Dr Bobby John is a medical graduate from the AFMC, Pune and a renowned global health advocate expert who has worked in international roles with the Global Fund to fight AIDS, TB and Malaria, and with the Bill and Melinda Gates Foundation. He is also a social entrepreneur in the health sector. Dr. John explains how India and Indians could deal with the looming crisis; and what to expect in the global fight against coronavirus in the coming days.
Also read: Coronavirus live updates | March 22, 2020
Excerpts from an interview.
Has India moved relatively early with containment measures?
When compared to Italy and the US in how the early response to the epidemic has been, yes, India has moved early on a country wide measure like Sunday's 14-hour lockdown. Such a step early on in an epidemic with high rates of transmissions, and consequent impacts on unprepared or inadequate health system, definitely helps in reducing the speed at which the population gets infected, and reduces the size of the avalanche of very sick people coming to hospitals.
That said, we need to understand that India is 3 times the size of the US in population terms, and we are way below in terms of our health infrastructure in terms of beds, equipment and, most importantly, trained personnel. We also need to check whether a nationwide lockdown of a day so early on makes as much sense as complete lockdowns of a few states where there have been more numbers of people tested positive.
Along with it, we need to be cognisant that our similarity with both the US and Italy is the relatively slow and lower use of diagnostic tests. Italy’s current situation may be an indicator for both US and India in not having ramped up testing more aggressively.
What does today's lockdown achieve?
In terms of managing this epidemic, or for that matter, any epidemic, we have a few tools to look for – 1. a vaccine, that will take a year or more to materialise, 2. a medicine that effectively treats the viral infection, which may be a matter of weeks, maybe months, and 3. in the more immediate timeframe, an intervention to reduce the speed at which the disease transmission occurs. Lockdowns are of the third kind, a kind of behavioural medicine.
In order to be effective, medicines have to be administered at a certain dosage – too much, and you kill the patient, and too little, it does no good, can cause more harm. To my mind, a 14 hour lockdown is a suboptimal dose of lockdown. If we take this 14 hour shutdown as a test dose, then it’s alright; but if we think this is going to do the trick of retarding the spread of disease, then we may be expecting too much from too little. As a signal for future actions, it does serve a purpose. Most medicines have side effects, and it is true for lockdowns too, but in this case, the kind of lockdown that Rajasthan has put in place is the way to go. It is across the state, for a definite period of time, and open to review for effects.
India is less globalised than Europe or the U.S. Does this help?
It may be true that the proportion of Indians who travel outside the country are way lesser than in Italy or the US – but even a small proportion of Indians constitute a very large number. And, we need to be mindful that within the country, mobility between states, and between cities and the rural areas is pretty high. It will not take too long for something that was localised to an urban centre like Mumbai or Delhi to be showing up in rural Bihar or small town Tamil Nadu .
Given that a lot of the tourism season was still underway in early February, like in Kerala where major efforts were made to track visitors, it would not be inconceivable that there could be more people infected in the Golden Triangle of Delhi – Jaipur – Agra, as well as on the Mumbai – Goa Corridor by tourists who have already left the country. Early availability and more testing could probably have informed us of this. It is true that a lesser number of people with the disease, and aggressive lockdown measures, could put India on a different epidemic trajectory from Italy or the US, but that remains an assumption at this point.
How to prevent geometrical explosion of cases?
Children play the statue game – on someone saying statue, the intended person is to become rooted to their place and remain there so long as not released. Lockdowns to limit the rate of disease spread is akin to playing Statue. It is tough medicine, and people need to be explained the benefits and side effects of it.
For many, many Indians, it immediately means loss of income, with no reductions in expenses. Good clinicians take care of explaining and mitigating side effects with complementary therapies. Ensuring an adequate set of mitigation measures to offset daily expenditures in times of zero income are necessary to get the most benefit of the prescription of lockdowns. Otherwise, what will happen is that Work from home and lockdown measures become reasons and excuses for people to pack bags and leave for somewhere else that they may be more comfortable at. We still have the opportunity of reducing the total numbers of people with infection and the rates at which they get infected, but to do so, we will need a set of measures that enable people to remain in place without going hungry and becoming poorer.
How do we ensure the optimal use of our existing health infrastructure?
India has lesser hospital beds and qualified personnel for its population than the WHO norms. Most of these beds and clinical capacity are taken up by people already sick. What we don’t want is the pressure on these limited facilities from the oncoming avalanche of people very sick because of the COVID-19 disease. I would think of retaining existing beds and gearing up personnel and facilities in these establishments to take care of those that need very intensive support.
For the vast majority of Covid-19 patients, who need to be in a healthcare setting but not requiring advanced interventions, large field hospitals will be the way to go. The Armed Forces Medical Services knows how to get them operational quickly. This would be the time to take 3rd MBBS students, and 3rd & 4th year Nursing students, and put them into clinical work in such settings, preparing them for a lifetime with clinical experience and exposure. The numbers of patients needing medical care but not advanced support would be large, and they should not overwhelm existing infrastructure.
Can those showing symptoms home quarantine, and how? How can housing societies etc help ?
Home quarantine and isolation would be very effective in 2 ways – reducing the spread of infection, as well as reducing the pressure on limited healthcare facilities. For most healthy young people, Covid19 could be similar to a self-limiting bout of flu. With adequate telemedicine support, a significant number of ill people could be taken care of at home, if their family or support circle members are adequately informed of the precautions. However, this idea of self-quarantine will be impractical in most peri-urban slums of India – which is why I would go back to my earlier proposition of large field hospitals to provide isolation as well as medical supervision.
In urban India, within condominium complexes, stigmatisation of those that are self-isolating or in quarantine is becoming more visible. Prejudicial behaviour in such gated complexes must be addressed, and police and local health authorities should not become accessories to stigmatisation of sick individuals. This crisis should bring out our best in neighbourliness. There needs to be more social solidarity, a caring for those that may be vulnerable, especially the elderly in our communities, all the while ensuring physical distance. I have personal difficulty with the terminology of social distancing in these fraught times, and would implore on greater social solidarity while maintaining physical distance.
Is community transmission now impossible to stop? How could that be managed?
Self-isolation, quarantine, physical distance, universal access to cheap or free tests are all essential components of prevention of transmission and slowing down its rate of spread. In short time I would hope that there would be specific antivirals available that make treatment and clearance of viral load possible. And in the not so far off future, I would hope that an effective vaccine will be in place, supplementing whatever herd immunity we will have created through this major epidemic.
How quickly could we hope for some breakthrough in treatment?
Linus Torvalds, the open source computing Guru is supposed to have said: “Given enough eyeballs, all bugs are shallow.” I think that is the case with SARS Cov2. Coordinated by the World Health Organisation, and with national efforts like the one led by the Indian Council for Medical Research, supported by regulators like the USFDA, the EMEA and the DCGI in India, I think a therapeutic breakthrough is on the horizon. Pharmaceutical companies are playing their part, and I think it is only a matter of months to have specific treatment recommendations.
Where the effort is lagging is in the area of diagnostics – I personally believe that now, and in the future, the lack of diagnostic infrastructure will be the single biggest gap area. Sometimes I think we are looking under a lamppost for something that we lost elsewhere. If we had more lampposts, we could look more thoroughly everywhere.