Click here for Press Release of AIPSN5JulyStatementonVaccinesandDrugs

AIPSN Statement on Covid-19 Vaccines and Treatment Drugs

India must follow Transparent, Reliable, Scientific Clinical Trials Protocols

Development of vaccines and medicines that treat Covid-19 are extremely important elements in the ways to overcome the Covid-19 pandemic. Around 150 vaccine candidates are currently undergoing pre-clinical and clinical trials globally, though none are yet available. However urgent the need, this vaccine development must also ensure both efficacy and safety, otherwise it will endanger the efforts to overcome Covid-19 and also vaccine programmes against other infectious diseases.

Scientists working in the National Institute of Virology (NIV) under the ICMR and Hyderabad-based BBIL have developed an inactivated vaccine candidate, BBV152 COVID, using a virus strain isolated in NIV. BBIL got approval for Phase 1 and Phase 2 trials on June 29 from the Central Drugs and Standards Control Organisation (CDSCO) as part of the fast-tracking of the process even while pre-clinical animal trials are still underway. According to the submission of BBIL with the Clinical Trials Registry of India (CTRI) also under ICMR, the enrolment for Phase 1 was to begin from July 13th and the duration of the trial covering all the three stages was to be 15 months. 12 hospitals with widely varying track-record and experience in vaccine trials have been selected for the purpose by ICMR in an entirely arbitrary and non-transparent manner.

On July 2nd, Dr. Balram Bhargava, Director General, ICMR, who is also Secretary, Health Research in the government, sent a letter to BBIL with copies to the 12 chosen hospitals for the trials saying that “it is envisaged to launch the vaccine for public health use latest by August 15th, 2020,” that is in less than 6 weeks compared to the planned 15 months.  The letter demands that subject enrolment be initiated no later than 7th July 2020, even though the CTRI registration itself shows July 13th as enrolment initiation, leaving no time for proper consideration and approval by the respective institutional ethics committees. Finally, the letter threatens these hospitals that “non-compliance will be viewed very seriously,” adding that the vaccine project is “being monitored at the top most level of the Government.”

Since “top most level of government” has been invoked, DG ICMR’s deadline appears for enabling the Prime Minister to announce “successful development of a Covid vaccine by India, before any other country,” from the ramparts of the Red Fort on Independence Day. However, as India’s premier scientific and medical research body, ICMR knows well the rigorous protocols required to be followed for vaccine trials, and therefore also that a deadline of 6 weeks to complete all three phases is scientifically absurd downright dangerous, and will cause serious damage to the reputation of Indian science and research. A desire to grandstand and please the political masters seems to have overtaken science and ethics within ICMR.  AIPSN deplores the emerging trend in India of short-circuiting established protocols for trials of Covid19 vaccines and treatment drugs.

Earlier, there was the instance of Coronil, an ayurvedic mix sought to be launched for treatment of Covid-19 by the Patanjali group headed by Baba Ramdev, based on spurious, improperly conducted and assessed clinical trials. . After uproar by scientists and in the media, the AYUSH ministry prohibited Patanjali from selling or advertising Coronil as a treatment for Covid-19. However, nothing was done about Patanjali not following due process of clinical trials and approvals. Glenmark obtained approval from DCGI for Covid19 treatment without any trials in India for manufacture of the antiviral drug Favipiravir. At a cost of Rs 103 a tablet and needing 122 tablets for a full course, the company stands to make a killing in profits. Highlighting the dangers of such hasty approvals without due process, the Lok Nayak Hospital in Delhi recently decided to stop using Favipiravir for Covid19 treatment following observations of problems in heart rate and uric acid levels in patients.

ICMR has also persisted with guidelines to administer Hydroxychloroquine (HCQ) to frontline health care workers and care-givers for patients in home isolation as a prophylactic. It is supposedly a ‘trial’ but without the strict protocols required for a trial. This despite published results of international trials showing lack of efficacy and possible adverse side-effects, and WHO guidelines against use of HCQ.

AIPSN demands that the due process of scientific trials be followed strictly and transparently for all Covid19 candidate vaccines and treatment drugs, regardless of systems of medicine, and overcoming temptations to make haste prompted either by corporate greed or false national pride.

AIPSN calls for a globally coordinated effort that puts people before profits to make drugs and vaccines that will be available free to the public and with allocations to countries made as per needs without any discrimination instead of the current perverted race to develop drugs and vaccines driven by jingoistic-nationalism and corporate profits.

AIPSN demands that the efforts of the scientists who came up with the BBV152 COVID vaccine candidate, or others likely to come up in the near future, not be wasted by such unseemly political pressures which compromise the safety of people by not following due process and which is highly likely to bring Indian science and research into disrepute.

For clarifications contact:

P. Rajamanickam  9442915101    D. Raghunandan  9810098621

click here for SummaryofPost-May3-LockdownStatement

click here for English version JSA AIPSN statement_Post-May3_Lockdown 

click here for Bengali versionBengali-JSA-AIPSNstatementonPost3rdMay-measures

Statement on post-3^rd May 2020 measures against Covid-19 Pandemic

 Jan SwasthyaAbhiyan (JSA) and All India People’s Science Network (AIPSN)

Background

 The Central Government has persisted with the Lockdown as the main, if not, the only strategy against the spread of COVID-19.  Underway since March 25^th, this lock-down has seen two extensions, one on April 20^th and now again on May 3^rd.  These one-size-fits-all country-wide lock-downs are badly planned and poorly implemented with measures imposed on the country by the Government using centralizing powers under the Disaster Management Act.

More than 28 Joint Statements released till nowby Jan SwasthyaAbhiyan and All India Peoples Science Network (JSA-AIPSN) have been released. These statements explain in detail why such all-encompassing restrictions of movements and activities that India has executed is a fundamentally mistaken approach with limited and temporary benefits, that fails to factor in Indian socio-economic realities. This will lead to many long-term adverse consequences.

WHO, public health experts and best practices of many countries all agree that population lockdowns are at best temporary, locale-specific, emergency measures which need to be accompanied by other more important health-related and socio-economic measures which we list as follows:

• extensive and rigorous contact tracing, wide-ranging and purposive testing, quarantining and isolation as required, and hospital treatment of infected persons
• buildingup preparedness of health systems using the lockdown leeway to respond to the anticipated high case load arising from Covid-19
• ensuring that the health system caters simultaneouslytonon-Covidhealth needs especially relating to maternal and child health, chronic or life-threatening ailments and needs of the elderly, disabled and other vulnerable sections
• ensuringreliable supply of and access to essential goods and services, especially to meet needs of the poor, elderly, disabled and other vulnerable sections
• financial and other special provisions for those who would lose essential incomes and jobs, such as migrant workers, daily-wage earners, the self-employed and workers in the unorganized and SME sector
• humane, effective and non-stigmatizing approach towards infected and suspected cases, and the economically worst-affected populations, with participation of community volunteers and civil society organizations as appropriate
• effective coordination between Centre and States/UTs, as the latter is being starved off revenues while also coping with demands arising from the Covid-19 epidemic.

However,although the lockdown is being implemented vigorously, none of these parallel measures have been implemented in the required scale and intensity. As a result, the capacity to undertake public health and economic measures to cope with the inevitable increase of infections when the lock down is lifted, are still not in place. The lockdown itself has also been imposed and implemented in a non-transparent manner without the epidemiological evidence required to inform both the classification of areas and the choice of activities to be restricted.

Current Status: The Central Government and its departments/agencies including the Ministry of Health and ICMR have been making various often unsubstantiated claims about the success of the lockdown,such asthat many more cases would have occurred without it, that the rate of new cases is becoming linear, that no community transmission is taking place, and so on. The reality is thatcases are fast rising especially in certain States/Districts, with surprisingly high fatality rates in some. There is substantial uncertainty about the true extent of spread given low testing rates, among the lowest in the world at around 0.4 tests per thousand population compared to the global median of 5.9 tests per thousand. Further, symptomatic cases without contacts have been largely excluded from testing by protocol.  Infection is certainly spreading to new areas through what is euphemistically termed “large outbreaks of local transmission” by the government. There are significant numbers of cases without any connection to persons with travel or known contact history.The rates of increase remain significant and accelerating. Whereas it took 10 days to go from 5000 to 15,000 cases it took only 5 to 6 days to go from 25,000 to 35,000 cases.

However, these all-India numbers mask the stark reality that the case load varies widely between States and also within States.At the time of writing the statement, 5 of the total 36 States/UTs have zero cases,130districts have been classified as “red zones”, 284districts as non-hotspot “orange zones”and319districts in 25 States reporting no new cases in the past 21 days as “green zones”. This colour-coding of districts and containment zones is not based on clear, stable and transparent epidemiological criteria, and yet forms the basis for policy recommendations for containment measures.

On top of this, within the red zones even more intensive “containment zones” or hotspots have been identified based on even weaker and more opaque evidence, but where even stricter forms of lockdowns have been imposed.

In light of this situation, the following steps are urged in the coming period:

1. Strengthen the disease surveillance mechanism, inclusive of COVID 19 surveillance,with appropriate design for collection, flow and analysis of information so that it can inform decision making for epidemic control at national, state and local levels as well as provide information on collateral costs in lives lost and morbidities due non-COVID causes.
2. Zero case reporting should not be made the exit criteria for lock-downs or basis for any zoning. Such unnecessary and unrealistic criteria run the danger of systems suppressing data to report zero cases. The realistic objective is to achievea manageable number of infections or case increase rates at any point so as not to overwhelm the system and to reduce deaths by protecting those that are particularly vulnerable to severe disease.
3. Many restrictions have no rationale in public health such as the country-wide restriction of movement after 7 pm. The specific rationale for such measures should be explicitly stated and subject to audit and review by impartial watchdog bodies.
4. Adopt a framework of participatory governance for determination of criteria for restriction of movements and activities, and guidelines for implementation of relief measures and allocation of resources. This could subsequently become part of a legal framework that would mandate functional consultative mechanisms involving public health expertise, health care providers and civil society organizations including of working people, all of whom would be affected. Such legislated provisions would also mandate watchdog bodies to ensure that the sweeping powers given under the Disaster Management Act are used in consultation with affected people and groups, and that the participatory framework is maintained.

Restrictionson Movements and Activities: It is strongly urged that a calibrated and graded easing of restrictions on movement and social and economic activities takes place, with broad guidelines within which States may decide on the extent of these restrictions.The main principle for making and implementing restrictions is that this must not call for creating or strengthening police raj using Sec 144 and other coercive measures. The public should be treated in a humane manner and as partners in the process, and not as criminals or subjects under colonial rule.

Relaxations should aim at reviving economic activity, especially in the unorganized and small-scale sector  while continuing to practice physical distancing and other precautions, improving services required by common people especially the elderly and vulnerable sections , considerably strengthening the health system to handle both Covid-19 and pressing non-Covid issues, and stepping up efforts at containment through expanded and rigorous testing, tracing, isolation or quarantining, and treatment. We note that several restrictions such as on agriculture, agricultural markets, fisheries, forest produce etc., as well as on enterprises in rural areas and activities by plumbers, electricians and carpenters in urban areas, have already been relaxed.

The following (indicative not exhaustive) additional relaxations beyond those already permitted since 15 April are urged, with States to decide on fewer relaxations in “red zones” if felt necessary:

1. Inter-State and inter-district movement of all goods should be freely permitted in view of the current severe shortages and supply-chain constraints impacting even food, medicines and other essential goods, besides other manufactured goods;
2. Students, tourists, and families that are separated and others who have been stranded by the lockdown should be allowed to book tickets in suitable public transport arrangements including special buses, trains and flights which are organized for this purpose, and facilitated to reach their destination within the next few weeks. Migrant workers should be transported to their native villages free of cost, so as not to add to their enormous burden they have already had to take on due to the lockdown.Those with symptoms suggestive of COVID 19 should be checked before travel and retained pending observation and subsequent clearance. . Further restrictions on public transport must be eased based on evidence

• All small-scale manufacturing and service enterprises be permitted to function in urban areas with suitable guidance on work-from-home where possible, proportion of personnel attending per shift, use of own or company transport, physical distancing and provision of protective measures such as washing stands, sanitizers, masks etc

1. All home-based enterprises, self-employed occupations and services such as care services, air-conditioner servicing/repairs, water purification and provisioning, neighbourhoodlaundries and pressing, courier services, roadside vegetable/fruit vendors, florists, and other similar categories should be permitted. Only exceptions can be stated such as where services providers are numerous with crowded clientele making social distancing difficult
2. Skeletal public transport and a limited number of taxiservices should be made availableand personal vehicles be permittedfor essential purposes like access to healthcare and for the vulnerable. Many of these should be decided locally and not micro-managed from the central MHA.
3. Types of shops allowed to function from local markets may be expanded to include hardware stores, electrical supplies, sanitary ware stores, cell phone repair, bakeries, hosiery and undergarments, stationeryetc., and small restaurants for home delivery.
4. Based on data related to social mixing and disaggregated infection rates, several countries have worked out risk criteria for different types of services according to which certain services like cinema halls, malls and pubs are kept closed for the time being while some other services such as restaurants operating at 50 percent of less occupancy with physical distancing norms are allowed to open.; some countries have opened up primary schools, others have allowed public transport and so on. Similar risk-criteria may be evolved for India and services opened up accordingly

 The efficacy and effectiveness of the “containment areas” approach is questionable on epidemiological and other grounds and measures implemented within these areas are highly arbitrary and unrealistic. If essential needs like outpatient healthcare or food purchases are disallowed, then people are forced to breach the containment perimeter by subterfuge to meet these needs. Further, once these areas are opened up, they are as vulnerable as before to infection from nearby areas. Whereas neighborhood spread is not a feature of the epidemic, such forms of containment may actively lead to it. This is essentially a policing approach that cannot be a substitute to contact tracing by community health workers with active community participation.

