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Saturday, 25 April 2020
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nCOVID 2019: Thought structuring at the time of Pandemic.

“Let not the cure become worse than the disease itself” – The old dictum of Medical science is paled by the actual reality of the nCOVID 2019– there is as yet (April 2020) no cure for the disease and the containment measures appear to be, at least for many, worse than the disease itself.

(1) While it is true that the human world has seen worse pandemics, estimated in the mortality of about 300-500 million people over the years. (2)This may not seem much considering the 12000-year history of humanity but the more modern data might show the issue in a clearer light.

Being a health care personal from India, the world’s second-most populous country, the current pandemic is indeed gravely problematic – learning from the history of the Spanish flu in 1918 is informative. India is supposed to have been the country worst affected by it – being a colonized country funding a “World” War amongst the colonizers with everything from food to soldiers & doctors – India is said to have lost 6% of its population to the pandemic within just two years.

That is about 50-100 million human lives or nearly the combined death toll of both world wars. This was worsened with the drought of 1918, and the continued shipment of food grains and other essential items along with personal to the British Empire even in the following years.

The problem with these statistics is that they don’t convey the morbidity, which is far more difficult to quantify and even more difficult to gauge years later. Our famous leader, M.K. Gandhi is supposed to have said about the pandemic – “All interest in the living had ceased”, which is expected considering that it was estimated that nearly all rivers of India were supposed to have been filled with dead bodies. (3)

Sadly, what humans the world over have revealed is that we indeed learn nothing from history. Over the years, the human tendency has been to spend far more on war, or supposed defence as we like to euphemise it, rather than on public health. This distinction between public and private health care expenditure is important, as the private sector is practically not going to benefit much in a grave pandemic like that of nCOVID, especially for the poor. India spends around 1.2 % of its GDP on healthcare (4), which actually boils down to even less being provided to the needy, along the lines of the waste that happens even in countries which spend a lot more, like the USA.

(5) Simply put the proficiency with which humans orchestrate war and profit is simply not extended to providing public health care, which has been the greatest hurdle in battling a pandemic in a developing country like India. Our country is within the top ten when it comes to spending on military (6), yet remains below even the low-income countries’ spending on healthcare (7). This has not happened over a single decade, rather has continued ever since the British times to our recurrent governments, despite the change in leadership over the years. In effect, the problem lies with us as a human race – as clearly neither the virus nor our preparedness against such outbreaks seems to be altered much over the century, despite phenomenal scientific advances.

Which brings us to the question of constructive criticism – while it is certainly great to sit back and use hindsight to blame others, we should take responsibility as a collective human race and try to figure out more innovative and perhaps useful suggestions. Clearly this is not possible for a single person or even a single branch of professionals, but must be a joint effort to offer solutions from each area so that a comprehensive response can be produced. I being from a health care background in a developing and densely populated country like India would humbly attempt a few, knowing full well that a lot of these may not seem acceptable to many others, it is still an endeavour to offer possibilities.

As per 2011 data, India has about 1.3 billion people, probably much more now as the new census is due next year. Out of this, 23.5 % are said to be below poverty line, which is earning about < 1.25$/ 96 INR per day. That amounts to nearly 226 million humans. (9).

Many more millions not included barely pass above the poverty line , though designated as lower middle class are also subject to extremely poor conditions of living with purchasing power capacity of less than 3.20$ only. What this reflects is the vulnerable segments of our population, as well as the economically weaker sections are usually the ones with poorer health and immunity, due to diet as well as hygiene issues. This is evident even amongst a robust public health system like the NHS of UK with a miniscule fraction of the population compared to our own, where minorities and the poor are at worst risk.

(9) Again, humanity seems to have failed in this front, even over centuries, as the spanish flu fatalities percentage in each group show that in Bombay, India were constituted by 60% amongst low caste Hindus, followed by 19% in Muslims while the least affected were the economically well off 8% Parsis and 9% Europeans.(10) One of the most basic functions is to strengthen commitment to the weaker sections – economically, socially and politically during this time of crisis. Sadly, the very economically poor and the minorities are often made scapegoats, being educationally weak they are fuelled to hatred using rumours like “quarantine is for making you COVID positive” and this is used to further political agendas, even in the midst of a crisis such as this.

