A step-by-step roadmap to fight Covid-19 – analysis
As coronavirus disease (Covid-19) spreads rapidly throughout the world and India, and healthcare systems fall to their knees, the general sense is that social distancing (SD) will contain the virus. But the evidence shows that in India SD may not produce the results we want. At the moment, the educated understand SD, but those who lack the necessary educational background and belong to the marginalized segments are unable to understand its importance and practice it. That is why we need to go beyond SD. The advice from China, Italy and other affected countries, processed and packaged by epidemiologists and data scientists, has led authorities to prepare for the worst possible situation. Moving fast, they have instituted a level of prevention that we’ve never seen before in healthcare. Keep in mind that India is a country where primary care and preventive medicine have always been inadequate.
Let’s first critically examine basic reality before assuming that we are on the right track, as the stakes are high and failure is potential devastation. Here are the challenges. First, while SD will become the phrase of the decade, we are still unsure of the scope of SD needed to create the desired effect. What is the threshold that humans have to stay away from each other to stop the spread? Is it enough to close schools, offices and shopping malls? If you walk, you will see that people continue to mingle at uncomfortably close levels. This happened even during the janata (people) curfew on Sunday. Social distancing is difficult to implement among the poor, where masks, disinfectants, and any length of isolation is an impossible dream, and overcrowding in the home / community is a form of existence. Two, what is the duration for which the SD should be maintained? The response changes based on the propagation information that is released daily, which is a function of how successfully the SD and testing performed. If the SD is performed successfully, the disease will be reduced, and if done halfway, the SD will not produce positive results.
Third, there is evidence showing that Covid-19 has a maximum impact on the elderly and people with chronic diseases, but the spread in various socioeconomic strata, especially the poor, does not appear to be defined. In India, this is our nightmare with similar terrors like tuberculosis, malaria and dengue that are marginally controlled at best due to overcrowding and poverty. We do not have a long history of infectious disease control.
Four, we also don’t have enough kits in the country (or anywhere in the world) to find the true denominator of the disease. With a population of 1.3 billion, a “limited utility testing” policy has been recommended, which is changing rapidly. The downside of politics is that we are not only undermining the information we need to define the penetration and nature of this pandemic in our country, but also isolating people who may not have the disease.
Five, we have a poorly defined and heterogeneous healthcare system that varies in infrastructure, skills, and economic strength. Nursing homes, small hospitals, government hospitals and corporate hospitals are different in their services and quality, an important factor that prevents planning in a pandemic like this: we have to take this into account in the planning process. And six, caring for sick inpatients is by far the weakest link in disease management. Infrastructure, healthcare personnel and personal protective equipment (PPE) are the three pillars of management in the hospital environment. If we get to the stage of mass health care deployment, there is a negligible isolation infrastructure, there is no comprehensive health care personnel plan for deployment and attrition, and there is not enough PPE available. An intact health care community is imperative to deal with the crisis, and without PPE this is an impossible task. What are the measures we must take to put the PPE train in order and have Covid-19 centers that can provide safe and quality services? Radical measures include increasing the production and supply of EPP. The management of Covid-19 centers, due to the need for trained healthcare personnel, EPP and high infectivity, are more challenging than managing even the best hospitals.
In the context of this unprecedented global crisis, this is what is necessary.
The first is a central EPP distribution system with military precision and implementation to ensure there is no waste. The second is an emergency PPE law enacted for production, distribution, and use. Third, as drugs and vaccines are developed for this infection, a similar strategy must be followed to ensure that they reach those who really need it.
Fourth, Covid-19 centers must be audited and approved by an external team of experts to ensure that shortcuts for staff / PPE have not been taken. Fifth, the judicious use of all resources for long-term planning, as the epidemic can go on for weeks as in other countries: We are seeing depletion at Covid-19 facilities around the world. Sixth, the system should allow patients with non-Covid-19 related problems to be cared for without risk of cross infection. And seventh, there is an urgent need to create an ombudsman for Covid-19 preparations. The ombudsman must be empowered and supported by the government and individuals alike.
The time to move is now like never before.
Ravindra M Mehta is the Chief of Pulmonary Medicine and Critical Care at Apollo Hospitals, Bangalore.
The opinions expressed are personal.