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.
