The Uttarakhand government is struggling to keep simple
preventive measures in place, such as successful thermal screening and mask
wearing, two weeks into the Kumbh Mela in Haridwar amid a COVID-19 surge across
the region. The second shahi snan (royal bath) in the Ganga drew over 28
lakh devotees. Over 18,169 devotees were screened, with 102 of them testing
positive, according to medical department officials. There were no plans for thermal screening anywhere over the
last 48 hours, despite a new AI-enabled CCTV system in place to monitor them,
over an area of more than 10 km — from the railway station in Haridwar to the
famous Har ki Pauri and the ghats. The required entry standard of Covid-negative RT-PCR test
reports was the first Covid barrier to break in the crushing rush. Devotees are
asked about their RT-PCR files at different checkpoints; a few did not have
them yet could proceed.
The Kumbh Mela in India continues to be the world's oldest
and longest mass meeting. Over 70 million Hindu pilgrims visit the festival,
which takes place over 55 days on a 1936-hectare flood plain at the confluence
of the Yamuna and Ganga Rivers and includes a ceremonial bath. The population
swells on the holiest swimming days. Unlike other religious, educational, and
sporting mass events, the Kumbh Mela's organisers have no way of knowing how
many people will attend. The occurrence poses significant and unusual public health
problems, including developing disease control and resource utilization
policies within a temporary health distribution system where population density
and mobility directly touch flowing bodies of water; supplying water,
sanitation, and hygiene to a population that often defecates in the open; and
implementing crowd control initiatives where population density and mobility
directly contact flowing bodies of water. This is a first-hand account of the
world's biggest meeting, and the public health issues, as well as the plans and
reactions to them. We give suggestions for how to boost your preparedness.
The Kumbh Mela, a Hindu religious festival held in
Allahabad, India, attracts over 70 million people each year from January to
March, making it the world's largest and longest mass gathering. Mass crowds, characterized
as massive temporary gatherings of individuals, often surpass the capability of
regular health and safety measures, necessitating the energy, coordination, and
effort to prepare for a variety of scenarios, including epidemics, stampedes,
random conflict, and terror attacks. We conducted an in-depth investigation into the variety and
breadth of public health needs posed by the world's biggest and longest human
meeting, in response to the growing need to communicate and benefit from the
'legacy' of mass gatherings.
Unlike other religious festivals such as the Hajj, athletic
activities such as the Olympics, or the world's biggest music festival, the
Donauinselfest, the Kumbh Mela is primarily a domestic affair. However, the
lessons learned from the Kumbh Mela's achievements and shortcomings in crowd
mitigation, water, sanitation, and hygiene preparedness, and health service
delivery can be applied to other major temporary agglomerations such as refugee
camps and disaster-affected population migrations. Given the limited but growing number of foreign visitors to
the Kumbh Mela in an increasingly interconnected world, public health crises at
this event can have far-reaching implications. Previous Kumbh Melas have been
marred by stampedes and cholera outbreaks that have crossed pandemic
proportions on rare occasions. A multidisciplinary community of academics must study
different facets of the Kumbh Mela in the fields of religion, architecture and
urban planning, commerce, and public health. Crowd management, water supply,
sanitation, hygiene, and disease monitoring are all priorities for the public
health team. Findings must be based on archival studies, interviews with senior
Kumbh Mela administrators prior to, after, and after the festival, and direct
observation over the course of the 55-day event.
The Kumbh Mela, or 'kumbh festival,' is held every three
years in one of four cities: Ujjain, Nasik, Haridwar, and Allahabad, in a
12-year cycle each. The Allahabad festival, which is considered the holiest of
the four, attracts tens of millions of people from all over India. Bathing at
the confluence of the Ganga, Yamuna, and extinct Saraswati rivers, known as the
Sangam, is thought to help attendees attain "liberation" from the
cycle of death and rebirth. Thousands of pilgrims visit the Allahabad Kumbh Mela every
day. Religious discussions, cultural festivals, and shared meals are all part
of their lives. They went to the Sangam to take the ceremonial bath. Their
numbers swelled by the millions during the festival's six holiest bathing days.
