Sunil Kaul is a medical doctor with a post-graduation in public health. He has been living and working in rural India for almost three decades. His essay on PUBLIC HEALTH & CORONAVIRUS PANDEMIC can be read here. Views expressed are personal.
The 2 country-wide lockdowns of 3 weeks each, one after another are unprecedented anywhere in the world. We all know of the distress caused to millions of migrant labourers but we can only wish that someone had planned the first lockdown much better! Maybe there were some compulsions that have been hidden from public domain! We may also like to be generous at such times and forgive those who took the decisions “for they knew not what they did!”
We can however give lockdowns the credit for having delayed the epidemic from reaching an early peak in India. The delay may not have been used well for preparing the system to be better equipped, and the delay may not be enough to wait for the vaccine – which may take at least a year to develop for use – but what it has achieved is fortuitous. It has allowed some indications to emerge as to what drugs may be effective in curing it and which existing medicines may be used to prevent the infection. This prevents doctors from feeling lost and hopeless in tackling patients when they start arriving in great numbers.
The delay has also given time for other countries from sharing their findings and their hands-on action-research. So, what is it that we have learnt new?
- Physical distancing: 3 feet distance may not be enough, and it would be better to keep a distance of 6 feet physical distance from the next person.
- Mask: Though droplet infection is the predominant way in which the virus survives and hence transmits, breathing into vapour hanging out in the air especially in enclosed air-conditioned spaces may be possible. Hence wearing any mask, including a folded handkerchief is better than nothing at all.
- Surface survival of virus: Heinsburg was the worst area in Germany affected by CoViD-19 and leant itself well to a study. The group of virologists studying it while reporting their preliminary findings indicate that all the brouhaha of prolonged virus survival on plastic, glass, laminates, etc. which could be responsible for transmission in shopping malls and elevator handles, and elevator buttons may not be correct. Although the findings are yet not approved, they indicate that the surfaces may have been testing positive for the virus because the antigen is being picked up, but viruses from such surfaces were not replicating even in ideal laboratory conditions. Of course, if a CoViD positive patient were to sneeze or cough into his hands soon before catching the door handle, the person following touching the door handle immediately may still get the virus. This is similar to what we see in Flu, TB or any other respiratory illness! What this may mean is that we may not need to be so fastidious as to keep washing our hands or apply the Hand Sanitiser while moving around in shopping complexes or Apartment lifts.
- True data of infection by Antibody Test: The Heinsburg study has also found that what appeared like a high death rate wasn’t so high as they found many silently infected people who hadn’t been tested and hence their numbers hadn’t been added to the denominator. The death rate, as is generally accepted all over the world was based on the number of deaths out of those who test positive for Corona virus detected from a swab taken from their nose and throat and tested by the highly specific PCR test. However, when neighbours, etc. were tested for antibodies, almost 15% of those tested were seropositive, which tells us that those people who had already faced the virus were now immune enough to possibly not get it again. This is the other important thing that has happened. Serum Antibody tests (where you test the blood to check whether the person has already been infected, with or without knowing about it, and is now immune to it as she has the antibodies to it) with reasonably good specificity have just been approved. If you add the results of these to the denominator, the death rates fell to just 0.36%! A Stanford study out of California shows the same. The fatality rate is 50 to 85 % lesser than what is being projected! Instead of Case fatality rates, we should have been looking for Disease Mortality rates where anyone infected gets into the denominator. Doing thus, the disease looks far more benign population-wise and universal quarantine across the board doesn’t sound logical!
- Geography: The longitude that marks the Indian Standard Time has for long been the dividing line between the economically better off states and the not so rich states. The same line seems to be bothering the CoViD virus as well, as most of the districts east of it are within the green zone and seen very few cases and deaths. Is it possible that these states have attracted very few tourists and outsiders and is that why the cases in these states are very few?
