daktre Profile picture
27 Jun, 38 tweets, 11 min read
1/ Thread on High Level Expert Committee for Prevention & Management of COVID 3rd wave chaired by #DeviShetty & nearly #allmale & clinician led committee with hardly any diverse expertise needed (covered in my earlier thread which fell on deaf ears @BSYBJP @mla_sudhakar);
2/ My view based on my training in medicine & #PublicHealth & what I have learned through several years of #CommunityEngagement & #PrimaryHealthCare in rural Karnataka #Chamarajanagar;
3/ While the original notification was all men, 2 women seem to have been added; the summary of the report is about 30 pages while the "detailed recommendations" are 60 pages; rather poor attempt at summarising IMO
4/ preface says various "disciplines of medicine" were included which is overly narrow for a social & community crisis that we saw; the ToC of topics covered shows total lack of a coherent framework in defining the technical inputs; clearly public policy expertise lacking
5/ Given that report has private-sector & corporate membership (Chair himself!), one would have expected an articulartion of "principles"/values/assertions that underly choice of recommendations; NONE listed; did you expect disclosures? NONE
6/ report is a list of bullet points; under PH infrastructure, committee makes "list for procuring drugs including consumables"; an operational detail which does not normally need a committee of experts; @DHFWKA already has/ought to have such capacity;
7/ Total lack of ANY structural reform; a huge missed opportunity; be it the Public health cadre need that's been suggested for 2 decades now & having good qualaity evidence for; instituting a hospital manager cadre for eg lacking; a good quality HR management system...none!
8/ A1. Public health infrastructure & HR: no structural reform, usual stuff on expansion of infra & filling up of vacancies (none of these need expert committees to tell us); complete lack of understanding of what is Governance on which more below
9/ The recommendations under Governance demonstrate lack of expertise in the Chair to be able to guide/conceptualise Public health; this is not surprising; furthermore for a corporate head to make recommendations on Governance w/o consultations or including experts is wrong
10/ Under recommendations for upgrading medical colleges, more vacancy filling; NOTHING on the poor technical & clinical leadership from medical colleges and how to improve that, limited convening function of current Community Medicine depts at district level decision-making?
11/ Not a MENTION of the Chamarajnagar oxygen tragedy where at least 28 died at a medical college hospital; what did we learn? How do we prevent this in the coming days? Did nobody bring this up?
12/ Section 2 on Vaccination strategy is entirely focused on urban middle class Bangalore save for "Whole of community" should be involved (how does this work?); only meaningful recommendation here is on micro-planning Bravo!
13/ Under vaccination sites, here is an interesting suggestion to NGOs: "Encourage NGOs to provide refreshment at the vaccination sites." (🙄 ) and some plain common-sense offered; any data-driven stuff on this? any analysis of measles/polio at GP level? NOTHING
14/ On vaccine hesitancy, I have read good quality high school essays that are more meaningful; again NGOs thrown in as some entity that magically can "mobilise rural populations" (what do they think rural populations are? sheep waiting to be "mobilised" by NGOs?)
15/ More common sense under under cold-chain management & clinical management & adherence. Did we need an expert committee for this? Is it possible that the job was done by unmentoried/unsupervised juniors?
16/ Such deep-seated ignorance and stereotype of "rural communities"; this heterogenous term has been stereotyped basically to indicate one thing: they need help for "slot booking" on COWIN! (Was the Chair unaware of the current walk-in strategy widely deployed?)
17/ Under a theme titled "Software" 2 bullet points belie a lack of understanding of both software or its social realities; and by the way, for them COWIN is the ONLY software;
18/ An eg of the lack of deeper engagement with details/lack of expertise in the M&E section: here was an opportunity for the expert committee to go into details of how district & taluka reviews can be made more effective; instead more common-sense assertions "Strengthen";
19/ In oxygen section, some focus on piped oxygen supplies in govt & private hospitals (low interest COVID package loans suggested for private hospitals); some good bullet point recommendations on oxygen concentrators but so few details?