 Hospitals and health care: Focus of the government hitherto has been almost exclusively on preparing public hospitals dedicated to Covid-19 care, to the extent that other important health services have been sidelined causing enormous problems to persons suffering from various chronic or life-threatening ailments and increasingly even to maternal and child health. Earlier JSA-AIPSN Statements have elaborated on this issue in considerable detail. Government claims that sufficient beds are now available for handling Covid-19 patients, but ground realities are that hospital beds have mostly been diverted from other non-Covid requirements, and ICU Units properly equipped with oxygen and ventilators are in extremely short supply even in metropolitan cities, for instance in Mumbai. OPD and many other services in public hospitals have also been suspended with, for example, outstation patients and their caregivers stranded in makeshift shelters in Delhi for over a month waiting for cancer or other treatment.

It is also notable that medical professionals and other health workers and auxiliary personnel have become infected by Sars-Cov-2 in sizeable numbers and hospitals have themselves become major “hotspots” for infection spread for a variety of reasons, most of which were avoidable.

1. In light of this situation, the following steps are urged in the coming period:
2. Urgently expand the number of beds and well-equipped facilities for isolation and initial treatment of Covid-19 patientsthrough non-hospital re-purposed facilities such as sports stadia, conference halls, panchayatbhavansetc, including by erecting purpose-built field facilities, so as to reduce pressure on hospitals . Where the patient is COVID 19 positive, institutional isolation with suitable medical care must the only option. Home isolation can only be considered in exceptional circumstances.
3. Better equip dedicated Covid-19 hospital facilities for management of severe disease.
4. Stop the conversion of functional multi-speciality public hospitals currently working on full capacity, leading to denial of access to essential healthcare for close to half the population in many medical disciplines. Where there are no other under-utilized public or private hospitals that can be re-purposed, with segregation of one wing of the public hospital and entrance through a separate gate, while ensuring all other departments function in same volumes as before could be a temporary arrangement. But in parallel- the government must rapidly build up new public hospitals.
5. Conduct independent audit of hospital procedures and protocols to prevent hospital acquired infection using standard quality accreditation guidelines as well as COVID specific guidelines in all hospital, public or private, irrespective of whether they are seeing COVID 19 patients.
6. Rigorously identify and test all symptomatic patients for Covid-19 infection, as also all patients with co-morbidities that are known for association with COVID 19 infection.
7. Provide appropriate PPE for all health care and auxiliary personnel in hospitals handling both COVID and non COVID patients.
8. Extend training, PPE and other support measures commensurate with requirements to ASHA workers and other community health workers, sanitation workers, police personnel, administrative staff, social workers, and volunteers working in potentially high-infection environment.
9. Ensure continuity in care, including access to diagnostics and medication and out-patient and in-patient care for serious. chronic and life-threatening ailments
10. Ensure safety of doctors and other health-care workers through provisioning of PPE in requisite quantities and quality standards
11. Ensureadequate ambulances and/or other vehicles for speedily bringing patients requiring hospitalization for both Covid-19 and non-Covid19 cases
12. Induct volunteers of recovered Covid-19 patients for interfacing between the public and the health care workers with periodic testing as required to ensure there is no recurrence.
13. Provide mental healthcare services as required to health workers, Covid-19 patients and their families, and to address mental health issues among school children, adolescents and others arising out of lockdown.
14. Strongly come down on the touting of fake cures and remedies, “immuno-boosters” and other similar gimmicks, including their advertisement on television and other media

 Quarantine: Contact tracing and quarantine of asymptomatic contacts of Covid- 19 is an essential component of epidemic control. However in densely populated slum and low-income areas in cities, there is little scope for home quarantine due to over-crowding, poor health systems support and lack of trust between authorities and residents. Recent instances of persons being kept in large numbers in a single room in Delhi with a common, dirty toilet, or of poor people being kept in UP like caged animals with food being thrown at them, show the utter callousness and carelessness with which quarantine is being viewed, except for the well-off who may stay in their own homes or even in hotels on payment.

In light of this situation, the following steps are urged in the coming period:

1. Institutional facilities for hygienic, effective, dignified and humane quarantine must be sharply increased for all classes and categories of persons, with adequate provision of nutritious food and other essentials.
2. Clear standard norms of institutional quarantine that includes medical and public health features as well as considerations of comfort, convenience, privacy and human dignity should be urgently drawn up, disseminated and rigorously monitored, including through community based people friendly mechanisms.
3. Such facilities may be created in repurposed public buildings, schools, college and university campuses, and other requisitioned private/institutional buildings or purpose-build facilities as required.
4. As many of these facilities as possible should be community managed, often engaging recovered patients from that very community in the management, so that there is trust and humanity in the way this is dealt with. Assistance of civil society organizations may be promoted and utilized in a coordinated manner.
5. In situation where it is reasonable to accept compliance and there is good community support and linkages with the health system, home quarantine can be permitted.

Testing and Tracing: The recommended relaxation of restrictions should be accompanied by expanded and more rigorous tracing and testing of all suspected cases, so that quarantine of contacts, and isolation and treatment of the infected are vigorously pursued towards breaking the chain of infection.In so-called red zones suspected cases,based on clinical symptoms and contacts of known positive cases need to be pro-actively identified through door-to-door surveillance contact-tracing and contact tracing.  Yet despite all the time gained by lock-downs the access to testing remains far below what is required for both individual patient management and for epidemic control.

In light of this situation, the following measures are urgently required:

1. Testing protocols currently specified by ICMR need to be revised to permit testing of all persons with symptoms suggestive of Covid-19 infection (mild, moderate or severe) as well as asymptomatic contacts. It could be further scaled up to include asymptomatic people without contact history if infection is high enough to label it a “containment” hotspot. Some of those at high risk like health workers in the COVID frontline may require periodic testing, while others may require testing if they develop symptoms.
2. Access to both viral antigen testing and rapid antibody testing needs to expand. Rapid antibody testingis very useful tool that clinicians can use to rapidly confirm diagnosis within a clinical setting, and for sero-surveillance including in so-called “green zones” for understanding spread of infection and the development of herd–immunity. In many clinical settings viral antigen tests would be required even if it is more difficult to access.

Test kits & PPEs:Test kits and PPEs need to be procured expeditiously in sufficient quantities and distributed to States proportionate to requirement. While government spokespersons have repeatedly released figures of Test Kits and PPE ordered, which was done very belatedly as recent revelations show, delivery has actually been slow. Official statements indicate that the required larger numbers of PPEs and test kits may not be available before end of May or even June, which is totally unacceptable. Poor procurement policies, delayed validation and an over-reliance on one or two foreign suppliers have led to this crisis. Indigenous PPE manufacture has been slow to pick up partly due to lock down related barriers of access to raw materials and labour. Indigenous test kit manufacture has also faced problems of delayed validation and is taking time to scale up to required levels.

In light of this situation, the following steps are urgently required:

1. Bottlenecks in manufacturing clearances and domestic production need to be urgently addressed, especially as regards supply chains and transportation.
2. Financial support should be extended to domestic manufacturers in order to scale-up and speed-up production, with products of adequate standards commensurate with international norms; this should be done with a long-term perspective of building up indigenous capability and eco-system in aspects of the value-chain towards a globally competitive medical equipment industry in India.
3. Validation and other clearances should be accelerated for indigenous tests developed (as for example the Chitra Tirunal RT-LAMP test or the CSIR-IGIB test kit) in order to include them into the program and expand the options available.

Stigmatization:The entire approach of the Government as well as its explicit messaging have been founded on creating fear which in turn has been transformed into stigmatization and aversion by a petrified public. Despite all the government-organized clapping and lamp-lighting, doctors, nurses, sanitation workers, testing technicians and even airline pilot and crew have been targets of stigmatization among all classes. Even the dead have not escaped this stigma. Stickers, posters, wall paintings etc. outside the door of quarantined persons have only increased the perception of infected persons as “the enemy,” to be shunned or even fought off. Various tracking apps will only make this worse and add to the surveillance capacity of the government well beyond this epidemic. Without trust and public cooperation they are unlikely to be effective. These tracking apps have therefore been opposed by many civil society organizations, especially those specializing in internet and data privacy.

The communalization of the epidemic, which has itself acquired epidemic proportions, is an extreme form of this stigmatization and needs to be fought back by all concerned, especially by the Government.

In light of this situation, the following immediate actions by the government are required:

1. Government must actively lead health education (IEC) activities that de-stigmatize the disease and promote a better understanding of how it spreads. Its message should be reviewed to ensure the messaging does promote social solidarity, not fear, guilt or hostility.
2. All norms of privacy and confidentiality of individuals and communities must be respected. A serious campaign must be organized to de-communalize the disease
3. Government must stop targeting its political dissent and making arrests and restrictions on political grounds using the opportunities provided under the draconian disaster management act and the difficulties in access to court. This is essential for building a broad based trust.

Gender based violence: The lockdown period has aggravated situations of violence that happen to people on the basis of their gender, sex, or sexual orientation-women, girls, trans-persons, children and others. Being restricted within homes/families has meant for many women and others to be isolated with their abusers. It has not only meant being more exposed to ongoing violence but also the inability to move out seeking protection and care. The sudden enforcement of lockdown and subsequent suspension of transport facilities/mobility has predictably led to this scenario as it created barriers for those who would have wanted to move out of situations of violence in the given context. Even before Covid-19 situation, gender based violence has existed as a pervasive issue having enormous impact on lives of survivors including negative health outcomes, thus forming a crisis situation of its own which was completely overlooked given the way lockdown was enforced with least sensitivity to the needs of these survivors. Overlooking one crisis while gearing upto respond to another- is paradoxical at least; and violation of the rights of survivors at large.

There are also,very disturbing instances of violence against women in quarantine facilities and at hospitals being reported must be urgently looked into and dealt with to ensure that no such violations happen in future. At a crucial time when the hospitals, healthcare workers and systems are seeking support of the communities and its varied members for their voluntary cooperation to control the spread of Covid-19, such incidents unfortunately breaches the trust of the communities, particularly women for trusting their well-being with the government systems.

Given this situation, we call on the government to take the following steps:

1. Prevention and redress of gender based violence must be made an important aspect of national response plans for Covid-19. The governments must send a clear message against all forms of gender based violence including sexual violence in all spheres of lives including health facilities and quarantine spaces. Public health preparedness, systems and protocols in the current context must take additional measures towards ensuring a dignified healthcare for all women, girls, and other marginalized groups.
2. Special emergency fund should be declared and allocated for responding to gender based violence in the current context including the utilization of existing Nirbhaya funds with states- with requisite directives and flexibility to draw up response suitable to different contexts.
3. Essential service providers must be recognized at the administrative level-including government helplines, one stop centres, police, protection officers, medical officers, legal services authorities, counsellors, shelter homes etc. and ensure that they remain operational universally.
4. Government should call for urgent consultation with women’s groups/organisations working on this issue to ensure a concerted/organized effort during the Covid-19 situation.

 Migrant Workers: Last but not least, is the terrible situation that migrant workers find themselves in, which is a massive blot on the governance system and the reputation of our country. These workers are the backbone of the Indian economy.They earn their livelihoods however meager with dignity, and do not deserve to be treated as supplicants. This crisis must be resolved urgently and humanely.We note that after a long and inexplicable delay, permission has been given to run special trains for migrants to return, but even this move is as yet inadequate in scale and support systems. Moreover, it has been reported that the workers are being made to pay for their travel back, which is completely unethical. Many migrant workers have already been subject to brutal and hostile quarantine conditions and many are exhausted by hunger, disease, heat and the exertion of trying to walk back home.

In such a context, we call on government to take the following measures:

1. Arrange adequate number of special trains for returning migrants to their home states, and further buses within the states for them to reach their home village. These should be provided completely free of cost.
2. Ensure that those who have symptoms are tested, and allowed to board only if negative. If positive they must be hospitalized at state expense, and when they become negative catch the next train back. Those who have no symptoms can be allowed to return without any further tests.
3. Arrangements for proper quarantine according to specifications as discussed above should also be made in their native villages or districts, if they are coming from a higher infection zone to a lower infection zone.
4. Transportation conditions should be decent with food and clean toilets ensuring physical distancing.
5. Whatever meager support migrant workers have been extended by the Centre and by some of the States where they had come to work and live, has been too little and too late. They require to be compensated for loss of income incurred due to the lockdown, and provided with financial assistance through MGNREGA or other means after they return to their villages.

Relief Measures for all Working People: The government has announced a slew of relief measures. JSA-AIPSN in an earlier statement has pointed out to the inadequacy of many of these measures, both in terms of covering all those who require relief and on the scale of relief provided.

