The HINDU Notes – 25th March 2020 - VISION

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Wednesday, March 25, 2020

The HINDU Notes – 25th March 2020

📰 As COVID-19 toll touches 10, PM announces 21-day lockdown

Govt. allots Rs. 15,000 crore to beef up infrastructure for treatment of patients

•As the death toll from COVID-19 rose to 10, Prime Minister Narendra Modi on Tuesday announced a 21-day lockdown for the entire country, stating that it was the only way for the country to break the chain of infection. The lockdown will be in effect till April 14.

•In a nationwide television broadcast, Mr. Modi said the pandemic was a huge challenge to every country and even countries like the U.S. and Italy, considered to have good health infrastructure, were struggling to control the situation.

•“In such a situation we have learnt from the experience of the countries that have managed to get some control over the surge in cases, and these show that a lockdown for a sustained period of time is the only way to break the chain of infection,” he said.

•India on Tuesday recorded 564 positive cases, with the number of positive patients in Kerala and Maharahstra crossing 100.

•Stating that it was the priority of both the Centre and State governments to set up health infrastructure as fast as possible to deal with the pandemic, Mr. Modi said the government had allotted Rs. 15,000 crore for the purchase of Personnel Protection Equipment for healthcare workers, setting up testing laboratories and quarantine centres.

•“Draw a Laxman Rekha outside your house door and do not step outside of it. Stay where you are. This will be the decisive battle against coronavirus,” he said.

•Sounding a note of caution, he said: “If we are not able to adhere to this lockdown sincerely for 21 days, believe me, India will go back 21 years.

📰 States must facilitate media outlets to fight fake news: govt.

Ensure smooth supply and distribution chain, says directive

•In a bid to fight “fake news”, rumours and speculation that have been doing the rounds on the social media in connection with the COVID-19 outbreak, the Union Information and Broadcasting Ministry has issued directions to all State governments to facilitate functioning of all print and electronic media outlets.

•In an order issued on Monday, the Ministry has said proper functioning of the media network is essential to create awareness among people, to disseminate important messages and also keep the nation updated on the latest status. “False and fake news need to be avoided and good practices need to be promoted and these networks play a pivotal role in ensuring the same,” the Ministry said in its directive.

•The Ministry orders come in the backdrop of the lockdown across the country limiting the movement of people and shutting all institutions and offices. Issuing the six-point directive, the Ministry has said all operators and their intermediaries should be permitted to remain operational.

•It has urged the State governments to facilitate “smooth supply and distribution chain”.

Provisions facilitated

•The media facilities should be permitted to be manned by the staff of the service providers.

•“The movement of the accredited staff of service providers be permitted; the movement of vehicles carrying media persons and others including provisioning of fuel may kindly be facilitated,” the order says.

📰 U.S. could become virus epicentre: WHO

Trump says he wants to reopen the country for business in weeks, not months; U.K. enforces lockdown

•The World Health Organisation said on Tuesday that the U.S. could become the global epicentre of the COVID-19 pandemic.

•Britain joined the ranks of countries in lockdown to try to hold back the virus, and data showed business activity collapsing from Australia and Japan and Western Europe at a record pace in March, with the U.S. showing expected to be just as dire.

•But amid the gathering gloom, the Chinese province of Hubei, where the virus was first identified in December, said it would lift travel restrictions on people leaving the region as the epidemic eases there.

•Confirmed COVID-19 cases around the world exceeded 3,77,000 across 194 countries and territories as of early Tuesday, according to a Reuters tally, more than 16,500 of them fatal.

‘Very large acceleration’

•WHO spokeswoman Margaret Harris said there had been a “very large acceleration” in infections in the U.S.

•Over the previous 24 hours, 85% of new cases were in Europe and the U.S., and of those, 40% were in the U.S. As of Monday, the virus had infected more than 42,000 people there, killing at least 559.

•Asked whether the U.S. could become the new epicentre, Ms. Harris said: “We are now seeing a very large acceleration in cases in the U.S. So it does have that potential.”

•Some U.S. state and local officials have decried a lack of coordinated federal action, saying that having localities act on their own has put them in competition for supplies.

•President Donald Trump said on Monday he was considering how to restart business life when a 15-day shutdown ends next week.

•“America will again and soon be open for business,” Mr. Trump told a White House news conference on Monday. “We are not going to let it turn into a long-lasting financial problem.”

•“We can’t have the cure be worse than the problem,” Mr. Trump said. “We have to open our country because that causes problems that, in my opinion, could be far bigger problems.”

•Of the top 10 countries by case numbers, Italy has reported the highest fatality rate, at around 10%, which at least partly reflects its older population. The fatality rate globally is around 4.3%, though national figures can vary widely according to how much testing is done.

•Britain on Tuesday began curbs on movement without precedent in peacetime after PM Boris Johnson ordered everyone to stay at home.

