3june
India had warning about the COVID19 epidemic in China spreading to neighbouring
countries well ahead of virus importations; yet, the nation faltered. In epidemics as in war, underestimating the enemy is a
costly mistake.
Strategy planning is dynamic,
with revisions as the ground reality changes. What is appropriate in
the beginning may become redundant midway. Eisenhower said:
“In preparing for battle, I have always found that plans are useless
but planning is indispensable.”
India’s early strategy (traditional pandemic control: prevent virus
importations from China and
neighbouring countries and interrupt importation related localspread) succeeded, but importations from the West and West
Asian countries before they were
red flagged seeded local outbreaks
in several places.
As transmission is through social contacts, social distancing in
its extreme form (a nationwidelockdown) was declared early and
abruptly, from March 24 midnight.
Indigenous wisdom
Indian experts are skilful to imbibe, distil and translate information into practical, socioculturally
appropriate action plans. When
HIV importations and local spread
were detected, Indian experts studied the situation, and, rejecting
advice from the World Health Organization (WHO) for only “syndromic diagnosis” of AIDS, devised multipronged interventions— “social vaccine” including hospital infection control and innovative laboratorytesting tactic calledsentinel surveillance. For safe
blood transfusion, labtesting wasmandatory. Sensitivity and specificity of HIV lab tests were near
100%.
For COVID19, polymerasechain reaction (PCR) tests were necessary to detect importations and
contact screening. For disease
diagnosis by physicians, clinical
criteria are adequate. Epidemics
were asynchronous in different
States; the simplest way to monitor epidemic growth was criteriabased clinical diagnosis and confirmation by PCR when deemed
necessary. Instead, India blindly
continues WHO advice: “test, test,
test”.
By May 18, testing covered
0.17% of India’s population, detecting almost 100,000 infections.
We cannot use such data to assess
the magnitude of the epidemic.
Openly admitting community
transmission of HIV was the signal
for the public to change behaviour
and take precautions. Social vaccine included public education
and social mobilisation; its legacy
is red ribbon clubs in schools and
colleges.
COVID19 community spreadwas denied for too long, promoting epidemic expansion and
deaths particularly among healthcare personnel. Early warning and
public education would have
slowed the epidemic and saved
lives. Everyone needed behaviour
modification to protect themselves when in physical closeness
in clinics and crowds.
Lockdown vs. mask wearing
Jain munis, realising there are organisms in aerosols and droplets,
wear masks to avoid inhaling them
— a unique preventive measure
born out of ancient wisdom. Hong
Kong and Taiwan demonstrated
the value of universal maskwearing to mitigate the current pandemic.
With our mindset of “big solutions” for ‘big problems’, we err.
Mask wearing is a simple solution;
if practised by every man, woman
and child when out of home, it is
twice superior to lockdowns: it
flattens the epidemic curve better
than leaky lockdowns; preserves
socioeconomic basics which alockdown destroys. Let us look at
another simple solution — oral rehydration for cholera, developed
by H.N. Chatterjee in 1957, was accepted by medical professionals
and administrators only decades
later.
Wise clinicians make presumptive clinical diagnosis of infectious
diseases, informed by the epidemiologic setting, the patient’s history, physical findings, simple laboratory tests, and initiate
treatment. Laboratory tests, used
to confirm clinical diagnosis, identify causative organisms in only
about 5060% of cases in many instances. Why should COVID19 bemanaged differently?
Specific epidemiologic and clinical criteria and basic blood tests
provide a clinical diagnosis of COVID19; PCR is useful to confirm this. Home quarantine of all with
mild symptoms is simple and safe.
Their medical supervision should
be through daily phone calls with
the assigned doctor. For those
with breathing difficulty, a chest X
ray or CT scan identifies pneumonia. This approach would have
fetched us more gains for less
expense.
We have tested 22,79,324 persons (incurring a cost of
₹22,79,324,000 by assuming
₹1,000 for all costs per test; private
laboratories charge ₹4,500). Only
95,622 (~4 %) were positive; remember PCR may miss up to half
of infected subjects. The original
testing policy was essential at first,
but became redundant and misleading by end March. Why evaporate the public exchequer for little
or limited public benefit? Now the
best use of tests is to confirm clinical diagnosis.
Superficially, flattening the
curve sounds attractive — infected
subjects trickle in rather than as
an avalanche. Lockdowns hurt
lives, livelihoods and economy,
while nonCOVID19 problems gounattended.
Risk identification
What we need to flatten is the
steep mortality curve. Who are
those at risk of high mortality?
Those over 60 years, and those
with diabetes, hypertension, heart
disease, chronic respiratory disease and obesity. This demanded
cocooning (reverse quarantine)
the elderly and the vulnerable.
Countries with their elderly living in institutions have witnessed a
veritable disaster: large numbers
succumbed, unprotected by cocooning; hospitals were
overwhelmed.
We have far fewer citizens
above 60 than the United States
and Europe; flattening the mortality curve is eminently feasible and
culturally appropriate. The norm
in urban middle class and rural families is to protect old parents and
vulnerable family members. Flattening the mortality curve by cocooning them would have resonated well with our people and found
nationwide acceptance.
“Social vaccine” stimulates society’s protective knowledge and
practices countering major health
threats. Social mobilisation subsumes public education for attitudinal and behavioural changes to
overcome social determinants of
microbial transmission. When
children and adults realise that
mask wearing is to protect their family, none will refuse to wear one.
If it is only to obey orders, many
flout; even feel good flouting.
Social vaccine keeps citizens
updated with authentic information and convinces them that their
behaviour makes a change to the
nation’s health and economy. For
this to happen, the government
must do its utmost to suppress social toxins and convince people
about a genuine concern for their
health and welfare.
Social mobilisation, our mainstay against community transmission of HIV from 1986, ensured
clear guidelines for medical professionals about preventing hospitalrelated transmission. Educational efforts, integral to social
vaccine, galvanised society to resist HIV transmission, like immunity resisting progression of infection within the body.
If social vaccine is the legacy of
HIV control, the legacy of COVID
control ought to be more farreaching. The convenience of districts as units for colour zoning
emphasises that they can be more
selfassertive in planning for unlocking the lockdown.
A practical platform
A COVID19 committee as a practical platform in every district, with
representation from civil administration, health management professionals, industry, businesses,
educational institutions, major
nongovernmental organisations,
voluntary organisations such as
the Rotary and Lions Club can
identify facilitators and deterrents
of preventive processes and practices and evolve locally relevant
solutions for COVID19 controlnow. It can evolve into a district
development committee in the
postCOVID19 future. With a wider agenda, the fruits of their labour, improved health and education, nationwide implementation of visionary concepts such as
Swachh Bharat for microbiological
cleanliness at home and in all places of human congregation, will be
ready for harvest.
We have a unique opportunity
to script a new narrative to win the
present struggle and perpetuate
its legacy, with will and wisdom