As the government goes into the second extension of the lock-down we note that most of these relief measures are yet to reach the majority for whom it is intended. No further measures from the government have been forthcoming. Only very few states have been able to supplement this package of relief. There are also many categories of workers like non-migrant urban poor staying in the slums, are out of work, and have no access to social security measured and food security entitlements and have no relief package directed at them. A number of NGOs are valiantly try to close the gap with community kitchens,- but the scale of this effort is too small.

In this context we call upon the government to:

1. First and foremost implement the promises it has made with respect to relief and ensure that bureaucratic barriers and implementation failures do not exclude large sections of those who need relief or fail to deliver the necessary quantity of relief.
2. Announce an increase in the resource allocation and use this to expand the scope of relief measures that are provided to the working people, especially the most vulnerable sections who are bearing the brunt of this crisis. The longer such lockdown continues the higher would be such burden on them.
3. Expand food supplementation and food security arrangements as called for by the Right To Food Campaign, without any mandatory requirement of Aadhaar. The FCI currently has a stock of over 60 million tonnes of grain, which should be distributed among the population.
4. Expand the MGNREGS to reach a much wider section of rural workers and extend it to all urban workers, so that all those in need of employment are able to secure employment for at least 200 days in the coming year, wherever they are resident. The kind of works permitted under MGNREGA should also be expanded and a basic unemployment allowance would be required in many states.

For more information please contact:

D.Raghunandan – 9810098621

T. Sundararaman – 9987438253

N. Sarojini  – 9818664634

Sulakshana Nandi – 9406090595

Follow for regular updates:

Website          www.phmindia.org               www.aipsn.net

Twitter           @jsa_india

Facebook       @janswasthyaabhiyan

Summary-health-worker-rights-Position-Paper

Position-Paper-Health-Worker-Rights_Final

POSITION PAPER
Health workers’ rights in the time of COVID-19
by Jan Swasthya Abhiyan (JSA), All India People’s Science Network (AIPSN) and
Public Services International India National Coordination Committee (PSI India NCC)

21 April 2020

Introduction
As of 21 April, the COVID-19 pandemic has infected about 2,482,158 people worldwide and contributed to 170,470 deaths. In India as on 20 April, the number of people infected with COVID-
19 is 17,656 with 559 deaths. The corona virus Sars-CoV-2 that causes COVID-19 is potent for certain biological reasons―its structure enables it to latch on to hosts easily, it has a long infection period, it is infectious even in asymptomatic carriers, and human beings have no immunity to it as yet. Hence it can spread easily and quickly. A large, sudden influx of patients can put extreme stress on both the healthcare system in India and on its health workers, as we are currently witnessing in many countries in Europe and the United States. Health workers are generally at high risk. In Italy for instance, it has been reported a staggeringly high proportion of all those infected are healthcare workers. India is witnessing an increasing number of cases of infection among health workers.
The situation is made worse by the fact that COVID-19 has hit India against the backdrop of a neoliberal assault on healthcare. This assault has meant that public health facilities are in disrepair,
neglected, and overburdened. At the same time, private hospitals and nursing homes have proliferated, without adequate regulation.
The main rationale for the poorly planned 27-day lockdown and its extension upto 3 May by many states, with disastrous effects on lakhs of informal and migrant workers, is that it will buy time for the government to prepare for COVID-19’s likely assault. However, governments’ actions
till now have been both late and inadequate. The current situation is dire. Testing is inadequate, there is severe scarcity of test kits and the much-publicized antibody-based kits have barely begun trickling in, more ventilators are needed, and the availability of personal protective equipment (PPE) is poor and uneven across regions and hospitals. Moreover, the high population density in slum settlements and bastis in all towns of India makes physical distancing, even in a period of lockdown, impossible and puts the poor and a very large number of workers at risk of infection.
Additionally, health facilities can become sources of the spread of infection, with three concentric circles of risk: individual health workers in direct contact with patients; other employees including fellow-nurses, doctors, and other health workers; and three, the public coming to a hospital.
Recent episodes, such as in Delhi, Mumbai, and Hyderabad have shown that this can occur at any health facility, not just at COVID-19-identified ones, particularly given that the current Indian testing and patient management protocol has no provision for testing symptomatic patients without a contact history and isolating those who are positive but asymptomatic. These patients might have high infectivity and will be coming into close contact with many healthcare providers without either patient or health providers knowing. There are also asymptomatic carriers in the public, many of whom will be seeking care due to co-morbidities. Health workers at the community level, such as ASHAs, who are deployed either for Covid-19 outreach and community awareness or for routine community level work such as immunisation, are also facing higher risk of exposure to the virus.

Hence, the rights and protection against risk of health workers on the one hand, and the robustness of the health system on the other, and the policies with regard to testing, all deeply intersect in the
times of COVID-19.

Because health workers are on the frontlines of our response to COVID-19, they face higher risks of infection, overwork, and stress. Hence, any strategy to fight the pandemic should consider the rights and protection of health workers, including through the following:
(a) adequate PPE should be provided;
(b) access to testing and treatment needs to be ensured;
(c) health workers should be covered for COVID-19-related sick leave, quarantine and provided compensation;
(d) workers should be allowed to opt out of performing their work in conditions that puts them at risk, without risk of losing their jobs;
(e) proper training needs to be provided regarding procedures before workers are deployed;
(f) representatives of health workers need to be actively involved in setting up safeguard measures in health facilities;
(g) the organization of work in hospitals (such as patient flow in the outpatient wards) should be such that their risk of exposure to healthcare workers is minimized;
(h) wages and overtime should be paid as per the law without any mandatory or so-called voluntary cuts;
(i) adequate facilities should be provided across needs such as adequate accommodation, transportation, child care, and nutritious meals;
(j) measures are urgently required to protect health workers against stigma, violence, discrimination, and sexual harassment;
(k) existing vacancies need to be filled with a long-term perspective;

The COVID-19 crisis and the effectiveness of health systems response both in India and globally, clearly underlines the need for healthcare to be in the public sector. The related, broader issues of health workers’ employment, equal pay for equal work, and rights to occupational health and safety and better working conditions is central for countries to be able to cope with COVID-19 now. We welcome the broader support and appreciation for the work that health workers are doing in the forefront in the fight against COVID-19. However, just appreciation and statements of good
intent are not enough. Nor are simply clapping hands and banging plates. We need this support to be legalized through notifications and legislation by the appropriate authority at varied levels of government: centre, state, and local bodies. How robust we make the healthcare system and strengthen
all health workers now is central to coping better not just with the present crisis, but how well we will be able to cope with any health crises in the future.

A precarious health workforce makes the health system more fragile.
The continuous underfunding of public healthcare has meant that in public hospitals, due to budgetary tightening, vacancies of health professionals―from doctors, to nurses to paramedics―have not been filled. This imposes a heavy workload on the existing staff that was
already hard for them to manage. In many facilities, especially under local bodies and poorer state governments, professional staff shortages have been dealt with by hiring on short-term contracts or deploying field staff in hospital settings, such as with ANMs. Health workers who are ‘non-profes-
sionals’, such as ward attendants and housekeeping staff, cleaning and security staff are most often hired through contractors, at low wages, pathetic working conditions, and too often in violation of the labour law.
While the private health sector has thrived and expanded, its workforce is highly underpaid, except for high profile and specialised doctors. Across the country, nurses in private hospitals are, at best, paid around the minimum wage for a skilled worker, and most often below this legal benchmark. This sets the scale for other staff, who also face the challenge of being hired through a third
party which makes their tenure highly insecure and without social security coverage.
The workforce at the primary level of care provided in health posts and at the community level are unarguably the most neglected. Field/community health workers, such as the Accredited Social Health Activists (ASHAs) in rural settings or Community Health Volunteers (CHVs) in Mumbai, are the largest group of health workers with more than 9 lakh workers in India. They are denied the status of a worker by the State. ASHAs are told they are ‘volunteer’ activists and not workers of the health system, thus denied minimum wage and any other rights of a worker under the law.
As health workers across the health system have been mobilised to respond to the pandemic, the pre-existing cracks and weaknesses in the system make it all the more fragile. Informal employ-
ment leads to unclear responsibilities towards workers, and has created blind spots in the system.
ASHAs and CHVs have been deployed for case identification without adequate safeguards. Sanitation and support staff who are contractual are being preferentially deployed as compared to regular staff, so as to avoid social security obligations in case of their illness. Public hospitals will be at the
centre of the response to the COVID-19 epidemic, but they will have to be reinforced by private facilities, either through collaboration, or preferably, through requisition by the government. The precariousness faced by the vast majority of the close to 40 lakh health workers has to be addressed as a matter of priority as part of health system preparedness that the lockdown is meant to enable.
Previous outbreaks of highly infectious communicable diseases have demonstrated that public health outcomes are significantly improved when labour rights are respected, and trade unions are able to effectively represent workers actually exposed and potentially exposed to the disease.
The active involvement of health workers’ representatives in government decision-making is necessary to safeguard workplace safety and health and ensure the cost of the crisis is not borne by healthcare personnel.
REQUIRED MEASURES
a) Adequate provisioning of Personal Protective Equipment
Reports coming in from Maharashtra, West Bengal, Tamil Nadu, and Bihar point to uneven availability of PPE of adequate quality, leading to protests. Workers are worried that raincoats are provided instead of medical gowns, that eye protection and other equipment has not been provided. Workers are forced to do risky procedures without proper PPE, or asked to quit if they refuse. This is creating confusion on stress amongst the health workforce and needs to be urgently addressed.
The guidelines of the government of India – that make recommendations regarding the use of specific PPE for different categories of workers, including medical masks, gloves, gowns, eye protection, and footwear and respirators depending on the kinds of patient care – have not been adhered to.
Even the WHO interim guidance of 19 March 2020 on Rational Use of PPE for coronavirus disease (COVID-19) have not been followed. Newguidelines (dated 20 April) acknowledge the risk of infection by asymptomatic patients who visit a health facility for other health reasons, yet they do not provide guidance on PPE requirements. We recommend that the Indian government ensures systems to monitor and enforce strict adherence to adequate guidelines for the use of PPE.
There has been a clear and criminal lack of preparedness and stockpiling, in disregard of WHO guidelines of 27 February 2020. The Ministry of Health has admitted a shortage of equipment and supply not meeting rising demand. This is compounded by an inadequate estimate of the size of the health workforce, which the government estimates at 22 lakh, while it should be closer to 40 lakh (A 2016 estimate suggests that the number of health professionals and para professionals alone (including doctors,
nurses and midwives, dentists, laboratory technicians and paramedics) was close to 25.3 lakh. The latter does not
include health workers such as cleaning staff, ward attendants, ambulance drivers, ASHAs and ANMs, to name a few. ASHAs alone are estimated to around 8.5 lakh, ANMs to around 2 lakh. While there is no estimate available for
ancillary health staff, it is safe to presume that at least 2 to 4 lakh, bringing the total number close to 40 lakh/4 million.)

Given the uneven nature of PPE availability across regions, we recommended that PPE be sourced
in priority from domestic manufacturers with a long-term view of development of domestic industrial capability, and supplied to deal with clusters of cases as they occur. This implies that PPE pro-
curement orders have to be increased to ensure adequate access to all health workers, and PPE be sent to regions where they are most needed.
The shortage of necessary PPE equipment and the traditional structures of social discrimination in India could lead to certain categories of workers, such as nurses who are at highest risk, but also ASHAs, non-permanent/contract workers and cleaners, not being provided adequate PPE. We urge that the government issue a directive that no such discrimination take place against any worker in any establishment. Health workers should not be forced to work under unsafe conditions without adequate protective equipment.

b) Free health care for all health workers
The announcement by the Finance Minister of a special life insurance scheme for health workers is
misleading and insufficient. Despite an announcement that all health workers would be covered, the package covers health workers in the private sector only if they are drafted for COVID-19
responsibilities. The recent case of health workers getting infected at the private facility Delhi State Cancer Institute shows that this is insufficient. Further, this is subject to the numbers indicated byMoHFW. The figure of 22 lakh health workers is a gross underestimation of the actual size of the workforce in the country, as mentioned earlier. The estimate should be modified correspondingly and increased to at least 40 lakh health workers and the omission of healthcare workers in the private sectors needs to be corrected immediately to avoid the possibility of denial of compensation.
Most importantly, this scheme is grossly insufficient as it does not provide any support to health workers and their families unless the worker dies. In case health workers are infected by COVID-19
they should be given treatment, care and support free of cost. Considering that health workers in informal employment conditions are more vulnerable as employers can hide behind this informality to deny their responsibility towards them, it is important that they are given special attention in this
regard. The latest testing protocol (31 March) has expanded testing only to symptomatic health care workers, whereas there is clear evidence of asymptomatic cases. As current testing protocols are restrictive, health workers might find that they are compelled to go for testing in private labs, and incur costs. Failure to detect infections early among healthcare workers may result in further spreading of the infection. Access to comprehensive and free health care, including outpatient, hospitalisation, and regular free testing need to be ensured, with special attention to informal
health workers. Special provision of regular testing needs to be ensured for health workers performing high risk tasks, even if asymptomatic.

