Title:

Humanitarian community intervention owned by people must replace coercive police led
interventions and precede mass Hydroxychloroquine prophylaxis planned for urban slums in India

Authors:

1. Eejrenab Natnayas,

Lead Volunteer of Infectious Diseases, PUBhealth – People without Borders united for
health, New Delhi, India

Email – mail@pubhealth.in

2. Varsha Eknath Gaikwad

Minister of Education, Government of Maharashtra and Member of the Legislative
Assembly of Maharashtra, Dharavi Constituency, Mumbai, India
Email – varshadharavi@gmail.com

There are only a few conjectures more baffling than that of Chloroquine (CQ) and Hydroxychloroquine
(HCQ) prophylaxis for COVID-19. While some of the in vitro 1, in silico2 and in vivo3,4 studies vouch for the
cheap and relatively safe5 antimalarial drugs, many expert opinions 6,7 and studies8 have raised concerns
based on minimal evidence and possible adverse effects if rolled out indiscriminately for mass
prophylaxis, without rigorous and intense monitoring. 9

Citizens of India are exactly one month into the six weeks nationwide lockdown, when social distancing
is practically limited to the rich and upper middle class of the urban society and the sparsely populated
villages, where there is the luxury of larger indoor floor space per capita and private toilet facilities.
According to the Indian Slums survey carried out in 2012 10, India had almost 9 million households living
across 33,510 urban slums. The populous state of Maharashtra had almost one-fourth of all the urban
slums, with the state’s capital Mumbai, housing the largest slums of the world since the late 19 th
century11, continues to contribute for a quarter of the national aggregate of 24,447 confirmed cases and
more than one-third of that of India’s recorded 780 COVID-19 related deaths as on 25 th of April.12

In contrary to the elegant metropolis decorated with Victorian “stately edifices, palaces, avenues and
parks”, the slums of Mumbai (then known as Bombay) resulted from the intense overcrowding with a
complete absence of urban planning due to sustained influx of migrant workers attracted to the ‘city of
dreams’ - India's financial, business and cinema capital, over the decades spanning from the end of
nineteenth century through the two world wars. Since the 1880s, the Bombay slums since then were full
of low-rise ill-ventilated shanty buildings, narrow insanitary filthy lanes occasionally flooded by the high
tides from the sea flowing in through the sewage canals distributing human and animal faeces, leaving
much of the city in environmental ruins during the rainy seasons. 11 Bombay has seen unprecedented
rates of mortality among the lower caste and marginalised people living in the slums during the plague
epidemic since 1896 with 50% of increased deaths in between 1896 to 1900 and 70% in the subsequent
decade, attributed to plague alone, which resulted in the enactment of The Epidemic Diseases Act of
1897. 11 The Act was enacted 50 years prior to India’s independence during the British colonial rule.
Unsurprisingly, The Act, coined by the imperial colonist rulers, heavily empowers the coercive power of
the state, instead of the rights and interests of the citizens. Humanitarian provisions for security, dignity,
wage compensations and individual civil rights of quarantined individuals during pandemics, particularly
for poor and marginalized people from the slums, who needs to be quarantined in a separate isolation
facility, is nowhere spelt out in The Act 13.

Dharavi of Mumbai is one of the largest and densest slums in the world, with its 1.2 million people
crammed into a sprawl of barely 2.4 square kilometers during the lockdown, with about 20 times the
population density of New York City—and has between 400 to 500 residents using each shared toilet
complex 14. Despite of the lockdown, due to such population density and shared facilities, social
distancing and isolation are impossible in such locations all over the world 15 and hence, Dharavi
continues to witness a surge in the pandemic with a total of 220 cases and 14 deaths as on 24 th of April.
16
Many of the localities within Dharavi, including Dr Baliga Nagar, Jasmine Mill Road and Matunga Labor
Camp, which are home to already vulnerable and marginalized communities are marked as hotspot
zones and are spatially sealed off as per municipal decree empowered by The Epidemic Diseases Act of
1897, compelling people to live in abominable crowded conditions, possibly facilitating the transmission.
While Dharavi being an extreme example, most densely populated lower income group urban
residential clusters in India are extremely crowded with shared sanitation facilities. 14

