Permanent Vigil

IN LATE JULY, AS it drizzled, Soumit Kuri stepped onto a bamboo raft, for the first time in his life, to cross the Kalshi river to reach a remote village in south Tripura. After floating for a while, the raft toppled and he fell into the river. By the time Kuri, a community health officer under the National Health Mission, reached Mathu Mog Para to administer the Covid-19 vaccines, he was drenched. The villagers laughed, but seeing in what condition he had made it to their remote locality, most of them agreed to get a shot. That day, he, along with the other health workers, managed to vaccinate 98 per cent of the 214 adult inhabitants. Those left out were not present in the village.

Another day, Kuri, his multipurpose worker Naresh Mohan and other team members removed their shoes, pulled up theirs trousers and, holding up the vials carrier of four ice packs, walked through a rivulet, part of their nine-kilometre walk to reach Joykumar Para from the primary health centre at Kwaifung, an area dominated by the Reang tribes. In Toofan Para, another remote part of south Tripura, they walked for miles through hilly and wooded terrain, crossing bridges made of bamboo and logs. Most of the villagers, taken in by rumours about the effects of the vaccine, were reluctant to take the shot. With the help of health and ASHA workers, the team had to first counsel and convince them to take the vaccine. “I was not only crossing geographical barriers but also communication and language hurdles. There was hardly any network. The local Tribals spoke Kokborok and did not fully understand my Bengali. But we managed to vaccinate most people,” says Kuri, 29. A few days later, he got an award from Chief Minister Biplab Kumar Deb for exemplary work in administering vaccines in destinations difficult to reach. Of the 2,471 above-18 people falling under Kuri’s health subcentre of Birendra Nagar—covering the remotest part of the state which has a difficult terrain, is malaria prone and was once insurgency-affected—he says only 186 are left to be vaccinated.

While Kuri passionately pursues his mission, it may be a drop in the ocean, as fears of a third wave loom over the country. Tripura, one of the eight states in the Northeast, which witnessed a high positivity rate even as cases dropped in the rest of India after a devastating second wave in April-May, has managed to give the first dose of the Covid vaccine to 93.68 per cent of its adult population. Cases had continued to rise in the Northeast even in June, with some districts reporting a positivity rate of over 10 per cent. “We are going by Prime Minister Narendra Modi’s directions in the battle against Covid. We have sufficient infrastructure, have motivated all our social organisations and convinced the people to cooperate,” says Chief Minister Deb.

By mid-August, as India geared up to face what is being predicted as a third wave, the Union Cabinet had allocated half the funds from Phase II of the Emergency COVID19 Response Package (ECRP) and health systems preparedness project to help states fight the virus. In the first week of July, just as the country was recovering from the second wave, the Government had approved the ₹ 23,123 crore (Central share ₹ 15,000 crore and state share ₹ 8,123 crore) Phase II package to be implemented till March 2022. On July 22nd, 15 per cent of the Central share of the scheme was released to states and 35 per cent more was released in mid-August. Of this, the eight states of the Northeast were sanctioned ₹ 1,352.92 crore. The ECRP-II, a Centrally sponsored scheme, lays emphasis on paediatric care, given some predictions that children may face the brunt of the third wave.

The panel set up by the Government, in its report in the last week of August, while warning that the third wave of the pandemic could peak in October, said the public healthcare system should have better medical preparedness for children who might be at a similar risk as adults. “Paediatric facilities including doctors, staff, equipment like ventilators, ambulances, etc are nowhere close to what may be required in case a large number of children become infected,” said the report of a committee of experts constituted under the National Institute of Disaster Management (NIDM). The report does, however, add that although children remain a cause of concern till they are vaccinated, there is no evidence that they will be more affected than adults in case of a third wave. The Government has recently approved the first vaccine—a three-dose ZyCoV-D DNA one by Cadila—for those below 18.

Since January 16th, when India started administering vaccines to its adult population, around 15 per cent have been fully vaccinated. Total shots were at 65 crore as of September 1st, which in terms of numbers is much more than the population of the US. But it also means nearly 85 per cent of the population is yet to be fully vaccinated. As part of ramping up its vaccination drive, which recently achieved the target of one crore a day with the aim of vaccinating all willing adults by December this year, the Government has authorised Cipla, an Indian pharma company, to import Moderna’s vaccine. This will be the fifth vaccine in the country after AstraZeneca’s Covishield, the indigenous Covaxin, Russia’s Sputnik V and Johnson & Johnson. According to the Union health ministry, by end-August, more than 64.36 crore Covid-19 vaccine doses were provided to states and Union territories, while over 15 lakh were in the pipeline. More than 5.42 crore unutilised doses were still available with states, it said.

The ECRP-II proposes to help states and Union territories with establishing paediatric units in all 736 districts, augmenting 20,000 ICU beds in the public healthcare system, of which 20 per cent will be paediatric, installing 1,050 liquid medical oxygen storage tanks, getting 8,800 more ambulances and ensuring stock of Covid medicines besides strengthening human resources and services. “We are acting on the Centre’s guidelines. There is a lot of emphasis on tertiary care. They have proposed establishing 50-bed field hospitals wherever the state feels it’s necessary. The exercise to administer the second dose of vaccine and reach those uncovered by it is being carried out,” says Siddharth Jaiswal, Director, National Health Mission, Tripura.

With the second wave testing the health infrastructure in the country, as the virus spread even to rural and remote areas, the package envisages care “closer to the community” by creating pre-fabricated structures for adding more beds at the existing community health centres, primary health centres and sub health centres, the nearest point of contact for medical needs in rural areas. Though there are contradictory predictions about the third wave, its intensity, timing and impact on children, the Government, having faced criticism over what was seen as the repercussions of its ‘unpreparedness’ for the second wave, is not taking chances.

In a Union Cabinet reshuffle on July 8th, soon after the second wave, Modi replaced Health Minister Harsh Vardhan, 66, with Mansukh L Mandaviya, the 49-year-old Rajya Sabha MP from Gujarat, who also retains the ministry of chemicals and fertilisers. Mandaviya has been monitoring the situation in Kerala and the Northeast, the regions which have been reporting the highest number of cases, and has sanctioned relief packages for hard-hit states.

After the second wave, which jolted the health sector, the Government in end-June approved a Loan Guarantee Scheme for Covid Affected Sectors (LGSCAS), enabling funding up to `50,000 crore to provide a financial guarantee cover for brownfield expansion and greenfield projects related to medical infrastructure. Recently, speaking at a webinar called ‘Resurgent India: Building Healthcare Infrastructure for New India’, Finance Minister Nirmala Sitharaman emphasised the need for stakeholders to strengthen the healthcare infrastructure in rural areas to mitigate the burden on cities, in case there is a third wave.

The third wave is still a topic of contestation. “I am not an astrologer. I am an epidemiologist. Any wave depends on three epidemiological factors—host, agent and environment,” says Dr Sanjay Rai, professor at the Centre for Community Medicine, All India Institute of Medical Sciences (AIIMS).

In India, he says, the infection rate has been very high in some places, which means a large number of people have developed immunity. Re-infection rate is low. He suggests that while vaccinating, priority be given to those who have not contracted the virus yet. “That way we can save thousands of lives by vaccinating those who have no immunity to the virus. There have been breakthrough infections after vaccination, but the severity of the disease in such cases is much less.” At the end of the day, whether there is a third wave or not, he says, India needs to strengthen its primary health system to face any new pandemic or wave.

Corona ChroniclesCovid-19pandemicpreparednessThird wave