c) Special COVID-19 related paid leave and compensation.
Health workers are at a higher risk of contracting infectious diseases, which is the case with  COVID-19 as well. Reports estimate close to 100 infections already confirmed in India, though there is no systematic reporting of this data. As facilities are short-staffed, managements of facilities are extending working hours. They might try to keep health workers on the job even when they are  already showing COVID-19-like symptoms, as we saw in Mumbai and in Bihar. Workers who have tested positive with COVID-19 should not be asked to continue with their duties if they are showing
symptoms. This is against protocols and puts the workers at more risk of developing more severe symptoms if they are not able to rest adequately.
Managements of facilities might also deduct leave taken for sickness or quarantine from existing leave provisions, and when these are used up, take recourse to cutting workers’ wages. Informal workers have a limited amount of paid leave that will run out quickly. Those on daily wages do not
even have paid leave. Special paid leave in case of COVID-19-related sickness and quarantine should be provided, including to workers on short-term contracts and employed through a third
party. A special compensation should also be announced for health workers who contract COVID-19 in line with the WHO definition that if exposure to corona virus Sars-CoV-2 happens at the
workplace, contracting COVID-19 should be considered an occupational disease.
d) Mental health support and the right to opt out
Health workers undergo considerable stress during emergencies such as the one we are facing.
Counselling and mental health support should be made available for health workers. Breaks and time-off should be maintained, as healthcare workers’ burnout could contribute to both their
catching the virus and its spread. As per WHO guidelines, health workers should not be required to return to a work situation where there is continuous or serious danger to their life or health. Health workers’ right to opt out of work when they are not provided with a safe working environment and adequate protective equipment should be respected, without undue consequences.
Health workers who are pregnant, or have co-morbidities have higher chances to contract the infection and develop more severe symptoms. They should not be put on duty in the COVID-19 ward and limit exposure to patients with suspected COVID-19. Instead, they should be assigned appropriate tasks within their profession that does not expose them the virus and be accommodated if they request so.

e) Training on procedures and infection risk management
Managing the risk of infection in health facilities, both in the public and private sectors, is essential to ensure that health facilities do not themselves become hubs of infection. Part of the risk management procedure is to ensure that all health workers understand the measures that are needed to protect themselves, protect patients, and protect the facility. The government should implement or
direct facilities to implement appropriate training for the diversity of workers categories across levels of risk.
The government needs to put in place online training programmes on infection control with a focus on COVID-19 for the entire medical workforce in the country, facility-based training for the entire
workforce in each facility, including ASHA and community-based health workers attached to different health posts. All health workers should be provided with communication materials in different languages on the appropriate safeguards, including but not limited to PPEs.
The entire staff in all COVID-19 earmarked hospitals, ICU units, and isolation centres should be given training and this should include both guidelines and protocols for COVID-19 care, as well as personal safety, infection risk management and the use of personal protective equipment. The government should provide guidelines for these procedures to be followed in private facilities. A helpline should be set up for health workers who face challenges at their workplace, with a defined
procedure to register complaints and interventions to resolve them. In case private facilities fail to follow the government guidelines and resolve issues with regard to adequate safeguard measures, the state government should consider requisitioning these private facilities in order to avoid the spread of the disease due to negligence of private operators.
f) Active involvement of representatives of health workers
The government should engage with trade unions of health workers to ensure that the guidelines effectively reach all concerned health workers. For instance, there is a need for clear information and
training regarding PPE use, disposal, and care. Health worker unions are well positioned to contribute to this process, as they have the organizational ability to reach out to large sections of workers
quickly. Hence, we urge that different state governments involve health worker unions in the process of information-sharing, training, and workers’ safety. Facility management should facilitate an
active role for health workers’ representatives in determining safety measures and safeguards of  their health.

(g) organization of work in hospitals that minimises risk of exposure to healthcare workers
The other part of risk protection is the proper organization of work processes that would limit hospital infection to patients as well as to (all) health workers. This is a part of most quality accredita-
tion programmes, such as the national quality assurance standards for public health facilities and multiple systems for private healthcare facilities. However, only a small proportion of facilities are
registered under these frameworks. One of the reasons why Kerala has reported fewer infections among workers and less spread of the virus overall is because it has much better level of accreditation and infection control. The infection control component of the quality accreditation programmes must be implemented universally across states, including in the private sector, along with a monitoring mechanism by the government.

h) Wages and extra-time to be remunerated as per the law
As society recognises that health workers are contributing to the common good by standing at the frontlines of the battle against the COVID-19 outbreak, longstanding violations of legal provisions with regard to their wages should be acknowledged and addressed. Notifications should be issued so that wages are provided as per existing government norms, and wage discrimination against workers in informal employment should be addressed. The current budgets of most municipal hospitals and state hospitals are too small to provide the legal wages to all workers, which has been covered up through outsourcing of services such as cleaning and housekeeping.
The central government has formalised the central role of ASHAs in containment and community outreach, highlighting once again their role as an essential workforce of the state health system. Yet,
the government guideline does not provide an additional budgetary allocation while, of course, all other tasks are to continue – ante-natal care, vaccination, etc. A paltry Rs 1,000 per month for April and May is to be paid by states from unspent money. Their contribution in the month of March is
not even acknowledged and, without additional budgetary allocation, most State governments might not even pay this inadequate incentive. The government pretence that ASHAs are not workers of the health system amounts to discrimination against an exclusively female workforce that is paid a fraction of the prevalent minimum wage.
Central and State governments should make the required budgetary allocations to ensure that ASHAs and other health workers deployed to respond to the emergency situation are provided the
remuneration they deserve, and at least as per the law. Such allocations should be incorporated in subsequent annual budgets.
As the crisis intensifies, health workers will be asked to provide extra-time on a regular basis. This extra time needs to be regulated to allow enough time-off to rest and recover. Healthcare workers’
burnout aids the spread of the virus. Breaks and time-off need to be maintained. Extra hours should also be remunerated as per the law.
It has also been reported that public and private sector hospitals are forcing their staff to contribute to the government relief fund from their wages, in part of in entirety. Health workers should not be
asked to compulsorily or voluntarily forego their wages in full or partly.
With the exception of specialised doctors, wages in private hospitals and other health facilities in the private sector are abysmally low. This led to the Supreme Court recommending a wage increase across the board in the private health sector (2016). The recommendation has largely been unimplemented. In some states, such as in Delhi, the High Court directed the state government to legislate towards the implementation of the Supreme Court recommendation. Yet, no such steps
have been taken. Considering that health workers in private facilities will also be involved in responding to the COVID-19 epidemic, state governments should ensure compliance with the Supreme Court recommendations relating to wages in private healthcare facilities.
Due to the financial crisis that preceded the COVID-19 pandemic many health workers such as ambulance drivers, but also cleaning staff and ward attendants, had not received their payments for
months. The increased budgetary provision should prioritize payment of such arrears. As the lockdown requires minimising non-essential activities and some workers have been asked to join
duty on alternate days, including for those working in hospital settings, special attention should be given so that those working fewer hours because of the lockdown are paid their full salaries, even if they are hired through manpower agencies, or on short-term contracts and other informal
employment conditions. For instance, safai karamcharis might find it difficult to travel to the hospital they work in because of the shutdown of public transport. They should be considered on
duty for the full period of the lock-down. Finally, private sector hospitals are threatening to cut wages in the month of April due to fewer patients and reduced “business” in that period. The government should actively monitor that wages of health workers are paid. A health worker helpline linked to both the Ministry of Labour and Ministry of Health should be available for health-workers to notify non-payment of wages and arrears.

i) Adequate facilities across needs
Health workers working in high-risk areas, such as isolation wards, have to be provided the option of adequate hostel accommodation so that they can avoid going home where there are old relatives
or young children whose health they are concerned about. They should not be asked to vacate the hostel once their 14-days shift is over, as they risk to expose their families if they go back home.
Separate restrooms for medical personal in direct contact with COVID-19 patients should be provided. Some states have taken steps to provide accommodation to doctors in hotels near the hospitals where their work. There is no justification for the same benefits not being provided to nurses and paramedics in direct contact with patients.
A large proportion of health workers are women who often face the double burden of housework and care for their families as well as work outside the house. Adequate provisions should be made to ease the burden of family care, including by providing options for crèche or childcare outside the
hospital setting. This is essential since regular childcare and schools are shut.
Soap and water should be made available in all facilities for workers and the public as a basic hygiene measure. Hand sanitizers and detergent should be provided to all health workers on a
regular basis to facilitate personal hygiene.
Transport to the place of work, especially for those who do not have private transport, should be provided, particularly if the lockdown is extended. There are reports of cleaning staff in cities such as Delhi not able to join work due to the lockdown and decrease in public transport facilities. This
impacts the smooth functioning of hospitals, as well as creates hardship and stress for the workers who are worried that their salaries will be cut for the days they are not able to attend work. ASHA
workers are facing similar issues as they have to travel from one house to an other.
Lack of nutritious food compromises immunity and puts health workers at risk of coronavirus.
Adequately nutritious food needs to be made available to health workers at the hospital, through the public distribution system, or through other effective systems.

j) Stigma, social exclusion, violence and sexual harassment
We have seen during previous virus outbreaks that health workers are at risk of stigma and social exclusion. Even during the current COVID-19 epidemic there are reports of health workers being
asked to leave their rented accommodation. Other reports have surfaced of health workers being
attacked or harassed during tracing of potential COVID-19 cases or during their routine service delivery. Particularly distressing are reports of healthcare staff who have become victims of COVID-19 being refused burial or cremation services because of such stigma, when it is well known that there is little danger of infection from dead bodies. The government should take appropriate steps to ensure a safe workplace and work environment, including a strong media campaign to counter stigma of all forms, and appropriate orders to outlaw stigma and discrimination. A grievance redressal mechanism should be put in place, including internal complaints committee in case of sexual harassment.
Health workers, including nurses, bringing lapses in treatment and protocols to the attention of the public or speaking out about their working conditions are being gagged and harassed. Hospital management and administrators may be stretched but unethical practices cannot be allowed to
persist and health workers’ role as whistle-blowers should be protected.
Health workers also face violence and harassment from the police while travelling to work, or crossing inter-state barriers to travel from home to their workplace. The government should order health facilities to provide letters on the appropriate official letterhead to all health workers, with an order to the local police and administration to allow their travel, so that they are not harassed
by the police and other officials when travelling to work.

k) Filling of vacancies with a perspective of long-term hiring
Existing gaps in human resources vary between states but are generally substantial. According to information collected through an RTI in 2017, in the facilities under the Delhi government, 14% of the sanctioned posts of general duty medical officers (GDMO) were vacant (though another 4% were filled by contractual staff), and 20% of staff nurse posts were vacant (though the large
majority were actually filled by contractual staff). According to reports, in Uttarakhand, 50% of sanctioned posts for medical officers and 31% for staff nurses are vacant. These vacancies need to be filled urgently, with a perspective of prioritising long-term hiring. The waiting list of the Union Public Services Commission (UPSC) and the Staff Selection Commission (SSC) should be used as a base to fill vacancies in health facilities under the central government. The waiting list of the equivalent board or commission under each state should be used to fill vacancies in facilities under the state governments. Kerala has undertaken this process successfully, using online interviews and video conferencing. More recently, the Government of Tamil Nadu has appointed 530 doctors, 1,000 nurses, and 1,508 lab technicians through this method.
Considering the lockdown and closure of inter-state boarders, the situation might arise where candidates on UPSC) or SSC lists are not in the state where the post is available. In such cases, a temporary adjustment between sanctioned posts under the States and the Centre can be considered.
Considering the need for additional staff, those currently employed on contract should be allowed to continue with their services. However, hiring on a short-term contractual basis or through
manpower agencies should not be seen as an adequate solution for increasing staffing under the impression that the time saved in hiring provides a considerable advantage. Those employed on short-term contracts and contracted through third party agencies are at risk of discrimination with regard to access to personal protective equipment, leave and other safeguards. This increases the
risk of infection of this vulnerable workforce and weakens the risk management process in the facility ― putting the larger public at risk.
The public expenditure on health as a percentage of GDP for 2017-18 was a mere 1.28%, while WHO advises for at least 5% of GDP. Increased budgetary allocation for health will be required to
fill existing vacancies and should be incorporated into subsequent annual budgets.

In summary, our demands are as follows:
SPECIFIC
1. The Government should provide updated guidelines regarding the rational use of PPE that also cover non-COVID-19 facilities, facilitate the production and logistics of distribution,
increase PPE procurement orders to ensure adequate access to all health workers, and if required, intervene in the market to ensure that PPEs are sent to the districts/regions where they are urgently needed.
2. The government should ensure that guidelines regarding the use of PPE are strictly followed in both public and private settings, and that there is no discrimination against workers on the
basis of hierarchy, employment status, or other reasons. A monitoring mechanism should be put in place in order to enforce strict adherence to PPE guidelines in public and private settings.
3. The government should ensure comprehensive health care free of cost to all health workers, including outpatient, hospitalisation, and regular testing, with special attention to informal health workers. Special provision of regular testing needs to be ensured for health workers performing high risk tasks, even if asymptomatic.
4. The government life insurance scheme should cover all health workers including in private settings and the estimate of health workers needs to be modified to reflect the real size of the
health workforce in order to avoid denial of compensation in the future.
5. Special paid leave in case of COVID-19-related sickness and quarantine should be provided, including to workers on short-term contracts and employed through a third party. A special
compensation should also be announced for health workers who contract COVID-19 as an occupational disease.
6. Health workers who are pregnant, lactating or have co-morbidities should not be put on duty in the COVID-19 ward. They should be assigned appropriate tasks within their profession that does not expose them to the risk of COVID-19.
7. Health workers’ right to opt out of work when they are not provided with a safe working environment and adequate protective equipment should be respected.
8. The government should facilitate appropriate training programmes and materials for the diverse categories of health workers and for the different levels of risk depending on the role
of workers and the role of facilities.
9. Extra hours should be regulated and remunerated as per the law. Breaks and time-off need to be maintained.
10. Adequate arrangements need to be provided to health workers in high-risk environments, such as ICUs and isolation wards, including accommodation and separate restrooms.
11. The government should take appropriate steps to ensure a safe workplace and work environment, protect health workers from harassment by the police and the community, including a strong media campaign to counter stigma of all forms, and appropriate orders to outlaw stigma and discrimination. A grievance redressal mechanism should be put in place,
including internal complaints committee in case of sexual harassment.

