Debating the process, impact, and handling of social and health determinants of the COVID-19 pandemic
2020; Medknow; Volume: 36; Issue: 5 Linguagem: Inglês
10.4103/ijsp.ijsp_226_20
ISSN2454-8316
Autores Tópico(s)Global Public Health Policies and Epidemiology
ResumoThe Impact Between January 14 and January 20, 2020, when top Chinese officials secretly determined they were likely facing a pandemic from a new coronavirus, the city of Wuhan at the epicenter of the disease was busy hosting a mass banquet for tens of thousands of people; millions began traveling through for lunar New Year Celebrations. President Xi Jingping warned the public about a new virus on the 7thday, i.e., January 20. However, by that time, more than 3000 people had been infected and traveled to different parts of the world, according to internal documents obtained by The Associated Press and retrospective infection data.[1] On March 18, a 35-year-old man, suspected of coronavirus infection, committed suicide at Safdarjung Hospital in Delhi. The 35-year-old deceased jumped off the seventh floor of Safdarjung Hospital, according to a PCR call received by the Delhi Police. He was admitted to Safdarjung Hospital at 9 pm on Wednesday only as a suspected coronavirus patient.[2] On March 25, a 56-year-old man in Karnataka's Udupi district committed suicide by hanging. According to police, deceased left a suicide note saying that he had contracted the COVID-19 disease and asked his family to be safe. The police said, "According to the preliminary investigation, he had committed suicide after reading extensively about coronavirus on social media which led to excessive fear about the pandemic."[3] A Chennai doctor, Simon Hercules, died of COVID-19 on April 19. He was denied even basic dignity at the time of his death as a mob attacked his friends and family with sticks and rods when they were transporting his body to a burial ground. This incident has, yet again, cast a worrying spotlight on the health and safety of our frontline soldiers in the collective fight against COVID-19.[4] A 42-year-old man was arrested late Wednesday evening for allegedly assaulting two women resident doctors of Safdarjung Hospital after accusing them of "spreading" COVID-19 in Gautam Nagar area, South Delhi, said police.[5] Manish Kumar who was employed in a factory says, "I am looking for any form of transport which takes me anywhere close to my destination. I am going to die soon anyway of hunger. There is no one here to even beg for food. Everyone's pockets are empty." Visual of hundreds of workers wearing gamchas, carrying heavy backpacks and wailing children, walking on national highways, boarding tractors, and jostling for space atop buses became defining images for days to come in India.[6] A 12-year-old child recently shared that she felt very scared at home. "My parents are very stressed and they end up taking it out on me. They think it is not affecting me, but I am terrified most of the time. Stress is like polluted air, and we are all breathing it in.[7] " Sixteen migrant workers were mowed down by an empty freight train in Maharashtra's Aurangabad district in the early hours of May 8. While 14 of them died on the spot, two of them later succumbed to injuries. The workers, who were walking to Bhusawal from Jalna to board a "Shramik Special" train to return to Madhya Pradesh, were sleeping on the railway line extremely tired after marathon walking for 40 km. Expressing grief over the incident, Prime Minister Narendra Modi tweeted, "Extremely anguished by the loss of lives due to the rail accident in Aurangabad, Maharashtra. Have spoken to Railway Minister Piyush Goyal and he is closely monitoring the situation. All possible assistance required is being provided.[8] " As of July 18, 2020, there are 13,824,739 confirmed cases of COVID-19 (coronavirus infection disease, 2019) and 591,666 confirmed deaths worldwide as per the World Health Organization (WHO)'s dashboard.[9] India has confirmed 1,038,715 cases and 26,273 deaths so far.[10] India has been under lockdown since March 25, 2020, for 6 weeks (extended again with revised guidelines), and jury is still out whether to continue with lockdown or resume normal or truncated life activities. The COVID-19 pandemic has been the fastest-moving global public health crisis in a century, causing significant mortality and morbidity and giving rise to daunting health and socioeconomic challenges. Governments are taking unprecedented measures to limit the spread of the virus, while health and social systems are struggling to cope with rising caseloads, supply-chain bottlenecks, movement restrictions, and economic strains. In humanitarian and fragile settings and low-income countries, where these systems are already weak, the pandemic is disrupting access to life-saving reproductive health services. It is also compounding existing gender and social inequalities.