Coronavirus outbreak presents chance for India to strengthen public healthcare system, train grassroots health workers to detect epidemics
What we have at the grassroots level are the frontline health workers like ASHA, ANM, AWW and MPW at the level of a health and wellness sub-centre covering a big chunk of the population.
Public health interventions are multidimensional and operate at multiple levels and include mass campaigns by national and state governments to observe cleanliness, ensuring hand washing, and a call to wear masks along with stronger measures like implementation of lockdown.
Apart from these, a more focused and deemed to be an efficient approach to prevent spread in communities is through regular surveillance of the susceptible population, case detection, containment and treatment. Countries like Germany, South Korea and China and the state of Kerala could successfully intervene to a large extent due to their strength in implementing this core public health intervention.
To accomplish this, two important factors are critical for any country or state. First, strong laboratory support for public health surveillance and second and most importantly, a competent public health workforce for active and passive surveillance regularly.
There is also a hindrance for this action which can be overcome if the first two factors are effectively implemented in the Indian context. The hindrance is the limited knowledge surrounding the new pandemic. These include dynamics of transmission, the proportion of symptomatic and asymptomatic cases and the nature of the most common symptoms and its severity present at the time of infection.
This information across diverse social groups like elderly, with or without comorbid conditions, unique behaviour patterns other than travel behaviour that can be linked to the occurrence of the disease who are infected and primary caregivers are all crucial for effective action. The list can be long as it is a ‘new’ disease and evidence is crucial for public health practice. Public health as an applied profession possesses the tools and techniques to simultaneously create knowledge sufficient enough to act effectively.
In the case of COVID-19, with a systematic approach, the knowledge gap prevalent can be reduced to an extent necessary for community action with the state governments taking the lead. The validation of a lot of the above knowledge depends on the laboratory test results as the case definition for public health surveillance depends on it.
Laboratory tests as litmus tests
Despite a lot of discussion on the lack of availability and accessibility to laboratory tests, less understood and more complex is the type of tests currently available and the purposes of each. The purposes of laboratory tests vary in the context of medical care and for public health surveillance.
First is the RT-PCR test which can more authentically confirm a case and the second is the antibody test (IgG and IgM) which indicate whether the person had exposure to the causative virus or not. The fact of the matter is that the purposes for which it is done is different and need to be only interpreted by an expert. The danger is that when left to interpretation by the public, it can have contrary interpretation than what it means.
This was obvious from the statement of a pathologist in the context of COVID-19 who said, “If you get your antibody test positive, you should celebrate it as you might have got the disease and your body has developed immunity without you knowing it.” From people’s point of view, laboratory tests are seen mostly as a way to rule out their worry and uncertainty and fear surrounding the disease. This is not helping people to alleviate their worry as once they get the information that their results are negative, the next worry will be will I get it soon?
This kind of mental state continues with or without a test. Hence, allowing people to walk in and get their tests done according to their convenience has serious consequences not only in terms of the possibility of wrong inference but also results in the wastage of crucial resource. There is a need to regulate over the counter laboratory investigations similar to that followed with over the counter drugs. There exist more efficient ways of using the lab tests at a population level by using pooled sample testing as in the case of Germany.
The direct contribution of lab tests for treating a patient is minimal as in the context of COVID-19, it is the symptom and comorbidities that is the concern for the treating physician. From a public health perspective, the laboratory tests should be supplemented with collecting information on the social, economic, cultural and more importantly epidemiological characteristics of the population with special emphasis on the dynamics of transmission and its pattern of spread.
This needs a broader perspective that focusses on the social characteristics including the living and working conditions and family characteristics that have always interfered with the epidemic spread. Only if one looks for it one will find it. This is also a golden opportunity to create the most crucial evidence not only for the sake of knowledge but which equip us to have evidence-based public health interventions.
Public health workforce: The real warriors
The second and the most crucial question is which staff of our health system will be able to accomplish this task of community engagement regularly for better understanding. Here comes the real challenge of the Indian situation which has a weak public health system.
Despite this, during the crisis, the nation needs to build on its existing strengths. As a national health system, we failed to build a strong public health workforce which over the years has been dominated by curative care services and recently more so of an insurance-based tertiary care system. One of the strengths we as a country developed not very long ago is the integrated disease surveillance project (IDSP) for tracking epidemics in the community. It has better control at the district and state level though grossly inadequate in terms of staff required at the grassroots.
Of the four grass root level workers, MPW cadre is almost eroding as many state governments have stopped appointments for several years.
In urban towns and corporation, the only field staff who engage with the community is the MPW cadre, both male and female, who are employed with the urban primary health centres and are engaged in ‘public health work’ at the grassroots level for the health services.
Moreover, the fact is that most of them cover only slum population leaving the middle class and better off out from their routine ‘public health work’ due to the latter’s non-cooperation. Further, due to the historic focus on maternal and child health programmes, most of them are trained in maternal health with very little training and skill in epidemic investigations, a key skill necessary during epidemics.
Attempts to pull these frontline workers off might lead to a graver disaster which they are otherwise preventing daily. The most effective response during COVID-19 includes routine contact tracing, sample collection for lab test and regular follow up in the community and is an intense and streamlined activity that needs to be carried out by those who are trained in public health.
The efficiency of this core task depends on the commitment of the public health workers towards their work, effective monitoring and regular reporting. The success of states like Kerala is due to the commitment of these grassroots-level health workers, namely junior health inspector (JHI), Health Inspector (HI) Health supervisors and Junior Public Health Nurse (JPHN), who are the real warriors and the least acknowledged in the state’s fight against COVID-19.
The public health workforce is expected to understand the dynamics of the community and need to garner public support and it is their response at the grassroots level that decides the fate of any public health emergency. All other activities can only supplement this activity and cannot substitute this core activity of case detection and referral for treatment.
As a country, we have several public health institutions across all the regions producing trained public health professionals and can be roped in for carrying out this effort on an immediate basis. This can be prioritised based on the extent of community spread identified and can be coordinated with those public health institutions identified by the respective states in those regions with the effective coordination of the district health department, towns and corporations and other local self-government bodies.
This then can be a starting point for building stronger public healthcare within the country’s health services. A public health action is only possible when you have a public health workforce at the grassroots level and the efficiency of public health depends on the knowledge, skills and competence of this public health workforce. Every crisis is an opportunity to learn from the mistakes and build upon what is lacking.
The author is professor, Centre for Public Health, School of Health Systems Studies, Tata Institute of Social Sciences.
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