INSTITUTIONAL
12. Central and State governments should involve health worker unions in the process of information-sharing, training, and workers’ safety. This will facilitate an effective outreach to all concerned health workers. Managements should facilitate an active role for healthw workers’ representatives in determining safety measures and safeguards of their health.

13. The infection control component of the government’s quality accreditation programmes must be implemented universally across states, including in the private sector, along with a monitoring mechanism by the government. In case private facilities fail to follow the
government guidelines and resolve issues with regard to infection control and other safeguard measures, the state government should consider requisitioning the errant private
facilities.
14. Management of health facilities should make adequate arrangements for health workers at the facility, including but not limited to options for crèche or child care, transport to the place of work, an official letter and an order to the local police and administration so that health workers are not harassed by the police when travelling to work, regular provision of soap and sanitizer, and adequately nutritious food at the hospital or through other effective systems.
15. Health workers who are not able to work on a regular basis due to the lockdown or due to precautionary measures should be considered on duty and paid their full wages. All governments and private facilities should refrain from asking health workers to compulsorily or voluntarily forego their wages in full or partly. A health worker helpline linked to both the Ministry of Labour and Employment and the Ministry of Health and Family Welfare should be available for health workers to notify non-payment of wages and arrears.
16. State governments should ensure compliance with the Supreme Court recommendations relating to the long overdue increase of wages in private healthcare facilities. Relevant directions should be issued in this regard.
17. There should be a health worker helpline that is able to provide online or telephonic support to health workers in both public and private sector, and protect health workers role as whistle-blowers without putting their jobs at risk. This helpline should register complaints and grievances and be linked to competent authorities who would be responsible for taking timely action on these complaints.
18. The waiting list of the UPSC and the SSC should be used as a base to fill vacancies in health facilities under the central government. The waiting list of the equivalent board or commission under each state should be used to fill vacancies in facilities under the state
governments. Health workers hired on a short-term contractual basis are a vulnerable workforce at increased risk of infection. This weakens the risk management process in the facility and puts the larger public at risk.
19. Central and state governments should/must increase their budgetary allocations for health in order to cover health workforce-related costs, such as filling up vacancies, regularization of
informal workers including scheme health workers, payment of wages as per the law and payment of arrears. This increase should be incorporated into subsequent annual budgets.
This will be of long-term benefit for strengthening the public health system in India, and so we can cope better when the next health crisis hits us.

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Read here our suggestions for What can the PM do?

Response to PM’s Announcement on 14 April 2020

The PM’s address to the nation on 14th April 2020 came as a major disappointment and a painful blow to the basic needs, indeed perhaps even survival, of a majority of the Indian people, especially the poor and otherwise vulnerable sections of the population.

Government’s assurance of a Rs.1.7 lakh crore, which accounts for 0.87% of India’s 2.6 trillion dollar economy, is too insignificant to fight the widespread distress that the poor have faced.

The Government’s decision to extend the 21-day lockdown by an additional 18 days, of which the first week till the 20th April would be under even more strict enforcement of restrictions, has cited no epidemiological evidence or data as a basis, only a mistaken notion that a Lockdown is the only or main weapon, a brahmastra or laxman rekha if one follows the PM’s favoured style of mythological reference. The way the Lockdown was conceived and been implemented so far, and the announced extension, seems to be a uni-dimensional approach treating the Covid19 epidemic as a law-and-order issue and relying mainly on the police to enforce lockdown restrictions, who often act as if the people, and not the epidemic, are the enemy. This is directly contrary to the PM’s claim that his government has adopted a “holistic and integrated approach.” 

The claims made in the PM’s speech that the “country has greatly benefited from the Lockdown,” even if it “looks costly” from an “economic only point of view,” are contrary to the facts, and also betrays an outlook from the viewpoint of the well-off. Migrant workers and workers in the unorganized sector continue to suffer untold hardships including lack of food or dry rations, overcrowded accommodation with no possibility of physical distancing thus exposing them to infection, and no opportunities to earn an income. An integrated approach would not have permitted this to happen.

Getting 1 lakh beds and many hospitals ready has been claimed as a major accomplishment of the Government. But these beds and hospitals are pre-existent facilities merely earmarked for Covid19 patients, thankfully now unused, but unfortunately unavailable for patients of other serious ailments who have been denied hospital facilities except for extreme cases and even OPD services. Total absence of transportation also denies people access to these essential health facilities.

PM also did not mention measures his government has taken to overcome the acute shortages of N95 masks, coveralls and PPEs putting at serious risk, even the “Corona warriors,” who the people were exhorted to hail with claps, vessel-banging, diyas and candles, many having already lost their lives. Nor did the PM address the abnormally low levels of testing in India, or the gross inadequacy of testing kits. 

Regrettably, when the nation needs to stand as one which the PM repeated stressed, PM did not condemn the growing communalization of the Covid19 epidemic and demonization of the entire Muslim community.

    In his speech, the PM called upon the people to do 7 things to help the fight against the Covid19 epidemic, including taking care of the elderly, boosting immunity through unproven Ayurvedic treatments, using the highly intrusive Aarogya Setu App, taking care of the poor especially with food, being compassionate towards employees and not depriving them of livelihoods, paying utmost respect to our Corona Warriors especially doctors, nurses, sanitation workers and police. As civic minded organizations and citizens, we are confident that the people will rise to most of the PM’s expectations.

    At this time of crisis, we urge the Prime Minister and his Government to urgently do the following 7 things:

1. Take on the full burden of providing adequate food/dry rations, proper and hygienic shelter enabling physical distancing, and financial support in lieu of the wages they would otherwise have earned, and not leave so much of this task to voluntary efforts.
2. Ensure speedy acquisition and distribution of quality masks, coveralls, PPEs especially from domestic manufacturers, for protection of doctors, nurses, sanitation and other “Corona Warriors”; also open up minimum OPD and other health facilities to meet peoples needs.  
3. Ensure acquisition of sufficient RT-PCR and anti-body “rapid” test kits, again especially from domestic manufacturers and quickly scale-up testing to required levels.
4.  Facilitate agricultural operations, including fisheries, poultry, dairy and NTFP sectors, and related procurement, agro-processing, transportation, and marketing, all while maintaining physical distancing norms, along with rapid scaling-up of MNREGA works with suitably amended norms so as to assist farmers, farm and non-farm workers and the rural economy.
5. Enable unorganized sector workers and self-employed workers to resume work, extend legal protection from dismissal or lay-offs, and eviction by landlords, including through unemployment allowance and financial assistance to SMEs, landlords etc.
6. Ensure free inter-state and local transport of all essential goods, currently facing poor implementation of government exemptions and disrupting supply chains including of medicines and PPEs; also facilitate provision of necessary transport facilities especially for the elderly, disabled and those with health and other special needs.
7. Launch effective publicity campaigns accompanied with prosecutions as required against all forms of stigmatization of Covid19 patients, positive cases, quarantine cases, health workers etc and against all forms of communalization of the epidemic.

Click  here for english version Third update_Final_April 12_JSA & AIPSN

Jan Swasthya Abhiyan (Jsa) And All India People’s Science Network (Aipsn)

Third Update on the Coronavirus Pandemic (Update #3)

April 12th, 2020 

This is the third weekly update by JSA-AIPSN. It follows the Background Paper ( http://phmindia.org/wp-content/uploads/2020/03/Background-Paper-COVID19.pdf ) and first JSA-AIPSN Statement (http://phmindia.org/wp-content/uploads/2020/03/Statement-COVID19.pdf ) adopted on March 15th, 2020, the first JSA-AIPSN Update ( https://aipsn.net/2020/04/04/2nd-april-weekly-update-on-covid19-situation/) of March 23rd, 2020 and the second JSA-AIPSN Update (http://phmindia.org/2020/04/03/weekly-update-2-april-the-situation-and-the-peoples-health-movement-response-to-covid19/)of April 2nd, 2020. This update thus covers developments of the last two weeks. 

In this document we provide an update on the epidemiology of the corona virus disease (part I), comment on the new public health strategy unveiled this week by Government of India and then discuss the considerations going into the lifting of the lock-down and our position on it (part II). We then present the weekly update of our four working groups looking at: access to essential technologies (part III); health system preparedness (part IV); lockdown restrictions and concerns of rights and ethics (part V) and the crisis in livelihoods and government response to it (part VI).

Part I- Weekly Update on Epidemiology 

1. The current number of cases detected as of 10th April was 6412 (including deaths and cured) which is about 4.9 cases per million population. The number of deaths from COVID-19 is 199, which comes to 0.15 per million population. Reported deaths  are 3.1% of reported cases. . The number of deaths is low by international standards, but as pointed out in the last update, this is comparable to figures from many LMIC countries that have such outcomes despite weaker public health systems. (See Annexure 1 pg 15-16 for more details)

1. The lower figures in positive cases have largely been due to the lower levels of testing that India undertakes and the much tighter protocol on who can be tested. (All mild , moderate and even mostt severe symptomatic patients were excluded unless they had a histroy of contact or were healthcare providers). However here there is an apparent paradox. As of 9th April, a total of 144,910 tests have been conducted, among the lowest per capita in the world. Internationally, higher test positivity rates are associated with low levels of testing.  For instance, South Korea has lowest test positivity rates since it has the widest base of testing. But India’s test positivity rate is around 4.4% , very close to South Korea and well below that of both developed and developing nations. Within India, Kerala has the lowest mortality and test positivity rates. One explanation given for this is that the spread of the virus in India is very limited as compared to any other country, either due to the lock-down or due to perhaps to other hitherto un-determined resistance factors.. We have shown in the past weekly update that the lock down in India was not particularly early and other nations with early lock-down have fared differently. Moreover, the evidence to support resistance factors is very weak. 
2. A more likely explanation is in the large number of aymptomatic contacts that are tested plus a very low threshold for defining a contact, as well as the systematic exclusion of symptomatic persons with a loack of contact history from testing .. Even substantial numbers of hospitalized persons with severe acute respiratory Infection (SARI) were being excluded from testing. Also, all those who test positive must test negative twice before they are released and this could also add to the number of negative tests. We note that India mainly reports on number of samples tested and has stopped reporting on the number of individuals tested. We cannot be sure that this is the answer, but we suggest that to interpret test positivity rates the disaggregation by indication for testing should be included. 

1. We are also concerned about the definition being used by Government of India for ‘close contact’. As a result of the current definition, many doctors and nurses who have been transiently in the room are quarantined if a patient who visited their out-patient later tested positive. Or a social worker distributing food packets in a community kitchen is quarantined if one of the beneficiaries with whom they had no direct contact tested positive. In many countries close contact is defined as having been close for at leaast fifteen minutes at a distance of less than six feet and without use of a surgical mask. Singapore has defined it as thirty minutes. If the exposure is shorter than the prescribed limit, but more than two minutes, they can remain on job but would have to wear a mask and have twice daily temperature checks. Other brief incidental contacts are just asked to monitor themselves for symptoms. We are concerned that unnecessary and excessive quarantines will cripple health services and other essential services, while doing little to contain disease, other than the problem of interpretation of aggregated test results. There is an urgent need to rationalize this defnition of close contact, in line with evidence as available, striking an an optimal balance and minimizing quarantine to what is essential.  An analysis of the circumstances under which each contact who got the infection from an imported case can be done quite quickly . This was done in Kerala and we know that closed spaces are the highest risk situations. A/C cars, A/C transport and A/C rooms.Further such epidemiological studies are an essential component of any strategy.

1. One important unique epidemiological feature of the Indian pandemic is the gender ratio. In almost all nations in the world the ratio of affected men to women is 50%. The range could be 40% to 60%.  In India, 76% of those affected are men. The only other nation that has a similar feature is Pakistan with 72% of the affected being men.   

Part –II Containment Plan for Large Outbreaks – The new public health strategy

1. One major step forward has been the release of the “Containment Plan for Large Outbreaks” by the Ministry of Health and Family Welfare (MOHFW) and in tandem with the new testing strategy announced by ICMR on 9th April. 

