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Covid-19: Countries rally to support India through “storm that has shaken the nation”

BMJ 2021; 373 doi: (Published 26 April 2021) Cite this as: BMJ 2021;373:n1086

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Open letter from Trustees of South Asian Health Foundation. COVID-19: Call to action on global inequalities.

Dear Editor

Over the last 18 months, images and data from China, Italy, UK, Brazil and now India, bring home the disaster which COVID-19 confers upon individuals and their fragile health systems. Currently India has the unenviable position of leading global COVID-19 numbers with over 17 million COVID-19 cases as of April 28th 2021, 195,000 deaths and over 300,000 new cases daily(1), which is likely to be a significant underestimate. So, as the world’s largest democracy fights and mourns in tandem, what more can be done to add to the global effort to date?

Health and politics are inextricably linked, no more so than at the time of an election. As India goes to elections, the election commission must consider postponement. India invoked an exemplary lockdown during the initial wave of COVID-19 and it is perhaps now a time to consider whether the benefits of a lockdown outweigh the benefits of an immediate election. Mass gatherings need to stop urgently. The Government has already called for support internationally. A number of countries including Germany and the UK have responded with oxygen concentrators and ventilators for immediate need. Further needs will emerge, and the scale of need is almost immeasurable in a country where many citizens living below the poverty line are unlikely to seek a test for COVID-19, let alone seek healthcare. The basics of public health advice and public adherence thereof are critically important to address, control and lower the R rate, as shown by other countries(2). Further needs assessment for acute care in hospitals and management in the community should be followed by ongoing monitoring to guide recovery from the pandemic. Perhaps it is now time to reprioritize India’s commitment on the road to universal healthcare through Ayushman Bharat(3), during and after the pandemic and also reinvigorate its public health spending. However, public health principles of strict lockdown and adherence to non-pharmaceutical interventions are paramount, reinforcing the importance of social distancing, masks and washing hands. To drive equity, care must be based upon need and not ability to pay.

Today, India has to not only fight the acute challenges of this wave of COVID-19 but prepare for the huge challenge of indirect effects of covid-19 on morbidity and mortality which will inevitably follow. To fight this acute challenge, not only is oxygen and ventilatory support critical, but so is governed access to healthcare.

Firstly, criteria-based access to the hospital and intensive care beds is essential to make best use of limited resources. Standardized protocols for access and step down to the most valuable resource of an ITU bed will enable the best chances of survival to as many as possible. It is time to share and standardize these protocols from across the world, including use of risk prediction models that are likely to benefit people the most(4,5).

Secondly, treatment should be evidence based. The evidence for management of people with COVID-19 is being updated at pace with clinical trials and observational studies of high quality demonstrating the most effective treatments at different stages. All patients should benefit from such evidence.

Thirdly, good governance is essential. Acute hospitalization in India comes at a cost, impoverishing those most vulnerable. The government should rapidly protect its most vulnerable citizens from such impoverishment by guarding against cost inflation of hospital fees and drug costs, while ensuring that supply chains of oxygen, essential drugs and other supplies reach those in need as rapidly as possible. Nodal officers should be appointed in each hospital to monitor beds and billing.

Fourthly, workforce planning should drive us to meet need. Across the globe, the South Asian diaspora is witnessing the desperate struggle. Health systems should consider how to harness diaspora constructively. Systems must balance the forces of economic workforce migration with the needs of health systems. Is it time for a global workforce concordat which meets the needs and rights of individuals as well as health systems?

Fifthly, we should empower patients across the globe to preserve their own health by utilizing all means of trusted communication to minimize mistrust in medical information. Furthermore, optimal management of non-communicable diseases, such as diabetes and hypertension, is likely to have significant impact in reducing morbidity and mortality both during and after the pandemic. Inequitable outcomes from COVID-19 have mostly been driven by wider determinants of health which culminate in increased exposure to COVID-19 and poorer outcomes due to the impact of comorbidities. It is time to redress the balance by now planning to address global health inequity by committing to coordinated action against non-communicable diseases which will kill those most vulnerable across the globe as the world recovers from the economic and structural devastation which the pandemic leaves behind. Total indirect deaths related to COVID-19 due to disruptions in care, access to care and poverty are likely to kill more patients that the pandemic itself. Is it time for a global drug fund to optimize population health outcomes from conditions such as diabetes in parallel with high level strategies on prevention and screening(6)?

