India had warning about the COVID-19 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.”
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India’s early strategy (traditional pandemic control: prevent virus importations from China and neighbouring countries and interrupt importation-related local spread) 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 nation-wide lockdown) 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 multi-pronged interventions — “social vaccine” including hospital infection control and innovative laboratory-testing tactic called sentinel surveillance. For safe blood transfusion, lab-testing was mandatory. Sensitivity and specificity of HIV lab tests were near 100%.
For COVID-19, polymerase chain 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 criteria-based clinical diagnosis and confirmation by PCR when deemed necessary. Instead, India blindly continues WHO advice: “test, test, test”.
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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.
COVID-19 community spread was denied for too long, promoting epidemic expansion and deaths particularly among health-care 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 mask-wearing to mitigate the current pandemic.
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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 socio-economic basics which a lockdown 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 50-60% of cases in many instances. Why should COVID-19 be managed differently?
Specific epidemiologic and clinical criteria and basic blood tests provide a clinical diagnosis of COVID-19; 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 non-COVID-19 problems go unattended.
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 nation-wide 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 hospital-related 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 far-reaching. The convenience of districts as units for colour zoning emphasises that they can be more self-assertive in planning for unlocking the lockdown.
A practical platform
A COVID-19 committee as a practical platform in every district, with representation from civil administration, health management professionals, industry, businesses, educational institutions, major non-governmental 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 COVID-19 control now. It can evolve into a district development committee in the post-COVID-19 future. With a wider agenda, the fruits of their labour, improved health and education, nation-wide 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.
M.S. Seshadri is Retired Professor of Medical Endocriniology, Christian Medical College, Vellore and now Medical Director, Thirumalai Mission Hospital, Ranipet, Tamil Nadu. T. Jacob John is Retired Professor of Clinical Virology, CMC, Vellore and Past President of the Indian Academy of Pediatrics