Even the UN has clearly warned against this trend the world over. (11) While surely some miscreants do exist and need to be punished for breaking the law, as the famous Jewish historian and philosopher, Yuval Harari said, blaming entire communities for the spread is “is complete nonsense, is extremely dangerous… we don’t need more hatred, we need solidarity, we need love between people.”(12)

Which brings us to one of the most important methods of building solidarity – sharing information; from the highest levels of authority and leadership to the lowest individual affected by it, along with accurate data collection from the ground level and its transmittance above. WHO in its advisory after the H1N1 outbreak clearly outlines that risk-communication at every level is one of the foundations of a robust response to any epidemic. (13) Instances like that of delayed reported, or under-reporting as might have happened with the death toll figures from Wuhan, China (14) at the level of countries or at individual like the erroneous quarantine of a woman based on spurious data from India’s app for surveillance(15) is devastating for human resources as well as mental health.

These apps should not serve for blanket surveillance alone, rather for getting inputs from the affected masses and actually doing something constructive about it. The communication should be clear and unambiguous, made available to those it affects most, not one generating fear or panic. This is a must to avoid instances like the daily wage workers collecting at the stations for a rumoured train promised to take them to their villages after the initial lockdown period was almost over in India, but was extended by a telecast, clearly not accessible to the poverty stricken and isolated ones above.

(16) The dictum that ignorance of the law cannot be an excuse to break it; is all fine in hearty situations, but how does one expect people to trust information when so much falsehood is flung around? The authorities must once again be strict against false news spreaders as well as information spewing hatred.

One unique problem of India is the large migrant worker population, most of whom fall below the poverty line, probably part of the near 250 million poor. Though WHO clearly does outline that isolation and social distancing is the way to go, one has to realize that the kind of poverty which exists in our land would cause these people to literally die without work, even if not affected by the virus at all. One should remember that this workforce, mainly of young, is not a burden rather they constitute one of the most hard-working populace on the planet, living in adverse conditions.

A sudden lockdown, with extensions and no clear end to them will make beggars out of these people, if not a large number of dead bodies, which have already started gathering. (17) Rather this unique man-power should be utilized to work during these dire times – giving them their due not out of charity but an appropriate reward for their hard work – it’s the reason they left their homes in the first place. This suggestion might seem drastic to some, but these are desperate times. It is naïve to believe that these people if kept in shelter camps or even housed in schools can actually maintain social distancing and isolation. The gatherings which have happened nearly all over India clearly shows that this is a failing strategy.

A land like India, which has neglected its public health care system for ages, cannot be expected to counter a disease which has brought much robust health care systems to its knees – like the Italian or even American. We need to start planning and implementing to improve health care from the now – utilizing the manpower of the daily wage workers, we must keep the supply lines running. Everything from building highways, to mining raw materials, improving transport, building hospitals away from residential areas can; and must be achieved if we are to actually fight such pandemics.

Once the effects are reduced, these health systems can be utilized to train future health care professionals and serve the poor in remote areas. These labourers don’t want to go home, they have no choice left hence collect together to walk miles. We must give them that choice to work and earn what they came here to do, but at the same time providing them with the possible isolation & health facilities. This cannot be done in the middle of bustling cities – rather should be away from all other public areas if possible.

This would need an updating of the supply lines and its maintenance – for which again the manual labourers can be utilized. The food from farmers which is being wasted – literally on the roads – can be diverted to feed these hard working people in the centres far away from crowded areas. (18). This work has been done in certain areas already, like the Hyderabad highways, but must be done with the pandemic and future built-up of health care system in mind, maintaining supply chains throughout. (19)

This brings us to our ailing public health care systems. While India is a hub for medical tourism, as it provides cheaper treatment compared to same level of car in other countries, especially in the private sector, we have been failing spectacularly on the public health issues. A simple visit during the monsoons to any public hospital is evidence enough. The classical health indicators also show the same grim picture (India ranks about 145 in the Maternal Mortality rate, and it’s not decreasing fast enough -20). This pandemic is not the time to fear and procrastinate in lockdowns. While it might be needed for preparation, lockdowns are not going to cure the issues which makes the morbidity and mortality from pandemics to go away.