Finally, social media in the medical community has been used to incredible effect during the pandemic and we must make every effort to utilize such communication to rapidly share evidence, guidelines and protocols across the globe. Publishers do that well and independently. Is it time for a global editorial collaborative to provide open access and oversight of science to ensure that highest quality science drives decision making for every patient?

Whilst history tells us that action and inaction has resulted in global inequity and iniquity(7), it is now time to define which actions and inactions we prioritise to drive equity and prosperity during and following the pandemic, which we do in a 10-point list of recommendations(8).

Amitava Banerjee, associate professor and honorary consultant cardiologist 1,2 @amibanerjee1

Kiran Patel, chief medical officer and consultant cardiologist 2,3

Wasim Hanif, professor and consultant physician 2,4

Sarah N Ali, consultant in diabetes and endocrinology 2,5

Kiran Sehmi, director of national and regional public health programmes 2,6

Vinod Patel, professor in diabetes and clinical skills and honorary consultant in endocrinology and diabetes 2,7

Ranjit Dhillon, cardiac nurse specialist 2,8

Amal Lad, general practitioner 9

Paramjit S Gill, professor of general practice 7

Harpreet Sood, general practitioner and board member 2,10

Kamlesh Khunti, professor and general practititioner 2,11

1 Institute of Health Informatics, University College London, London, UK
2 South Asian Health Foundation, Birmingham, UK
3 University Hospitals Coventry and Warwickshire
4 Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Trust, Birmingham, UK
5 Department of Diabetes and Endocrinology, Royal Free Hospital NHS Trust, London, UK
6 Royal Society for Public Health
7 University of Warwick
8 Department of Cardiology, University Hospitals Birmingham NHS Trust, Birmingham, UK
9 Sherwood House Medical Centre, Birmingham
10 Health Education England, London
11 Leicester Diabetes Centre, University of Leicester, Leicester, UK

1. Worldometer. (Accessed 27 April 2021)
2. Baum F, Freeman T, Musolino C et al. Explaining covid-19 performance: what factors might predict national responses? BMJ. 2021 Jan 28;372:n91. doi: 10.1136/bmj.n91.
3. Zodpey S, Farooqui HH. Universal health coverage in India: Progress achieved & the way forward. Indian J Med Res. 2018 Apr;147(4):327-329. doi: 10.4103/ijmr.IJMR_616_18.
4. Clift AK, Coupland CAC, Keogh RH et al. Living risk prediction algorithm (QCOVID) for risk of hospital admission and mortality from coronavirus 19 in adults: national derivation and validation cohort study. BMJ. 2020 Oct 20;371:m3731. doi: 10.1136/bmj.m3731.
5. Knight SR, Ho A, Pius R et al. Risk stratification of patients admitted to hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: development and validation of the 4C Mortality Score. BMJ. 2020 Sep 9;370:m3339. doi: 10.1136/bmj.m3339.
6. Banerjee A, Hollis A, Pogge T. The Health Impact Fund: incentives for improving access to medicines. Lancet. 2010 Jan 9;375(9709):166-9. doi: 10.1016/S0140-6736(09)61296-4.
7. Samb B, Desai N, Nishtar S et al. Prevention and management of chronic disease: a litmus test for health systems strengthening in low-income and middle-income countries. Lancet 2010. 376: 9754: 1785-1797.
8. South Asian Health Foundation. The COVID-19 crisis in India. A 10-point action plan.

Competing interests: All authors are Trustees of the South Asian Health Foundation. AB has an unrelated research grant from Astra Zeneca. PSG is part funded by the NIHR Applied Research Collaboration West Midlands and a NIHR Senior Investigator. KK is Director of the University of Leicester Centre for Black Minority Ethnic Health, Chair of the Ethnicity Subgroup of SAGE and Member of Independent SAGE. There are no other conflicts to report.

27 April 2021
Amitava Banerjee
Associate Professor of Clinical Data Science
Kiran Patel, Wasim Hanif, Sarah N Ali, Kiran Sehmi, Vinod Patel, Ranjit Dhillon, Amal Lad, Paramjit S Gill, Harpreet Sood, Kamlesh Khunti
University College London
Institute of Health Informatics, 222 Euston Road