Robust leadership at the NDMA, preparing the healthcare system for new viruses and infectious diseases, and designing a decentralised, intensity based tier structured approach to care delivery can help the country tackle crisis like COVID19 better in the future
World War III, it seems isn’t between humans but with an entity that even in millions isn’t visible to humans. The enemy in the form of bacteria and Viruses have always been at the gates. However CoVID-19 has punched through defences and like Dominos, every pocket of settlement across the globe seem to falling. The enemy is now inside the gates and it shall not disappear because we wished or prayed. There has to be a bitter battle fought by everyone to hold the fort.
Most disasters, like empires don’t happen instantaneously. There are clearly indicators of the work in progress so that the end result is achieved. For instance, one of the oldest disaster management agency in the world is the FEMA of USA founded by an Executive Order on April 1, 1978. FEMA has been a role model on disaster management for the World. However in the last few years, there has been a consistent etching on the budgets of FEMA. The most recent being a half a Billion Dollars in 2020! Most of this budgets cuts has been on training and other initiatives on disaster management.
India needs an integrated approach towards Disaster Management
to fight COVID19 like crisis in the future
India, although a tad late, did raise its own National Disaster Management Agency (NDMA). Through the disaster management act of 2005, this agency was enabled and empowered. It was envisioned to be a cross-functional unit working across Departments. This required the PM to head it as Chairman at National level and CM at State Level. The operational leadership was with the Vice-Chairman who had a Cabinet rank and Members with Minister of State Rank.
A fledgling NDMA hasn't had a Vice-Chairman since 2014. It was an administrative mistake to have brought this agency under one of the busiest line ministry. The cost of not having an independent and effective leadership for this critical cross-functional agency with its own in-house think-tank and a sword arm of NDRF is being clearly felt in India. Whilst NDRF has been an effective force in the nation, the agency is found wanting to provide the leadership required at times of disasters. It will be prudent to correct this oversight at the earliest and nurture independent leadership to the NDMA.
It is a disaster that an agency formed with a good vision to have a cross-functional team to game, predict, prepare and provide leadership to manage disasters ended up as yet another bureaucratic establishment under a line Ministry.
Emergency care in hospitals were traditionally geared for managing infectious diseases caused by various pathogens. Overtime owing to various factors the key killer of humans drifted away to non-communicable diseases (NCD). Most of the NCD such as, STEMI in heart, Strokes, Cancers, were keeping the system busy. The high volumes of road traffic accident (RTA) trauma cases, which on an average is over 1500 daily in a State like Tamil Nadu stressed the ER system significantly more than infectious diseases. This naturally results in the drift of budget focus towards surveillance and registries for NCDs and trauma.
This global shift of focus from infectious diseases to NCD could be written off as either hubris of human for having won the battle with pathogens or simply a budget balancing to respond to the necessity of changing stressors on the system. Irrespectively, the epitaphs for another disaster were clearly written but was hidden in plain sight. We lay in wait for our ancient enemy at the gates to breach the wall without paying any attention to our perimeter defences.
While we are at the pathos with pathogens, a jingle of happiness should come from our infinite capability to learn, adapt, innovate and attack.
A demonstrative case for this would be the TN Model for road safety. TN had 17,218 road accidents fatality in 2016 and could bring it down to 10,472 by 2019 by data driven interventions. This was possible due to unique leadership and working across political, bureaucratic, academic, professionals and public. One of the many initiatives in this effort was the Emergency Care program called Tamil Nadu Accident and Emergency care Initiative (TAEI) under the MoHFW in Tamil Nadu.
The NDMA hasnt had a Vice-Chairman since 2014 which has
proved to be a costly administrative mistake being clearly felt now
TAEI was a disruptive approach to emergency care based on concepts of lean manufacturing and quality management to bring excellence in health care delivery. This was conceptualized, funded and implemented by the professionals from within the State. It could demonstrate its success by being a light house for rest of the wings within the Hospitals where TAEI wards were built.
Similar disruptions in the planning and care delivery during this CoVID-19 battle has to be brought about to improve our odds for wining.