1. The Containment Plan has several welcome features and marks a big step forward. Firstly it goes beyond the “Are we in stage 2 or stage 3?” discussions that had bogged the country down (see Update #2 of April 2nd for our comments on this) and calls for a scenario based approach- and these scenarios varying across the country. It talks of five scenarios instead of stages and lists them as follows: 

1. Travel related cases reported in India
2. Local transmission of COVID-19
3. Large outbreaks amenable to containment
4. Wide-spread community transmission of COVID-19 disease 
5. India becomes endemic for COVID-19

1. The Plan talks of large outbreaks without specifying whether or not this is community transmission- which, as we discussed before, is quite acceptable and then goes on to detail a strategy of response in this situation. Within this containment area it relaxes testing strategy to all symptomatic influenza like illness (ILI) cases. More importantly it would then limit strict lockdown to such clusters. There is considerable flexibility given to defining the cluster and the features of the lockdown required- allowing for better location-specific response. We note that the plan does not define how wide-spread community transmission situation is defined as compared to large outbreaks- but we can leave it at that. It is note dthat the exit point is being defined as India becoming endemic for the disease, which is realistic, rather than complete elimination. 

1. JSA-AIPSN calls on the government to build on this plan with the following suggestions and amendments:
   1. Clarify the strategic objectives and major interventions, not only in scenario III, but also in Scenario IV and V, and how each of these scenarios would be defined and distinguished from each other.  
   2. We demand that a vigorous Covid Disease Surveillance Programme (CDSP) forming a part of the Integrated Disease Surveillance Programme (IDSP) as called for in the first JSA-AIPSN  Statement and now elaborated upon) In synergy with a strategy of “Identify-Test-Isolate-Treat-Trace” (ITITT) would be the strategy in scenarios I, II, and V. We clarify that CDSP would be a part of the Integrated Disease Surveillance Programme (IDSP). 
   3. In scenario III and IV also the main strategy would remain CDSP and ITITT, but in addition there would be a small area lock-down in scenario  and a state-wide lock-down in scenario IV. It is noted that the measures that constitute “containment” are not limited to any one of the scenarios- but the scale and scope of containment would change. Even those districts and states in sceenario V could revert to one of the other scenarios and rquire containment again. 
   4. The governemnt is also cautioned on using geographic physical distance as measured in kilometers as the main criteria of defining the area under containment. This may have worked in Bhilwara where the main source of infection spread were medical doctors working in a healthcare outpatient department-. Patterns of health-seeking to behaviour are known to correspond to such simplistic circles. But this would not be true if a vendor in a market was the source of spread, or if a gathering of a community or an association was a source of spread, or if it were spreading in an occupational group, or even within a large slum like Dharavi. Thus social mapping would almost always be more important that physical distance as the basis. 
   5. The difference between physical distance mapping and social mapping could become a big problem during implementation. Social mapping to identify disease spread, would require interaction with the communities concerned, and would require social workers to enage in persuasion, negotiation and trust and  would further have to depend a lot on ITITT. Lockdowns based on physical distance alone is seen as best enforced by the police department and with the use of force and coercion. Though we concede that there is a considerable overlap between the two, a mechanical and exclusive reliance on physical distance would fail for both epidemiological and societal reasons. 

Core Strategy: Identify, Test, Isolate, Treat, Trace (ITITT)

1. Recognition on the importance of ITITT as the core strategy is near universal at the policy level. However, there is need to empasise that lock-down is not a substitute for it, but will be needed during and after this and further lock-downs. (Identify= actively seek out symptomatic cases; Test= Test for COVID 19; Isolate: All those who test positive must be placed in isolation, even while waiting to be tested; Treat = All COVID 19 patients who are symptomatic would require treatment based on their severity; Trace= the contacts of all COVID 19 positive patients must be traced based on the patients movement in last 14 days, but especially sine fever had developed and three days before it. These persons would need to be put on quarantining. The main purpose of tracing is on identfying those who need to be on quarantine. Isolation refers to COVID 19 positive patients or symptomatic suspects while waiting for testing. Quarantine is for  asymptomatic patients who have had contact and may or may not develop the disease)
2. Some states have teams of workers going around and looking for cases of fever and of recent travel outside the town of residence. This seems to be the best way to detect cases early. When fever is detected the team calls in on a line and an ambulance picks up the patient and takes them to a nearby center. If they test positive, they are isolated in earmarked beds and if severe, are taken to dedicated COVID 19 hospitals.. These are the states that are doing well. However, all states need to ensure that workers are protected through adequate PPE and training.
3. Some states do all of the above, but their emphasis is more on those with travel history, who they test even if asymptomatic. Unfortunately, those without travel history but with fever are ignored. Many states have even failed to test all those with signs of Severe Acute Respiratory Illness (SARI) if they have no contact or travel history. Often only if an X-Ray or CT scan indicates a problem, and sometimes only half of such patients, are tested even if all are such patients are hospitalized. This is completely unacceptable, but probably happening because these are the protocols currently in place for testing.  A combination of lack of testing kits and concerns about detecting high numbers of positive cases which would challenge the states narrative of a great control, combine to cause such deviation. 
4. A recent ICMR study has shown that in the 5 day interval of March 29th to April 2nd, the number of SARI patients testing for COVID-19 positive increased to 2.6% as compared to 0% in the first two weeks of March and about 1.8% in the latter two weeks of March. Further, of the 104 COVID-19 positive patients about 40% had no history of contact or international travel, which is clearly is community transmission as defined. We also note that the strategy of “large outbreaks amenable to containment” is implcitly an acceptance of communtiy transmission even if it is defined as happenning within a geographically defined hot-spot. 
5. We now know from case studies of severe patients that they have spent considerable time when they were mild and moderate visiting numerous healthcare providers using public transport, before they were finally diagnosed. The infection spread due to undiagnosed mild and moderate cases is considerable and the clearest reflection of this is the increasing number of healthcare providers who are not in the direct line of COVID-19 duties but are nevertheless coming down (and even one dying) due to COVID-19 infection which they may have got from their general out-patient care. Often it is due to co-morbidities like cancer that patients visit hospitals and pass on the infection to the care providers, such as in the case of the Delhi State Cancer Institute. 
6. We welcome the steps taken by the government to earmark beds for isolation purposes and hospitals for COVID-19 care in anticipation of a surge of cases. This is most welcome, though we are concerned that where arrangements are of poor quality  many patients prefer to escape. We are particularly concerned that train coaches would not be an adequate alternative. 
7. While steps taken by the Government to step up procurement of ventilators, oxygen supplies, PPE etc, these initiatives have been very late in coming, and also face huge challenges due to transportation disruptions arising from poor implementation of the lockdown. These problems are discussed in the next section. 

.

Strengthening Disease Surveillance- CDSP as part of IDSP

1. One of the more inexplicable aspects of the government response is the non-use of the integrated disease surveillance programme and within that the flu surveillance programme to track and manage the COVID 19 epidemic. This system is designed to pick up and test for epidemics of respiratory viruses, and could have been easily geared to include COVID19 testing from early February.
2. The IDSP system has both event-based reporting and population-based reporting. It provides for suspect-reporting by para-medics, presumptive reporting on clinical crtieria by medical doctors and laboratory based reporting from 168 flu surveillance labs. The 1.5 lakh sub-centers submit S forms (Ssuspected cases) – and they should now be reporting any sudden increase of flu like illness (for which a definition has to be created- like more than 5 fever cases increase in the preceeding week) and any fever releated deaths. But more importantly, all PHCs, CHCs, DH and private cliinics and hospitals should be filling out the P form (Presumptive cases) which should now include a presumptive diagnosis of COVID19 based on clinical crtieria. Such criteria have been proposed by many specialists and are adequate for this purpose. And the laboratories for testing should be expanded from the current 168 to include one or more per district, especially now that rapid tests are available. In the malaria endemic areas, where the malaria surveillance is robust, this may be the preferred framework.
3. Any rises of presumptive cases must be followed by a field response team and a testing of a sample of cases if not all cases. In all areas, where COVID 19 is currently at zero levels at least 10% of fever cases must be tested by the rapid test kit with confirmation testing if they test positive. In areas which are reporting increasing COVID cases the testing must try to cover all fever cases. Testing as required for the ITITT strategy would continue. 
4. Where a lockdown is ordered the testing can include all those with fever and those who are contacts of COVID19, plus those who are asymptomatic and in that area even if they are not close contacts.
5. We understand that some states have not invested in their IDSP and many epidemiologist posts lie vacant. No state should consider a lock-down unless they have a minimum CDSP/IDSP in place. Norms for this should be rapidly reiterated and the center step in to close the gaps by transfers, fresh recurits  and on the job support as required. 

Box: Example of how a Clinical Case definition for presumptive diagnosis could be constructed (based on note by M.S.Seshadri & Jacob John)

Mandatory criterion: Fever of 3 or more days duration without other obvious localizing symptoms (such as dysuria, skin or soft tissue infections) 

Epidemiologic setting: Travel within the past 4 weeks to or from any other country or a big crowded city in the country; Visit within the last 4 weeks to a crowded place (bus stand , railway station, movie theatre, airport, place of worship etc)

Major criteria: 1.  Dry cough 2. Sudden recent onset Anosmia or loss of taste sensation  (anosmia due to nasal block and sinusitis to be excluded 3. Physical findings of crepitations on chest auscultation 4. Chest X Ray showing peripheral patchy infiltrate (not lobar pneumonia or cavitating lesion)

Minor criteria: 1. Diarrhoea 2.  Severe headache, body aches (Myalgia) 3. Normal or low normal  total WBC count and lymphopenia ( Lymphocytes < 20 % on differential count)    

Any persons with a mandatory critiria and at least one major criteria and an epidemiologic setting and/or one more major criteria or one minor crtieria can be taken as presumptive COVID 19. In COVID-19 active areas, this should be enough for isolation even if testing is not available. In other areas, one could self-isolate till testing is done. 

On lifting the Lock-Down & Hot-Spots for Containments

1. As the National Lock-down period comes to an end, the issue of continuation of lock-down has become the most important topic of discussion. The lockdown is imposing huge economic costs on the majority of the population. This economic shock that majority of the working people have to bear, combining with the virtual suspension of much of essential but routine healthcare could lead to a much greater mortality than the worst case scenario of a corona virus pandemic.  However we are concerned that the popular (largely elite and middle class) perception of lockdowns as reflecting strong and determined leadership may push states and the center to re-impose lock-downs all too readily. One view is that lockdowns are being preferred because they can be implemented through a single agency like the police. Many States do not have confidence in their administrative abilities for a multi-dimensional approach that includes rapid scaling up of public health services and manufacture as well as logistics for a variety of essential health commodities, like testing kits and PPEs. A case in point is Odisha which, for a total of 44 positives and one death has decided to lock up 4.6 crore people till April 30th. Only five out of 30 districts test positive but all 30 are locked down. They are the first to announce it and are receiving so much praise for the same. There can be relatively little doubt that deaths due to the withdrawal of other services and the continuing crisis for people’s livelihood would be high. There is also the great possibility that the disease will enter Odisha whenever the lockdown is lifted- say another month from now and peak thereafter. Many other states have also enthusiastically responded to continued lockdowns. Two state task forces/expert committees- Kerala and Karnataka- have recommended a phased withdrawal of lock-downs, but their understanding of phasing is different. The Kerala committee report has important contributions to make, especially with regards to the phased re-introduction of economic activity  and further the concept of phased withdrawal / re-introduction of public health measures including travel bans. The challenges are with regards to the criteria of phasing and the data on which this could be measured. 
2. It is worth noting that both in India, and world over a large number of epidemiologists and those with past experience of epidemic management, and those engaged with health systems strengthening have not quite shown the same enthusiasm for the lock-down. We also note that many nations went for later lock-downs and lifted it when transmission was low, and then returned to lock-downs in areas where transmission aceelerated. This was a part of their strategy, and not a failure of strategy. In this understanding lock-downs are most effective, and the best benefit to loss (pain to gain) ratio, when community transmission is widespread.. However effective a lock-down, whenever that lock-down is lifted, cases will start going up again and one must educate the public and poltiical leadership to understand that this will happen and can be managed. If however the rise crosses a threshold (as measured by a set of indicators that are agreed upon) further area- specific lock-downs could be considered, with adequate preparation and advance notice. But just extending this current lockdown and in general extended lockdowns, will take a huge toll on morbidity and mortality. For example many cancer patients and heart disease patients who needed elective surgery will possibly develop conmplications and start dying if surgey is further postponed. Deaths due to non-COVID causes would rise exponentially with each extension of the lock-down. 
3. We are agreed that the early lockdown as was imposed now was required for preparing health systems. We also agreed that this lock-down should have been much better prepared for and implemented- and not sprung as a surprise. We however DO NOT agree with the nation-wide extension of the lock-down or even across any State. We think that the current plan for “Large Outbreaks Amenable to Containments” its identification of hotspots is a good way to move forward and state-wide lockdowns should be considered only with wide-spread community transmission of COVID-19 (i.e scenario IV) and which is defined by multiple large outbreaks or clusters or hotspots in all regions within the state. 
4. Of course lock-down has to be lifted in a phased manner. But the manner of phasing and re-organization of work should have at its core a humane and poor-friendly approach. The arrogance that at times of epidemics we need “stern action” that necessarily will trample on the rights of the working people and the marginlised is often elite arrogance combined with bad public health understanding and is not acceptable. The main question is how to phase it so that it does not lead to a rush of migration and loss of all efforts at physical distancing. 
5. Re-imposition of lock-downs in a district or cluster of districts should require a rising number of new cases that indicate a R0 value of above an agreed upon threshold (A value of R0 of 1 or less is endemic disease). Disease incidence below that can be managed by ITITT approach alone. Lock-downs in smaller hotspots defined by a physical distance radius must be temporary till a house to house search is carried out, unless the nature of contacts made by the source necessitates it. 
6. To know the R0 level reliably, the Coronavirus Disease Surveillance Programme (CDSP), which would be part of the IDSP, should be put in place, almost immediately. The current numbers when used as the basis for setting lockdown thresholds are going to be very misleading as increasing numbers due to improved quality of surveillance and case reporting would be interpreted as an increasing epidemic.
7. Both state and central governments are trying for lockdown lifting criteria that pertain only to absolute rates of number of cases per million population and without reference to testing protocols and standards of testing and without any proposals as regards to establishing a CDSP.  We urge that a lock down should be considered only if there is a sustained increase in cases, and further that the increase occurs only in those who are not already in home or facility quarantine (and therefore indicative of community spread). This allows for withdrawal in an endemic situation, where there are steady new cases, but no accelerated increase in new cases. In other words, where there is still contagion, but there is no epidemic, i.e. we have reached an endemic scenario. This would be the immediate strategic objective. When lock-downs are lifted public transport and workplaces must be opened up in a responsible manner- and phased out carefully. (Reference: JSA-AIPSN statement on proposed extension of national lock-down)
8. Across all states and areas irrespective of COVID 19 status measures of physical distancing, ill persons required to wear masks, prevention of large gatherings ( above 20 initially) and basic rules of hygiene would be observed. We may also start testing and certifying for recovered patients who are now testing negative for virus and positive for antibodies and who can therefore be selected for certain tasks. 
9. The above strategy would hold good till a vaccine is introduced. 