[11] Prelude On December 31, 2019, the WHO China Country Office was informed of cases of pneumonia of unknown etiology detected in Wuhan City, Hubei Province of China. China had kept it as a secret from the world. From December 31, 2019, through January 3, 2020, a total of 44 case-patients with pneumonia of unknown etiology were reported to the WHO by the national authorities in China. During this period, the causal agent was not identified. On January 11 and 12, 2020, the WHO received further detailed information from the National Health Commission of China that the outbreak was associated with exposures in one seafood market in Wuhan City. The Chinese authorities identified a new type of coronavirus, which was isolated on January 7, 2020. On January 12, 2020, China shared the genetic sequence of the novel coronavirus for countries to use in developing specific diagnostic kits. When such cases were reported in other countries, the WHO declared this outbreak as a "Public Health Emergency of International Concern" on January 30, 2020, and raised the level of global risk to "very high" on February 28, 2020. Although the WHO had not declared COVID-19 to be pandemic by that time, it asked the countries to remain prepared. The WHO finally declared COVID-18 as "pandemic" on March 13 since its spread crossed geographical boundaries affecting a large number of people.[12] "We are fully prepared," that is what the Hon'ble Health Minister of India is quoted to have said on March 2 or 3, 2020, on being asked by a news channel how well prepared India was, to tackle the possible spread of coronavirus.[13] By that time, that goes to India's credit, India had already started country-wide screening, entry screening of all overseas passengers reporting at the national airports and seaports, and contact tracing.[14] It is worth highlighting that India initiated required preparedness and action at field level since January 17 itself, much before the advice from the WHO. Notwithstanding Health Minister's assurance about India's preparedness, there were doubts if we had really understood what it takes to get into a "fully prepared" state. Were thermal screening and travel advisory enough measures to contain an epidemic that soon would be a designated pandemic? Coronavirus disease that made its surreptitious beginning in 2019 in human beings (that's why nicknamed COVID-19) has taken the entire world by storm and within a few months driven the world gasping for breath. No one could fathom that even the affluent and developed countries would be caught unprepared and ill-equipped, leave-alone low and middle income countries (LAMIC) or poor countries. It is causing unprecedented morbidity and mortality cutting across all geographical boundaries, irrespective of gender, age, and socioeconomic status. Moreover, its spread and devastation have affected lives in a way no one has been able to imagine its magnitude and severity. The lockdown, which seems at this time the only strategy to contain the spread, has made a serious dent on people's lives by affecting their physical and mental health, employment, earnings and income, livelihood, training and education, social inclusion, etc., In India, it has brought out never seen before problems such as reverse migration and assault on health workers. There is now an urgent need to study and discuss the psychosocial aspect of this pandemic. Social determinants shape and govern our responses to not only health but also overall development of societies and nations. The social determinants are the conditions in which people are born, grow, live, work, and age.[15] These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen between various ethnic and socioeconomic groups. Access to health is not uniform in India; there has been a significant difference between rural versus urban, between low-socioeconomic versus high-economic groups, and between different cast systems and ethnic groups. How India Processed and Handled the COVID-19 Threat? Thermal screening at the airport On January 17 itself, India began thermal screening for all the incoming travelers, though thermal screening is only a screening tool but not a diagnostic method to rule out the presence of flu-like illness. All incoming internal passengers were required to have nontouch thermal screening for detecting high temperature, since it may be an early and easy symptom to detect. If any person was found to have high temperature, he/she was put in quarantine and had to undergo further testing. However, thermal screening is not a simple, fool-proof, or inexpensive method. First, it requires extensive training of the airport staff engaged in screening process.[16] They have to be, importantly, provided with proper personal protective equipment (PPE) since the airport staff comes in contact with a large number of incoming patients within a short time. They should know how to maintain a minimum distance of at least 1 m and yet keep the thermometer at a proper distance from the passenger to take the correct measurement of body temperature. The nontouch thermometers, infrared thermometers, should be of reliable quality so that it accurately measures what it purports to measure. There have been reports that the quality of available thermometers in the market has been quite variable.