Are we afraid of Corona or deaths caused by Corona?

“Choosing ‘important interventions’ over ‘less important’ will help in handling the pandemic.”

It’s been a month since the nation-wide lockdown in India is in force. The primary objective of the lockdown was to reduce close human-to-human contact, in the hope that this intervention will considerably slow down the spread of the virus. Perhaps we also assumed the lockdown will somehow eliminate the virus. 

India’s response to the situation was based on the horrifying experiences of countries like Italy, America, and Iran. Fear of COVID-19 had already reached people’s minds equating it with death, total devastation, and end of the world. It was speculated that India’s population of 130 crores might be an unfavorable disadvantage in its fight against Corona. Considering the size of the population, socio-economic conditions, density, and social habits of people; handling the pandemic seemed to be an impossible task. However, the current situation has surprised us pleasantly. Although the number of Corona related deaths in our country is worrisome, considering the population it is not alarming. 

The pandemic was acknowledged by WHO on January, 30th 2020 after the virus appeared to have already penetrated in a few countries. On March 22nd, India suspended the operations of international flights. Every day, approximately 70,000 people arrive in India from other countries. Considering the span of 45 days between the two milestones, approximately 3,000,000 people crossed our borders. If we assume a small number of travelers entered as asymptomatic carriers, that can imply a significant number of infected individuals were already in the country by the time lockdown was declared. These people must have interacted with more people across the country. To further validate the argument, the red zone localities are mostly low socio-economic pockets where people with no international travel history have been tested positive.

This impossible objective of reducing the spread of the virus has led to a series of consequential actions. As we continue the lockdown, the government is overwhelmed by dealing with various aspects of the pandemic such as testing, policing the closure, supplying adequate essentials, and providing medical attention to patients. While the lockdown can be an impactful strategy to cope with the first stage of the outbreak, in the current situation the government should exclusively focus on the crucial healthcare measures. The lockdown has diverted the government’s efforts and resources in the peripheral activities.

It is practically impossible to conduct tests on a large number of population and chasing down potential people that may have been in contact with every COVID-19 patient. Many countries have limited their testing efforts to people in critical conditions and most likely to get exposed to the virus (for example, healthcare workers). Due to the country’s restricted mobility, activities like policing, closing down roads, punishing morning walkers, and maintaining law and order are exhausting the government resources and frontline workers.  As the nation-wide lockdown continues, the economy is at a standstill and migrant labor workers are stuck in shelter camps. Maintaining physical distancing seems next to impossible in densely populated areas due to peculiar socio-economic conditions.

In order to effectively deal with the pandemic situation, we have to come out of the fear-based arguments and have a thoughtful look at what we focus on moving forward. Do we want to focus on reducing the spread of COVID-19 or do we want to limit the number of deaths?

The Key Question: Should we be afraid of COVID19 or the death toll it takes?

 

If the death toll is our main reason for concern then we should be focusing on analyzing, preventing, and overcoming deaths with an aggressive plan of action. In this state of emergency, other supplementary activities should not distract the government’s vision and focus. If we are afraid of the death toll it may take, the government’s first and foremost priority should be the patients with a high probability of reaching the critical state. The communication to citizens, strategic efforts, and expenditure of financial and human resources should be concentrated on survival and recovery of the critically ill patients. 

Hence, let the government be focused on saving individual deaths and make that the prime activity while handling the pandemic. 

COVID-19 patients can be widely divided into 3 categories. Asymptomatic (no symptoms), victims displaying mild to moderate symptoms and critical victims (patients needing oxygen, ventilators, and/or intensive care). Almost 70% of the COVID-19 victims who are tested positive are asymptomatic. On the other side of the spectrum, approximately only 3% of infected patients reach the critical conditions which can potentially result in death.

Considering only a small percentage of patients end up needing intensive care, our focus should not be at engaging our limited medical, financial, and human resources in asymptomatic victims, patients with mild symptoms, and potentially infected people. This groups the virus in the same category of influenza for the majority of the population. Hospitalizing patients withmild symptoms is an unnecessary load on the healthcare facilities.

Focus of Government - only on Critical patient care

 

If we accept this reality, then only the critical cases should be escalated to hospitals for intensive care and treatment. We need to arrest the criticality much before it arises. This is the point of concentration in the whole operation against the pandemic. The focus of the government should swiftly shift from too many interventions in all directions to only one goal i.e. to avoid the deaths due to the virus as far as possible. This is the worldwide recommended strategy at this stage of spread because this is ‘crucial’. This is best illustrated in the following Sanskrit couplet:

अनाराम्भो ही कार्याणाम्  प्रथमं  बुद्धिलक्षणम्

 The first and foremost thing a strategist should know is, ‘what not to do’.

Therefore, we need a well-executed protocol to identify the criticality of the suspected disease and to recognize the golden hours for the patient in need.

Proposed system:

 

Strengthen the identification systems for serious patients

1. Create a ‘hub and spoke model’ to capture the inflow of potential critical patients in the vicinity with existing general practitioners and a COVID specialty state of the art hospital. Create an app for facilitating the actual operations
2. An adequate number of PPE kits, ventilators, oxygen cylinders and other necessary logistical support should be provided to the specialty centers. Also, provide safety gadgets and other necessary equipment for GPs.
3. A well-led protocol for handling different levels of the criticality of COVID-19 patients and for their needs to be strictly monitored. Build the success criteria of operations around them.
4. Health care workers should be made comfortable mentally and physically by providing the right equipment, safety gadgets, resting facilities, rotating schedules, and other social facilities to keep them in good protective care. They are the real warriors who will fight this battle for the country.
5. Monitor people who are highly susceptible to the virus such as – elderly citizens, pregnant women, patients with underlying conditions, young children, as well as people residing in pockets of severe viral threats with the help of local leaders, NGOs, and interns. (in case of an alert, convey contingencies to the GPs in the locality)

Government efforts could be concentrated on –

1. Reducing fear of the word ‘corona’ by effective advertisement campaign. Create acceptance of the situation  instead of fear.
2. Restrict social gatherings only. The norms of hand washing, masks, and physical distancing at public places should be followed by people. Community pressure may be effectively used in this situation
3. Reducing points of daily monitoring only to critical care.  Other than severely affected areas, monitoring should be for serious contingencies only. Detecting corona cases, policing etc. should stop.

If this critical care system model gets implemented, the economic activities can start and they will not abruptly halt due to an outbreak of coronavirus which might keep coming in waves. There might be unforeseen contingencies as the nature of the spread of the virus can't be predicted. However, once the basic systems are established to mitigate the damage to the lives of people; all these contingencies may be handled with undivided attention.

The assumptions need to be changed to create an impactful system to address the most critical situation of this pandemic. The success of the battle against the virus depends upon focusing on ‘important’ and saying a big ‘NO’ to unimportant.