By Antony KR
Ever since the clouds of the Corona Pandemic were looming large on the horizon, we lived with anxiety and fear. Almost about 11 months passed. We have been bombarded with various types of remedial measures, preventive steps, and so on from the authorities and individuals from all walks of life. There was information of all types — good, bad, misleading, and dangerous. WHO set up a monitoring cell to take care of this infodemic along with the pandemic. The modern, efficient technology made sure that any information useful or harmful spread fast and penetrate even isolated communities.
There was a delay in declaring a pandemic by WHO till March 11, 2020, though China announced the Wuhan epidemic on the last day of 2019. This declaration itself was delayed by more than a month. No international flights into or out of China were stopped. Flights out of Wuhan operated straight to Northern Italy igniting the fireworks in Europe. The human tragedy of millions dying in suffocation without oxygen, especially the institutionalised elderly, was heart-breaking. Common men heard these horror reports from many countries, saw miserable pictures of human sufferings. It created further curiosity, panic, and helplessness.
One immediate speculation was how did the virus get inside human beings? Wuhan wet market was blamed for the original crime site and quickly the world took offense to the curious eating habits of the Mongoloid race. It had its repercussions in India too — Chinese-looking Indians and the ethnic groups eating insects, snails, frogs, bats, and snakes were ostracised. It took some time to leave the bats alone to fly at free will world over.
The common men were willing to obey all instructions from medical teams and civil authorities. But that is where we faltered. There was no consistency in what was conveyed to the public. The medical teams – epidemiologists and public health experts — never had a consensus on what they understood or said. They were not seriously consulted or allowed to take the centre stage by political leadership. One typical example is the obvious difference of opinion between President Trump and his technical advisor Dr Anthony Faucci. The result was that the common man got confused by conflicting information.
One reason could be that the pandemic and the causative virus were new to scientists and their behaviour was unpredictable. Everyone was learning and there was no real expert around. There was no prior experience or documented data as evidence. True to scientific temper, technocrats postulated theories and embarked upon empirical treatment. The idea of repurposing drugs got accepted as a desperate try. Scientifically, approval was sanctioned under emergency use authorisation.
WHO came out with advisories on handling the Pandemic. Physical distancing, hand washing with soap and sanitiser, seeking medical help or hospitalisation only if there’s a need for oxygen and intensive care were on the list of advice. WHO was emphasising only on droplet and fomite transmission, not sure of aerosol transmission. So, the face mask was not the first line of defence. The yes-no controversy about face masks continued for some time. More and more scientific discussion based on evidence demanded the use of face masks as an important tool for halting the spread of coronavirus. Very little police enforcement was required to make communities practice this new behaviour. Even the president of the US got trumped into accepting face masks.
Tests, tests, and more tests was the main mantra from WHO to control the pandemic. Test alone prescription was based on the success of South Korea, Japan, and Singapore in containing the pandemic. But it didn’t work everywhere because the pandemic was in different stages of evolution. There was no role of aggressive community-based testing when the imported virus was circulating in confined geographical areas. In the first week of April 2020, when South Korea conducted 8,500 tests per million, Germany was conducting 11,200 per million tests with no halting of virus transmission. India was conducting 70 and Kerala 350 tests per million only because we did not have adequate testing facilities. Nevertheless, our transmission rate was low compared with Europe.
WHO couldn’t be seen effectively supporting capacity-building ventures in member nations, while whipping up the testing exhortation. People had an impression that the government is not doing enough. India progressed systematically in testing capacity from a single virology lab in Pune in February to 192 testing centres in March, 419 in May, 688 in June, 1,180 in July, and 2,134 labs by November-end. The testing rate has increased almost parallel to the geographical spread of virus transmission. India reached a testing capacity of 10,99,545 tests per day by the end of November.
Increasing number of tests will have the desired effect only where there is increased transmission. For example, in mid-April Tamil Nadu and Andhra Pradesh had 4.5% and 5.6% test positivity rates even with less than 285 tests per million, whereas Kerala with an aggressive 483 tests per million had only 2.3% TPR. It is a different matter that in November it even reached as high as 15% with the second wave of community transmission.
There was unreasonable demand for testing the wider community in March to May when there was no reporting of a single case from 213 districts. Only by the end of May, there was reasonable evidence of community transmission in Delhi, Mumbai, Pune and Chennai. Luckily, the government did not waste precious human resources and funds in April and May on wide community testing. But people got misled again and were asking — are we doing the right thing at the right time? People reading newspapers and listening to TV channel discussions got confused, bored, and felt helpless.
Trace contacts, test, isolate, treat and contain was the surveillance and pandemic control model adopted by Kerala from the beginning which was globally recognised and appreciated. It had a public health system much more efficient than elsewhere in the country. Besides the massive community mobilisation it launched to spread awareness and the involvement in arresting community transmission till September opened the eyes of the public. One thing that this pandemic exposed nationally is the poor condition of the public health system and its neglect by successive governments. India spends 1.09% of its GDP on healthcare, compared with Malaysia (2%) and Thailand (2.8%).
