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‘Social solidarity and extended lockdown are crucial’

Home quarantine, isolation will reduce spread of infection and pressure on limited facilities, says global healthcare expert

Global health advocate and expert Bobby John , who has worked with the Global Fund to Fight AIDS, TB and Malaria, warns that despite its early start on containment measures, India faces an uphill task because of its poor healthcare infrastructure. He calls for social solidarity to care for patients.

Has India moved relatively early with containment measures?

When compared with Italy and the U.S., yes, India has moved early on a countrywide measure like Sunday’s 14-hour lockdown. Such a step early on in an epidemic with high rates of transmission 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 three times the size of the U.S. in population terms, and we are way below in terms of our health infrastructure in terms of beds, equipment and, most importantly, trained personnel.

What did Sunday’s ‘Janata Curfew’ achieve?

In terms of managing any epidemic, we have a few tools to look for — a vaccine, that will take a year or more, a medicine which may be a matter of weeks 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 sub-optimal dose of lockdown.

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 is way lower than [those who do so] in Italy or the U.S. — but even a small proportion of Indians constitutes a very large number. And, we need to be mindful that within the country, mobility 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. The tourism season was still under way until early February.

How to prevent a geometrical explosion of cases?

Children play the statue game — on someone saying ‘statue’, the intended person is to stand still. 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. Everyone should stay where they are.

For many, many Indians, it immediately means loss of income, with no reductions in expenses. 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.

How do we ensure the optimal use of our health infrastructure?

India has fewer 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. 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 put MBBS and nursing students into clinical work. 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 go into home quarantine, and how?

How can housing

societies help ?

Home quarantine and isolation would be very effective in two ways — reducing the spread of infection, as well as reducing the pressure on limited healthcare facilities. For most healthy young people, COVID-19 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.

How quickly can 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 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.

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.

For a majority of COVID-19 patients, large field hospitals set up by the armed forces will be the best option

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