Opinion: Decentralized COVID-19 response can save Indian health system

My friend was orphaned by COVID-19 recently. Before that, my mother had been a constant bearer of bad news. First, a neighbor died, then his parents, and the last to go were the children. Then, her cousin's father followed by a roll call of 2-4 dead relatives per day. Little by little, her grief faded into apathy as cremations became a secretive affair, and condolences replaced the small talk in India.

My memory fails me on the number of desperate calls and SOS messages I received ever since the beginning of the second wave of COVID-19 in India, but the worst was when my friend in New York, Shanta, called me.

She began with an apology. It was past midnight for us, but her father back home was sick. It had been impossible to find him a doctor or get tested. His oxygen saturations were now shooting down to the 70s. Having lost her mother not too long ago, Shanta was desperate.

Her father lived in the neighborhood I grew up in. I was well connected in the area, but that was no good anymore. We discovered the lack of drugs and oxygen had caused all the hospitals to shut down. On ringing a physician — a relative who owned a hospital — I learned both he and his wife were sick. Like all hospitals, his, too, had been out of oxygen.

We posted SOS tweets and reached out to networks on the ground to secure contacts of oxygen suppliers. Beds in intensive care units were impossible to find in New Delhi. His best chances were to search outside the city. State helplines were dysfunctional. The Sprinklr dashboard, which curated real-time bed availability from Twitter, was his best bet. I scrolled in horror through the SOS tweets of waning oxygen numbers; a series of such posts ended abruptly.

By the time they found a bed, his case was escalated to the ICU. Unfortunately, I learned he passed away shortly after. Shanta's father, healthy in his late 50s, could have been alive with timely intervention.

If death is inevitable, untimely death is preventable. Many deaths in India are preventable because they result from collapsed health care infrastructure rather than a failure of COVID-19 treatments. In a country with many state-of-the-art hospitals and medical technology, this tragedy is unprecedented.

However, there are solutions. One of them is the implementation of decentralized care. To start, it's essential to recognize what works in one region of the country may not apply to another. Each state or district has its own set of needs and modus operandi. Therefore, rather than implementing one single model, each must be allowed autonomy to respond based on its local needs.

Compared to New Delhi, in Mumbai, the empowerment of the district-level civic body had good payoffs. It established 24 administrative divisions to handle the crisis, which received COVID-19 test reports and triaged patients. Mumbai also arranged a walk in COVID-19 clinics, especially in its crowded slum areas.

Since the second wave, a team of doctors reviews each case to determine the need for hospitalization. This ensures timely allocation of “oxygen beds” to those most in need. Mumbai's success also comes from gathering accurate data. This accurate needs assessment had also led to increasing its oxygen storage capacity ahead of time.

Recently, the state of Karnataka also set up decentralized triage centers in its urban districts. In rural India, such decentralization would mean empowering the elected representatives of each village — known as Sarpanchs. Building community resilience among its villages had allowed Odisha state to contain the pandemic efficiently last year. In addition to capacity building, states must implement a decentralized, community-oriented strategy to avert further loss of life.

Concerns for an even more catastrophic third wave likely to hit in early fall call for robust preparedness to prevent further loss of life. This is crucial to avoid the continued emergence of variants that could prolong the pandemic. Besides providing infrastructure support, the international community, government organizations, and NGOs can assist by technical support and direct deployment of trained personnel on the field.

Last but not least, the ongoing vaccine rollout must be supported by upscaling manufacturing and expediting tech transfer of messenger RNA vaccines that are more effective against the newer variants.

Since my friend Shanta's call, many friends and colleagues have lost their loved ones in India. For the rest of us, this kind of stress has been a nagging presence. As the borders remain closed, I try to gather hope from the other side. There is still time to turn the tide of this crisis in India. That can only happen by learning from our past experiences and rapid remodeling of existing care delivery mechanisms.