Rather this is the time needed to upgrade and revamp the entire health system wherever possible – from gram panchayats, district head quarters to the metropolitans – ALL need public health providers as well as facilities and NOW is the time to upgrade what exists and build what doesn’t. This includes facilities for isolation and nCOVID 19 specialised hospitals and quarantine areas, included residential facilities for staff and support workers. Areas beyond a kilometre of supply lines, like bus stops, railway stations near each major village or post-offices, can be designated as health providing facilities, built big enough depending on the population they serve. While facilities can be built within months, China is supposed to have built a COVID hospital in days (21), it is not possible to get professional health providers as easily or as fast. This is one of the greatest flaws of the existing health systems – our near total lack of family practitioners & emergency physicians with MBBS as the backbone and the almost absolute neglect by authorities to do something about it. This has to change and it has to begin now.

Although AYUSH is unique to our country and is undoubtedly needed due to our vast populations, it cannot be a replacement for a fully trained MBBS professional course in Allopathic Medicine. This distinction is important and is clearly evident from the need in a pandemic of the professional background. Similar is the case with nursing and support health care personal, whose training is an absolute must for handling something so critical, rather than using makeshift certification and bridge courses. While they too have some role for outreach, it cannot and should not be used to provide half-baked public health simply because the powers that be did not deem fit to improve health care training & outreach.

Once again, residents, interns and training nursing staff are also not to be made scapegoats for something as enormous as this. At one side if our authorities claim that they are students and hence cannot be compensated with deserved stipend or facilities for even decent stay and food, then is it not hypocrisy to make use of the same “students” to fight a pandemic which has broken the backs of entire health care systems in the developed world? We as health care providers understand the need in an emergency like this to utilize our resources of manpower and professional training.

However if there are advisories which literally are enabling “conscription” without due compensation, then do you really believe that such a workforce will be able to give efficient outputs needed in these times? (22) Simply because there are pending degrees of students or the threat of ESMA for faculties, can they be justifiably utilized without additional compensation when they are literally risking their own lives as well as that of families? The key point lacking here is justice, be it for remuneration or for action against those who harm health care workers, our society as a whole is miserably failing. There is another distinction here which must be made apparent, this is NOT like the war at the borders, nor are those risking their lives treated as soldiers in our society – be it the police, the sweepers, the health care workers or even those maintaining supply lines. In the times of an infectious disease, these risk the lives and perhaps more importantly the health of their loved ones. If they are not compensated with stay facilities, insurance for health (not death alone), adequate payment, their own nutrition, and of course the Personal Protective Equipment (PPE) then these are not being treated as heroes, but as human sacrifice. Again the blame is not just on the governing bodies, the entire human society must understand that this methodology of sacrifice, if not changed quickly will surely cost the rest of humans dearly as well. No matter how many lockdowns are ordered and followed, every one of these essential service chains will become a source for the spread, if not adequately protected and compensated.

This leads to the entire concept of prevention and its implications for one of the essential sectors – health care. If equipment like PPE, quarantine facilities in the form of stay away from rest of society, including family and friends, basic provisions of daily living is not provided, it is impossible to expect that the disease will not actually spread from the ivory towers of medicine. The hospital catering to such patients cannot be made in the middle of bustling cities without fear of spread. Similarly, giving hotel rooms to essential service providers specifically catering to COVID patients in the middle of cities, mixing them with others in society is an infectious bomb waiting to explode, at the cost of PR brownies.