Unlike many other orchestrated public events, there are no specific means or
strategies for predicting or controlling crowd size or anticipating attendance
on any day. The inability to forecast surge patterns poses significant problems
in terms of planning for public safety. The Indian government built a 1936-hectare (19.4 km2)
temporary village, or Nagri, on the riverbanks flanking the Sangam to serve the
visiting millions. The entire township is established in less than three months
since work on the sandbanks can only begin after the rivers have receded
following the monsoon season. Ridges, housing, water, sanitation, trade, and
cultural spaces abound in the Kumbh Nagri, as they do in every modern area.
It had health centers, police stations, food stands,
markets, and lost-and-found facilities in each of its fourteen administrative
sectors. The administration also assigns compounds to religious orders, or
Akharas, so that they can house the thousands of holy men who visit the
festival and provide communal space for cultural activities and communal meals
for their followers. The state government appoints the Mela Adhikari, the
festival's principal logistical organizer, a year ahead of time; he oversaw all
preparations and execution. The administration is responsible for laying 156 kilometers
of steel-plated tracks, 18 pontoon bridges, and 980 kilometers of electricity
cables, as well as managing a budget of more than $200 million. Given the gap
in time between activities, there was no institutional or manpower consistency
after the last Allahabad Kumbh Mela.
The construction team relies heavily on institutional memory
captured in archival government records and the memories of the few workers who
have worked at previous Kumbh Melas in the absence of written operating codes.
Resources for the event are provided by a network of relationships between the
state, private companies, and religious orders. A hierarchical, bureaucratic
chain of command governs communication between stakeholders. During the
festival, real-time information moved steadily through these diverse networks.
Over the last century, the Kumbh Mela has been afflicted by
stampedes. A rogue elephant slipped into a throng of people gathered to see the
visiting Prime Minister in 1954. This resulted in a stampede, killing 500
pilgrims. As a result of the widespread public outcry, subsequent Kumbh Mela
administrations have made crowd protection a top priority. The Mela Adhikari entrusted crowd control to the Kumbh Mela
police force. The police have formulated safety steps to mitigate stampedes
based on years of witnessing the actions of Kumbh Mela pilgrims. Specific
pedestrian characteristics and habits are considered, and officers are educated
in the macroscopic self-organizing concepts of crowds, both of which shape
pedestrian dynamics.
Most tourists only stayed for a limited period at the Kumbh
Mela, despite travelling long distances with their luggage. Their possessions
are usually packed into a single bag that is slung over the shoulder or borne
on the head. They usually ride in pairs, either from the same village or from
the same religious sect. Despite the wide variety of activities and the various
periods of participation, most pilgrims come for the Sangam's annual holy dip. Thousands of people ride to the Sangam in massive religious
processions, which include chariots, buses, and trucks, in addition to the
millions that walk there. Pilgrims who move in groups prefer to wait near the
Sangam: women dry their sarees and wrap their robes before going on their
return journeys; families sat together to pray or eat a meal after their bath.
As a result, the area immediately adjacent to the confluence is preserved as a
large open 'staging area', where millions of visitors gather to wait their turn
to reach the water or to relax afterwards.
Pilgrims travel from the rest of the Nagri to the staging
area through a vast network of roads built by flattening and covering the
riverbed with metal plates. The sixty-foot-wide roads were laid out in a grid
pattern and are connected by a parallel series of numerous 'pontoon' bridges
that facilitate smooth flow from one riverbank to the other.
This surprisingly sound town planning decision is close to
that made in other major river cities such as New York or London, where a slew
of aligned bridges (and tunnels) allow high-volume one-way flow traffic through
the riverbanks. The temporary bridges, which were made up of 1400 locally
commissioned floating pontoons, were large enough to support tens of thousands
of pilgrims and vehicles.
Almost both foot and vehicular activity was unidirectional
on busy bathing days. Before approaching the Sangam, police reroute incoming
crowds into a network of roads to slow them down. In most days, the crowds are
well-behaved. However, as the number of people increases by the millions, the
crowds get denser and lose speed. The 60-foot-wide roads narrow as they
approach the 12-foot-wide pontoon bridges, resulting in risky
bottlenecks—exactly what the multiple bridges were designed to avoid.
