Representative image. Photo: soham_pablo/Flickr, CC BY 2.0.
The announcement of a 21-day nationwide lockdown by Prime Minister Narendra on March 24 was indicative of the fear and suspicion of community transmission of SARS-CoV-2, in view of the sudden upsurge of new cases in the preceding days. It is expected to buy us precious time by slowing down COVID-19 growth. But while we talk of using this span for preparing our health services for tackling an increasing influx of COVID-19 cases, we tend to ignore another imperative: averting a rural COVID-19 outbreak.
A subtle theme of India’s anti-COVID strategy thus far has been of largely limiting the virus to urban regions – home to most imported cases and their contacts. The lockdown offers no guarantee for the same, and experts have already forecasted that the viral scourge is likely to stay around for much longer. This fact, along with people scrambling to return to their native-lands in the days preceding the lockdown, offers the prophecy that a devastating rural spread may not be a distant possibility.
Risk communication includes assessing local knowledge levels; disseminating risk information and advice suited to the context; and listening and acting to local concerns and problems, including rumour-mongering – with an intention to align community behaviour with practices desirable during an epidemic. Clearly, risk communication and resultant behavioural change are the substratum of an effective epidemic response and will determine how far control measures, including lockdowns, will be successful. As COVID-19 threatens to overrun hinterlands, it will demand overhauling of the current strategy which is designed largely for urban consumption and attuning it to rural needs.
Multiple related issues have already been raised, including how rural and peri-urban communities can minimise COVID-19 risk in view of threatened livelihoods, and their lack of luxuries to practise hygiene and social distancing. In addition, even a modest percolation of the viral threat into these areas can engender a spate of superstitions, distorted perceptions, and resultantly, stigma and panic. The modes of rumour mongering in these areas can be totally unresponsive to urban techniques like cyber-policing. Transplantation of rather alien etiquettes and practices could face resistance due to cultural redundancy. The modes of risk communication hitherto envisaged can prove ineffective, demanding deeper and more meaningful community engagement for furthering crucial measures to control the epidemic.
The importance of a decentralised yet integrated approach cannot be overemphasised here. Rural local bodies should be empowered for and galvanised into risk communication and containment activities, and an earmarked budget must be assigned for the purpose. Various influential sections of the community, including religious entities, untrained medical practitioners and healers, and community-based organisations must be co-opted. Untrained practitioners must be involved in tasks such as responding to initial signs of an outbreak and pouring into a common referral pathway, embedded firmly in the overall control strategy. Health system preparation, including bolstering referral arrangements, actuating telemedicine facilities, and shifting bureaucratic workload of frontline staff, has to ensue alongside.
The importance of highlighting these steps lies in three things. First: our frail healthcare capacity isn’t nearly capable of handling a rural deluge of COVID-19 cases, which therefore needs to be averted as far as possible. Second: the current and any future lockdown will owe its success considerably to effective risk communication. And third: that the current lockdown provides an opportune window for envisaging or reinforcing such steps.
An important ingredient for the success of measures like lockdowns will be strong public confidence in the government’s approach and intent, which will require effective public engagement. The current government approach of abruptly enforcing an otherwise much-needed lockdown, without first securing enough public confidence except from a thin urban stratum, trivialises this aspect. This could beat the purpose of the lockdown – particularly given our weak capacity to monitor it and penalise transgressions. Deficient risk communication and public engagement can instil suspicion and resentment towards what could be perceived as heavy-handed measures insensitive to the plight of the poor.
The element of temporality becomes all the more important here. What if we need to further extend the lockdown? And what if a series of such lockdowns are needed at intervals over a long period? These are very realistic possibilities with COVID-19. Mobilising public cooperation for such scenarios will be both crucial and challenging.
Logistical and infrastructural constraints militate against the hope of successfully confronting a possible rural amplification of COVID-19. There is critical need of acting in wise anticipation. There is need for strong public engagement and bolstering of the risk communication machinery in all its aspects from funding to skillset, directed particularly at the vast non-urban population. This will have to be complemented by relief and income support provisions like cash transfers.
Cultivating trust among the public will be instrumental. Emerging cases of dismal conditions and practices in medical facilities, stigmatisation in the name of COVID-19, and coercive approaches to behavioural change will need to be tackled with dispatch. The government’s transparency with respect to information sharing would also be crucial. More and frequent high-level public engagements akin the PM’s address to the nation will also be essential for mobilising solidarity.
Dr Soham D. Bhaduri is a Mumbai-based doctor, healthcare commentator and editor of the journal The Indian Practitioner.