📰 Economic package soon, says FM

Task force still not constituted, but FM speaks of multilayered sub-groups holding consultation

•An economic package to deal with COVID-19 situation will be announced soon, Finance Minister Nirmala Sitharaman promised on Tuesday afternoon, adding that the government and regulators are constantly monitoring the state of the economy, markets and rupee depreciation.

•However, she still offered little clarity on the composition of an economic task force announced by the PM last week, and explained the delay in announcing an economic package by saying extensive consultations were needed, and till yesterday, Parliament was in session and the Finance Bill had to be cleared.

•“Work is going on and we are very close to coming out with an economic package, which will be announced sooner rather than later,” she said, adding that the Centre, the Reserve Bank and the regulators have been jointly monitoring the volatility in the stock markets thrice daily. “Every attention is being given to the economy. The Prime Minister himself is closely monitoring the situation. A multi-layered composition of the task force is already working.”

•As The Hindu had reported on Tuesday morning, the economic task force announced in the PM’s address to the nation on March 19 has still not been constituted, with the Finance Ministry saying the PM’s Office or the Cabinet Secretariat would be responsible for issuing an order to create it. On Tuesday evening, after the FM’s press conference, a Finance Ministry spokesperson once again confirmed to The Hindu that no order has yet been issued to set up the task force.

•Ms. Sitharaman was more ambiguous about the status of the task force, saying that sub-groups of MPs, academics and industry leaders were already generating ideas for the task force, but refused to elaborate on its composition or specific mandate. “The Finance Ministry is working intensively on all these suggestions which are coming in from the various sub groups within the multi-layered task force that exists,” she said. “So the work of the task force which is multi-layered is already almost nearing a conclusion. So the task force and the task force based report and the action following the task force’s report are almost at its peak and that is why I have said we will announce the economic package sooner rather than later.”

•She did not respond to specific queries on how the economic package would provide relief for millions of informal sector and daily wage workers who have been hit the hardest by the shutdown.

•Ms. Sitharaman attributed the delay in announcing an economic package to the need for extensive consultations and to first pass the Finance Bill. “I appreciate that you would have liked the package to be announced last week. But most things which are as big as an economic package for this kind of unusual situation requires a lot of consultation to get it right,” she told journalists.

‘No intention to delay’

•“We had no intention to delay, we don’t want to delay, but then but let us be realistic. Till yesterday, the Parliament was in session and the Finance Bill had to be cleared,” she said adding that she would have been happy to announce the package in the House if it was ready and the Finance Bill had been passed. “And once the Finance Bill got cleared, it was important for the MPs to recognise there is a lockdown in this country, so everyone had to go where they had to go and serve and be of use for their own constituents. So the Parliament adjourned sine die.”

•In the final hours of the Lok Sabha session on Monday, a number of opposition MPs had been pressing the Finance Minister to make a statement on the COVID-19 situation and the government’s package before the Finance Bill was passed.

📰 Ironing out wrinkles in India’s pandemic response

Some critical weaknesses in the country’s health system can come in the way of a credible strategy to combat COVID-19

•Much concern about the novel coronavirus in India is understandably about the number of cases and related deaths. It is important to remember that the vast majority (80%) of COVID-19 cases will be mild. The estimated mortality rate varies considerably between 3% to 0.25% of cases, and is much higher among the elderly. Mathematical models and the experience of China, Italy, and now the United States, suggest that COVID-19 is likely to infect a significant number of Indians, though this can change due to current physical distancing and lockdown measures. Notably, wealthier countries with stronger and better financed health systems such as Italy and China have struggled with containing COVID-19. As such, it is prudent to understand how well India’s health system can respond to COVID-19, especially since it is unclear how long this disease will persist. We believe that there are some critical weaknesses in India’s health system that can prevent a credible response to COVID-19.

State-to-State coordination

•In truth, we do not really know how widespread the epidemic is in India because such a small number of people have been tested and many mild cases go undetected. To what extent India’s ongoing efforts to control COVID-19 using physical distancing and isolation will be successful is yet unknown. It is likely that, as in other countries, there will be regional or sub-regional disease hotspots, rather than a nationwide outbreak. The higher number of confirmed COVID-19 cases in States such as Kerala and Maharashtra suggest this (though this could also be due to more testing). This highlights the importance of approaching India’s COVID-19 response from the perspective of State health system capacity. Second, it is unlikely that States which experience a COVID-19 hotspot will have the resources to manage the outbreak independently. As such, it is critically important to put in place well-functioning between-State and within-State coordination mechanisms that enable efficiently leveraging resources such as doctors, nurses, equipment, supplies from elsewhereand direct them to regional/sub-regional hotspots.