Those making such decisions must realize, most doctors and nurses have lived or are already “living on the mattresses”, they simply need assurance for being provided basic protection as scientifically needed against this disease, food and sanitation for themselves, decent shelter which protects them from a crazed society from pelting stones on them(24) and protects their families from infection risk along with an insurance that in case of their own health being compromised, they be adequately compensated, not just given money after possible death. The policy makers might think that gimmicks like “life insurance” announcements are enough, but the scientific reality is that most of those working on the frontline are from the younger age, which is unlikely to die, but might suffer morbidity even after recovery for the rest of the life (25). It is imperative that the authorities assure assistance to such workers, irrespective of the field, for the rest of their lives. After all, it is they who are putting their lives at stake in these dark times. India has been having a brain drain of doctors and professionals for ages now. The world over, you might find professionals from Indian origin working on the frontlines against nCOVID, be it doctors or nurses and support staff. This despite the fact that India itself has a very poor doctor and nurse: population ratio (26). The authorities must understand that the future of our health care providers doing work in India has to be ensured in these times of crisis. And it is for this reason that they should show good will, rather than abuse those stuck for degrees or lack of better jobs. This can be in the form of pay package, or incentives like waiving off double the statutory bond duties for MBBS and MS/MD if they work either as residents or interns in COVID duties during these months. It is surely easier to simply abuse those under their power, but this will cost us dearly in the decades to come, and now is the time to prevent it.

The aspect of death, albeit mortality to this day is not much, cannot be neglected. The rites of the dead are the rights of those who pass away upon the living, irrespective of the cause of their death. It is sickening that in our so called ancient culture, a person dying on the frontlines for the rest of us, fighting this menace while much of the society is sitting at home; is not even allowed to be buried. (27) This is once again a human societal issue, although this degree of despicability is probably unique to our soil. When even women doctors are physically harassed for travelling to their duty schedules by the police itself what hope is there for the society as a whole?(28)No amount of fear about getting infected should make a human stoop so low, yet we see it nearly all over the country. (29) It is difficult to offer solutions when the mentality of people itself has been poisoned to such an extent. We hope that a strict legislation against the perpetrators and some serious counselling can give at least some semblance of hope to repair this society. Further, the news reportage should be channelled not to spread false news and panic, as these lead to hatred and the extreme response seen nearly all over the country. Once again, there should be clear guidelines and help from the authorities to crematoriums and burial grounds to give the respect due to the dead, irrespective of the cause, especially in these times.

We come to another pivotal issue in our land – poverty and it handling. India wasted 4135.24 MT of food grains a year as on January 2019, which amounts to 14$ billion dollars a year worth, while nearly 190 million of the impoverished going hungry each day in India (30,31). Similarly, India’s water crisis is also a grim picture with 600 million people face “high to extreme” water stress and reports says that nearly 200 thousand die every year due to lack of safe water supply. (32) How are people expected to wash even hands in a lockdown if only one fifth of Indian households are reported to have piped water supply? (33) There are an estimated 1.8 million homeless people in India, with 52% based in urban areas and around 73 million families lack access to decent housing (IGH, 2018; Habitat, 2019). How can it reasonably be expected that social distancing and lockdowns, or even basic measures of preventive medicine can be effectively carried out for long in such a scenario? These issues have been going on since decades and must be addressed quickly. If not for the present pandemic, we must ensure that we are not caught in such a precarious situation in the future. Once again, the conditions of the poor cannot be improved if the lockdown is extended indefinitely. We as a society simply cannot afford it, even if the government is rich, the nation is not.

