Much of the public debates on Covid 19 response are focused on things like testing, vaccines, drugs, ventilators, PPEs, isolation wards and the like. While these are all important, perhaps a more critical requirement is the mechanics of the physical lifting of the restrictions currently in place. This assumes great significance since governments across the world are debating strategies to manage the exit from their current lockdowns.
This is perhaps understandable given the natural inclination of human beings to focus on the tangible and the tractable. Instead, something like the details on managing the lockdown exit is fraught with multiple possibilities, is diffuse and long-drawn, and not about any product or technology but about processes. And it requires a painstaking and iterative engagement response. In simple terms, these are all about implementation, and its quality.
There are essentially three categories of medical response activities in the Covid 19 universe. One, the immediate mitigation and containment strategies, which include the likes of trace, test, and isolate. Second, the focus on improving testing, and development of vaccines and treatments. Third, the strategy of managing the exit from the lockdown.
While the first and the second on the medical side are currently the focus of attention, there has been limited discussion and critical analysis about the options for exit from the lockdown. This is important since this exit from lockdown may not be a linear process with a 3-6 month closure. It is most likely that it will take 2-3 years for vaccines and drugs to become accessible to everyone, especially the poor, and herd immunity to develop across populations. That, after all, is the only possible denouement to any such infectious disease outbreak.
Further, while developed countries can rely on technical solutions like work from homes, isolating the old-aged, home-delivery, social distancing in public places and at homes, mass-testing, home and hospital isolation, and the likes, these are largely unavailable for the vast majority of people in many developing countries. Weak state capacity also means that micro-targeting and other intense surveillance activities are unsustainable beyond a few months.
The likely realities of the post-exit world
In the post-exit world, certain requirements are evident. Foremost, the use of masks will perhaps become mandatory, at least in work and public places. Two, protecting the old-aged and immuno-compromised will have to become a priority. Three, workplace safeguards, with elements of social distancing etc, will have to be adopted. Four, periodic screening and testing of frontline medical staff will be critical. Finally, mass gatherings will have to become avoidable, atleast for the foreseeable.
All societies will have to make adjustments to follow these, in some form or other.
Further, the first phase of the exit strategy too is clear. Ease the current lockdown by first permitting less risky economic and social activities and travel modes, and gradually allowing the riskier ones through a calibrated approach. Public transport will accommodate less people in the first phase. Restaurants will start with take-aways and then allow socially distanced eat-ins. People will have to adjust to standing in ques. Factory floors and workplaces will keep in mind principles of social distancing. Educational establishments will have to figure out some combination of class and home-based engagement. Large shops and malls will start with restricted capacity. Entertainment mass gatherings will perhaps be the last activity to resume.
But the action space beyond this is not at all clear. As the economic activities resume and regions and countries open up, the diffusion of Covid 19 will become unavoidable. There could be mutations and eruptions of variants of the disease. There will be recurrent episodes of local flares up of differing intensity, which would demand appropriately varying responses. Such responses will have to be at the levels of household, shops and public facilities, workplaces, localities, villages and towns, and perhaps even cities and provinces/states. Behaviours and practices will have to swiftly (and as a matter of routine) adapt to these changing conditions. These local responses will be a combination of the likes of pooled testing and restrictions on movement of people and economic activities.
Complicating matters, these episodes will be sporadic, largely unpredictable, and emerge suddenly. All this demands an adjustment to a new reality, with behaviour changes at individual level and new practices at workplaces and public spaces. Foremost, it requires quick adaptation and internalisation of these responses into the daily routines of people, organisations and businesses.
How can data and technology be used as decision-support in the post-exit world?
A critical requirement for these responses would be the availability of good data on underlying trends about medical conditions in a locality. The pure medical response to this may be to undertake clinical and other tests. But there are serious technical issues with the with the administration of standard polymerase chain reaction (PCR) tests and the reliability of the antibody tests, and there is also the sheer challenge of doing such tests at scale in weak state capacity environments. In the circumstances, a more practical and appropriate response at scale in developing country contexts may be to use data from alternative sources to assess the underlying disease progression.