20/ Why have an expert committee if it can't come up with some templates/guidance and clear "new way of doing things" or a different way of doing things or lessons learned?
21/ Such a narrow view of fundamental public health concepts; see below for eg. 2 recommendations under "Patient safety"
22/ 2 pages on public awareness & messaging appears mainly targeting urban middle class communities with limited opportunities for actually "engaging" & involving people; instead just passive information offloads; also these are rather generic IEC/campaign mode stuff;
23/ 3 pages of psycho-social support is rather well written & important; but short on implementation detail on how to roll out in health & WCD departments across state; which are the specific staff at district & taluka who will receive this training?
24/ How will these integrate into care-seeking processes at PHCs & taluka hospitals? That's why the need for wide spectrum of public health & community medicine expertise needed
25/ The only section that addresses "lessons learned" is the 3-page section on PH preparedness; heavily biomedical with limited engagement with particular vulnerable populations;
26/ section on sentinel surveillance is particularly useful; willing districts struggling to set up & looking for models; in this section there is some attempt at a template of surveillance that could be established at district levels & could be an early-warning system
27/ As someone who's at a village/district level, the 5 bullets under Public health and social measures are quite entertaining; again, did we need an expert committee to put together these brilliant "social measures"?
28/ "Additional Preparedness for COVID 3rd Wave (Pediatric)", extensive calculations projecting population beds, HR & pediatric patient load; careful calculations done in tables have not been synthesised into district-wise actions which could be sent to DCs, Deans DHOs;
29/ On the nutrition recommendations, focus on milk; but NOT one mention of egg/meat; given huge protein-energy malnutrition, AT LEAST eggs will be vital to overcome the limited protein quality in staple cereals; also bizarre to list cherry-picked NGOs (unclear why these)
30/ Yay for COVID registry; hope this comes through and with good ownership by the participating medical colleges this will yield important insights if well done;
31/ section on PPP shows lack of Public policy expertise; so many PPPs either have limited effectiveness evidence or even plain negative evidence against their use esp for contracting out services; one of the PPP modality is to partner with "public at large" (sic!)

See for eg.
32/ the limited understanding of typology and diversity within "NGO" which are all bunched together thus and arbitrarily 3 out of 3225 have been named specifically to give the reader an "example" (as if readers may not understand what is an NGO)
33/ Partnership with IAP receives extensive mention; where they are working, probably useful & must be better documented; indeed allowing for better engagement of doctor, nurse & other professional bodies in public engagement on key topics is important and lacking till date;
34/ section on re-opening of schools leans on IAP guidance but paradoxically, DS had made non-evidence based assertions in media about huger wave in children; current preparedness for measures in govt schools still lacking & needs decentralised attention at district level;'
35/ Yes, I know it's easy to critique from "outside", & perhaps there are several individual members who worked hard on this; but for public health trained people to NOT engage critically with this would be a pity; also those of us involved at GP & taluka/district level have…
36/ …seen that listening & praxis are vital in co-creating a response; with limited consultation & participation, the report & recommendations are only as good as what went (& what did not) go into them
37/ Ultimately, a more participatory & decentralised consultative approach that privileges equity, empathy and caring will be most vital; and that can only happen through broadbased alliances, coalitions and committees at the lower levels
38/ the DS led committee does mention (in passing) district level committees; this is welcome and hopefully will be more broad-based; perhaps just strengthening & empowering GPTFs too needed </theEnd>

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More from @prashanthns

9 Jun