[17] There has been no clarity in technical specification of these thermometers; a defective equipment would defeat the purpose of entire exercise. Multiple scanners reviewed by this report on the same human body within a span of 30 min found temperature in a range of 87.0°F–97.5°F. Temperature screening alone, at exit or entry, may not be an effective way to stop international spread, since infected individuals may be in the incubation period, may not express apparent symptoms early on in the course of the disease, or may dissimulate fever through the use of antipyretics.[18] It has been reported in mass testing that up to 75% of positive cases may remain asymptomatic, but yet be infective to others. It may be more prudent to provide prevention recommendation messages to travelers and to collect health declarations at arrival, with travelers' contact details, to allow for a proper risk assessment and a possible contact tracing of incoming travelers. Countrywide lockdown India had started responding to the COVID-19 threat in January 2020 itself by thermal screening, putting restriction to flights coming from countries with a large number of cases, suspected cases being put under quarantine, and issuing general advisory about social distancing, frequent hand wash, use of sanitizers, personal hygiene, etiquettes of coughing and sneezing, etc. However, in view of the news coming from all over the world about its fast spread across geographical boundaries, and the virus of being highly infective nature, but fortunately of low lethality, Hon'ble Prime Minister of India declared nationwide strictest lockdown in the history of India under the Disaster Management Act, 2005[19] for effective management of COVID-19 starting 25th March. COVID-19 had already been declared 'pandemic' by the WHO on 13th March. COVID-19 is the first pan-India biological disaster being handled by the legal and constitutional institutions of the country. A disaster is a sudden, calamitous event that seriously disrupts the functioning of a community or society and causes human, material, and economic or environmental losses that exceed the community's or society's ability to cope using its own resources. The Central Government enjoys immense powers under this Act and can issue any directions to any authority anywhere in India to facilitate or assist in the disaster management.[20] Importantly, any such directions issued by the Central Government and National Disaster Management Authority (NDMA) must necessarily be followed the Union Ministries and State Governments. The present national lockdown was imposed under this Act as per the Order dated March 24, 2020, of NDMA "to take measures for ensuring social distancing so as to prevent the spread of COVID-19." The Ministry of Home Affairs (MHA), being the Ministry having administrative control of disaster management, issued additional guidelines on the same day. This was to remain in force for 21 days. By this order, all activities including travel by any means, all commercial and private business establishments, industrial and manufacturing hubs, educational institutions, religious gatherings and congregations, all social and entertainment activities, and entire hospitality sector were to remain closed. There were notable exceptions for health services, essential services, defense and police personnel, ration shops, essential supplies such as milk, fruits, and vegetables. By its revised Order dated April 15, 2020, the MHA further extended the lockdown by another 3 weeks till May 3 with further relaxations made to ease the ground situation. Please refer to the MHA's Order for details (No. 40-3/2020-DM-I (A) dated April 15, 2020). This was further extended till May 17 vide MHA's Order number 40-3/2020-DM-I (A) dated May 1, 2020, with some relaxations on the movement of people, transport services, movement of goods, and opening of limited commercial activities. The lockdown had one further extension till May 31 with considerable relaxations, and more powers are being given to the states to take necessary actions regarding the extent of lockdown and opening of travel and commercial activities. The COVID lockdown effectively halted people's movements and closed all avenues of income generation, but health services had no clear guidelines about what services to remain open and how to gear a hospital toward COVID preparation. How loss of income will impact the laborers and daily-wagers would remain unfathomable as discussed below. As an economist has warned, "continued lockdown will mean a loss of 2 lakh crore every week, while the expenditure on 'testing, tracing, isolating' 1%–3% of population will cost 75 thousand crore a year."