Half a dozen states in the country are under lockdown for a few weeks to a month following state governments announcing a slew of emergency measures to stop coronavirus disease (Covid-19), but it’s not enough.
This has to become the new reality for all Indians over the next few months as the country must pull out all the stops to prevent a surge in infections that inevitably follow a couple of weeks after the first trickle of cases, say public health experts. Because if they don’t, the country’s health system will collapse under the load of an exponential spike in the number of patients needing intensive care.
“Infection patterns from countries such as China and Singapore show that enforcing social distancing, early diagnosis, contact tracing, home quarantine and isolation measures to contain the infection can reverse the curve, while failing to do so will lead to sharp spike in cases and deaths, as we are seeing in Italy and Iran,” said Dr K Srinath Reddy, president, Public Health Foundation of India. With 81 cases and one death, of which 78 across 13 states have occurred since March 2, all states have rolled out emergency infection-control measures because “alarming levels of inaction” have fuelled outbreaks in several countries, according to the World Health Organisation (WHO). March 2 marked the start of the second wave of cases after the first three cases were reported from Kerala.
Social distancing
Unlike Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) viruses, the Sars-Cov-2 that causes Covid-19, is likely to be around for months, if not years, but the surge in cases can still be reversed, say experts.
Over the next two weeks, all Indians, irrespective of where they live, must prepare to stay at home as much as possible, while states, businesses and educational institutes must prepare for restrictions on study, work, travel and celebrate. Restricted travel, closed schools and colleges, staggered work hours or working from home, compulsory telecommunicating, and cancelled public gatherings, including religious festivals, will be the new reality.
“Restricting movement is essential to stop the infection from spreading from person to person, which is why the government revises travel advisories as the pandemic evolves and issues travel history of all cases to empower people to make informed decisions to protect themselves, and get tested, if needed,” said Dr Raman R Gangakhedkar, head, epidemiology and communicable diseases, Indian Council of Medical Research (ICMR).
If India fails to contain cases now, the teetering health system will be pushed to the brink. Once community transmission begins and the source of the infection cannot be tracked, everyone with symptoms of fever, cough and difficulty breathing, and not just people who have travelled to outbreak areas and their close contact, will have to be screened.
With 80% cases getting mild symptoms, general practitioners (GPs) can be trained to guide people how to isolate themselves and rest at home. Delhi, for example, has directed all hospitals to establish flu corners to screen people with fever, cough and collect nasal and throat swaps for testing.
Heath systems collapse
“This virus can test and overwhelm any country’s preparedness. India has not yet reported any community transmission, and must make use this window of opportunity to ensure the new cases plateau and then decline while preparing for the worst-case scenario by strengthening its health systems,” said Dr Lalit Kant, former head of epidemiology and communicable disease at ICMR. India’s overstretched health system is already grappling with shortages of doctors, health workers and hospital beds, especially in rural areas and densely populated underserved states.
India has 1.1 million allopathic doctors registered with the Board of Governors/State Medical Councils/Medical Council as of December 2019. “Assuming 80% availability, it is estimated that around 9.26 lakh doctors may be actually available for active service,” said minister of state for health Ashwini Kumar Choubey in the Lok Sabha. For a population of 1.36 billion, this makes the doctor-population ratio at 1:1,457, which is lower than the WHO recommended norm of 1:1,000.
For people living in rural areas that are completely dependent on government hospitals and clinics, the government allopathic doctor-patient ratio is at 1:10,926. With intensive care unit (ICU) beds limited to district hospitals and medical colleges, rural India risks deaths in very high numbers.
“Around 20% cases need hospitalisation, and 5% develop severe pneumonia that needs ICU. With cases rising, hospitalising and isolating every case will not be possible even if India creates additional capacity, like China did,” said Dr Randeep Guleria, professor of pulmonary medicine and director, All India Institute of Medical Sciences.
Intensive care scarcity
The training, accreditation and quality assurance of health professionals and health infrastructure also varies widely within states, cities and neighbourhoods. Health staff need to be trained in infection control and emergency protocols. “If there are large clusters of cases, India will have to commandeer private hospitals and triage the most critical cases and postpone elective surgeries and procedures to free up hospital beds. You cannot do this without private sector participation,” said Dr Reddy.
“Besides, identifying hospitals and trained medical staff, we will need to convert wards into isolated ICUs and ensure large-scale availability of ventilators to treat the 5% patents who need hospitalisation,” said Dr Guleria.
The acute encephalitis syndrome outbreak during the monsoons in Uttar Pradesh and Bihar demonstrates what ICU shortages can do. “All sick children need ICU care, which is not available locally, so they all end up at BRD Medical College in Gorakhpur, which collapses under the massive patient load,” said Dr Reddy.
Training health workers
India has a little more than two million (2,048,979) registered nurses and midwives, most of whom need infection control training to care for patients with airborne infections. “We need to a continuous supply of oxygen, personal protection equipment and ventilators and we need to train health workers to use this equipment while ensuring routine health programmes like antenatal care, immunisation and disease-control programmes are not affected,” said Dr Kant.
Countries like Singapore, for example, plan to hospitalise only serious cases if there is a sharp increase. “With larger numbers, the sensible thing will be to hospitalise only the more serious cases, and encourage those with mild symptoms to see their family GP and rest at home – isolate themselves. This way, we can focus resources on the seriously ill, speed up our response time, and hopefully, minimise the number of fatalities,” said Singapore prime minister Lee Hsien Loong on Thursday. Countries that act fast can reduce the number of deaths by a factor of 10. “Apart from social distancing, we must get used to practising good personal hygiene, adopting new social norms and discouraging large gatherings, and generally, maintaining some physical distance from one another,” said Dr Reddy.
