COVID-19: Moving from flattening the curve to a pandemic resilient nation

The nation cannot afford the psychological and economic toll of heavy restrictions on the population at large

By Raghu Murtugudde
Published: Monday 04 May 2020

India has received high praise for managing a billion people in the early phase of the spread of the novel coronavirus disease (COVID-19), starting with the first official case on January 30, 2020 followed immediately by airlifting Indians from Wuhan on February 1.

Several actions — such as airlifts from other countries, airport screenings, visa and travel restrictions, one-day curfew and a three-week lockdown — continued to be implemented. The three-week lockdown was subsequently extended as testing increased substantially.

An app called Arogya Setu was launched by the government with features such as the COVID-19 risk to the user, self-assessment tools, safety tips and COVID-19 updates.

The process has not been completely smooth though, in terms of internal migration due to the sudden lockdown and ensuing economic hardships. Some relaxations of the lockdowns have begun.

The big challenge of moving from the stage of stopping the spread and flattening the curve, focused on the entire population, to a phased-return to a fully functional nation requires a clearly defined roadmap.

The nation cannot afford the psychological and economic toll of heavy restrictions on the population at large on its workforce, educational institutions, domestic and international travel and economic activities.

Any action plan to return to normalcy also has to be nimble enough to treat this as an adaptive management problem with a learning-by-doing approach. Quick returns to stricter lockdowns at local and regional scales may have to be implemented if there are new hotspots or clusters of COVID-19.

Harvard University’s report on the roadmap to pandemic resilience released on April 20 is designed for just such a return to normalcy but focused on the United States. Many of the steps developed in this roadmap are of direct relevance for India which can serve as a starting point to be adopted to the Indian context.

A national plan for return to normalcy must ensure a pandemic resilient citizenry and economy, with functional exchange of people and goods in the global economy.

The most important step in the roadmap to resilience is seen as Testing, Tracing, and Supported-Isolation (TTSI). Restrictive lockdowns have to be eased by a massive upscale of testing.

A new study just released by the Indian Council of Medical Research (ICMR) lays out a series of steps to accomplish such an upscaling. The team relies on engaging multiple institutions in India with related facilities, increasing working hours for the testing workforce and testing methodologies to accomplish a substantial increase in testing.

A critical assessment of the daily tests needed — as the phased relaxation is rolled out — is necessary. The ICMR study estimates the public sector could scale up to 120,000 tests per day. If more are needed for ending lockdowns, then private sector participation may have to be invoked.

Materials, facilities and human resources are needed and the overall costs of increased testing, tracing and isolation are expected to be lower than the economic bleeding that is underway in a full lockdown.

The biggest challenge of phasing in sufficient relaxations to mobilise the economy is meeting the need for massive testing of millions of people per day to avoid re-imposing stricter lockdowns on wide scales in the absence of reliable data for hotspots.

Various levels of testing may be needed for the larger uninfected population versus the frontline doctors and nurses, health workers, police and essential workers who are exposed routinely.

Support for isolation must also consider novel provisions for job protections in addition to providing economic and healthcare assistance. How to ensure compliance on such support for isolation from private sectors requires a pre-emptive approach to appropriate legislation and financial incentives.

Contact tracing has to be just as meticulous with isolation facilities equipped with medical and other support to manage the economic and psychological burden of those isolated. The challenge of infected but asymptomatic people has to be managed by random testing that constantly identifies these silent carriers.

The scale of testing, contact tracing and isolation facilities also has to be efficient at early detection, effective at surveillance and at imposing rapid containment measures at new hotspots and clusters.

The implementation of such a system must ensure communal harmony, equal access and protection of privacy.

The sheer magnitude of the population combined with the different religious, cultural and ethnic mores must be kept in mind while requiring compliance to testing, tracing and isolation as eventually, even social distancing will have to be removed for full functionality.

It is unclear how research, development and technology transfers will occur in the global context even as the COVID-19 crisis is still underway and in the post-COVID-19 world as well. India, however, needs to consider relevant innovations in testing methodologies and approaches beyond those suggested by the ICMR team.

Manufacturing of PPEs also need to meet the demand for the foreseeable future. Self-sufficiency for the country may become more critical than ever in the healthcare industry.

New governance structures for testing, tracing and isolation — from the national to the tehsil and panchayat levels — will need to function smoothly. Codification of testing, tracing and isolation for uniformity is important for avoiding miscommunication and gaps in implementation.

Additional training of frontline workers and healthcare and community workers can be implemented through existing mechanisms under the Department of Health Research.

A new workforce will be needed for massive testing and contact tracing as well as for managing isolation centers. New legislation may become necessary for protecting data gathered for contact tracing from commercial exploitation and identity theft.

The new infectious disease centre that was proposed must manage data during the return to a pandemic resilient India. Infectious disease forecast activities that are being run in an ad hoc manner must now be brought under a national umbrella to maximise their utility for managing the return to normalcy.

Their role in monitoring and early detection of new hotspots and clusters can also be rendered most effective when they are integrated with data gathering and curating efforts despite their limitations

The huge investment needed in this effort should be strategised for a long-term pandemic resilient India, since the next pandemic is likely to assault the country anytime. Sustaining a workforce trained and deployed for transitioning out of the current lockdowns, along with infrastructure, is thus a priority.

Routine gathering of health data internally and scanning the horizon for emerging infectious diseases are critical for early detection and prevention. Jurisdictions over data gathering, curating, quality control and visualisation — including data security — need to be well defined.

The current transition and future pandemic resilience can only be accomplished by focusing on the differential risks faced by different sections of the population.

Risk is a function of the health hazard, socioeconomic vulnerability of a particular demographic and their exposure to the hazard.

No matter how elaborate and efficient the pandemic resilience infrastructure, the last mile to reach from the tehsil or panchayat level to households often requires foot soldiers who are best provided and managed by qualified non-governmental organisations (NGOs).

They must be made fully transparent and any distrust between the governments and NGOs must be greatly alleviated for the sake of the country’s pandemic resilience.

The private sector has faced a perturbation that could not have been imagined just a few weeks ago. The government can aggregate lessons learned by all sides and develop a level of public-private partnership that also could not have been imagined a few weeks before either.

India can become truly pandemic resilient for the foreseeable future only with all the sections of the society, industries, and the government working together.

The timescales of this transition will also require close consultation between the government at central and state levels, as well as the private sector and frontline workers.

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