Part III: On Access to Medicines and Essential Technologies

1. New testing guidelines: New Testing Strategy: The ICMR issued new guidelines on testing allowing rapid antibody based blood test for COVID-19. The ICMR is using this as a strategy for areas reporting clusters (containment zone) and in large migration gatherings and evacuees centres. Resident of areas designated as hot spots and which have reported a large number of cases may have to go through this screening test.   According to the guidelines issued by the ICMR, at the facility level, all symptomatic patients with influenza like illness (ILI) are to be tested using antibody tests. The ICMR has given a full treatment protocol regarding testing using antibody test as screening tool and RT-PCR as confirmatory test.  

2. The Antibody Test Kit: The government is in the process of procuring 5 lakh rapid antibody tests kits from various companies. These tests are useful for their speed as they can suggest whether a person is  has COVID19 antibodies within 15 minutes. In most clinical situations where we are testing symptomatic patients with mild, moderate or severe diseases, this test in combination with the clinical setting, would be adequate  for a reliable diagnosis that can lead to isolation and defnitive treatment and the use of PPEs by care providers. RT-PCR is desirable but isolation and treatment of the patient and tracing contacts need not wait for that. This also means that testing in clinically symptomatic cases can go down to PHC levels and this offers great advantage in reducing spread of disease ( as these patients would be visiting multiple health centers in search of care) as well as strengthen disease surveillance.

One problem that has been raised with this kit is that it is not useful to detect early cases in the pre-symptomatic phase and will give false negatives in first few days. Also in population studies or in asymptomatic patients a further viral  RT-PCR test would be required for confirmation. However after four days of fever (or number of days of fever as recommended after validation studies) in combination with the clinical picture it is very useful and this should be emphasized. 

The other problem with this kit is that after the patient recovers the test will remain positive. So it cannot be used for judging recovery. For that we would need a neative viral antigen test. The antibody test is  useful to measure past infection and therefore the main tool of population based sero-epidemiological studies.. 

Governments must report antibody positive patients with clinical symptoms as COVID 19 positive and isolate and treat them as such without waiting for a confirmatory viral antigen test. 

3. Procurement of Testing Kits: The entry of these rapid antibody testing kits into India would be a game changer. It is not clear as to how many Indian companies would manufacture them and at what scale and what proportion would be imported. These are cheap test at about Rs 400 per test and costs can be lowered further. Scaling up manufacture of this must be priority. The government has provided a list of approved 33 Indian suppliers Rapid / CLIA/ ELISA Corona Kits with condition that they must be first validated by NIV Pune.. All of these 33 are bringing in imported kits, one  from Israel, 2 from South Korea, and all the other 30 are importing from China, 

As of now though central government and states have placed import orders. The first batch was to have been delivered on April 8th, but as of now.no consignment has arrived, and this is attributed to failing quality tests in China. There are also issues with tendering and payment.

There are also 27 PCR mit suppliers approved. Of these only three are indigenous. Of the rest 10 are from China, 6 are from USA, 4 from South Korea, 2 from Germany and one each from Spain and UK. Given the high needs in their home countries, the actual supply remains to be seen. 

There are other cheaper viral antigen tests that have become available ( like the Viral NAT – which is a blood test for viral Nucleic Acid Amplification Tesing ), which is much cheaper than the current PCR test, especially if done on pooled samples. CRISPR-based tools have been developed as a viral tests to test COVID 19 within 30 minutes. These tests are simpler and easier than RT-PCR test with no need for bulky instruments and complicated operationsT This is another option that has to be rapidly explored and scaled up. 

The forecasting figures are also not clear. Our annual requirement may be upward of 10 million test kits- and this needs to be factored in when thinking of the manufacturing and import strategy. 

4. The Scaling up of Testing Services and Payment for Testing: The JSA – AIPSN statement had clearly articulated the need for “free-to-patient” testing. While the government made it free in the public sector it allowed private sector to charge Rs 4500 per test. Fortunately the Supreme Court in an order this week mandated free testing even in the private sector but left modalities undecided.  This has forced the government to consider what it should have done in the first place, namely the rate of reimbursement to the private sector for testing. They could negotiate the rate with government based on a quick costing analysis but the private sector would have to provide it free to the patient. Problems of delays in payments can be overcome by giving an advance amount and then refilling it as and when 80% of it is exhausted. The private sector has objected to limiting testing to only those samples/cases which government approves. On this issue, we recommend that the private sector should be allowed to test anyone who by the standard protocol deserves to be tested – and that should definitely include all mild and moderate cases. In the current context, of government limiting its testing to align with its narrative, this autonomy to the private sector to be responsive to the need as certified by its doctors must be respected. 

The number of labs doing testing for COVID was only one laboratory even in February. This is now reported to have increased to 223, of which 157 are in the public secor, and and 66 in the private sctor. Daily testing rates were low but now have reached about 10,000 per day. 

5. PPE: The government statements indicates an order for 1.74 crore PPE sets and N95 and masks. That there is a huge shortage in N95 masks, coveralls and other PPE is too well known to need reiteration here. Doctors, nurses, sanitation staff and other auxiliary staff have been complaining regularly about this, to the extent that gag orders have been issued by government but to no avail since the problem is so severe and threatens the lives of these health care personnel and their families. There is not only a large gap between need and supply, but also a gap between the government’s assertions about plentiful supplies and the reality that most numbers referred to relate to orders rather than actual availability on hand.. There is both lack of transparency and a lack of preparedness. Media reports supported by documentary evidence suggest that most orders for PPE (34 out of 39), were placed only after announcement of the lockdown, a full two months after COVID-19 made its appearance in India, and 24 of these were placed in April 2020. Deliveries both imports and domestic are lagging far behind orders, production against some of which have barely begun. Domestic manufacturers have faced massive pin transportation bottlenecks due to extremely poor implementation of government instructions on the ground, in this case exemptions granted for transport of essential commodities. It is to be noted that public sector undertakings (PSUs) are supplying most of the requirement, despite many years of debasement and under-valuation of their capabilities. Government requires to do its utmost to immediately resolve transportation and supply chain bottlenecks, and extend support to manufacturers to enable rapid scaling up of domestic production.    
6. Ventilators: The government has announced that it has placed orders for 49,000 ventilators, most of  which 10,000 are from BEL, DRDO and the Railways, with some private companeies working with automobile majors. The exact deliverey dates are uncertain.. 
7. Oxygen: A six fold increase in supply of oxygen purposes since February 1st is reported. There is no news on oxygen concentrators. 
8. Drugs: The government did a flip-flop on Hydroxychloroquine by first banning its export and then hastily withdrawing it in response to US bullying. Consdering the government’s and manufacturers’ statements that there is enough for Indian needs and considering that India commands the market for this medicine, there is indeed a requirement that we help other nations like US and Brazil that have asked for it. We hope we have got a quid pro-quo for import of ventialtors, PPE and testing kits from these nations. On other drugs, it is good news to note that India has joined the WHO solidarity trial. 
9. Costs of emerging COVID-19 medicines: Many clinical trials are underway looking at efficacy of various drugs for treatment of COVID-19. Prof. Andrew Hill of the University of Liverpool, United Kingdom has published a paper in Journal of Virus Eradication titled “Minimum costs to manufacture new treatments for COVID-19” in which he and his team have calculated costs of these drugs which are repurpose drugs, normally indicated for other diseases. His results show minimum estimated costs of production are US $0.93/day for remdesivir (produced by US multinational corporation Gilead), $1.45/day for favipiravir, $0.08/day for hydroxychloroquine, $0.02/day for chloroquine, $0.10/day for azithromycin, $0.28/day for lopinavir/ritonavir, $0.39/day for sofosbuvir/daclatasvir and $1.09/day for pirfenidone. Costs of production ranged between $0.30 and $31 per treatment course (10–28 days). Going forward, we need to keep a tab on their costs as some of them will be used for COVID-19 depending on the results of clinical trials.

Part IV. Health Systems Strengthening

1. On 7th April, the MOHFW issued a Guidance Document on appropriate management of suspect and confirmed cases of COVID-19. The dedicated COVID centres have been divided into 3 types:

1. Dedicated COVID Care Centres (CCC) for mild suspected and confirmed cases. These are makeshift facilities. They may be set up in hostels, hotels, schools, stadiums, lodges etc., both public and private. 4000 raliway coaches are also reported as having been readied for the purpose. If need be, existing quarantine facilities could also be converted into CCC. It must also have a dedicated Basic Life Support Ambulance (BLSA) equipped with sufficient oxygen support on 24x7basis
2. COVID Health Centres (DCHC) for moderate suspected and confirmed cases. These should either be a full hospital or a separate block in a hospital with preferably separate entry\exit/zoning. These hospitals would have beds with assured Oxygen support. They must have a dedicated BLSA equipped with sufficient oxygen support for ensuring safe transport of a case to a Dedicated COVID Hospital if the symptoms progress from moderate to severe.
3. Dedicated COVID Hospitals (DCH) for severe suspected and confirmed cases. It should either be a full hospital or a separate block in a hospital with preferably separate entry\exit. These hospitals would have fully equipped ICUs, Ventilators and beds with assured Oxygen support. 

2. The official government statement is that it has now readied 520 dedicated COVID hospitals, with nearly 85,000 isolation beds, and 8500 ICU beds. At the next level they also have prepared another 5570 additional health facilities, another 197,400 isolation beds, and a further 36,700 beds. Another 40,000 isolation beds have been prepared from 2500 railway carriages. 
3. There are reports from every state of such designated centers being created at two levels- for isolation and for ICU care. States are now having to empty out their busiest and most functional of public hospitals and government medical college hospitals to put a DCH in place. The effort to bring a private sector hospital as a COVID19 fell through in many states like Chhattisgarh. But we are not hearing much on the corresponding increases in HR, minor equipment, and major equipment and skills. Moreover, this threatens to have a crippling impact on provision of other routine essential health services, especially in the tertiary level public hospitals. 
4. While the aggregate numbers of orders placed and hospitals planned are encouraging, reports from many states show a large number of district hospitals which have yet to establish ICU beds and have the necessary equipment and skills for the same. There is concern that in large number of districts, bottlenecks in human resources, skills and supply chains may be inadequate to meet the challenge. Years of lack of preparedness and under-investment cannot be corrected overnight, but at least we can welcome the fact that the government is now seized with the issue. 
5. Private sector involvement has been varied. Bringing some private hospitals under public authority has been mooted but not done. COVID 19 testing and treatment has been included in PMJAY package but not clear whether this has been availed of.  In some states like Tamil Nadu and Mumbai some private hospitals have been accredited for COVID 19 patients but allowed to charge and reports are of very high charges. There are also reports of many accredited hospitals not seeing any COVID 19 likely patients and making no special arrangements to refer them to COVID 19 hospitals. Finally there are also reports of private healthcare having to shut down all services because of healthcare providers becoming infected. There is a clear need to bring select private hospitals completely under a public authority and where they are operating on their own bring them under PMJAY reimbursement  protocol for all COVID 19 cases and all cases of SARI. They must be monitored to ensure that their staff is protected and that they do not deny patients the care that is needed. 
6. One major problem arising is the major decrease in access to essential healthcare services. These include all patients with non-communicable diseases unable to access essential medicines or the care they need from public hospitals and private hospitals, and therefore at much higher risk for complications and mortality. The more critical the patient, like in the case of cancers, renal dialysis, the more severe the problem. On communicable disease front also, postponement and suspension of immunizations services, and difficulties in access services for HIV, TB etc are being reported. Out-Patient and In-Patient services for non-Covid-19 patients in both public and private have been substantially reduced.  The decreased access to services is due to four factors:
7. a) active elective suspension of services as part of the lock-down- and stay at home instructions. 
8. b) shifting of staff essential for routine services to COVID 19 related work-especially in states with weaker healthcare systems.
9. c) Lack of public transport to reach these services
10. d) Many doctors and nurses who are NOT on COVID 19 duty getting COVID 19 infected due to exposure to general patients in whom cases of mild or moderate COVID 19 are intermingled. Once someone tests postive all the staff get isolated or quarantined- shutting whole hospital or much of it down. 

