Dear Dr Harsh Vardhan,
The ongoing second wave of Covid-19 in India with over 3.32 lakh new cases counted in the last 24 hours is extremely concerning and demands imperative and urgent action. This is necessary in the immediate term as well as through longer term preparedness to mitigate the current medical and humanitarian crisis and to prevent its further escalation. We, concerned public health practitioners urgently request the Government of India, particularly the Ministry of Health and Family Welfare to implement the following without delay.
1. Implement mitigation measures to reduce infection transmission and fatalities due to Covid-19
There is an urgent need for interventions at both state and district levels to facilitate easy accessibility to data about available medical facilities and then to actively ensure measures to minimise fatalities while providing humane care.
a) Maintain a real-time dashboard for available beds (with categorisations of ICU, non-ICU, oxygen and ventilator supplies) and transport facilities to ensure seamless movement, which providers and users can access through apps, websites, and functional toll-free helplines. Strengthen this service by appointment of designated nodal officers for better coordination and accessibility at least at each municipality/sub district level, towards improved and coordinated Covid-19 response measures as well as to address public grievances and gaps in services.
b) Ensure that once a patient reaches a government facility, there is no turning away for lack of beds. Using the dashboard, and public ambulances, the government must take the responsibility to transfer the patient (at no cost to them) to the nearest appropriate hospital bed that provides free care. This would save lives and reduce transmission enormously.
c) Create guidelines and enable States to take over private health facilities to provide Covid-19 care and treatment.
d) Expand designated Covid-19 care facilities for isolation of asymptomatic and mild symptomatic patients so that all those who either cannot isolate at home and/or are willing for institutional isolation, have access to the requisite space and care. Create community isolation facilities with the standards/infrastructure for these with state provided medical, food, social, and emotional support.
e) Provide tele-medicine facilities for patients who are isolated at home, and ensure they are well-briefed about home-based care and the know-hows of their treatment. Provide free food rations for them during their home isolation.
f) Ensure adequate availability of oxygen, ventilators and intensive care under trained doctors, as well as access to steroids and other drugs as appropriate.
g) Ensure adequate supplies of oximeters, thermometers, soaps, sanitisers and masks for all patients irrespective of socio-economic backgrounds or geographical locations, with accessibility at least at panchayat level. Convert community halls, hostels, hotels, etc, to Covid-19 facilities with adequate human resources and PPEs.
h) To address the shortfall of oxygen, step up creation of in-hospital oxygen plants in large hospitals, introduce oxygen concentrators widely – in addition to improving oxygen cylinder and tank logistics. In addition to this, the industrial use of oxygen needs to be curtailed to the absolute necessary level across states and the oxygen should be diverted to medical use in public and private hospitals.
j) Pay fair and regular remuneration to Accredited Social Health Activists and other frontline workers who are being engaged for Covid-19 related work with all protective measures.
2. Provide clear treatment guidelines
a) Update treatment guidelines based on current evidence. The Drug Controller General of India must revoke permissions or emergency use authorisation of drugs or treatment regimens that have been proven to have not worked.
b) Ensure transparency of details in the public domain about rational treatment protocols for Covid-19, information about what medicines, therapies and procedures that work or have been effective in care and treatment as well as what does not work for Covid-19 patients.
c) Provide such details in multiple languages including media that are accessible to persons with disabilities
d) Provide clear guidelines and information on common post-Covid-19 conditions and the care that is required to address them.