This is not to belittle the killing potential of the virus. No! As we still struggle with the pathophysiology of CoViD-19, we are still not sure what treatment will help. There are people jumping the gun for a few seconds of fame, but the final word is not out yet. Some say that Hydroxychloroquine – used primarily against Rheumatoid Arthritis, and not malaria – can prevent the virus from attaching, and so can some antibiotics like Azithromycin – usually given for sore throats and some other infections – but given together they have caused a few deaths already. After getting the go-ahead for making hundreds of thousands of ventilators, newer reports – not studies, mind you – are questioning the use of ventilators and even try to say that they may be dangerous except to a very few of CoViD patients. The Corona virus has opened up the whole globalized world to a pandemic and has killed tens of thousands of people already directly.
Medicine worse than the disease?
As mentioned earlier, we have had fortuitous benefits because of the lockdown though much of the misery should have been avoided. But can we afford to have a medicine that is worse than the disease? I am not arguing for sacrificing lives just to keep the economy running instead of a universal quarantine. I am arguing for saving lives from childhood illnesses, from TB and abortion and maternal causes AND not just from Corona!
I have not found a single fatality from CoViD-19 recorded for a child below say 10 or 15 years of age of all the deaths reported from around the world! Even if there was the odd one, the risks of serious CoViD are minimal and hence can we have the schools and Anganwadi running again? Under 5 death rates are double for malnourished children than for others and hence this can be a game changer. This would have to be with physical distancing and hand wash discipline, of course. At almost 50% of children below 5 years being malnourished, we can’t afford to go worse.
Can we also get the schools back on track? The nutrition that children get through Mid-Day Meals was a well thought out strategy of supplementing nutrition and here too, we can’t afford the children to slide further on the malnutrition scale.
Children in rural Govt schools attract the poorest and we can’t afford to worsen their learning levels. Unfortunately, these students can’t be taught online as their parents often don’t have a phone, let alone a smart phone! Maybe teachers can be asked to teach them in two shifts a day to care for physical distancing.
Hospitals that are closed for all but CoViD can start providing normal care of children and women and others – with physical distancing, handwash and hand rubs of course, so that we can delay the spread. The current model of lockdowns, however localized we may try, has the threat of old people getting CoViD and wherever it spreads, the local hospital WILL get overwhelmed, be sure of that.
With schools and markets opening up, we can get the economy up and running, offices and administrations working and running again. But this may be at the cost of old people who would catch the infection and possibly get serious and die. After all, 80% of the CoViD deaths all over the world have been of people above the age of 65 years (though it doesn’t mean that 80% of the old shall die – of patients above the age of 65 years, around 15 to 20% have died).
So how do we manage the old? Suppose we assume that a 55-year old Indian is equivalent in health to a 65-year old Chinese, Japanese or an American or European. They shall be the most vulnerable to develop CoViD-19. Is it possible to encourage all villages and hamlets to set up old age homes where the Anganwadis and Ashas can look after the old? A nurse, doctor and the 102 services can be made regularly available to them. Families could come and see them, meet them across the fence but yes, with physical distancing and face masks. Kith and kin could even provide nutritious food to the old and this to me can lessen the burden of severe disease considerably. My public health guess is that these old age homes may not be required for more than 6 months as herd immunity would have built up considerably by then in the younger people which would reduce transmission to a trickle. We could even keep younger people who have co-morbidities like heart disease or diabetes or severely obese (>30 BMI) to look after the old as they too are also at higher risk of CoViD and could do well with segregation. (I am not clear of how we can segregate old people in the Urban areas, but i guess other people could suggest good ways to do that!)
We can’t see the slipping back of mortality indicators of women in pregnancy, delivery and abortions; of children below the age of 5 dying of dehydration and pneumonia with underlying and worsening malnutrition; of TB touching a million deaths. It would be really sad to see our strategies to counter Corona kill more people than the virus itself!
We need to be smarter than the Corona virus, and more compassionate! For all its faults, Corona hasn’t shown a predilection to any caste, creed, religion or economic status! Neither should we. We need to see an infected Corona patient as a victim and not as an accused. Naming and shaming doesn’t help! Discriminating between the haves and have-nots looks terrible – some state governments paid as much as $2000 to their people stranded abroad, but didn’t seem enthusiastic in initiating help for its stranded labourers. The Indian race has faced many more immunological insults and Corona will easily be defeated! It is time to show solidarity and compassion!