<p dir="ltr">Time is life, delay is death.’ India is on the cusp of realising the truth in those words. As COVID-19 spreads rapidly across the world and India, the spread presents a never-seen-before event in the history of mankind. The velocity of the spread, its impact and the constant stream of distressing information on the pandemic has created panic. And while healthcare systems across the world are being brought down to their knees, the general feeling is that social distancing (SD) will stop the virus in its tracks. But evidence points to the fact that SD, in India, may not produce the results we wish for. </p>.<p>At the moment, the educated understand SD (how much they will adhere to it is a question) but the uneducated and poor socio-economic class are unable to grasp the importance of SD. This is why we need to go well beyond SD, a measure which slows down the pandemic and buys time to prepare for the next potential onslaught.</p>.<p>The advice coming from China, Italy and other areas, duly processed and packaged by epidemiologists and data-scientists, has led authorities to prepare for the ‘worst possible situation.' Moving rapidly, they have instituted a level of prevention we have never seen earlier in healthcare. Bear in mind that India is a country where primary care and preventive medicine has always been inadequate. Paradoxically, we have, in the largest preventive move ever seen, marshalled extensive social and system measures to prevent the spread of this disease, before ‘the horse has left the barn.’ Amidst this urgency, ground-level issues to tackle the impending crisis of those who get the disease are inadequate. The gap between policy proclamation and operational delivery is vast. Let’s look at the ground reality before arriving at the solution.</p>.<p><strong>Social distancing: Will it work? </strong></p>.<p>SD will go down as the ‘phrase of the decade’ as tabloid after tabloid, and news television programs expound on it when we aren’t sure about the extent of SD which is needed to create the desired effect. What is the threshold of keeping humans away from humans, to actually nip the spread in the bud? Is shutting down schools, offices and malls enough? SD is impossible to implement in the poor socio-economic strata where masks, sanitisers, and any duration of isolation is a pipe dream, and proximity is a way of existence. This is something we are not talking about. The system must account for this or the next wave will consume the hapless poor. SD has never been seen in this country earlier, underscoring the need for a clarion call for extensive public cooperation or radical enforcement as done in other parts of the world. </p>.<p>The other question that no one can answer is: “What is the duration for which SD needs to be maintained?” The answer to this question changes based on the information of spread coming daily, which is a function of how successfully SD was done. Here a circle is set where successfully done SD will curtail disease duration and half-heartedly done SD will come with all the uncertainties and no endpoint. Clearly, at this point, India is winging it with SD. As we speak, SD challenges are apparent in the mass wave of migrant workers moving home – nobody in history has tried to lockdown a population of 1.3 billion.</p>.<p><strong>The testing conundrum</strong></p>.<p>It is essential to understand the true denominator of a disease. This understanding helps create measures to fight it. As this is a ‘novel’ virus, we do not have enough kits in the country (or anywhere in the world) to find the true denominator. This has led to many practical approaches adopted by various countries. In a 1.3 billion population such as ours, a policy of ‘limited utilitarian testing’ has been recommended, which is changing as we speak. The disadvantage of the policy thus far is that we are not only undermining the information we need to truly define this pandemic’s penetration and nature in our country, but also isolating people who may not have disease. That said, the social impact of the higher incidence revealed by extensive testing can fuel unrest and anxiety. We have to be ready to handle the level of panic this can unleash. As of today, despite all the announcements, testing at the ground level in Bengaluru is still limited.</p>.<p><strong>Tools to fight the pandemic</strong></p>.<p>It cannot be stressed enough that we need a never-seen-before effort to marshal and coordinate resources – a process where measures are recommended, implemented, audited and modified with a 24/7 push, with efficiency at the level of SWAT teams.</p>.<p>Care of the sick inpatient is the weakest link in our system. Infrastructure, healthcare personnel (doctors, nurses and supportive staff) and personal protective equipment (PPE) are the three pillars of management in the inpatient setting. If we reach the stage for massive deployment of healthcare, there is negligible isolation infrastructure, no obvious healthcare personnel plan for deployment and attrition, and scarce PPE available.</p>.<p>In addition, there is a shortage of healthcare personnel. We have been reeling under a nursing crisis for years. You cannot easily get personnel back if they get infected, and you also cannot send infected health professionals back to their families as they will infect them and perpetuate the community cycle. An adequate supply of PPE is the foundation for defeating the virus. </p>.<p>What then are the measures we need to take to get the PPE train in order and have COVID-19 centers who can deliver safe and quality services? First off, we need a central PPE distribution system with military precision and implementation to ensure there is no waste, willful or inadvertent. We will also need an emergency PPE law enacted for production, distribution and utilisation. This must be one of the most stringent laws ever seen.As drugs and vaccines develop for this infection, a similar strategy needs to be followed to ensure they get to those who actually need it.