Police install temporary barricades at the entry ramps to
monitor foot traffic to prevent overloading the bridges. Although the
barricades aid in bridge defense, they also add to the formation of thick,
restless throngs that ebb and flow through the bridge. Baton-wielding cops are
on hand to monitor the traffic and avoid stampedes at the bridge bottlenecks. Given the vast number of pilgrims entering the water at the
same time, including the weak and aged, the possibility of drowning or a
stampede at the water's edge was important. The riverbanks are coated in
several inches of hay that is regularly replaced during the Kumbh Mela to avoid
erosion and slips and falls on the congested waterfront. The hay was replaced
by over 300,000 sandbags closer to the water's edge, providing a stable and
gentle slope for tourists to reach the water.
A fence of bamboo poles surrounded the shallow swimming
areas, within which stood a row of lifeguards in boats, ready to respond
quickly to any water mishaps. The administration optimized water flow by
controlling a system of upstream dams to achieve a 2500 ft3/second flow rate,
which was slow enough to ensure protection but fast enough to avoid water
stagnation. Mauni Amavaysa, the holiest of bathing days, fell on
February 10, 2013. Overcrowding on an overhead footbridge at the nearby
Allahabad railway station resulted in a stampede by the evening, shortly after
the authorities announced the successful completion of 30 million visits at the
Sangam. The stampede, which was triggered by a bi-directional rush of weary
pilgrims negotiating closely crowded railway platforms to board a departing train,
killed 36 people and wounded more than twice as many. The wounded were sent to
a tertiary hospital for further treatment, which took a long time. A closer
look showed that the stampede was caused by a failure of bureaucracies to
coordinate.
On February 10th, the federally controlled railway ministry
ignored the state police department's order for additional trains. Kumbh Mela
security's preparatory crowd simulation activities were not coordinated across
jurisdictions, making it impossible to perform crowd motion studies to track
pilgrims' journey from the locally managed Nagri premises to the federally
owned railway assets. The absence of an on-site incident management system was
shown by a lack of central planning and delayed emergency attention. Similar
findings have been made in the past at Indian religious meetings. Cholera outbreaks have been a part of the Kumbh Mela since
1783. The Kumbh Mela's high population density, possible exposure time, and
indigenous activities allowed for rapid disease transmission. Thousands of
pilgrims eat communal meals every day, and tens of thousands bathe in the
Sangam, sometimes drinking some of the holy water to cleanse themselves.
Attendees' health was constantly threatened by feces runoff and disease spread
by water. The government spends a lot of money on water and sanitation systems
to reduce these risks.
Organizers of the Kumbh Mela provide potable water through a
network of 40 tube-wells and 20,000 taps linked by 550 kilometers of pipe that
delivered 90 million liters per day. Given the widespread practice of swimming,
the administration took numerous measures to enhance the river's water quality,
focusing on both microbiological and chemical wastes.
In time for the Kumbh Mela, Allahabad doubles its sewage
treatment capacity. Upstream distilleries, sugar mills, and tanneries are
allowed to operate at full capacity for the duration of the Kumbh Mela and are
forbidden from dumping any effluent into the river. The lower-than-expected
coliform counts upstream and downstream from the Sangam are most likely due to
active sewage management paired with an optimized water current at the Sangam.
There were no coliforms in random samples taken from several drinking water
taps around the Nagri.
For the pilgrims, the administration supplies 35,000
toilets, mainly plain open-air pit latrines and urinals divided by fabric
partitions, as well as 340 tin sheds each containing ten squatting plates and
68 advanced bio-digested complexes using "zero waste" technology. Most
rural visitors to the Kumbh Mela do not have access to sanitation at home,
preferring open defecation fields to enclosed toilets. Recognizing this, the government hired 7000
"night-soil" sweepers to sweep up feces and lime open defecation
areas around the clock. The public works department conducts an active vector
control program by spraying DDT and malathion on areas of standing water,
including graywater holding ponds, on a regular basis. Hand hygiene is still a problem, raising questions about
fecal-oral transmission, especially at large communal meals. Though hand
sanitizers are installed in restrooms, most of them are stolen. At the 2013
Kumbh Mela, Lifebuoy, a local soap company, launched a clever promotional
campaign that acted as a potent public health marketing tool: they branded one
million rotis (flat breads) with the slogan "Have you washed your hands
with Lifebuoy today?" in Hindi.
