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Saturday, May 30, 2020

The way forward is graded opening up, not an indefinite lockdown

While we open up, we have to protect the vulnerable and ensure the known preventive measures. We need to accept that a large number of the young will get infected.

Written by Mathew Varghese | Updated: May 14, 2020 9:44:57 am
Did India get the timing of its lockdown and containment measures right? All the early cases were related to international travel and known to immigration authorities. Illustration by C R Sasikumar

People are watching the daily COVID-19 mortality statistics like they watch the Sensex. So, how do we know the truth? We must get our facts clear, only then can we analyse them correctly.

The first case in China was reportedly detected on November 17, 2019. The new coronavirus was announced in December 2019. But they hit the panic button about 68 days or 540 cases, and 17 deaths, after the index case. That is a sufficient delay to infect a large number of people.

Despite the experience of SARS and H1N1, were they able to open the lockdown in two or three weeks? No. The lockdown kept getting extended, and only after 76 days of lockdown did Wuhan reopen, hesitantly, with a death toll of 2,563. In less than a month, Italy went from having only three cases to the highest number of cases and deaths outside of China. Despite a total lockdown for weeks, on May 5, Italy had 2,11,938 cases and 29,079 deaths.

After 47 days of lockdown, India had 46,476 cases and 1,571 deaths (Worldometer, 2020). So, are we going the Wuhan or the Italy way? Neither, probably. It seems the timing of the lockdown is important. Reportedly, in India, the “janata curfew” was ordered at 390 cases and seven deaths but extended repeatedly. China at lockdown had 540 cases. How come our situation did not worsen? Many argue that our innate immunity — from exposure to several pathogens or the BCG vaccination — may have helped. The average ambient temperature, higher than 21 degrees celsius, is supposed to kill the virus too. Then, why do we have so many cases south of the Vindhyas? These are all, possibly, mere conjectures. We had the advantage of hindsight and knew many facts about the virus and its spread.

To know community infection, we need 100 per cent testing of the population. No country has done such population-wide testing. Though this was done aboard a cruise ship — Diamond Princess — where they found 18 per cent of all infected people without symptoms; and, in an aircraft carrier — USS Theodore Roosevelt — where 60 per cent were asymptomatic, but COVID positive.

Again, how does one explain the low mortality in Germany which has a population similar to France or the UK? One of the reasons given is that Germany adopted aggressive testing, contact tracing, and containment measures. Germany, with the hindsight of experience from China and Korea — and a robust, free public health system — was able to contain the virus without a lockdown. In Italy and Spain, the average age of the infected was more than 60 years while in Germany it was 40 plus years. South Korea also managed with testing and containment without lockdown. I suspect that here, too, it has to do with the timing of the containment measures.

In the UK, France and Spain, the lockdown happened possibly after the virus had reached the vulnerable masses, thus presenting an “explosive” number of cases.

Why were healthcare workers in the UK, Italy, and the US affected more than in China? All had deficiencies in the availability of PPEs and skills. Another possible factor was that after the SARS experience, all COVID positive care areas in China are negative pressure zones. In most countries, only intensive care units are negative pressure areas. Negative pressure washes away virus-rich aerosols which otherwise accumulate in the care space, becoming lethal gas chambers of the virus. This leads to higher staff infections and mortality.

In the US, from the first case on January 19 in Washington to May 5, there were 3,27,374 cases and 24,944 deaths in New York alone — this despite 10,07,310 tests in New York and over 74,62,597 tests in the US as a whole. So, testing alone does not work.

Did India get the timing of its lockdown and containment measures right? All the early cases were related to international travel and known to immigration authorities. One-and-a-half months after my trip to Europe, 10 days after the lockdown, officials came home to check if I was unwell. It is easy — track everyone, test all and do aggressive contact tracing. But the entire month of February and early March, which were critical months for stock-taking, were wasted hoping that the infection would not spread.

In India, health planning is not an easy task as health is a state subject. Intensive care beds with ventilators have always been deficient in India. For instance, do we know the number of functioning ventilators, pulse oximeters, syringe pumps, and staff skilled in intensive care?

Quarantine is the isolation of a person suspected of harbouring an infection for a period equal to the longest incubation period of that disease. This is done to prevent that person from infecting others. But isolation is very stressful — fear of death adds to the distress. Many experience psychological problems, show aggression, even violence.

In India, a total lockdown like this has not been done before. In public health, the interest of the community is primary — but there is always a tension between the concerns of the individual and the interest of the community. There is no ethical principle that can provide a solution to this perennial tension in public health. Still, there remains the need to pay attention to the rights of individuals when exercising the powers of public health.

Was a lockdown essential? I do not think so. Not if we had timed our testing and containment strategy early on. In Sweden, the health experts refused a lockdown. There, the schools are open, public transport is operational, as are offices, restaurants, bars, and parks. The only precaution is to maintain physical distancing. This model could be better in the long-run, with higher herd immunity. A country such as Sweden doesn’t have the “when to unlock” dilemma.

So, what else should have been done in India? Our public health systems have been systematically undermined over the years. The corporatisation of healthcare and the push for insurance-based healthcare has ruined our public hospitals. Earlier, all bureaucrats and politicians would consult these hospitals. So, it was in their interest to keep these facilities well-equipped. Today, they visit corporate hospitals. In the UK, Boris Johnson was taken to a public-funded NHS hospital, not a private facility. And, that gives a message to the masses.

My understanding of public health tells me that, unlike private healthcare, public health strives for the greatest good to the largest numbers. Lockdown may have inconvenienced the largest numbers, but mass quarantine should be the last step in our armamentarium. A total lockdown is like a nuclear weapon unleashed on society — with short-term and long-term collateral damage across the board.

In low-income countries, it could mean starvation for people. Why would someone sentence so many people to death if there is another path that is known? The virus exploits the weakness in health and healthcare. The result? Poor people walking on the highways with their bags and baggage. A sea of humanity walking on the roads. Mass migration. While every death diminishes us as a society, I am more worried about all those marginalised for whom existence is now no more than being on the edge of extinction.

A vaccine is, at best, one-and-a-half years away. Let us not forget that HIV (a virus) was discovered 36 years ago, and we still have no vaccine. Anyway, as yet, there is no drug for any viral illness. Neither the virus nor we are going anywhere.

The way forward would be a graded and gradual opening up. No one can sustain this level of lockdown. But, while we open up we have to protect the vulnerable and ensure the known preventive measures. We need to accept that a large number of the young will get infected. That will provide herd immunity. But, most importantly, this should be a lesson for the time to come — to build our public health facilities, our intensive care facilities, and develop our research and development in public and tertiary healthcare.

This article appeared in the print edition of May 14, 2020, under the title ‘The cure that lasts’. The writer is consultant orthopedic surgeon, St Stephen’s Hospital, Delhi

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