COVID-19: A Doctor Writes About How India Can Build Capacity
India needs to use this time to steadily build capacity and invest more in healthcare.
It is the second week of the world’s biggest lockdown in history. Nearly 18% of the world's population has been put under nation-wide lockdown. Yet the numbers of COVID-19 cases have been slowly but steadily increasing in the past few days in the world’s second most populous country.
Two months have passed since the first case of COVID-19 was reported in India from Kerala. While the number of cases has risen to 2300 on April 3rd, India has been testing much less than the rest of the world.
Singapore and South Korea have tested about 6000 to 7000 people per million people but India has only about 25 people per million people.
Though many people had expressed concerns over the daily wage labourers, migrant workers and the unorganised working segment of the population, experts say that India did not have an option better than this at the breakpoint. The Indian government though late by over a week took measures to break the chain of transmission.
While the lockdown, though not very effective, is in place, India should be a step ahead and take measures to build capacity.
I being a clinical dermatologist am not in the frontline of treating the COVID-19 patients, but owing to the sudden exuberance of time at hand, have been doing a lot of research about the disease itself, the spread in other countries, their responses and mistakes. By virtue of this research, I have found a few red flags and concerns about how the COVID-19 situation is being handled in India. The following is a piece of my mind about the measures for better handling of the COVID-19 situation in India.
Most health experts opine that imposing a total national lockdown in India came at a little later stage than it was necessary. So rather than wasting time in debating about its time of implementation, it is better to look for ways to make it more efficient because hardly anyone with a fair knowledge of SARS CoV-2 can brush off its necessity. A stringent measure like a complete lockdown can be implemented with utmost ease in strong communist countries like China and also in very literate countries like the USA but the same cannot be so practical in India. Stuck in the crosshairs, Indian administration should recognise the uniqueness of the fabric of India and take adequate measure.
The unorganised workforce and daily wage labourers will be the ones to succumb first under the burden of the continued lockdown and will be followed by the farmers, lower middle class, MSMEs, etc.
The government should do much more than just putting food on the table for these strata of the society and give them moral courage by reassuring them and instilling confidence in them, in these uncertain times.
India has successfully battled epidemics such as Polio, Smallpox, HIV Cholera etc in the past, but the present population in India is very young with the average age of 28 years and we have not seen an outbreak or epidemic of this scale and enormity. So naturally there are a lot of concerns. Also simple measures like social distancing, hand washing etc will not be adhered to with enough vigour.
In order to drive home the message and importance of these simple non pharmacological measures, they must be involved and technically educated as to why these measures are essential.
For example, though there have been a lot of repeated instructions about the necessity of social distancing, the average Indian (viz. My non medico educated friends) does not know that the route of transmission of this virus is through droplet infection which can occur by coming in line of a coughing/sneezing/shouting carrier person, up to 2 meters, and hence social distancing of 2 meters is important. If the health department officials go on record in all media channels, social media etc and try to explain the logic behind the need for all of these measures, it will be easier to drive home the message and will bring in community participation to make the lockdown truly effective when it matters the most.
Use of Technology
South Korea has come up with an app which is installed in the smart phones of persons under investigation (PUIs) who are quarantined or sent for home quarantine. For the entire period of quarantine or observation, PUIs are expected to type in the symptoms if any twice daily in the app and the designated medical officer monitors it closely. This app also monitors and tracks the GPS and alerts the relevant authorities if the PUIs have moved out of quarantine. Such constructive use of technology is being introduced by some and worth looking at.
The debate in my opinion should not be on what stage of transmission we are in. We have to build capacities and be prepared with whatever comes our way.
The first capacity one would want to build is definitely the testing abilities. You cannot fight this monster in the dark; you must light up the space around and detect all infected persons right now. There are PCR tests and antibody tests; antibody tests are economical, faster than and as accurate as PCR tests.
The screening should not be restricted to the “suspect cases” and also include the general population including the elderly, people with comobidities viz. Diabetes, Respiratory problem, Heart ailments, Cancer etc, children below 10 years, pregnant women and eventually everyone, probably in that order.
Some may argue that this process of testing will not qualify to be called screening anymore. To them, my humble reply would be, in the face of this new threat that we know so less about (this virus is only about 100 days old), no stone should be left unturned. We must protect the susceptible population first and also treat them first; for this we need to test a lot more people now!
Some who think we don’t have that kind of a budget to spend on testing, let me tell you, diverting funds and spending now would be far better than when it's late and you are trying to save lives. For, we all know very well, prevention is better than cure and more aptly for COVID-19 since there are no proven treatments as of today.
If you do not believe in this argument of testing, please look at the way things turned out for Singapore and South Korea for its good, early testing measures. South Korea especially had learnt its lesson the hard way, trying to fight the MERS outbreak in 2015.
“With past experiences from Swine flu epidemic and MERS outbreak (2015), South Korea knew that Vaccines and medicines take a lot of time, so a lot was invested in building capabilities to make test kits very swiftly in the event of an outbreak”Kim Woo-Joo, Professor, Infectious Diseases, Korean University College of Medicine
In contrast, USA is at the far end of spectrum today, partially due to the lack of adequate testing in the initial period.
So the take home message for the bureaucracy and the government is build capacity now and start massive inclusive testing today.
We have a very weak healthcare system, much of which is due to the very poor expenditure of the government in the healthcare segment. I will not even get started about the financials since I being a doctor know the hard truth and believe me, we are sitting ducks for many more such epidemics. Italy or the USA’s situation is every Indian doctor’s worst nightmare.
In spite of having one of the best healthcare facilities in the world, Italy was not prepared for this.
Just to put things into perspective, Italy has 3.2 hospital beds per 1000 population whereas India has about 0.55 hospital beds per 1000 population (National health profile 2019 data). The number of beds per person is an important indicator of the healthcare system. The abysmally number will complicate this for India, when the time comes. Based on my research, the following healthcare capacity building has to be done now without waiting.
Sending our medical personnel to treat COVID-19 patients without personal protective equipment (PPEs) will be ill-advised. So stock it up.
Build good quality makeshift hospitals with no less than 1000 beds per 1 crore population in bigger sports stadiums, playgrounds, trains etc.
Encourage and train more medical personnel from the private sector to volunteer for a situation that may arise.
Add at least 1000 ventilators per 1 crore population.
Stock up adequate good quality medicines.
Pursue active surveillance more vigorously.
Involve the tech companies to help in quarantine and contact tracing.
Create an epidemic intelligence department and send the epidemic intelligence officer for instigation and learning from countries like China, South Korea, Japan and Singapore.
Seek support from Infectious diseases experts from these countries which have handled this pandemic better.
Involve more doctors in scientific research for drug repurposing.
I am aware of the fact that there is a collective voice of many experts in the field advising about all the measures to the government to fight our way out. But I believe it does not hurt to hear out advice from the intelligentsia of a well-educated scientific community in the private sector. So the government and bureaucracy should reach out and should not shy away from taking advice.
(Dr Dilip Kumar is an Asst Professor of Dermatology in Akash Institute of Medical sciences and founder of iSkin Clinic Bangalore. The opinions expressed are the authors own and in no way reflect the opinion of The Quint.)
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