The municipal corporation of Greater Mumbai (BMC) has decided to roll out a seven-week-long course
of CQ and HCQ prophylaxis for the slums. 17 Apparently the decision is backed by the announcement of
the Indian Council of Medical Research (ICMR) dated 22 nd of March, for the prophylaxis of asymptomatic
healthcare workers involved in the care of suspected or confirmed cases of COVID-19 and asymptomatic
household contacts of confirmed cases 18. Among the plethora of pandemonium during the pandemic, a
senior Director of the council has been held accountable for making self-contradictory statements on
the whereabouts of ongoing observation studies and trials for CQ and HCQ prophylaxis in the country 6
and for promoting the prophylactic therapy without enough evidence 9. Along with such an intervention
plan, in absence of a vaccine, clear information regarding the risk/benefit ratio of CQ and HCQ mass
prophylaxis along with approval from the appropriate ethical bodies needs to be shared among the
community health professionals and extended to patients and the population to mitigate confusion,
mistrust and rejection. The multicenter randomized controlled trial registered in Spain, studying the
efficacy of prophylactic hydroxychloroquine in preventing secondary SARS-CoV-2 infections
(NCT04304053) can serve as a template for such an intervention, which is based on the ring vaccination
design used in Ebola ça Suffit vaccination trial for Ebola in 2015. 19

It is well known that albeit low risk, patients receiving CQ or HCQ, if kept unmonitored, might have fatal
electrocardiac abnormalities, particularly those with serum electrolyte abnormalities, receiving other
QT-prolonging medications or hypokalemic diuretics, with chronic renal insufficiency, or with structural
and functional heart diseases 20 21 or even with simple and widely prevalent conditions in slums like
gastroenteritis. It has been widely recognized that the nationwide lockdown has already reduced
people’s access to routine healthcare including weekly hemodialysis schedules for chronic kidney
patients and routine checkups of cardiovascular patients 22. And it is a no-brainer to understand that the
poor and the marginalized are the worst victims of such a situation. Hence, while rolling out CQ and HCQ
mass prophylaxis in slums, a baseline QTc value should be obtained prior to HCQ administration. Instead
of an ideal 12-lead ECG, for reducing possible exposure to the community healthcare workers, frugal
indigenous Indian innovations approved by the relevant national regulatory authorities like SanketLife,
which is a low cost (33 USD for each device), finger held, portable, pocket sized 12 lead ECG compatible
iOS & android phones that connect wirelessly via blue-tooth technology can be game changers in such
an effort.23

The noble intention of the ICMR and the BMC to protect the people from the pandemic through empiric
and pre-emptive mass administration of CQ and HCQ, exploiting the relative safety and availability of CQ
and HCQ for a defined time is fully acknowledged. 8 However, it is not difficult to understand that in
absence of a people-owned humane community intervention program, a police led forceful
implementation of any public-health measures including rolling out of mass prophylaxis of CQ and HCQ
in the present situation to the urban slum communities might lead to mistrust, rejection and violence.
Series of such unfortunate incidents have provoked India’s national cabinet to amend a part of The
Epidemic Diseases Act of 1897, in a meeting held on 22 nd April, to include harsh punishments against
violent offenders who damage and attack the healthcare service personnel during the times of epidemic
by booking them for cognizable and non-bailable offence with hefty penalties and seven years of
imprisonment. 24

From the people’s perspective, a humanitarian community intervention plan is needed for the urban
slums, replacing the spatial sealing off plans and preceding the rolling out of CQ and HCQ mass
prophylaxis. The intervention must include significantly enhanced numbers of testing and using smarter
methods of surveillance, coupled with early isolation of the infected cases to a common community
quarantine facility, which is secure, transparent in terms of governance and internal affairs, and
dignified for the quarantined individuals with necessary wage compensation for the daily wage workers,
who would constitute for the maximum number of such quarantined individuals.

Smart and proven strategies like sewage surveillance for identifying the high burden urban slums 25 and
indoor self-collected gargle samples for less bio-hazardous sample collection by community healthcare
workers without the need for repeated changing of personal protective equipment should be employed
immediately. Such self-collected gargle samples for adults as well as children have already been found to
be comparable or even more sensitive than cough inducing and uncomfortable throat and nasal swab
samples. 26–29 Coupled with labelled and mapped binary hierarchical pooled sampling method, RT-PCR
kits can also be saved in large numbers while carrying out the community and environmental
surveillance, yet tracing back to the exact positive individual person or sewage drain. 30 Early
identification of infected high-risk individuals in such quarantine centers and aggressive triaging and
escorted referrals of such cases to secondary or tertiary care centers will further help in reducing the
preventable mortalities.

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