[21] Testing for virus One effective strategy to beat the spread of COVID virus is presumed to be quarantining of people with suspected or confirmed virus infection. It required screening by testing for the presence of virus in a body fluid (throat swab for COVID-19) in general population. India started testing, under the guidance of Indian Council of Medical Research (ICMR) with the objectives of containing the spread of COVID-19, and to provide reliable diagnosis to all individuals meeting the inclusion criteria for COVID infection. Initially, the strategy had been to test all the symptomatic cases of international travel, all symptomatic cases of confirmed laboratory cases, all symptomatic health workers, all hospitalized cases with severe acute respiratory symptoms, and asymptomatic high-risk contacts of confirmed cases. The ICMR had validated the Truenat Bet Cov test on Truelab Workstation as a screening test. All positive cases were needed to be reconfirmed by a separate confirmatory assay for SARS-CoV-2. Initially, only laboratories in the government setup were authorized to carry out the testing, and the capacity to test in the community had remained limited.[22] The daily count of positive cases in first few weeks had been low since we were able to test only limited number of cases due to constraints of trained workforce, kits, and number of laboratories. That was the main criticism by the experts, when the WHO had been saying, "test, test, and test." It took a while before government agreed for private laboratories to begin testing with the ICMR providing guidance. As of the time of submission of this write-up, there were 885 government laboratories and 368 private laboratories engaged in various tests, viz., Real-Time RT PCR for COVID-19: 643 (government: 395 + private: 248), TrueNat Test for COVID-19: 507 (government: 453 + private: 54), and CBNAAT Test for COVID-19: 103 (government: 37 + private: 66). As of July 18, 2020, India has tested 13,433,472 samples with daily testing of nearly 200,000 samples; there are 358,692 active cases, 653,750 recovered, and 26,273 deaths. On March 10, India had reported just 50 cases till then. "Are we testing enough?" that has been a constant refrain from various experts in the media. There seemed to be two diametrically opposed positions on COVID-19 testing in India. On the one hand, the Indian government claimed that there were no problems with the testing process or the number. The evidence, according to the government, is the low positivity rate (ratio of positives to total persons tested) for India, which was 4.76. On the other hand, critics of the government strategy pointed to the low testing rate (ratio of total persons tested to the total population) as the evidence of serious problems in India's COVID-19 testing process.[23] According to Deepankar Basu, Associate Professor, Department of Economics, University of Massachusetts Amherst, writing for The Week, vide supra, "Low testing rate does not fully account for the low prevalence of COVID-19 in India, contrary to what critics might claim. But, India needs to keep ramping up testing. A rough number to use as a benchmark is a TPR of 2%, i.e., India needs to keep ramping up testing till its TPR falls to, and then stabilizes at, 2%. For this, India needs to carry out more than 16 million tests." However, India has to strike a balance considering the finances, capacity, and geographical spread of the virus. In the beginning, when the government was scaling up the testing and had roped in private laboratories, it fixed up their charges as Rs. 4500/- per test. That is an expensive proposition for a country like India. In response to a PIL, the Supreme Court ordered the government to carry out the test free for all but did not clarify who would reimburse the private laboratories. Without a free test, it was a big question how India would scale up its testing strategy. On Government of India's plea to the Court, the Supreme Court in its revised Order dated April 13 stated the government would reimburse the private laboratories up to 500 million tests through its flagship public health insurance scheme.[24] This again focuses on the poor funding of public health at just 1.3% of India's GDP. The insurance cover is limited and largely unregulated. It is high time now that the public health receives major investments, and there is a proper policy framework for covering even the poor people under insurance schemes. Social distancing A major strategy adopted the world over, and advised by the WHO too, to contain the spread of the virus has been social distancing or physical distancing, i.e., to maintain a distance of at least 1 m from other persons while in the public.[25] It also means not gathering in public and staying out of crowded and mass gatherings. COVID-19 spreads mainly among people who are in close contact for a prolonged period. Spread happens when an infected person coughs, sneezes, or talks and droplets from their mouth or nose is launched into the air and land in the mouths or noses of people nearby. The droplets can also be inhaled into the lungs. Recent studies indicate that people who are infected but do not have symptoms also play a role in the spread of COVID-19.