A highly significant observation arising out of a pioneering health-care initiative led by a doctor couple in Ahmednagar, Maharashtra in the 1970s greatly inspired primary health-care delivery, both within and outside the country. This observation was that a significant cultural gap existed between health-care personnel such as auxiliary nurse midwives and rural and tribal beneficiaries, significantly impeding delivery of preventive and promotive health care. It was realised that a cadre of health workers recruited by and from within the community, and also accountable to the community, would have greater affinity with people, thus ensuring greater community participation in care delivery. Soon, a series of community health worker schemes followed, the latest being the accredited social health activist (ASHA) programme.

The recent attack on an ASHA worker conducting a COVID-19 survey, due to an alleged suspicion that she was a government National Register of Citizens agent betrays the faltering of our community health worker programmes in a way. Over time, they have become de-facto public health employees rather than being community representatives enjoying the unswerving confidence of people as originally envisaged.

Two things remain common to the sporadic incidents of non-cooperation with our anti-coronavirus campaign, from the Tablighi Jamaat fiasco to migrants escaping quarantine and allegedly unleashing violence against the police. First, that a strong felt need for coronavirus control remains absent due to deficient threat perception. Second, that deficient threat perception has resulted in strict control measures such as quarantine to be perceived as high-handed government instruments. What this signifies is that government messaging of the coronavirus threat will alone not suffice, and that a willingness to cooperate can only be engendered from deep within the community.

Community engagement is a pre-requisite for risk communication, which entails effectively communicating the threat due to the virus, instilling the right practices and etiquette, and combating rumours and stigma. Till date, the government’s machinery to communicate risk has served a thin upper- and middle-class segment quite well. However, with COVID-19 moving briskly towards slums and rural hinterlands, one should not be surprised if such incidents of non-cooperation start surfacing at a brisk pace too.

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Rural awareness generation and community engagement has unto now comprised mainly of engaging with local panchayats, disseminating publicity material in local vernacular, and calling on the participation of civil society organisations. For our anti-coronavirus campaign to be a success, community engagement has to ensue on a war-footing, much akin to the production of ventilators and masks. Like the Antyodaya approach, it has to embrace the remotest community stalwart who enjoys the community’s confidence and is perceived as an impartial non-state agent.

One may say that we are too far into the pandemic to focus on risk communication. But community engagement is more than just risk communication. It is the bedrock of community participation, the need for which will only be felt even more acutely as the epidemic worsens. Contact tracing activities will have to pick up as COVID-19 increasingly percolates to rural areas. Enhancing testing for SARS-CoV-2 and concomitant expansion of quarantine, isolation, and treatment activities along vast expanses will tremendously strain our thin public health machinery. This will not be possible without community participation at every step.

Further, mitigation activities in case of considerable rural penetration of COVID-19 will require efforts of dreadful, phenomenal proportions. Imagine a primary health centre equipped with one doctor and a nurse catering to 20- odd villages spread across miles of difficult terrain.

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Even attending to the mildest cases and referring severe ones will not just be infeasible but highly risk-laden too. Strongly involving the nearly 2.5 million informal health-care providers would become crucial for a range of activities. Makeshift arrangements for transportation and care, such as motorcycle ambulances and mobile medical units, will need to be made. Further, initiatives such as community kitchens of Kerala will assume tremendous importance in cases of a stringent and prolonged lockdown. These, along with simply a strict adherence to social distancing throughout the pandemic, cannot be conceived without full community participation.

The criticality of community engagement on a war-footing is underscored by a set of factors. First, a concoction of local culture, values and beliefs can lead to blithe disregard of the coronavirus threat and gravely endanger containment and mitigation efforts.

Second, threatened livelihoods due to lockdowns and a resultant downplaying of the coronavirus risk can instil indignation and non-cooperation, as witnessed in the case of many migrants. With our weak social support system, we cannot afford quarantine allowances like in Sweden and Singapore; even the entitled modest relief could get delayed.

Third, there is increased likelihood of repeat lockdowns due to the virus likely to bounce back, which will greatly test public patience and co-operation. Lastly, we also need to remember the trust deficit between health workers and the public that has lingered on since decades, given our unsatisfactory public and profiteering private health care. One may say that these challenges are not completely mitigable through community engagement, but that is undoubtedly the best shot we have.

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Urgent reinforcing and galvanising of community engagement activities will largely decide the trajectory COVID-19 undertakes in India. Recruiting a medical workforce, augmenting infrastructure, and manufacturing personal protective equipment on a war footing – unless these go hand-in-hand with the former, will result in undermining of both.

Dr. Soham D. Bhaduri is a Mumbai-based doctor, health-care commentator, and editor of the journal, The Indian Practitioner

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