The lockdown of cities aren’t a solution to the problem. It only buys us time to get battle hardened in smaller groups so that causalities can be handled by our healthcare systems. It is a war where all of us will have to eventually get in contact with the pathogen (hopefully in a small viral load through a vaccine!) so that our body develops defence through anti-bodies. Our only way out from this battlefield is by fighting and winning.
As far fight worsens, the Sanatorium model to have a single rallying point for all infected may not be a cost-effective approach. There will be varying levels of infection among people, who will all be grouped into a small area. This will create acute logistics issues from moving patients, managing resources and housing healthcare workers.
A decentralized, intensity based tier structured approach to care delivery can force multiply our capacity and ensure that our resource availability isn’t stressed beyond comfort. This is a time to leverage the 73rd amendment to Article 243. Time to leverage our Panchayat Raj Institutions (PRI).
PRI such as PHC and Police Thana have a significant influence in the local population. This influence can be used to have an effective localized lockdown and quarantining. This will be probably a panchayat or block size in the village to a Mohalla in the cities. This can bring a good containment of the pathogen into a small local area.
A large number of beds could be created in the smaller containment area by using marriage halls, etc. The healthcare professionals in that smaller area can be trained to deliver care in a safe way using appropriate PPEs. They can be supported in the care delivery by experts using technology via tele-consulting.
For patients who may require respiratory support (RS), a positive pressure support system, such as a the BVM (Bag-Valve-Mask) respirators could be provided as a bridge support. Leveraging the Indian manufacturing to help mass produce these devices and open market procurement will have to be made for large numbers of bridge RS devices, patient monitoring systems, PPE, etc. Some of these could be rotated out of one hotspot to another where the battle with pathogens have to be waged.
When the patient condition worsens to a point when the localised care at PRI can’t support, they can be moved to a higher tier hospital with full-on ventilators and specialised care. This inter-facility patient movement can be calibrated by the availability of beds and the criticality of the patient. With clear patient arrival information the receiving hospital can also be prepared and have a full case history of the patient before arrival.
This model will help if we are in a position to provide PPE to our PHC workers. It will also be strengthened when we are in a position to perform large volumes of test and obtain results in a shorter time span. In most cases, the patient could stay at home within the quarantine zone and may not even require respiratory support.
The current leadership of the nation has demonstrated their will to fight irrespective of the size of the enemy. This appetite is an essential requirement to stay in the battlefield as an organised unit. The nation too has demonstrated its elasticity to fight a long war of attrition with our ancient enemy. Quite a few battles have been reversed by our fathers over generations, and we too shall write history as we fight.
To summarise, an effective model that can be used for Disaster Management as we are tipping to community spread of the virus are as follows. Whilst war rooms for managing the outbreak in cities and States across the country are trying to perform similar efforts, a structured approach in the defence will have better results.
- There should be multi-Department establishment with clear devolution of powers for sectional leadership all the way to the grass roots level.
- Create geographical containment grids with some natural boundaries (riverine, Nallas, roads, tree cover, ward, Police Thana jurisdiction, etc). Each of this grid boxes should have a detachment of field level staff that has members from the various services (Health, Police, revenue, etc) and having clarity of their responsibilities.
- A structured tiered approach to managing the disaster should be there. PRI or equivalent in urban setting should be the lowest tier with effective containment responsibility and adequate support.
- Develop primary health support system (from monitoring of health condition progress, to basic respiratory support as a bridge therapy such as positive pressure ventilation by automated BVM. Technology (apps, mobile tower, etc) based mapping of social contact and tracing should be used. As patient gets to be critical, move them to the Apex facilities that can provide ICU care.
- Lockdown is an expensive and powerful tool, it has to be selectively used and not continued ad infinitum. It would be prudent to have a grid based stiffness condition for lockdown implementation. Relaxation of lockdown and mobility can be systematic and monitored continually to avoid secondary waves of infection.
We shouldn’t forget that our enemy will not relent. They will keep it on waves, which will be enabled by human movement around the globe. Therefore the real question in disaster management will be, are we going to be ready in a different way in future?
(Author is a Professor in the Department of Engineering Design at IIT Madras)