Finally, we come to the question of finance. Surely all of this needs enormous amounts of money and resources, with our economy already faltering, an extended lockdown might just sound the death knell. Once again, clarity in communication and transparency offered to open public scrutiny is the need of the hour. There is no point in creating multiple fund sources, if their spending is opaque. It is silly, if not outright inhuman, to transfer money into accounts and expect the poor to pay fines if they are desperate to come to banks to collect them. (34) Financial assistance in these desperate times for a cash-based society like ours, would be benefited by cash donations directly to the very poor. Is it not cruel to expect those below the poverty line, illiterate, without jobs and even a place to stay can produce documents in these dire times? India is supposed to be witnessing the worst migration since partition due to the lockdown. These people need cash or kind transfer, while many NGOs are doing good work, but again maintaining transparency is the key. The government should certainly use the various “Relief Funds” already in place, but this is also a time to gather resources from the wealthiest few – for these are desperate times. The richest 1 % of Indians own more wealth than the bottom 953 million (nearly rest of 70 % Indians) put together (35), it is time that at least 1-2% of that money be channelled back to the poorest – again maintaining transparency. It is certainly better than advising student doctors to “donate” their one day payment to the PM fund, which is as yet opaque. (36,37). And it is much better than taking more loans from former colonizers, India already is the largest loan recipient of World Bank and has to repay nearly 73$ billion. (38) There are many commendable initiatives already by some industrialists, like the recommendation by Mahindra group to become a supply hub for the world and reducing dependency on China, as also the initiative for self-constructing ventilators and PPE. This would go a long way to prevent cases like spurious kits, imported from places like China. (39) This has already been attempted in places like Turkey, who have also constructed a new nCOVID hospital and set in supply lines to indigenously manufacture equipment. (40) The globalization project which mainly benefits the multinational corporations has to be looked upon far more sceptically and instead of the slogans of “make”, we should already have labels of “made” in India.

So here is a summary of recommendations –

Communication – two-way, where leaders, administrators & policy makers must directly interact with the ground reality to know the needs and inform the people of measures taken.
Taking care of the vulnerable – the poor, the minorities, the old, those already unwell, children. Providing isolation and quarantine of working population, especially in high risk areas away from them. To remove xenophobia.
Graded lockdown – to maintain essential services, food production, raw materials, supply lines and equipment sources even during the crisis. Food produced to be supplied and farmers compensated.
Giving appropriate work to the migrant population – utilize their expertize rather than make them beggars. Utilizing the migrant population to build care & stay facilities away from population centres.
Construction of infrastructure and strengthening of essential services, specifically targeting health care using above populations. To start building the future NOW.
Strict isolation with transport, stay and care facilities for patients and staff of COVID care AWAY from centres of populations, to prevent further spread.
To start building personal – MBBS based family physician and emergency services in earnest at every level of health care, including nursing and support staff. This includes the huge need for infrastructure and logistics at each tier, but is need of the hour.
To compensate health care and other essential service providers with adequate remuneration for risking not only their lives, but future health in the form of waving of bond duties and health insurance schemes rather than life insurance alone.
Finance transparency and mobilisation of funds from the super-rich in our own country, rather than take loans from abroad, always within the framework of public scrutiny.
Respect the dead – allowing their burial/cremation/ last rites as would be their due. The fact that this even needs to be penned down, is disheartening but clearly required.

I humbly conclude, tackling nCOVID – 19 pandemic is by no means an easy task. My own suggestions might be mistaken in more ways than one. These are only some ideas from a health care personal perspective, obviously each branch and its tributaries in society have their unique needs which should be sought and catered to. However the handling of our vulnerable sections by indiscriminate lockdowns will shatter the already weak economy and will have disastrous fallout on basic necessities like food, water and shelter, let alone the lack of care for the already sick population even without nCOVID. It is in the hope of mitigating the morbidity of this pandemic that these ideas are shared – so that the societal “treatment” of the illness does not become worse than the disease.

References:

Written By – Dr Syed Faraaz Hussain, Consultant Eye Surgeon, Paediatric & Squint specialist.

MS Ophthalmology ( Nair H. Mum), MBBS ( KEMH -Mum), DNB, FPOS -USA, FICO -UK, FVRS (Surgical Retina – Nair H. Mum.) FCPS -Mum, DOMS -Mum.ICO –Sub-specialty Paediatric Ophthalmology & Strabismus FAICO Paediatric Ophthalmology & Strabismus –Delhi.

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nCOVID 2019: Thought structuring at the time of Pandemic.

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