</p>.<p>Further, COVID-19 centers must be audited and approved by an external team of experts to ensure no short-cuts for personnel/PPE have been taken. If this is not implemented, these centers will also spread the disease and take valuable unprotected healthcare workers out of the workforce. The so-called current isolation beds are an eyewash if they cannot last at least for a month with adequate personnel/PPE. </p>.<p>We need to be prepared for the judicious but non-compromising use of all resources over a long haul, as the epidemic may stretch for weeks as in other countries – we are seeing burn-out in COVID-19 facilities worldwide. Lastly, the system has to allow patients with non-COVID-19 issues to be taken care of without risk of cross-infectivity, needing separate facilities or zones.</p>.<p><strong>Uncomfortable truths</strong></p>.<p>Amidst all this, there are several uncomfortable truths that need to be tabled and discussed. Our hospitals, especially government hospitals with high volumes and overcrowding are poorly equipped to handle a highly virulent strain such as COVID-19. There is no clear voice addressing this. Are we convinced that our public hospitals can handle the stress of the pandemic effectively? Private hospitals are trying to prepare on their own, but most are reeling under budgetary constraints and are unable to move rapidly as the situation mandates. </p>.<p>We need a centrally organised committee that cascades into state and cities to take stock of the situation, identify and earmark COVID-19 places with ‘high quality’ care, and put all resources there: Administrators/clinicians, training, PPEs so we have these comprehensive well-equipped COVID-19 ready facilities. China created one such center in one week to mitigate their crisis. Do we have the capability?</p>.<p>There is an urgent need to create an ombudsman for COVID-19 preparations. This could be the ‘COVID-19 General of India,’ who leads the ‘surgical strike’ against the coronavirus with 24/7 planning and implementation. The ombudsman should be totally empowered and supported by the government and people alike, with no vested interests, rule deviations, and dynamically adjusting as the situation changes daily. </p>.<p>The rich and the poor, the powerful and the weak, the famous and the nameless are all at equal risk. It is important to understand that SD will buy us time, however, avoiding the harshest consequences to human life will take more than SD. We cannot afford to lose this window for emergent action. </p>.<p><em>(Dr Ravindra M Mehta is Chief, Pulmonary and Critical Care Medicine, Apollo Hospitals, Bengaluru. He tweets at @DrRavindraMehta)</em></p>.<p dir="ltr"><em>The views expressed above are the author’s own. They do not necessarily reflect the views of DH.</em></p>
<p dir="ltr">Time is life, delay is death.’ India is on the cusp of realising the truth in those words. As COVID-19 spreads rapidly across the world and India, the spread presents a never-seen-before event in the history of mankind. The velocity of the spread, its impact and the constant stream of distressing information on the pandemic has created panic. And while healthcare systems across the world are being brought down to their knees, the general feeling is that social distancing (SD) will stop the virus in its tracks. But evidence points to the fact that SD, in India, may not produce the results we wish for. </p>.<p>At the moment, the educated understand SD (how much they will adhere to it is a question) but the uneducated and poor socio-economic class are unable to grasp the importance of SD. This is why we need to go well beyond SD, a measure which slows down the pandemic and buys time to prepare for the next potential onslaught.</p>.<p>The advice coming from China, Italy and other areas, duly processed and packaged by epidemiologists and data-scientists, has led authorities to prepare for the ‘worst possible situation.' Moving rapidly, they have instituted a level of prevention we have never seen earlier in healthcare. Bear in mind that India is a country where primary care and preventive medicine has always been inadequate. Paradoxically, we have, in the largest preventive move ever seen, marshalled extensive social and system measures to prevent the spread of this disease, before ‘the horse has left the barn.’ Amidst this urgency, ground-level issues to tackle the impending crisis of those who get the disease are inadequate. The gap between policy proclamation and operational delivery is vast. Let’s look at the ground reality before arriving at the solution.</p>.<p><strong>Social distancing: Will it work? </strong></p>.<p>SD will go down as the ‘phrase of the decade’ as tabloid after tabloid, and news television programs expound on it when we aren’t sure about the extent of SD which is needed to create the desired effect. What is the threshold of keeping humans away from humans, to actually nip the spread in the bud? Is shutting down schools, offices and malls enough? SD is impossible to implement in the poor socio-economic strata where masks, sanitisers, and any duration of isolation is a pipe dream, and proximity is a way of existence. This is something we are not talking about. The system must account for this or the next wave will consume the hapless poor. SD has never been seen in this country earlier, underscoring the need for a clarion call for extensive public cooperation or radical enforcement as done in other parts of the world. </p>.