Ramping up hospital capacity

•Addressing the scarcity of hospital and intensive care unit (ICU) beds in India is critical for providing clinical support to severe COVID-19 cases. Without flattening India’s COVID-19 epidemic curve, our current hospital capacity is so low that it will be quickly overwhelmed if infections surge. India has around 70 hospital beds and 2.3 ICU beds per 100,000 people. To put this into perspective, China (Italy) has 420 (340) hospital beds and 3.6 (12.5) ICU beds per 100,000 people, and both these countries struggled to care for the severely sick. According to our rough calculations, based on estimates from recent studies, in a hypothetical State with a population of 50 million (about the size of Andhra Pradesh), with the national-level endowment in hospital and ICU beds and bed occupancy of 50%, assuming there are currently 10 COVID-19 cases with a doubling rate of five days (5% of the cases hospitalised and 16% of hospitalisations need ICU care, median length of stay 12 days), without any mitigating measures, the ICUs will fill up in six weeks and hospital beds in about eight weeks from now. This will happen sooner in States with lower hospital capacity.

•It is critically important that India puts in place a strategy to ramp up hospital and ICU capacity, as well as provision for essential equipment such as ventilators and personal protective equipment for health workers. In both China and Italy, hospitals were rapidly constructed to accommodate infected patients. It is doubtful that we can construct new hospitals as quickly as China or even staff them adequately. Therefore, it is important to consider alternatives, such as, extending current hospital capacity, hospital trains that can easily move from one location to another, or converting university dormitories into treatment centres. Tapping the resources in the private sector is particularly important. India’s health system is highly privatised and most of the country’s health-care capacity in terms of human resources, hospital beds, laboratories, and diagnostic centres is in the private sector. Recognising this, several State governments have initiated action, such as enlisting private laboratories for testing and using the private hospital bed capacity to treat positive patients. More of this is needed, as well as, engaging private hospitals in planning and coordinating the COVID-19 response.

Health workers are crucial

•Health-care workers are a critical resource for the COVID-19 response. They go into communities to carry out preventive care, trace potentially exposed people, and treat the infected. The success of countries such as South Korea and Singapore in controlling the spread and mortality due to COVID-19 has been credited to the ability of health workers to locate, test and treat cases. This requires a substantial number of health workers, and India faces an acute shortage of them. India has around 3.4 qualified doctors and 3.2 nurses and midwives per 10,000 population; in contrast, China (Italy) has 18 (41) doctors and 23(59) nurses per 10,000 population. Moreover, health workers in India are mostly concentrated in the urban areas and there are huge disparities between States (Bihar has 0.3 and Kerala has 3.2 doctors per 10,000 population). Importantly, nurses have been in the forefront of caring for infected people elsewhere; India, has far fewer nurses than both Italy and China. These characteristics of India’s health workforce will affect its COVID-19 response, particularly in rural India and in States with fewer health workers. While increasing the health workforce in the short term is difficult, it is important to consider task shifting and multi-skilling strategies where a variety of health-care workers (Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy doctors, nurses, as well as general and specialist doctors) are engaged. Because it is highly likely that certain regions in India will become COVID-19 hotspots, to contain these outbreaks it is important that human and other resources can be flexibly shifted to these areas from other parts of the country.

•Primary-care providers, whether they are formally trained (e.g. medical officers, nurses, auxiliary nurse and midwives, pharmacists), or lay workers (accredited social health activists) or informal workers (rural (not registered) medical practitioners, or RMPs, drug shops) will likely be the first contact health workers for COVID-19 patients. For example, more than 70% of the outpatient visits in India are to private providers, the majority of whom are RMPs. Engaging these primary-care providers in the COVID-19 response is important. For one, they are critical for contact tracing, a strategy that has been successfully used in South Korea and Singapore to contain the virus. Because primary-care providers will encounter patients in early stages or with mild forms of the disease, they play a crucial role in treating and referring patients. While this may not be easy to accomplish, COVID-19 response strategies should involve engaging these primary-care providers and providing them information on preventing the spread of COVID-19, danger signs or where to refer in case of serious illness.

Health worker safety

•Health workers also take on a disproportionate share of infections. Health worker safety is particularly important for India because it already faces a shortage of doctors and nurses. In China and Italy, the fight against COVID-19 has taken a huge toll on health workers. One of the enduring images from Italy is of an exhausted nurse lying face down on her desk. As a recent article in The Lancet notes, estimates from China’s National Health Commission show that more than 3,300 health-care workers have been infected as of early March and, by the end of February at least 22 had died; in Italy, 20% of responding health-care workers were infected, and some have died. Health workers also face physical and mental exhaustion, which affects their morale, in addition to the infection risk. Protecting health workers in the forefront of the COVID-19 response will be critical. Procuring and ensuring the widespread use of personal protective equipment (e.g. masks, gloves, gowns, and eye wear) in the care of all patients with respiratory symptoms needs to prioritised. Such actions will be particularly important if there is a prolonged response to COVID-19.

•India like other countries faces important health system challenges in mounting a credible response to COVID-19. Many of these issues are not new. Addressing these health system issues will require much effort, financing, and, in some cases, not even entirely possible to remedy in the near future. How India deals with these health system issues in the days to come will make all the difference.