Covid-19 in India: time for bold experimentation: analysis
To counter the Covid-19 crisis in India, many have recommended increasing annual health spending, primarily for testing, tracing, isolating, and wearing universal masks. This view places funding above the governance concerns at the heart of the Indian healthcare sector. The availability of more resources may not be enough for the country to implement a model of Vietnam, Tamil Nadu or Kerala in all states. Although we have been demanding greater spending on health for almost two decades, the varied capacity of the State to implement programs remains a fundamental limitation. For example, a recent study in the Lancet Global Health, in the mortality of children under five years of age at the national, regional and state levels and by specific causes (2000–2015), revealed great variations between the states, ranging from 9.7 deaths in Goa to 73.1 deaths in Assam (per 1,000 live births) ). These disparities cannot be explained as due only to the shortage of health funds, since the study highlighted that; “… the evaluation of health initiatives shows a varied governance and responsibility of the programs among the states. Therefore, a high and constant commitment from local government is crucial to ensure that the programs work as planned. “
In the current pandemic, ubiquitous tests seem logical and necessary. However, there are several practical considerations that suggest alternative interventions. Research from the previous SARS epidemic has shown that there was wide variability in individual infectivity; 10% of the cases were responsible for 80% of the spread, implying that the super spread events caused outbreaks.
Therefore, we must use existing contact trace data to identify if there is dispersion in individual infectiousness and, more importantly, if there are identifiable factors affecting disease transmission, such as crowded working conditions, confined places , age, sex and comorbidities. We should use our existing resources to build relevant local intelligence on the transmission, and the testing strategy should be prioritized accordingly. A recent study from Japan also shows how cluster analysis can be used to identify and isolate super spreaders, which contains the overall outbreak.
The role of the private sector is critical for India to control this pandemic. If companies are going to operate in today’s uncertain environment, there is a possibility of a Coasian negotiation between an employer and an employee to mitigate the risk of infection. Market solutions will emerge with the will to pay for tests, masks and compliance with strict rules of social distancing. We must explore alternative mechanisms where the private sector pays to mitigate uncertainty. Furthermore, the prevailing elasticity of self-protection demand also means that the demand for self-protection will increase significantly. Government testing should then focus on areas where market-based solutions will not work.
Beyond testing, it is important to put more thought and resources into your contact search efforts. Ebola virus research has revealed that delayed and ineffective contact tracing was a significant contributor to the outbreak in 2014-2015. Challenges include identifying all contact persons; This requires research and probing skills. In Kasaragod, Kerala, the local police played an essential role in the effective search for contacts. Given their training in reporting and verification, local police personnel are naturally trained in extensive contact tracing. Therefore, what is needed is special personnel with skills in contact tracing who can be temporarily recruited at the police station level. Another challenge is the logistical problem of physically tracing the identified person, mainly, where the addresses are not well defined. This requires the extensive use of technology such as monitoring of Internet data and call logs, and in some cases, CCTV images to physically identify the people involved. After all this, tracked people must be evaluated daily for a significant period, which requires cooperation, willingness and, most importantly, trust. The management and performance of contact trackers should also be addressed in advance. While there have been suggestions about the use of additional ASHA workers, this is based on the assumption that there are optimal tools for contract tracing, and what is needed is for ASHA workers to simply learn these tools and implement them in the land. Our experience with tracing contacts in this pandemic suggests that the Ministry of Internal Affairs (MHA) needs to work closely with the Ministry of Health. Given the importance of contact tracing, MHA must develop standard operating procedures (SOP). SOPs must circulate between police stations and local health departments.
Most importantly, this crisis could be an opportunity for policymakers and researchers to work together and take advantage of the knowledge of epidemiology and other observational studies to design a series of randomized control trials of ethical, economic and psychological costs, such as suggested by Haushofer and Metcalf in Science (May 21) to identify “non-pharmaceutical interventions” that could have a significant impact on human health with low social and economic costs. Interventions range from stimuli and recommendations to regulations and sanctions, which ones work best in a pandemic?
In short, since we know so little about what works and what doesn’t, it’s time to experiment. We should increase the budget allocation for research and experimentation and design data-driven policies. In short, solving uncertainty until a vaccine is discovered and widely available will require several trial and error experiments and a willingness to learn.
Shamika Ravi is an Indian economist and former member of the Prime Minister’s economy.
Advisory Board. The article has contributions from Mudit Kapoor of the Indian Institute of Statistics.
The opinions expressed are personal.
The opinions expressed are personal.