Personal hygiene messaging, on the other hand, was neither
widespread nor well-targeted. Given the wide spectrum of literacy among the
participants, successful targeting of sanitation and hygiene messages should
have included public announcements, flyers, and reminders at communal meals,
among other things. The state government invests in a massive temporary
"hub and spoke" healthcare infrastructure that serves the whole
Nagri. The system's center was a regional referral hospital, with fourteen
‘sector' hospitals providing primary and urgent care facilities. Each sector
hospital has a 20-bed inpatient unit and an outpatient clinic with an on-site
pharmacy. The sector hospitals, which were built along major thoroughfares and
were free to everyone, saw hundreds of patients every day, nearly all of whom
were ambulatory. Each sector hospital is staffed by a physician, two nurses,
and a pharmacist who work 8-hour shifts around the clock. The central hospital,
which has a 100-bed inpatient facility with reduced critical care capacity and
several specialist outpatients services, including pediatrics, radiology, gynecology,
cardiology, orthopedics, and otorhinolaryngology, is where sicker patients are
sent.
The number of patients presenting to sector hospitals
nearest to the major thoroughfares and the Sangam increased enormously on busy
bathing days, many times the number presenting to other hospitals. The length
of each patient visit was significantly shortened due to a lack of reallocation
of capital to match this dramatically increased demand. In an 8-hour turnaround
on February 10, doctors at the busiest sector hospitals saw an average of 500
patients. Between January 25 and February 25, the fifteen hospitals had a total
of 2-80,755 patient experiences. Patients were given a free three-day shipment of
prescriptions by the on-site pharmacists, with the option of returning to the
clinic for refills. Because of the high throughput, a staggering number of
drugs are dispensed without taking vital signs, doing a physical test, or
adhering to care protocols. Most of the cases were mild, and they were treated
symptomatically with a mixture of antipyretics, analgesics, and antibiotics.
The state conscripts ambulances from across Uttar Pradesh
and equips them with field emergency supplies as well as special burn and
stampede kits. On busy days when heavy foot traffic surrounded them, most of
the 143 ambulances drafted in 2013 lacked qualified paramedics, had unavailable
(under lock and key) onboard resuscitation devices, and faced long response
delays. Handwritten patient records are kept by health care providers. Physicians keep track of each experience in a diary, which
includes the patient's name, age, gender, chief symptom, diagnosis, and
medications prescribed. Every evening, each sector hospital submits its daily
census to the central hospital. During periods of high patient demand, record
keeping becomes virtually non-existent, resulting in data shortages that
prevent systemic monitoring to inform time-sensitive resource allocation
decisions. Furthermore, despite being a top priority at other global
mass gatherings, there was no monitoring mechanism in place at the onset of the
event to monitor outbreaks or alert a response. Conclusions and Recommendations
Over the years, the government's involvement in the Kumbh Mela has evolved into
an active engagement with population protection and health.
The administration's experience of large-scale, low-cost
strategies to prevent stampedes, drownings, and epidemic outbreaks can be
applied to other crowded urban areas, such as other mass demonstrations, urban
informal settlements, and refugee shelters. However, there is still space for
improvement. According to the government and the internet, 100 million
pilgrims are expected to attend the festival. While a high estimate, even a
modest estimate of 70-80 million people suggests that the Kumbh Mela will see
close to 6% of India's population in 2013. Exposure to this segment of the
population from all over the world provides an unrivalled platform for public
health advertising and programs on a large scale. One might argue that the healthcare offered at this open
religious fair goes way beyond the state's responsibilities, and that expecting
more would put unreasonable demands on the public sector. For low-acuity cases,
the new complicated healthcare system ends up providing symptomatic pharmaceutical-based
management.
Diverting these funds to public awareness programs,
vaccines, disease control, and even medical screening could help the public's
wellbeing. The Kumbh Mela clinics have an opportunity to screen patients
presented with a cough and fever, and then refer reported cases to
well-established tuberculosis programs throughout urban and rural India, given
the pervasive burden of tuberculosis and the emergence of extensively
drug-resistant TB in India, for example. Diabetes and hypertension, both of which are on the rise in
India and are underdiagnosed and badly treated, may be screened in the clinics.
