Responding to COVID19 in resource limited settings like India – questions and suggested approach

By Dr. Santhosh Mathew Thomas

Much has been written and shared about COVID19 and ongoing responses. But mostly from places where the epidemic is quite advanced and more so, from resource rich contexts, struggling to contain and mitigate even with all their resources. The resources they have is not enough for the numbers they are facing. The resource limited nations thus far have much lesser numbers than the richer and developed nations. But for health care professionals in such contexts, this is not a time for complicity, but a time to refocus and reorganize for when we would face similar or many more numbers of patients with much lesser resources to respond with.

This article considers some questions that health care professionals in resource limited settings and developing nations need to consider as we look ahead, with a lack of clarity, to what the future holds for COVID19 pandemic.

Most of our nations are in lockdown. Experiences from countries that acted early and tried to contain the epidemic, show that population wide measures do play a major role in containing or suppressing the epidemic. But there are alternative opinions too. A leading epidemiologist from a developing nation made this statement:  “Suppression is not going to work in a nation like ours. In an organised society, where food can be delivered into each house, it is possible. In our nation, suppression would mean hurting each other, exploitation, giving power to wrong kinds of people. That is not my response to a public health emergency. Community participation is. And community participation and suppression do not go together.” One might agree to disagree on this but nations need to find the best solutions they think will work and act on it. And most nations have acted, and we need to support the actions our nations have committed to.

As health care professionals, we need to reflect on the potential impacts of such solutions and prepare for the same. Lockdown for 2 to 3 weeks in contexts where basic food security systems are not in place, public food distribution systems do not optimally function, where majority of the community are informal work force on daily wages, where safety net for health is not there, what would the impact be?   Chronic illnesses that need regular prescriptions, ante natal mothers who need their regular check-ups, children who need their immunizations etc, when the health care system itself is in lockdown for regular services, what could the long-term impacts be? What about the mental health related impacts on the population? What would happen in such challenged situations to the vulnerable, like the elderly and disabled? We need to think and reflect how we can mitigate some of these today, as we struggle with containing the pandemic. We need to be ready to address the impact of these issues as they come up in the future.

What can we do today? Some thoughts to consider

1. We could explore permission from authorities, for medical out reaches for ARI and other – as community clinics?
2. Through various social media and other local channels to communicate about the need of protecting the elderly and other vulnerable.
3. Explore working with the state authorities for food supply through the PDS systems
4. Train people in counselling, so that there is a group ready to support post lockdown.

As far as the epidemic is concerned, we might end up with a contained or partially suppressed epidemic through these measures, but what would the it be like after these measures are shifted? We need to use these lockdown days, when the pressure on health care systems have been eased, to reflect and reimagine a world after such a lockdown. Thinking and planning how to reposition, how to reorganize our own lives, our institutions and our systems for a tomorrow when we might face numbers and health care contexts that are much different from what it was a few weeks back.

WHO Secretary General in his press briefing yesterday, highlighted a few pertinent issues the nations should doing amid these lockdowns. He said, “as you buy time, and reduce the pressure on health systems they alone will not extinguish the epidemic”. He asked nations to use this as a second window of opportunity to do 6 key actions.

1. Expand, train, and deploy your health care and public health workforce
2. Implement a system to find every suspected case at the community level
3. Ramp up production capacity and availability of testing
4. Identify, adapt and equip the facilities you will use to treat patients
5. Develop a clear plan and process to quarantine contacts
6. Refocus the whole of government on suppressing and controlling COVID19

Very pertinent actions that if we get our act together and implement, by the time the lockdowns are over, we might be ready for the long haul of fighting this pandemic.

But it is important to understand that in many of the resource limited and developing nation  settings, the nation and public health care system do not and will not have the capacity to move and act in a war footing with these 6 actions. With less than 2 to 3% GDP as health care budget and the economy being adversely impacted by the pandemic with no resources to draw on, what would these nations do?

This is where we as the larger community of health care professionals need to reflect and consider, what roles we can play, in supporting our nations to move in these directions or alternative directions as the context might call for.

Every one of us, will need to be educated and educate each other in basic principles of disease control and prevention. We need to talk the public health language to each other every day. We need to encourage each other to prevent, mitigate and care. We need to come alongside communities when the lock down loosens up or even today through alternative ways and spread the sane messages of prevention.

What can we do today?

1. Teach and build capacity of all HCWs in COVID19, and related respiratory viruses, public health perspectives and communicating the right message
2. Create alternative communication materials and methodologies to share messages of prevention and mitigation

What does it mean to be sane voices and messages of prevention and mitigation? Where there is lack of running water, where in a single room 4 to 6 people live, where daily life is linked to the daily wages people earn, what would be those messages that make sense? Can we quarantine contacts the way developed nations did? If this is not the feasible solution, what lifestyle and practices would we advise that will limit spread but will not disrupt the family?

What can we do today?

1. Start communicating about simple ways of respiratory hygiene, buckets and water outside every room,
2. Help creating face cover with ordinary cloth at home and use it if people have ARI,
3. Encourage people to spend more time outside in the fields than inside the house together and other ways to protecting each other?

Would we ever be able to implement a system to find every suspected case at the community level in settings where health care systems are far from optimal? If that does not happen, what would it mean for us? What would an alternative way of empowering the communities to move into a lifestyle that protects the vulnerable elderly of the community?

What can we do today?

1. Start preparing to teach and train families on how to protect and care for the elderly and other vulnerable
2. Encourage families to use simple protective and preventive measures

Would such nations be able to ramp up production capacity and availability of testing? If such a context is impossible, what would an alternative diagnostic protocol look like? How will we plan to diagnose and treat every ARI and SARI, as a potential COVID19 or other similar viruses? What would it mean to our regular systems of care and treatment?

What can we do today?

1. Start working on simple clinical protocols for all ARI and SARI
2. Start implementing and setting up systems of an ongoing ARI clinic that will continue even after the epidemic
3. Start relooking at out IPC systems and train and teach HCWs to implement these systems

What would it mean to identify, adapt and equip the facilities you will use to treat patients with COVID19? Where for millions of populations there are no centers for critical care, no ventilators, would the state put its act together and respond? After 20 years of MDR TB, most nations still do not have systems for caring for the same. After 40 years of HIV/AIDS epidemic, most state-run institutions do not admit or manage HIV/AIDS patients. Can we really expect “state of the art systems” to take care of COVID19? What would an alternative system look like? Would the system have the capacity to buy and supply PPES and other requirements, or what would an alternative PP system look like that is cost effective at the same time efficient?

What can we do today?

1. Start setting aside a ward or a few rooms for ARI, SARI management
2. Come up with clinical flow charts and protocols, adapted from emerging evidences that are relevant for rural context
3. Come up with alternative ways of doing PP, – cost effective and efficient with local materials
4. Start teaching and training teams to set up systems and be ready

Will the whole of government refocus on suppressing and controlling COVID19, if the pandemic becomes an endemic, it continues for a few months? Even if it wants to, can it do by itself without the rest of the civil society coming along side?

What can we do today?

1. We set up the above systems and then offer to the state our availability to be part of the response

This is where we as the larger body of health care professionals need to come alongside our nations, the public health care systems and try to make a difference to the challenges our nations face. Our call is to bless our nations! Can we be blessing to our nation’s efforts?