3. Improve vaccination efficiency and equity
a) Scale up the pace of vaccination in terms of procurement, availability and distribution.
b) Bring the vaccine under price control so that the vaccine manufacturers sell them to all at a uniform cost and enforce price caps for vaccination in the private sector.
c) Place vaccines outside patent regimes, ensure sharing of technology and rope in more manufacturers to produce them. India has the capacity to do this. Profiteering by the pharma companies in such times has to be condemned and stopped. Vaccines should be distributed freely to all, as public funds have paid for it.
d) Ensure adequate physical distancing at vaccination centres. Simultaneously, ensure there are adequate efforts towards public health messaging so as to increase public awareness for vaccination and to tackle vaccine hesitancy.
e) Scale up facilities for treatment of Adverse Events Following Immunisation. A vigilant adverse event recording post vaccination and making the data available in the public domain.
f) Ensure free vaccination for all, and prioritise the vulnerable populations for Covid-19 care including vaccinations free of cost – migrant workers, daily wage labourers, sanitation workers, essential service workers, people in informal settlements, homeless persons, sex workers, incarcerated persons, people in mental health institutions, people living with disabilities, people living in rural, peri urban and tribal areas, reporters and others who do not have the luxury of completely avoiding crowded spaces.
g) Develop outreach programs to reach the most vulnerable groups who are at a higher risk of infection and transmission.
4. Conduct adequate gene sequencing
There has been a lot of confusion and miscommunication about the role of the variants, including the ‘double-mutation’ variant, in this latest surge in new Covid-19 infections. However, with the rapid pace at which this peak has arrived as compared to the peaks last year, it is crucial that there be more publicly available data on mutants and gene-sequencing. There has to be adequate encouragement from the governments to identify variants of interest, establish the extent of their spread and their role in the current surge of cases, and advise on how this information should guide action.
5. Focus on public health messaging
a) Revise information, education, and communication material to ensure that they are based on a good evidence-based understanding of the determinants of Covid-19 appropriate behaviour in different sub-groups. And that they incorporate an appropriate communication strategy and messages to secure the behaviour change.
b) Launch a sustained high visibility campaign against all forms of stigma and denial of the pandemic, especially the sense of shame and guilt associated with getting the disease, and build trust to enable effective and timely contact tracing and quarantine.
c) Provide clarity on preventive practices, when to test, self-isolate, home treatment, and when to call a doctor. This must also be duly accompanied by free and regular provision of masks, soaps and sanitisers, especially for underprivileged socio-economic communities, through mechanisms such as the Public Distribution System.
d) Reiterate public messages on the need for and the right ways to wear a mask, wash, and maintain physical distancing. This may not be possible for a large number of people who live in extremely cramped and harsh living spaces and conditions, necessitating the need to create appropriate alternative spaces that are accessible as and when required.
6. Avoid compromising on non-COVID-19 care:
Ensure continuity of non-Covid-19 care including for maternal and child health immunisation, abortion services, non-communicable diseases, tuberculosis and vector-borne diseases. The shutting down of outpatient services and non-emergency surgeries in these times only puts the patients in more distress. There are a large number of best practices that demonstrate that Covid-19 care can be integrated with non-Covid-19 care, and shutting down any essential healthcare service is neither desirable nor ethical.
7. Provide full rations
a) With curfews and/or curbs on working hours, it is imperative to continue provision of social security measures like the public distribution system for the public. The Pradhan Mantri Garib Kalyan Anna Yojana must be extended and universalised, with 5 kg of additional cereals per person, 2 kg of dal, and 1 kg oil per month to all families, even to those without ration cards, for at least the next six months.
b) Ensure the regular provision of meals (hot cooked or dry rations) under Mid-Day Meal Programme in Schools and Supplementary Nutrition Programme in Anganwadi centers.
We request your urgent attention to the appalling and worrisome situation right now. We anticipate that you will take the necessary urgent measures to address this crisis and to prevent further loss of health and lives.
Sarojini Nadimpally, Former Member, Mission Steering Group, National Health Mission and Former member Expert Committee of National Human Rights Commission on Covid-19, year 2020
T Sundararaman, Global Coordinator, People’s Health Movement and Former Executive Director, National Health Systems Resource Centre
Sulakshana Nandi, State Convener, Public Health Resource Network, Chhattisgarh
Deepa Venkatachalam and Neelanjana Das, Sama Resource Group for Women and Health
Priyam Liz Cherian, Public Interest Lawyer