India’s per capita public healthcare expenditure is $83, compared with $500 in China and $9400 in the US. The government healthcare expenditure in India is Rs 2,149 with wide variation in states like UP (Rs 772) and Bihar (Rs 504). The out-of-pocket expenditure was 62 percent for healthcare.
With all its inadequacies, it is this public health system that rescued the common man during the pandemic. The private sector was conspicuous by its absence and even denied services in a time of need. It showed its ugly head as an opportunist to exploit a humanitarian crisis by overcharging for services under false pretences. Treatments with everything under the Sun — antibiotics, hydroxychloroquine, bleach, cow dung, Arsenicum, Patanjali medicines — were tried.
Luckily the research scientists and doctors have made progress in trying out various initially proposed drugs. They found that some of them are not useful.
- Tamiflu (Oseltamivir) which was good for bird flu
- Hydroxy chloroquinoline (HCQ) used for Malaria and arthritis
- Azithromycin- used for Upper Respiratory Tract infection
- Tocilizumab/ Itolizumab which are Monoclonal antibodies
- Convalescent Plasma Therapy
- Remdesivir was not found effective, but trials still continue
The only medicine that proved to be effective in reducing death and complications is steroids in serious cases. Oxygen through the nasal catheter and intravenous fluids for vital circulation and electrolyte balance are the mainstay of management. Blood thinners are life-saving when there is evidence of clotting in small blood vessels. When the allopathic system comes out with frank and transparent statements, various other systems of medicine come out with exciting promises. Media gives wide coverage to such flickering hopes.
Everybody was waiting for a panacea and that was supposed to be vaccines. A competitive close race for the discovery, field testing, and clinical trial was undertaken by many governments or public-funded research laboratories and pharma corporates. The Pfizer vaccine is NOT a vaccine for Indian public health system because of the cost and cold chain requirements. Among the two rival vaccines, Covishield and Covax, produced in India, the best vaccine is the mRNA vaccine Covishield produced by Oxford, Astra Zeneca, and Serum Institute of India, Pune. This can be operationalised with the existing cold chain system. The disadvantage of Covax by Bharat Biotech Hyderabad is its larger volume of antigen required for adequate immune response — it is from killed whole virus that do not multiply in the host after inoculation.
Our health ministry has made a detailed rolling out operational plan. Unlike the polio vaccine, we don’t need that much of a vaccine literacy campaign to raise awareness and social demand. People are desperately looking for a magic wand to save them from the Covid-19 and no antivirals are available. So, the uncertainty of safety or efficacy is not a concern of the public. Even when we leave it as an optional vaccine, given free on-demand without enforcing it on anybody, the demand will multiply. One confusion still remaining among Public health professionals is how long the immunity after vaccination will last and what impact it will have on the building up of herd immunity.
The lockdown was meant to arrest virus transmission. And people should have been allowed to, even helped to, return home safely before imposing the first lockdown on March 23 and asking them to stay indoors. International and domestic flights should have been stopped from March 11. Halting interstate movement by train or bus to and from 75 districts in the three states — Kerala, Maharashtra, and Delhi — would have been justified. Timely action was missing. End of lockdown 2 was announced on May 3 in ‘green zones’ — 319 out of 733 districts in the country where not a single case was reported. There we did not achieve anything epidemiologically by continuing the lockdown, except self-inflicted economic destruction and social inconveniences. Epidemiologically guided containment measures and a granular decentralised hotspot-based approach were missing.
Total shutdowns, partial shutdowns, night curfew all have been imposed in various combinations — without any scientific rationale. Professional bodies of public health specialists and epidemiologists came out openly with joint statements. Then when the daily case count was ascending the peak at phenomenal speed till mid-September, on June 1, unlock 1 was declared with no rhyme or reason. We started the festival season with various pujas and public venerations and conducted campaigns for elections in Bihar and some other constituencies. Bars and malls were opened, but not colleges and schools. Information overload was adding to the confusion in the minds of people during the lockdown.
There has been an enormous amount of discussions about the merits and demerits of every measure. People were hailing how an X country or state did very well with correct measures at correct time — only to be humbled a few months later with an enormous increase in cases. Kerala, Australia, and Sweden are a few examples. A lot of mixed advice by technocrats and political coterie pervaded the media.
The media is full of clever suggestions and advice by people who are called ‘experts‘ about how to tackle the crisis. Unfortunately, none has produced any beneficial effect so far. Point blank questions were raised to such experts to tell exactly when the pandemic will end. Some gave predictions about the end in June, September, and December, soon to realise with embarrassment that such predictions are without scientific basis. The public enjoyed the foolhardiness of such prediction experts with sarcasm.
This virus looks smarter than most of us. Honestly, we do not know how to get rid of it. All we can do is take sensible precautions like physical distancing, cough/sneeze etiquettes, face mask, and lead a low social activity life. Hope it will slowly go away before it takes any of us. Vaccines already discovered at a heavy investment may or may not change the course of the pandemic. Let us hope for the best. But research to find alternative pathways should continue without confusing the public through self-contradicting communication.
(Dr Antony KR is independent monitor, National Health Mission, Govt of India. He is former director, State Health Resource Centre, Chhattisgarh and former health and nutrition Specialist at UNICEF India.)