Another data source, one of tagging and tracking individuals who are tested positive too may have limited use at steady state for multiple reasons. For a start, there are practical challenges associated with its implementation – getting people to use mobile phones, carry them always etc. Two, it also demands high engagement monitoring by public health officials, a challenge in weak state capacity environments. Three, it opens up serious privacy concerns whose costs may, in the long run, far outweigh the immediate benefits.
Already there is sufficient awareness about the disease and with sufficient periodic reinforcement and some community-level monitoring, it may be more effective and possible to manage compliance to isolation by those tested positive than by using complicated techniques like digital technologies.
In the circumstances, what are the data sources that are more practical and relevant in this regard? How can such data be captured, consolidated and integrated? How can it be analysed to generate relevant and actionable decision-support information? Can underlying trends be used to detect possible future scenarios? How can this information become accessible to various stakeholders? How to interpret such information? What are the protocols for actions based on such information?
These are questions that demand critical scrutiny.
he data sources will include basic details of the OP/IP cases from public and private hospitals of various kinds, ambulance and emergency call cases, data from health outreach functionaries and municipal public health departments, data from civil society organisations and community/business associations, workplace medical leaves etc. It is also important that it is able to draw data from Government of India’s Aarogya Setu App to supplement these other data sources.
In addition to these proxy measures, it may be also useful to undertake telephone-based and other remote screenings (even self-reported) of symptomatic cases and use that data too to derive actionable insights about the disease progression in any community. It may even be useful for the largest cities to have call-centres which are used to undertake symptomatic screenings of random households in vulnerable localities (think large slums like Dharavi).
Digital technologies and AI may be useful resources in generating actionable insights from the associated data.
An illustrative list of decision-support use-cases could be as follows
1. Trends in pneumonia or respiratory infection cases etc which could point to either the likelihood or the presence of some geographical flare up
2. Trends in cases within hospitals which would help them with more effective management of their own facilities.
3. Effective symptomatic screening of patients for Covid 19 symptoms and their triaging for referral (say, testing) and other (say, isolation) actions.
4. An efficient protocol for symptomatic screening of patients in vulnerable localities through telephone and other remote approaches.
5. Developing an efficient strategy of pooled testing and formulating the appropriate medical response in different types of communities – habitations, larger villages and slums.
As a first step, even mere analysis to identify trends or incidence rates can be useful to inform reactive actions of stakeholders. As data accumulates, advanced technologies like artificial intelligence (AI) can be used to support with pre-emptive action by stakeholders.
Software solutions and Apps that can integrate feeds from different sources and help with simple data analysis by hospitals and villages/towns/cities can help inform reactive actions. Similarly, AI algorithms that can be layered on to these solutions to help them with assessments can trigger pre-emptive actions. There may have to be versions of each customised to meet the requirements of different types of stakeholders – hospitals of various kinds, schools, public facilities, and villages/towns/cities.
What should governments do with managing such data?
The officials of cities and gram panchayats, and managements of hospitals and workplaces can use such data to calibrate their plans and activities accordingly. The process of adaptation or change can be integrated and done a manner so as to not disrupt the entire system.
Governments will have to respond to the situation in different dimensions. One, they will have to issue guidelines to local authorities, hospitals, businesses, and households that outline the protocols to respond to these scenarios. This will have to include a standard categorisation of areas based on Covid 19 incidence rates (inferred mainly from such data, as against testing) and defining a response strategy for each area category. With time, as more data points accumulate, the response strategy itself will get refined.
Two, they will also have to play an important role in creating channels to make available such information for dissemination and uptake by stakeholders. For example, making available the Application Programming Interfaces (APIs), with data appropriately anonymised for privacy, is an essential requirement. Ensuring that civil society organisations actively engaged in this process should be a priority.
Finally, the governments will have to ensure that local governments, hospitals, workplaces etc are monitoring these trends and are then adhering to the requisite protocols.
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