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Responding to COVID-19 challenge in India

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Initial emergence of the problem: From China

When COVID-19 was first known to world from China in December 2019, everyone thought it would be some new virus affecting China and rest of the world is immune to us. When WHO announced that as Global Health Emergency in January 2020, world started to take notice. But only a few acted, and others waited.

Worldwide Scare: Challenge to a few and Opportunity to many

The spread to Europe, with virus ravaging through Italy in March 2020 got people in rest of Europe scared. Even in that situation, only a few countries acted fast and promptly, like South Korea and Germany. The comparison of this virus with flu and placing their hopes on yet unknown herd immunity made some countries like UK give the virus a freehand to pass through their own country. Before they could realise the mistake, virus was in the community, taking away so many lives and threatening the healthcare system. Despite robust public healthcare system in UK, the death toll showed us that this is not any serious flu, but more dangerous than that.

How did we use other countries’ experience?

When all these were happening around the world, I was pleased to see Govt of India taking fast and prompt actions. In the month of March, when there were only a few imported cases in India, they promptly stopped all the overseas visas and prevented entry of other nationals. In an ideal world this step alone, along with screening, tracking, and isolating overseas visitors should have been enough to stop the virus from spreading in Indian soil. But it was never going to be ideal, with so many Indians working and visiting abroad, and people willing to risk (not knowing the magnitude) by flouting the rules in place, the community transmission should have started by April despite ICMR’s claim.

With nationwide lockdown since 25th march, community transmission was brought to as minimum as possible. Despite all the deficiencies in preparation for lockdown, causing many migrants and businesses to suffer, it was effective in slowing the spread. I believe there was time for preparation for lockdown at that time, nevertheless it was a prompt and fast action.

If the lockdown was effective, why have we ended up in the situation we are currently in? We are currently seeing alarmingly high rates of infection and death rate, even more than the numbers would suggest. We also need honest admission from government regarding true numbers which would reflect the ground reality as seen by doctors.

It has been proven by the worldwide experience in the last few months that, limiting people from close contact of each other is the only way to bring transmission to minimum. In other words, people staying at home is the only way. But that is not a long-term solution and I am not a proponent of that as well. Lockdown is a temporizing measure, till we can make a better system in place for us to be battle ready to fight this virus. And it is possible to fight, when we have minimum transmission, where ‘test, trace and isolate’ would work well rather than when the virus is rampaging like fire through the community.

I have followed the virus spread in many countries through the eyes of WHO, various govt measures and world leading public health experts. I have also seen this unfold in front of me in UK and how NHS healthcare system responded.

Based on those, the responsible actions in different scenarios in India would have been as follows:

  1. Virus new to the country, and only way it can enter your country is from overseas:

The situation we were in, during February – March 2020. Stopping entry of overseas visitors and bringing back Indian nationals safely and having a quarantine facility with adequate testing before they can safely enter the community. A few steps were in place, but small deficiencies were enough for this virus to escape our vigilance.

2. Virus within the country, a few people flouted the rules and have entered community:

The situation in end of March till April, when more testing and micro lockdown of those hotspot areas would have been more useful. Contingency plans for migrant workers and other people likely to get affected should have been considered before nationwide lockdown. Lockdown helped in delaying the peak which would have otherwise happened in April-May, but the timing and preparation were not adequate.

3. Virus has rapid community transmission and likely causing increased mortality and strain in the healthcare system:

The situation we are in now. I have elaborated the actions in the next section.

4. Virus in minimum community transmission (likely secondary to lockdown):

The situation currently seen in many developed countries like UK, Italy, France etc. Minimising the transmission in the community by public guidance in each setting for appropriate measures while people resume their usual activities, appropriate test-trace-isolate system and constantly being vigilant by monitoring of health and public activity data.

How could we fight better?

There is no point in rueing the missed opportunities when the enemy is powerful, invisible and is not giving us time to blink, affecting so many of us every day. With Indian population and healthcare in mind, what I would like to see now:

  1. Management of extremely sick patients needing hospitalisation and ICU care:
    • Ministry of Health and Family Welfare guidelines are quite elaborate and good.
    • Adequate personnel and equipment for ICU management – easier said than done; will need co-operation of private hospitals, public hospitals, and doctors & trainees in all sectors. It is important to keep everyone together on the same page with regards to guidance.
    • Maintaining availability of beds to needy: Discussed in point 4
  2. Detection of mildly symptomatic patients and effective isolation:

Testing of all symptomatic patients and making sure they are isolated effectively while shielding the vulnerable population. This will put a heavy strain on public departments and there is a need for everyone including volunteers to step up to this challenge.

3. Bringing down community transmission with the knowledge of asymptomatic individuals infecting others:

It is not possible to test the whole community. All contacts of symptomatic patients need to be tested and effectively isolated. At the same time, every asymptomatic individual should consider him/herself infectious and should take all necessary precautions – wearing face masks outside, maintaining social distancing and frequent hand washings. Everyone should think all the people they are encountering in the society may be infectious and take necessary precautions.

4. Management of healthcare facilities and optimising healthcare delivery:

It is important to understand the health care delivery system currently in place to optimise service delivery. Majority of our population (nearly 75%) are dependent on public health care, which has the system of primary health care centres(PHC), secondary health care hospitals in district hospitals and tertiary hospitals in a few cities.

Primary care in India is provided by PHCs and private practitioners. PHCs are strong in many states, and it is important to co-ordinate working between these two groups so that mildly symptomatic cases are managed effectively and contained there effectively.

When it comes to secondary and tertiary care, many families are reliant on private health care due to appalling facilities in public hospitals. Poor has significantly high morbidity and mortality due to inability to access high quality health care. This is the time to bridge the gap. By acknowledging deficiencies in the public hospitals, it is high time there is private-public partnerships. By making private hospitals take care of poor patients by using government incentives, we can effectively use the number of beds available to the whole population, rather than having highly disproportionate beds based on one’s ability to pay.

5. Being a fair place to all in the country: All patients, migrant labourers, daily wage workers, small scale and large-scale businesses, healthcare workers:

Giving guidance and support to all sections of public by creating a central-state cooperative task force. This system should give daily data, co-ordinate health care and make sure services are delivered fairly. This should also make sure adequate PPEs are available to doctors, and businesses and labourers are supported where possible with necessary precautions. It needs evidence-based guidance at the top and enough personnel on the ground to act responsibly.

These responses must be tailored to each country based on landscape, population dynamics, likely compliance of the public and structure of the healthcare system.  This may even differ between states and sometimes within a state. There is no ‘one size fits all’ approach. The situation in India and hence the public health response will be extraordinarily complex.

Need of the hour:

Based on these observations, we should have the following things in place immediately as a matter of priority to fight this invisible enemy effectively and minimise the damage to our people:

  1. Increased testing and transparent data for all symptomatic cases
  2. Co-ordinated effort between different health care systems, to manage mildly symptomatic to severe cases, with particular focus on preventing spread
  3. Consistent public health guidance for asymptomatic individuals to prevent spread
  4. Support of businesses and daily wage workers with guidance to prevent spread in workplace.
  5. Creation of large task force with state-centre co-operation including community volunteers to make sure the above measures are in place.

Dr. Gokul Ramanathan, DCH, DNB (paeds), MRCPCH(UK), IDPCCM, EPIC Diploma
Author is a paediatrician, currently working with University Hospitals of Leicester NHS Trust in UK. He did most of his medical training in India, working across both large public and private hospitals. You can reach him on twitter @GoksDr or by email [email protected]

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