Why are cities the first to be hit in wave after wave of the pandemic? Why did healthcare capacities of most cities crumble when pressured by a surge of infected persons? How did the poor and vulnerable sections of the population, especially migrants, fare when challenged by multiple inequities? How can we plan better as we revamp our urban planning and rebuild our health systems to be more resilient, responsive, efficient and equitable?
We must address these questions as we emerge from the second wave of the Covid pandemic and prepare ourselves for a possible third. Vulnerability of cities, as entry points for potentially pandemic-causing microbes, is easily explainable as international airports and seaports bring infected travellers. Even within-country spread is easy, through the many domestic travellers who visit or transit through a city by rail road, air or sea. From these cities, microbes radiate to neighbouring districts or further afar as they travel with people.
High levels of population density and mobility make cities vulnerable to rapid spread of infection, with a big surge in the number of cases and a long time for the wave to ebb. Levels of air pollution are higher in cities, adding to greater vulnerability to severe disease due to generalised inflammation affecting blood vessels besides causing lung damage that respiratory viruses aggravate. For microbes capable of spreading by water, cities offer a huge opportunity to do so through extensive water supply lines and sewage systems.
Surveillance systems have to be strengthened to detect infectious agents, monitor the routes of spread and identify infected individuals who can transmit to others. In Covid, this called for early, effective and extensive testing to detect the virus and genomic analysis on a subsample of the positive test isolates. Equipment, labs and reporting systems for these must be well planned and ready for an early and anticipatory pandemic response, rather than a hurried scramble when a pandemic is rapidly advancing. Surveillance of traveller entry points must be scientific and strict. Newer modalities like sniffer dogs and breathalyser machines are being validated for detecting the presence of specific volatile organic compounds (VOCs) in infected persons. These may come into greater use in future. Apart from diagnostic tests, clinical symptoms, history of close contact with infected persons and recent travel to pandemic hotspots must determine the probability of infection in an individual.
Epidemiological surveillance as well as efficient management of cases demand strengthening of public health capacity and primary healthcare services. These have been areas of great neglect in urban health planning and financing. Much of the rush in hospitals during Covid arose because primary care teams were unavailable for home visits, symptom-based screening, early testing, supportive home care and appropriate referrals for hospital care. Even contact tracing and vaccine confidence building require primary healthcare teams. Detection of comorbidities like hypertension and diabetes that increase the risk of adverse outcomes is a function of primary care. Oxygen-equipped district hospitals and advanced care institutions for intensive care must be well connected to primary care, through readily available emergency medical transport. Investments will be needed for an expanded, multi-layered, multi-skilled health workforce to deliver efficient services at all levels of care.
While much of planning for coordination and resource allocation will need to be done by the state administration, local micro-planning and contextually adaptive implementation have to be entrusted to municipal authorities. Mayors and municipal corporations have played a strong role in Covid pandemic response in many countries. In India, this has been invisible, with rare exceptions like Mumbai and Kerala. Data-driven decentralised decision-making is critical for timely detection and efficient control of outbreaks in community clusters. With the Fifteenth Finance Commission allocating more funds for urban health and directing them to local bodies, the situation may change. The local bodies will need technical support for evidence-informed decision-making, requiring augmented public health expertise at that level.
Community engagement is pivotal for an efficient pandemic response. From early alerts of outbreaks to supporting home care, from countering stigma and discrimination to building vaccine confidence, members of the community can play an active role, whether as individuals or organised groups. Health literacy is also best promoted through community networks. Social solidarity, promoted by collective community action, provides the best defence against the debilitating mental health and corrosive social effects of a prolonged pandemic.
Besides strong health system competencies, pandemic response must pay attention to urban redesign to replace slums with better housing, provide for less crowded public transport and safe cycling lanes, more open and green spaces, adequate and equitable access to clean water and air, affordable nutrient-dense foods, efficient sanitation services, universal education and inclusive digital literacy. UN-Habitat’s report on ‘Cities and Pandemics’ (30 March 2021) also calls for financial support to cities to create financial resilience through “a new urban economy that allows investments in disaster risk reduction as well as climate change actions”. Indeed, we need many complementary actions as cities aim to build forward, better, broader and fairer.
(Views are personal)
Dr K Srinath Reddy
Cardiologist, Epidemiologist & President, Public Health Foundation of India (PHFI)
(ksrinath.reddy@phfi.org)