1/ #Vaccination #Adivasi #COVID thread; day begins with an orientation meeting to #Solega #Adivasi leadership on #vaccination at a hamlet; we address doubts and misconceptions; leaders criticise the stereotype of #Tribal Community as being hesitant and "running away";
2/ ask that officials & NGOs engage meaningfully and respectfully with their leadership at multiple levels; refuse the idea that they are ALL hesitant which often prevails among "others"; they explain what is the best way of engaging #Adivasi communities
3/ They offer to identify #COVID volunteers in each podu (hamlet); volunteers can be oriented in small groups & shall help with obtaining proper consent and participation of their elders;
Read 11 tweets
8 Jun
1/ Shared few insights emerging from community-based #COVID care that some communities have begun in #Adivasi populations in #Chamarajanagar with support from #ZillaPanchayat in live video interaction with #Karnataka #GramPanchayats thanks to @gokRDPR
2/ #COVID19 care needs to be rational & #evidence-based but also respectful & dignified; these are not aspects we have done well with in our #HealthSystem & hence need special attention;
3/ Dignified & respectful care requires an awareness of diverse socio-economic & cultural contexts at individual, household, neighbourhood & societal levels; we haven't substantively engaged with (#caste #gender #disability #sexuality #privacy )-aware care at systemic level
Read 7 tweets
4 Jun
#COVIDSecondWave care requires local #CommunityEngagement for it to be meaningful, respectful and dignified; at one of #chamarajanagar #solega #adivasi settlements yesterday was a humbling experience learning together with the people how to organise care in a culturally safe way
A remote forest settlement; sudden spurt of cases; testing hesitancy and immediate referral to far away #covidcare centres driving anxiety for testing and failing trust in ASHAs; #Panchayat president on location, NGOs, health workers, tribal welfare officers on site
Hours of respectful dialogue follows; various modalities discussed; an amazingly enthusiastic #Panchayat president convenes impromptu consultation at local tribal residential school; CEO and Zilla panchayat admin patiently listen to local proposals
Read 8 tweets
2 Jun
1/ Joining some wonderful people from what I am seeing as a diverse group of researchers at the #EditorialBoard of @PLOSGPH; journal has given itself the tall order of “addresses inequities in public health and makes impactful research accessible to all… (1/n) #Threads
2/ In words of @paimadhu "the journal will amplify the voices of underrepresented and historically excluded communities and prioritize equity, diversity, and inclusion at all levels"; I am highly skeptical of this,
3/ yet I am thrilled that a #PublicHealth journal would give itself such a vision; #Knowledge #Science #Evidence all reproduce the same kind of social hierarchies that drive unfair accumulation of resources in our society
Read 12 tweets
31 May
Thread on #GramPanchayat task force chaired by #Rangamma frm #Soliga #Adivasi community #brhills #Chamarajanagar; praise for #HealthWorkers but frustration at lack of “higher officials” coming to GPs; @readingkafka @iphindia
PHC MO and other doctors address the gathering about the last one month experience of #Chamarajanagar and how situation is slowly improving; need to address hesitancy towards testing and vaccine; also not to become complacent about dropping numbers
PHC Dr frm #Gumballi patiently heard & clarified how these are stressful times for all #HealthWorkers; members demand at least one visit a month from #taluka officials; patient listening of complaints is an important function even if they are not immediately resolved;
Read 8 tweets
27 May
Will we EVER learn about #PublicHealth?
3rd wave “expert” committee is nearly-ALL #Pediatricians (to keep Devi Shetty’s non-#evidence-based assertion on #children will be entirely affected), #AllMale #Manel, nearly-all #clinicians headed by #PrivateSector #Cardiologist
I request this committee members:
- Please QUESTION Devi Shetty’s credentials to lead this
- Please hold to account #Manel #AllMale membership
- Please include #RuralHealth #CommunityHealth #PublicHealth
- Expertise is NOT only CLINICAL; also social; include grounded voices
Unfortunately no time & bandwidth; but putting this out there
We need:
- campaign for a DIVERSE expert committee including #Citizen #CommunityEngagement #Dalit #Adivasi voices
- Devi Shetty’s position as Chair is NOT tenable; appoint a #PublicHealth expert in his place
Read 6 tweets

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