have enough beds and patients are dying at the doorsteps of hospitals after being denied treatment. There is also a huge backlog of tests to be conducted.
To escape this prevailing situation, BBMP needs to start ‘death audits’ and conduct periodic review meetings to prevent deaths from modifiable causes. The city needs to allocate a higher budget for procurement of oximeters, oxygen concentrators and non-invasive ventilation options like high-flow oxygen. Instead, it squandered the lockdown and didn’t keep enough ambulances and coordination plans ready, and is now resorting to unscientific measures like using mist cannons, purchased for Rs 14 crore. Such actions have sown doubts about BBMP’s current priorities.
Seventh, good governance, leadership and accountability should be the government’s guiding values as millions of lives are at stake. A few simple steps can help. For example, if a person tests positive, information about the development should be provided to the local medical officer, so that they may initiate contact tracing. There is no such system in place at the moment.
There is also a mismatch between the actual number of cases in the ICMR’s list and what the BBMP has been reporting each day. Why? If a list of 1,200 positive cases is downloaded today, the corresponding allocation of these cases to different zones is completed only by the succeeding afternoon. As a result, urban health centre are not sufficiently equipped to deal with day 1’s cases until day 2, and in turn contact-tracing is not done for all patients. As a result, there is a mismatch in the number of cases reported by ICMR and BBMP’s day-wise announcement. To resolve this, BBMP should decentralise activities to the urban centre level, which should be supported with additional human resources.
Indeed, most of these issues can be resolved with training and decentralisation.
Finally, the lockdown’s primary motive was to buy time to plan and hire enough personnel in advance. Sadly, the city has taken only reactive measures, including the day-to-day management of its case load.
Instead, it is time Bengaluru proactively plans and strengthens itself. It is unfair to conduct a retrospective analysis and stop there. We can only hope for positive changes as we move forward. So we hope the BBMP learns from its mistakes and successfully reclaims its model. We, the citizens of Bengaluru, deserve a second chance.
The author thanks Daisy John for her help with proofreading and inputs.
Giridhara R. Babu is a professor at and the head of life-course epidemiology at the Indian Institute of Public Health, PHFI, Bengaluru.