[26] Advisory by the Ministry of Health and Family Welfare on social distancing [27] Closure of all educational establishments (schools, universities, etc.), gyms, museums, cultural and social centers, swimming pools, and theaters. Online education to be promoted Possibility of postponing examinations may be explored Encourage private sector organizations/employers to allow employees to work from home wherever feasible Meetings, as far as feasible, shall be done through video conferences. Minimize or reschedule meetings involving large number of people unless necessary Restaurants to ensure hand-washing protocol and proper cleanliness of frequently touched surfaces. Ensure physical distancing (minimum 1 m) between tables; encourage open air seating where practical with adequate distancing Keep already planned weddings to a limited gathering, and postpone all nonessential social and cultural gatherings Local authorities to have a dialog with organizers of sporting events and competitions involving large gatherings, and they may be advised to postpone such events Local authorities to have a dialog with opinion leaders and religious leaders to regulate mass gatherings should ensure no overcrowding and at least 1 m distance between people Local authorities to have meeting with traders associations and other stakeholders to regulate hours should exhibit Do's and Don'ts and take up a communication drive in market places such as sabzi mandi, anaj mandi, bus depots, railway stations, and post offices, where essential services are provided All commercial activities must keep a distance of 1 m between customers Nonessential travel should be avoided, i.e., buses, trains, and airplanes, to maximize social distancing in public transport besides ensuring regular and proper disinfection of surfaces Hospitals to follow necessary protocols related with COVID-19 management as prescribed and restrict family/friends/children visiting patients in hospitals Hygiene and physical distancing have to be maintained. Shaking hands and hugging as a matter of greeting are to be avoided Special protective measures for delivery men/women working in online ordering services have to be considered. Keep communities informed consistently and constantly. India strictly followed the norms of social distancing to break the spread of virus and prevent community transmission. India succeeded in enforcing it to a large extent; however, there were clear violations not only by some individuals (marriage in a prominent politician's house, or birthday bash by another politician) but also by a religious group that led to spread in many parts of India where virus had not yet made its appearance till that time. Dr. Shekhar Saxena, Former Director, Mental Health Division, WHO, prefers the term "physical distancing" rather than social distancing (emphasis added), "We are all talking about social distancing. Actually, what we need is physical distancing, not social distancing – because that conveys the wrong message. In fact, in this time of stress, we need more social togetherness; we need more social support than social isolation. You talk to people on the phone, on any other media, you support people in each other's difficulties and that is what the community needs to fight it together. Saying 'social distancing,' which means you are alone, increases your stress. International organizations and national authorities are all exercising 'social distancing' when actually, what they should be saying is physical distancing but social togetherness.[28] " It may be a question of semantics, and if the social distancing was considered inevitable, it still has potential of impacting mental health of people. Prolonged and forced isolation is likely to take its toll on one's ability to cope with tension and anxiety, and we are already noticing a spurt in cases presenting with anxiety-, depression-, and stress-induced mental health problems.[29] The impact is likely to be felt more by elderly, children, and people with disabilities. Another fallout of social distancing has been stigma; there are reports of local people shunning those who arrived home from other cities and shopkeepers refusing to engage with them.[30] Aarogya Setu app In its fight against the COVID-19, Government of India launched its Aarogya Setu app on April 2 this year.