The morbidity and mortality due to the decreased access to essential healthcare services is going to increase sharply and exponentially as the lock-down continues. This should be obvious enough, or else such healthcare servies would not have been seen as a fundamental right, but we are yet to come across a modelling exercise that has factored this in.. We had warned against such a situation at the beginning of the lockdown period. However we are seeing the situation getting worse (Ref. Press Statement by JSA Delhi on Denial of Healthcare to Critical Patients and Sudden Discharge from Hospitals without Alternate Arrangements).

Part V: Stigmatisation and Rights violations under the Lockdown 

• Stigmatisation and the communalisation of the pandemic: In midst of the ongoing crises, the members of a community who participated in a religious congregation are being hounded and criminalised by the state, police and media. While there may have been lapses by participants of the gathering (such as not reporting that they had visited a Covid-19 affected country), there are instances of people from other communities who have also failed to  isolate themselves after coming to India from other countries and have passed on the infection to others. Further, there are reports of religious gatherings of other communities that have taken place as well, some even after the specific congregation11 12 (from rt 2 food). The targeting of Muslims has led to diverting public attention away from the safety precautions that need to be taken to prevent the spread of the virus. Rather than focusing on safety measures, the government, media and the public are instead busy blaming the Muslim community. The attempt to extrapolate the stigma of COVID infection to an entire community, i.e. the Muslim community in India, is nothing short of targeted vilification in a public health crisis.  It is also in contravention of the World Health Organization’s advisory issued on 6 April, 2020 that “Countries should not profile novel coronavirus disease (COVID-19) cases in terms of religion or any other criteria”, asking “governments not to politicize the issue and stop profiling people on religious basis.” The advisory also requested people to “never spread names or identity of those affected or under quarantine or their locality on the social media”.  This kind of victim-blaming, religious profiling and stigmatising could significantly undermine the public health efforts in Covid-19 epidemic.

• Stigmatisation and suicides and social ostracisation: Even without the above event, this pandemic has become highly stigmatized due to the highly moral tone attached to social distancing and individual responsibility. This pandemic has therefore seen an incredible level of stigmatization, similar to that seen in HIV pandemic or even worse. There are a number of suicides reported because of testing positive or even the fear of testing positive. There are cases of ostracisation by villages and families. There are many reports of people hiding their disease and their symptoms. 

• Stigmatisation and attacks on health workers: There are widespread reports from across the country of attacks on health staff and even doctors. Doctors themselves afraid to pass infection to their loved ones are staying away from home, even sleeping in their cars. Resident associations are refusing accommodation to doctors and even turning them out. Doctors and other health workers working with Covid-19 positive patients have been assaulted by people blaming them for spreading coronavirus in their area. The large mobilizational event by government of lighting a lamp and earlier of applauding the health workers for their work by clapping has not made enough difference at the local level where the hate and stigmatization generated by the sub-text has dominated. Health workers are also more at risk due to lack of PPE. When doctors and nurses complain against this, strict gag orders are passed and there are instances of suspension of health workers. 

JSA-AIPSN calls for an active end to stigmatization. This requires a major change in media strategy where not only the need but the limitations of social distancing are pointed out. Neither individuals nor communities must be blamed for either getting infected or passing along infection. Social distancing helps but is no guarantee. There have to be active efforts to reach out to aggrieved communities. 

• Rising violence on women, girls and children during lockdown: In planning responses to the lockdown, its impact on girls, women and gender-diverse persons has largely been invisible. The burden of domestic and care work which is borne by women has been exacerbated by the lockdown. Given the extreme curtailment of movement, girls and women find no respite affecting their physical and mental health further. Violence – verbal, physical, psychological and economic – against women and girls within homes and institutions are reported to have worsened due to the lockdown, also leading to adverse physical and mental health outcomes. The National Commission for Women reports a sharp rise in number of cases of domestic violence against women and of child abuse. The total number of complaints by women increased from 116 in the first week of March to 257 in the last week of March. In 11 days the Childline India helpline got more than 92,000 SOS calls from children asking for protection from abuse and violence. Reports indicate that police is even more unsympathetic and resistant to registering or acting on complaints. In the Press Release on World Health Day we have urged the government to immediately make arrangements for responding effectively to counter violence related to the pandemic and its control. Calls to the phone helpline should be responded to immediately; a local response team including for providing first aid, counseling should reach the survivor and coordinate all necessary steps and requirements as per the needs of the girl/woman. For example, transport to a safe space or shelter, as may be identified by the girl/woman. All support services, one-stop centres should be functional.  

• Rising number of FIRs and police violence for violation of lockdown: Throughout the lockdown we have seen shocking visuals of brutalities against those going out for essential work and there are far too many reports of persecution. Whereas a middle class looking person is likely to have his reason for stepping out accepted, the law is much less flexible with a poor or marginalized person stepping out. Instances of FIRs and police action against such sections including arbitrary actions like seizure of vehicles also abound. We demanded that the government should take strict action against any form of police excess on migrant workers, wage labourers, vendors, the health care workers and others who out of sheer necessity need to break stay-at-home restrictions. (Ref. JSA-AIPSN statement on lock down brutalities)

• Quarantines undermined by poor facilities: There are many reports of conditions of quarantine being so poor that persons break quarantine surreptiously or openly. On hearing about these conditions many deny history of travel or having fever or take paracetomol to hide it- to escape not only stigmatization but also the poor conditions in which they are kept. The risk of infection under such conditions rises for those who are quarantined. We demand that adequate facilities should be provided to those under quarantine, and that the basic rights of the person to food, water, clean sanitation, hygiene, electricity and good health care facilities should not be breached.  (Ref. JSA statement on concerns with regard to isolation and quarantine for COVID-19)

• Privacy concerns regarding Apps for surveillance and monitoring during Covid-19

The central Government and many State governments have, or are soon planning to, release mobile Apps as part of their strategy in the fight against the COVID-19 epidemic. This has presumably been done following other countries that have set up similar systems, such as South Korea and Singapore. While in South Korea concerns around privacy and invasive nature of this surveillance were underplayed through a nationalism discourse, Singapore on the other hand was concerned about these issues, and assured users it would not use compile or use data for any purpose other than contact tracing. The various Apps developed and at various stages of being deployed in India seem to be following the South Korean model, believing perhaps that the Indian people and regulatory agencies, maybe even the judiciary, would allow privacy concerns to take a backseat to control of the epidemic. 

The Central government’s Aarogya Setu App is supposed to track movements of Covid-19 positive cases and those under quarantine, and even perhaps all people in hotspots and sealed areas. The Aarogya Setu App seeks all personal information such as full name, address and so on, assigns a unique identifier to each user’s phone (with a proposal to also seed it with the Aadhaar number). If a person tests positive, then all her/his contacts are notified and other App users notified if the Covid-19 positive person is nearby. The same company that has provided the Centre and several State governments with facial recognition software for police and other surveillance is providing inputs to integrate such features with Apps being developed in India. While the Aarogya Setu App’s privacy policy states that the data will exist only on anonymised data bases, it would not be difficult to recreate the original data. The policy also states that the data will be retained only for 30 days, but there is the danger that it could easily be available on back-end servers virtually in perpetuity. 

State governments are gradually starting to introduce these Apps and also making them compulsory. The Delhi government has decided to use Apps for quarantined persons and for the hotspot containment zones, with the Chief Minister even announcing he is contemplating making use of the Apps compulsory. Punjab has started the COVA App and made it compulsory for companies such as Google and Apple and all social media players to push their customers to download it.

There is little clarity or transparency about which agencies would be running and sharing the App’s data, who can access this data and how long they will be available for. The Indian Apps have little transparency as regards to their privacy policy or potential use of this surveillance data much after the Covid19 epidemic is over and for purposes that have nothing to do with the epidemic. Whatever its supposed immediate benefits during this epidemic, this surveillance trend is deeply worrying for its harmful future potential, especially given India’s steady drift deeper into authoritarian rule.

• Condition of prisons and prisoners: In a joint Statement, JSA and AIPSN expressed deep concern regarding the preparedness of Indian prisons to meet the challenges of the Covid-19 pandemic. (Ref. JSA-AIPSN Recommendations for Prisons in light of the Covid 19 pandemic). JSA and AIPSN made recommendations on decongestion of prisons and for those who cannot be releases, to make COVID related changes and set up a detailed contingency plan.

The Supreme Court is hearing the petition on the issue of overcrowding of prisons and the infrastructure therein. Court has already passed an order that arrangements for transportation of prisoners to their homes or to temporary shelters should be made.  

Part VI: Crisis in Livelihoods and the Government Response

Government figures now establish that nearly 50 million short term migrant workers as having lst their work. According to an affidavit filed in the Supreme Court over one million migrant labourers are stuck in shelter homes because they could not make it back home. A mass movement home and then back to their place of work would have to be anticipated once the lock down is lifted. This would need to go along with measures of a minimum wage and a pressure to ensure that these workers are re-employed. Govrnment has announced no plans of how they would reach their homes and how families disrupted and separated by the suddenness of the lock down can re-unite. Clearly the problems of migrant workers continue to be an after-thought. JSA and AIPSN have previously issued a statement on the Economic Package and Demands and deals with the background of the issues mentioned in this section. (Ref. JSA-AIPSN statement on the economic package announced by the government)

• Government relief measures: A number of states have announced relief measures but they are highly inadequate and there are huge gaps in reaching them to those who need it. At the time of writing this, the vast majority may have received little relief except those who got food in shelter homes and community kitchens. Instead of setting up systems for relief measures, the government has left it to the NGOS. In a submission made to the Supreme Court the government stated that in 13 states, NGOs provided food to more people than the state government. A large proportion of migrant and rural workers are expected to further fall below the poverty line due to the Corona virus pandemic that is exacerbated the already existing agricultural and economic crisis. A rapid assessment of the impact of COVID-19 lockdown on migrant workers was undertaken by Jan Sahas who found that the migrants were in near destitute conditions, with high debts and hardly any resources to fall back upon. To overcome the economic slowdown imposed by the lockdown and boost up industrial production, the Government of India is planning to increase the daily working hours from 8 hours to 12 hours as reported by media. Trade unions, like CITU have already expressed their concern that on the issue. Such a move may relieve the employers from paying overtime for extra-working hours, but it would add to the distress of millions of working people in the country, who have been already hit badly due to the lockdown.

The Right To Food Campaign in its latest update it has cited a thread of new reports of atleast 45 deaths, which includes deaths due to hunger, exhaustion and accidents of people walking back to their homes, police atrocities, inability to access medical services and suicides. Along with the migrant workers and rural poor, urban slum dwellers across states are struggling to get access to food and ration as often they do not have ration cards. JSA has endorsed the Right To Food Campaign’s demand to government that PDS should be expanded to cover every individual, irrespective of whether they have a ration card, with 10kg of grain, 1.5kg pulses and 800gms cooking oil per month per person for atleast six months.

• Greater fiscal support to state governments: The central government has notified the release of Rs 11, 092 crores to the states under the State Disaster Risk Management Fund for combating Covid related relief measures. However, the state wise distribution of the funds shows that there is discrepancy in allocation if determined on the basis of number of Covid cases. Maharashtra with highest number of cases has been allocated Rs 1611 crores, while Kerala which had the second largest number of cases till the 3 April received only Rs 157 crore.  There have been repeated demands for providing greater fiscal support to the state governments, who are at the frontline of dealing with the situation on the ground. 

• Release of foodgrains and pulses: The central government announced in its economic package that ration to priority households under the National Food Security Act would be raised to 10 kg of rice or wheat, and 5 kg of pulses. Issues concerning the policy have been raised in the statement of the Economic Relief Package. According to the latest PIB statement a total of 2 million metric tonnes of food grains have been unloaded by states during the lockdown, while, there was a surplus of total 77 million tonnes with the Food Corporation of India.  The pulse reserve with the National Agricultural Cooperative Marketing Federation is also finding it difficult to transport the surplus to the states due to lacking transportation and private milling facilities. The demand for further opening up the food reserves to take care of the food security needs of the growing number of vulnerable people has never been greater. Recently the government has announced that ration would be extended to non-NFSA beneficiaries with ration cards issued by state governments. News coming from the ground shows that this criterion too leaves scope for exclusion. Our demand, as stated above, is for government to provide ration to all who need it. 

In conclusion: 

We have flagged many of these concerns to the government in our Press Release of April 7th. Now in parallel with the release of this weekly update we shall be releasing three statements which would contain the main demands and recommendations that flow out of this understanding:  

1. 1. Proposed Extension of Nationwide Lockdown: Concerns and Demands by JSA and AIPSN ( http://phmindia.org/2020/04/12/proposed-extension-of-nationwide-lockdown-concerns-and-demands-by-jsa-and-aipsn/ )
   2. Press Statement on the communalization of the pandemic (in draft stage)
   3. Press Statement on adverse impact of stigmatization and what must be done to counter this (in draft stage)

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