Such large-scale scanning will be possible with portable wireless record
sharing and rapid diagnostic aids. The Akharas provide enough opportunities to
disseminate essential health messages to a captive and responsive audience,
particularly as the Indian government addresses the rural issue of open
defecation and access to potable water and sanitation.
A good example is public awareness advertising around
ingesting river water. Although promoting hand washing before eating flatbread
is clever, cost-effective, and relatively non-offensive, stepping into a sacred
cultural phenomenon would necessitate a careful anthropological approach. Coaxing
anyone who knowingly defecate to use pit latrines or biodigesters would also
work. These educational public health issues must extend beyond the Kumbh Mela
by tying in with other group and national programs, such as Prime Minister
Modi's 5-year Open Defecation Free challenge, and then reiterating the message
during the festival to ensure consistency.
Beyond the benefits of anonymity, protection, 'green'
technology, and personal health, the Kumbh Mela's festival environment lends
itself to valuable incentives for users of modern sanitation technology. On
crowded bathing days, where the participant to toilet ratio can be as high as
750:1, no one would be motivated to use such sanitation facilities. As a
result, the administration of the 20x3 Kumbh Mela described structural
deficiencies in water and sanitation during crowd surges as a critical future
problem. The near universality of mobile phone ownership in India
opens up doors for public health communications as well as knowing crowd behavior
and population trends. Better emergency relief may be supported using computer
technology. At the Kumbh Mela, effective crowd surveillance systems and
accelerated population projections are conspicuously missing, like they are at
the Hajj or the Olympics. The use of remote sensors to assess crowd size is a
first step toward improving crowd control and offering real-time warnings.
This festival will benefit from spatial-temporal density
analytics because there are no systems in place to predict participant numbers
in advance, and the population rises and ebbs during the holiest bathing days.
Thermal video sequence analysis, which uses algorithms to record acute behavior
changes within a crowd, has the ability to provide continuous information on
crowd composition and flow, as well as improve an early warning security
decision support mechanism that may assess the need for critical first
responders and emergency activity at critical moments. Though improving crowd
surveillance technologies will help with early warning and prevention at the
Kumbh Mela, it must be done in tandem.
The failure of ambulances and emergency personnel to reach
and exit on property, in areas away from bathing areas, must be discussed on
bathing days. This will mean creating emergency-only lanes that would intersect
at various points in the network of roads to allow for participant travel.
These lanes will ideally have access to Allahabad's central hospital, which
should have a mass casualty injury command system in place and be in line with
higher levels of service. The digitization of patient contact data will allow
real-time analysis to aid disease detection and resource allocation and
management. Sector clinics' new paper-based registries couldn't keep up with
the frequency and complexity of patient experiences. At four sector clinics, we
installed portable tablets with pre-designed user interfaces. Patients with
syndromic case descriptions could be quickly identified using the device's
drop-down menus and radio keys. We uploaded the data to a cloud database for
fast tracking, giving us a tool for future outbreak monitoring. The device may
also be used to monitor services by documenting patient visits and procedures.
Future versions of this technology will provide
evidence-based care guidelines for typical chief problems, avoiding
over-prescribing and improper prescribing. Future Kumbh Mela health
administrations will have a deployable data-driven alternative for health care
delivery and public health prevention and response thanks to the demonstration
of an affordable contact and data processing technology. Lessons learned from
previous Kumbh Melas may be very useful to organizers of future Kumbh Melas.
Future qualitative studies that concentrate on the most practicable and
efficient way to progress these guidelines will have an impact on participant behavior
and garner support from Kumbh Mela stakeholders. While the administration has proved to be highly successful,
breaking down the bureaucracy's bureaucratic nature remains a significant
obstacle. Adopting a monitoring mechanism modelled by incident command
structures used in disasters may help participants communicate more
efficiently. Holding electronic records can help with reliability and
transparency. Reallocating patient services to promote strategic preventive
care strategies may be more cost-effective than the existing approach of
misusing drugs for non-acute conditions. As India's rapid urbanization,
middle-class expansion, and population growth continue, the burden of infectious
disease will increase.