[31] Aarogya Setu, a GPS and Bluetooth enabled app, is a mobile app to track COVID-19 and is developed by the National Informatics Centre, Ministry of Electronics and Information Technology. With the launch of this app, the governments seeks to limit the spread of the COVID-19 cases in India via technology and artificial intelligence, as well as helps create self-awareness among the citizens with relevant information on the infection. Aarogya Setu has four sections. Your status (tells the risk of getting COVID-19 for the user) Self-assess (lets the user know the risk of being infected) COVID-19 update (gives updates on local and national COVID-19 cases) E-pass (if applied for E-pass, it will be available). It tells the user how many COVID-19-positive cases are likely in a radius of 500 m, 1 km, 2 km, 5 km, and 10 km. Very soon, this app became the fastest downloaded app in the world and by May 11 had 98 million users; 1.4 lakh people got alerted via Bluetooth tracing of their possibility of coming in the vicinity of an infected person. On April 29, the MHA vide its Order No. 40-3/2020-DM-I (A)[32] made it mandatory for all government and private sector employees to download this app on their phone. Gradually, it became obligatory for all people visiting hospitals, traveling by air, trains, and buses, and people living in containment zones. As soon as the app was launched, there have been misgivings about its "true" purpose; it being a sophisticated surveillance app, its security issues, and fear of violation of privacy rights.[33] On May 12, Former Supreme Court Judge Justice B. N. Srikrishna termed the government's push mandating the use of Aarogya Setu app "utterly illegal." He said so far it is not backed by any law and questioned under what law, government was mandating it on anyone.[34] Although many countries have developed some kind of tracking apps and have encouraged their citizens to use this app to remain aware of their surroundings, India remains the only democracy that has made it mandatory.[35] Notwithstanding above concerns, there are other reasons why the stated purpose of the app may be defeated. Epidemiologists reckon that for a contact tracing app to be successful, 60% of population should be using it.[36] There is a huge digital divide in India between urban versus rural areas and men versus women. In spite of a very high teledensity in India, smartphone use and availability of internet are a dismal (24%). Even in urban areas, it remains only 51%. By making the Aarogya Setu app mandatory for any kind of movement, it will make difficult for people, especially women, to access public services including health. While the app is being promoted as a tool to contain the spread of virus, our rates of COVID testing continue to remain low. Ministry of Finance The Hon'ble Minister of Finance Nirmala Sitharaman announced the first package of Rs. 1.78 lakh crore to help mitigate the suffering of a large segment of India's population. On May 12, the Hon'ble PM of India announced a total package of Rs. 20 lakh crore as a stimulus to the economy and to help the marginalized sections of the society, such as farmers, daily-wagers, construction workers, and street vendors. Since May 13, the Finance Minister announced five financial packages on each consecutive day. It was hailed as a massive package to the size of nearly 10% of India's GDP and comparable to packages announced by leading economies of the world such as the USA and Japan. "Seen against the scale of economic distress, and expectations raised by the Prime Minister's announcement of a Rs. 20 lakh crore package, the measures announced by the Finance Minister over the past few days have been underwhelming," says the Editorial in Indian Express dated May 18.[37] It further states, "A crisis of this magnitude needs to be tackled at multiple levels – relief for the most vulnerable, support to specific sectors, short-to-medium term measures to boost demand, and structural reforms. But, so far, the government's response has centered around only providing some relief measures, extending liquidity to select sectors, and stating its intent to push through contentious pieces of reform." It is a foregone conclusion that the health crisis posed by the COVID-19 is likely to continue for a longer time than it was assumed earlier. During this time, people's income and spending power must improve through a timely and aggressive economic and fiscal stimulus. It is essential to break the cycle of loss of income, poverty, starvation, and poor health and death for a large section of our population, that is, young. Telemedicine Through a Gazette Notification from the Government of India, CG-DL-E (14052020)-219374; Notification no. MCI 211 (2)/2019(Ethics)/100659 detailed guidelines have been issued for the Registered Medical Practitioners to use telemedicine to assess and advise the needy patients.[38] It states, "Disasters and pandemics pose unique challenges to providing healthcare. Though telemedicine will not solve them all, it is well suited for scenarios in which medical practitioners can evaluate and manage patients. A telemedicine visit can be conducted without exposing staff to viruses/infections in the times of such outbreaks. Telemedicine practice can prevent the transmission of infectious diseases reducing the risks to both healthcare workers and patients. Unnecessar
Referência(s)