Kolkata: Ease in restrictions and surge in cases call for a rethink of our pandemic control strategies, public health experts say, suggesting that the focus must turn to community participation, which has been completely lacking in India’s COVID-19 responses so far.
Community participation is key to public health and has been central in fights against previous epidemics such as Ebola. In the present context, the importance of active engagement with the community has been highlighted by many, including Nachiket Mor, former country director for the Bill and Melinda Gates Foundation, in an interview with IndiaSpend.
Community involvement could play a key role in planning local-level actions in collaboration with local bodies to identify vulnerable households, provide support to the elderly and those in quarantine, develop better communication strategies and help in contact tracing, said Indranil Mukhopadhyay, associate professor of public health and economics at Jindal School of Government and Public Policy.
Although there have been sporadic community efforts across the country, cities and states ought to build on and scale those efforts for effective and sustained community engagement, experts told IndiaSpend.
Community and COVID-19
During the pandemic, the government has advocated large-scale behaviour modification measures like maintaining physical distancing, hand washing, cough etiquette and following the rules of the lockdown to curb infection transmission. But such measures might not be effective unless the community is engaged to the point where they accept these interventions actively, said Rakhal Gaitonde, professor of public health at the Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram.
Community engagement could be the missing link in enabling adoption of and adherence to the government’s public health guidelines, said Ritu Priya, professor of public health at the Centre of Social Medicine and Community Health, Jawaharlal Nehru University (JNU). Also, involving the community in decisions about their own health and wellbeing would make a difference, she added.
For instance, the experience from the Ebola epidemic management showed that community engagement has a much broader scope than just risk communication. Social Mobilization Action Consortium, Sierra Leone’s largest community engagement initiative during the Ebola outbreak in 2014, trained 2,500 volunteers for implementing the Community-led Ebola Action (CLEA) approach. In this approach, the volunteers used structured tools (such as body mapping to identify key symptoms of Ebola, danger discussion and survivor stories) to evoke community response around triggering events. Their meetings were attended by representatives from different sections of the community. Through collective deliberation, the communities arrived at their own plans of action to prevent disease transmission, promote self-ownership and community agency.
Apart from imparting a sense of urgency, these exercises also helped highlight other competing issues like hunger or loss of work that influenced the adoption of preventive behaviours. The Sierra Leone initiative was credited with a significant reduction in unsafe burials and with increasing early reporting of symptoms. Talking about the biggest lessons from the Ebola epidemic of 2014, the WHO also noted that “community engagement is the one factor that underlies the success of all other control measures.”
“First and foremost, it is important to recognise the role of the community as a rights holder. We have to stop assuming the community to be a set of people who are wrongdoers, ignorant, dirty and unhygienic. Rather, we need to acknowledge them as people who are affected by the pandemic and our (state’s) role is to serve them,” suggested Vandana Prasad, community paediatrician and public health professional from New Delhi.
In India, where communities are a diverse mix of identities and interests, an exercise such as the CLEA approach, if appropriately adapted and implemented, could help reveal specific needs of the different sections in the pandemic and assist authorities take appropriate action, said Ritu Priya. This could create greater awareness and sensitivity about varying needs and conditions of others and direct collective action towards the common objective of pandemic prevention, she added.
Community engagement will finally depend on the nature of the government, said Sulakshana Nandi of Public Health Resource Network (PHRN). “Ideologies drive public health practices and determine whether governments consider communities to be important enough to be engaged in a dialogue. Clapping hands, banging plates is not the way to engage communities,” she noted.
Transparency, equal partnerships
The pandemic represents a singular moment in what has been an ongoing process, according to Gaitonde, the professor from Thiruvananthapuram. “Decades of uneven development policies have created fissures within and between the communities and, hence, the onus is on the government to spread a clear message that the services during the epidemic would not be biased or that any particular demographic group was responsible for the spread of the virus,” he said.
Mutual trust between the government and its people is indispensable for popular adoption of government initiatives and this trust has to be earned and maintained through people-centred decision-making and action with the active involvement of the community. “We don’t know who all were involved in the central government’s decision of nationwide lockdown… certainly not the communities,” said Ritu Priya.
In contrast, Gaitonde noted, the Kerala government engaged with many different fora during the pandemic, such as nursing associations, government doctors’ associations, the private sector, panchayat leaders, frontline workers, local self-help groups, traders’ associations and so forth. “Many organised groups within the community have an access to the government's response, they are being heard and are contributing to the pandemic response,” he said.
Despite concerns over the growing divide within and between communities, there have been instances where communities came together to help each other and also assist those in need. The community kitchens of Kerala, conceived, organised and run by the people, lend one such example. States such as West Bengal and Karnataka also ran such initiatives as a possible solution to the local food security crisis during the lockdown. In Maharashtra, farmers formed a cooperative with the help of block officials to supply their produce to urban households directly, said Ritu Priya.
