There should be at least one primary health centre and 5–10 health and wellness centres for each of the 198 wards
The current public health efforts in managing the pandemic in most urban areas are similar, with some minor differences. Bengaluru is no exception. In contrast to rural areas, the proportionate number of frontline health workers are not appointed by urban local bodies, and therefore, urban primary healthcare services suffer from a design weakness. Consequently, fewer trained persons are available for carrying a syndromic approach to detect suspected cases, subject them to targeted testing and carry on contact tracing.
In the first wave, this was temporarily addressed by mobilising staff from other departments in Bengaluru, which cannot be sustained when the pandemic rages on for many months. In the absence of such personnel, expanded testing and self-referral were the mainstays of case detection as the cases started surging in April. However, with the increasing workload on conducting RT-PCR in the laboratories, results of the tests could be available with a delay of five days, defeating the purpose of early isolation. Hence, the Government was compelled to decrease the total RT PCR tests to test mostly symptomatic persons and fewer categories. This led to an increase in test positivity in the later half of April from below 10% to 39% by May 5, 2021. At the same time, many persons who are not tested continue to spread the infection. Also, the contagious nature of the newer variant, at least in part might be responsible for the higher number of cases due to population movement.
In this scenario, a complete lockdown in Bengaluru would have helped to reduce the rate of transmission. However, the current mitigation measures (called Janata curfew first and semi-lockdown from May 10) are incomplete and ineffectively implemented. Due to inefficient containment (testing, tracking and treating) and weak mitigation (restrictive measures), the infection has continued to spread unabated resulting in a faster and wider spread.
The capacity to provide critical care to persons with moderate-to-severe respiratory distress is limited in Bengaluru as in other areas. It is mostly the private hospitals that have more capacity for critical care, including ICUs and oxygenated beds, that have surrendered to the extent of 75% to treat persons with COVID-19. Despite this, there are not many beds available for critical care (https://bbmpgov.com/chbms/). Due to ICU beds not being available, not many persons with severe distress can be saved. At the same time, the occurrence of fewer oxygenated beds pushes many persons with mild or moderate respiratory distress to deteriorate towards severe distress, creating a vicious cycle leading to higher fatality. This chain can only be broken if timely oxygen availability is ensured to all persons mild and moderate, preventing them from worsening further. Since the death numbers rise with a lag time from case surges, Bengaluru will see an unfortunate increase in fatality from the current week.
The solutions to address Bengaluru’s problems cannot be transient since this is not the last wave and certainly not the last pandemic.
Fortify human resource
First and foremost, the human resources in all the urban local bodies need to be augmented. In Bengaluru, it amounts to having at least one primary health centre (PHC) and 5–10 health and wellness centres (HWC) for each of the 198 wards. In addition, there should be at least 2 to 3 medical officers and nurses permanently hired in each PHC. At the same time, each HWC should have permanent positions of nurse health practitioner, junior health assistants, also known as Auxiliary Nurse Midwife (ANM) ( one for every 5,000 population) and USHAs (one for every 1,000 population). Hiring them for a short duration and discontinuing them after the wave recedes will hurt their morale and this weakens the health system.
Second, the containment efforts should be strengthened as a permanent mechanism, pervasive and persuasive to withstand the long haul of COVID-19 management. It is time to have a State centre for disease control, an analogous body of the National Centre for Disease Control (NCDC) at each State level to coordinate the control measures.
Third, the surveillance, testing and control strategies should be dynamically updated to guide the implementation in the field. For now, increasing the rapid antigen tests for all the symptomatic persons will accomplish dual goals of earlier isolation of more than 50% of people and reduce the burden on the labs to do the RT-PCR. Even beyond the second wave, stronger syndrome–based case detection and higher testing levels should be sustained to ensure that the signs of future waves are picked up earlier.
Finally, managing the persons with poor oxygen saturation shall be the most critical aspect of managing current and future surge in cases. In addition to setting up newer facilities, the capacity of the oxygenated beds should be enhanced by oxygenation of all the available beds. Furthermore, the Government should set triage facilities having basic healthcare and oxygen supplementation in each of the wards. Doctors and Nurses alone cannot handle the workload during the surge in cases. Therefore, the Government should create a platform to engage volunteers and civil society in handling the supplementary clinical processes to make a meaningful impact. They can help in efficient community triage, prompt referral and offer support to the hospitals to fetch oxygen and other supplies as needed.
The fight against the novel coronavirus is a long-drawn-out battle. The second wave has offered some harsh lessons. While expanding vaccination coverage at faster rate is non-negotiable, the system should learn from the evidence and incorporate changes to combat this better in future. We simply cannot afford to repeat the same mistakes or commit newer ones.
(Giridhara R Babu is a Professor and Head of Lifecourse Epidemiology at the Indian Institute of Public Health, Bengaluru, a constituent institution of the Public Health Foundation of India.)