<p>The other question that no one can answer is: “What is the duration for which SD needs to be maintained?” The answer to this question changes based on the information of spread coming daily, which is a function of how successfully SD was done. Here a circle is set where successfully done SD will curtail disease duration and half-heartedly done SD will come with all the uncertainties and no endpoint. Clearly, at this point, India is winging it with SD. As we speak, SD challenges are apparent in the mass wave of migrant workers moving home – nobody in history has tried to lockdown a population of 1.3 billion.</p>.<p><strong>The testing conundrum</strong></p>.<p>It is essential to understand the true denominator of a disease. This understanding helps create measures to fight it. As this is a ‘novel’ virus, we do not have enough kits in the country (or anywhere in the world) to find the true denominator. This has led to many practical approaches adopted by various countries. In a 1.3 billion population such as ours, a policy of ‘limited utilitarian testing’ has been recommended, which is changing as we speak. The disadvantage of the policy thus far is that we are not only undermining the information we need to truly define this pandemic’s penetration and nature in our country, but also isolating people who may not have disease. That said, the social impact of the higher incidence revealed by extensive testing can fuel unrest and anxiety. We have to be ready to handle the level of panic this can unleash. As of today, despite all the announcements, testing at the ground level in Bengaluru is still limited.</p>.<p><strong>Tools to fight the pandemic</strong></p>.<p>It cannot be stressed enough that we need a never-seen-before effort to marshal and coordinate resources – a process where measures are recommended, implemented, audited and modified with a 24/7 push, with efficiency at the level of SWAT teams.</p>.<p>Care of the sick inpatient is the weakest link in our system. Infrastructure, healthcare personnel (doctors, nurses and supportive staff) and personal protective equipment (PPE) are the three pillars of management in the inpatient setting. If we reach the stage for massive deployment of healthcare, there is negligible isolation infrastructure, no obvious healthcare personnel plan for deployment and attrition, and scarce PPE available.</p>.<p>In addition, there is a shortage of healthcare personnel. We have been reeling under a nursing crisis for years. You cannot easily get personnel back if they get infected, and you also cannot send infected health professionals back to their families as they will infect them and perpetuate the community cycle. An adequate supply of PPE is the foundation for defeating the virus. </p>.<p>What then are the measures we need to take to get the PPE train in order and have COVID-19 centers who can deliver safe and quality services? First off, we need a central PPE distribution system with military precision and implementation to ensure there is no waste, willful or inadvertent. We will also need an emergency PPE law enacted for production, distribution and utilisation. This must be one of the most stringent laws ever seen.As drugs and vaccines develop for this infection, a similar strategy needs to be followed to ensure they get to those who actually need it.</p>.<p>Further, COVID-19 centers must be audited and approved by an external team of experts to ensure no short-cuts for personnel/PPE have been taken. If this is not implemented, these centers will also spread the disease and take valuable unprotected healthcare workers out of the workforce. The so-called current isolation beds are an eyewash if they cannot last at least for a month with adequate personnel/PPE. </p>.<p>We need to be prepared for the judicious but non-compromising use of all resources over a long haul, as the epidemic may stretch for weeks as in other countries – we are seeing burn-out in COVID-19 facilities worldwide. Lastly, the system has to allow patients with non-COVID-19 issues to be taken care of without risk of cross-infectivity, needing separate facilities or zones.</p>.<p><strong>Uncomfortable truths</strong></p>.<p>Amidst all this, there are several uncomfortable truths that need to be tabled and discussed. Our hospitals, especially government hospitals with high volumes and overcrowding are poorly equipped to handle a highly virulent strain such as COVID-19. There is no clear voice addressing this. Are we convinced that our public hospitals can handle the stress of the pandemic effectively? Private hospitals are trying to prepare on their own, but most are reeling under budgetary constraints and are unable to move rapidly as the situation mandates. </p>.<p>We need a centrally organised committee that cascades into state and cities to take stock of the situation, identify and earmark COVID-19 places with ‘high quality’ care, and put all resources there: Administrators/clinicians, training, PPEs so we have these comprehensive well-equipped COVID-19 ready facilities. China created one such center in one week to mitigate their crisis. Do we have the capability?</p>.<p>There is an urgent need to create an ombudsman for COVID-19 preparations. This could be the ‘COVID-19 General of India,’ who leads the ‘surgical strike’ against the coronavirus with 24/7 planning and implementation. The ombudsman should be totally empowered and supported by the government and people alike, with no vested interests, rule deviations, and dynamically adjusting as the situation changes daily. </p>.<p>The rich and the poor, the powerful and the weak, the famous and the nameless are all at equal risk. It is important to understand that SD will buy us time, however, avoiding the harshest consequences to human life will take more than SD. We cannot afford to lose this window for emergent action. </p>.<p><em>(Dr Ravindra M Mehta is Chief, Pulmonary and Critical Care Medicine, Apollo Hospitals, Bengaluru. He tweets at @DrRavindraMehta)</em></p>.<p dir="ltr"><em>The views expressed above are the author’s own. They do not necessarily reflect the views of DH.</em></p>