Kerala’s Sannadha Sena, comprising over 100,000 young volunteers, served at quarantine centres and helped the elderly. In Delhi, trade unions helped in providing aid and care, especially in the urban slums, said Mukhopadhyay of Jindal School. They were also effective in disseminating information wherever the state machineries had limitations, he added. An ex-panchayat chief designing a low-cost sanitiser and Indian start-ups formulating contact tracing apps and digitised surveillance methods are all examples of participation and solidarity during the pandemic.
However, according to Gaitonde, most of these were informal initiatives and required necessary government engagement to unlock their full potential. “Tapping such responses can help strengthen government mechanisms and that is acutely needed now,” he added.
The local administrative bodies responsible for local level containment management should facilitate such initiatives and actually ask for them, suggested Ritu Priya. “The local agencies can check with the residents’ welfare associations about what they were doing to ensure their workers’ wellbeing, whether they were giving them wages and so on,” she said.
Depending on the effectiveness, the best practices of such community efforts could become a part of containment protocols at the state or national level, Ritu Priya said, adding, “While administrative leadership is needed in managing something of this scale, the protocol should encourage innovative ideas by the communities themselves.”
Drawing on the smallpox immunisation programme, Ritu Priya recalled that despite a whole century of efforts, it only picked up pace in the 1970s and the disease was finally eradicated when the local public health functionaries worked with the communities to tailor their interventions specifically suited to the local context.
Communities’ existing knowledge of dealing with a highly infectious disease like chicken pox could also come in handy in managing uncritical cases in the community, taking the load off the beleaguered public health system, said Prashant Kesharvani, public health researcher and chairperson of undergraduate studies at Tata Institute of Social Sciences (TISS), Guwahati.
While action is indeed needed at the self-community level, it has to be supplemented by a robust public health infrastructure, said Prasad, the community paediatrician from New Delhi. “If we learn anything from the pandemic, we will focus on strengthening the public health system and not continue allowing rampant privatisation,” she observed. The community can only function to its fullest potential when all its members have access to the required resources. “Our efforts should now be directed towards controlling profiteering in health and decentralising all governance mechanisms, including that of health. The vision of communitisation proposed by the National Rural Health Mission, albeit never fully realised, could offer us possible ways of achieving that,” said Prasad.
Previous epidemics have shown that crises are usually indicative of deeper governance issues resulting from weak institutional arrangements. But they also demonstrate that community engagement can play a critical role in enhancing governance capacity in times of need. Any democratic government should facilitate more equal partnerships in decision making by communities in matters concerning their health and wellbeing, said Ritu Priya.
Power of positive messaging
Facilitating such community initiatives would require the government to create an enabling ethos first, said Ritu Priya, suggesting that India could draw lessons from the idea of an enabling environment in HIV programmes. Creating an enabling environment is critical to removing barriers to uptake of health services like testing and counselling and increasing their effectiveness in communities, according to the WHO. It can be done by improving availability, accessibility and acceptability of services and by promoting inclusivity and de-stigmatisation through positive messaging.
In the current pandemic, alongside providing necessary support, the government saying that “this is a situation where we have to keep a physical distance but we all have to look after each other,” could prevent unnecessary paranoia and send a positive message of cooperation, Ritu Priya noted.
However, there have been questions over the central government’s messaging in addressing the COVID-19 crisis. “If you are saying sit at home, wear a mask and wash your hands, do not touch anything, do not interact with anybody else, just take care of yourselves and your family... then you are creating an environment in which you are looking at everybody else with suspicion and as a potential spreader,” noted Ritu Priya.
Messages focused on invoking fear of the unknown have already started taking a toll on society, said Kesharvani of TISS. “This pandemic is changing the nature of relationships within communities. The erosion of trust, the desperation to control the lives of others... that is fuelling more discriminatory behaviour,” he said.
The stigmatisation of migrants and the relative silence around the issue of people returning from abroad, he noted, betrayed a class bias in India’s response to different groups. “The problem is that you are not understanding the living conditions where social distancing is not possible,” Kesharvani added. Housing, livelihood, food security and access to resources significantly determine communities’ ability to comply with public health guidelines during the epidemic, a recent paper showed.
Kerala, on the other hand, presented an example of positive government messaging where the chief minister emphasised on social solidarity and physical distancing while downplaying the mispositioned thrust on ‘social’ distancing. “The openness and clarity in conveying a message as a part of epidemic response like the chief minister’s regular 6 p.m. press conference has been very effective in creating a discourse that builds on solidarity and prevents the creation of panic, while also putting a stop to the spread of fake, stigmatising, stereotypical and communalising news,” said Gaitonde.
This kind of communication goes a long way in minimising othering and stigmatisation in communities and helps create an ethos of cooperation and altruistic sensibility, said Ritu Priya.
(Tiwari is an independent researcher. Das, a medical doctor, and Aich, are pursuing a PhD in public health at JNU.)
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