Combating COVID-19: A Fourth Review

Former Director General Artillery, Lieutenant General PR Shankar's fourth review of India's options for combating the Coronavirus.


9 min read

Combating COVID-19: A Fourth Review

General

Day 20.  Phase 1 closing out. India on top. Phase 2 starting shortly. It seems that there is no getting away from lockdown. Details shortly. Will not second guess it. We have done extremely well so far.  Ahead of the curve. The Chinese Virus held at bay. Phase 2 will be a grind. Long haul to roll it back. We are in a battle in a ‘frontier sans medicine’.

Democracy is visibly at work. Good to see the PM talking to CMs, past PMs and Presidents, Opposition and the cabinet. Fantastic to see CMs giving out their views. Corona has forced our diverse leaders to come together! Do they have any other choice? The common message was – save the common man at any cost. I am confident when this is over India will emerge a great power. Compliments to our leaders for rising to the occasion.

Studies coming out of the West with prescriptions for India are well-intentioned. Good aids. No more. Everything in India vastly differs from abroad. Outliers like Tablighi Markaz, Migration, Unreported cases of health care workers being attacked, and their second order effects are beyond comprehension of outside writers. Another example. The number of male infections is 2-3 times female infections in India. Abroad, it is almost equal. Discussed it with someone with intimate knowledge of UP.

A plausible reason emerged. Men do ‘bottle parade’ all around the countryside (specially on railway tracks) and do not wash their hands. It is established that Chinese Virus transmit through feces also.  QED. Can someone in Cambridge or Michigan or John Hopkins dream that there is no water beyond the ‘bottle’. And soap? Forget it. We need to solve such Indian problems with Indian solutions.

The Enemy

The enemy is well entrenched. Attempting to paralyze us. It has not mutated. Seems less effective in India. It has started to spread its wings.  Sooner or later it will break down our walls and make deep inroads into our society if we are not vigilant. Besides hitting us through asymptomatic cases and making a second wave reappearance, it has shown that it can re-infect people in South Korea. That is dangerous. Herd immunization concepts at risk. This needs further urgent study.

Crystal clear that a vaccine is minimum 18 months away. After that? Another 18 months for production, distribution and implementation of immunization programs. 7 billion doses are involved. There are collaterals with vaccines. They are no silver bullets in the offing.  Expect no curative or therapeutic medicine for this Chinese Virus before a year.

That is the essence of a CNN interview with Bill Gates (yesterday). Stark reality is that we will have to live with the Chinese Virus without a medicine or vaccine for up to three years. We will ‘sleep with your enemy’ for long.  Lock downs temporarily buy us time.  We must seek other solutions.

Our Own Forces


Climate. The climate is hovering around 32-36 deg C in India with high humidity in the South and dry atmospheres in the North. Temperatures are set to go up. The weather does not favor the Chinese Virus. Good news.
Case status. The current status of cases is in the graphic below. The lock down so far was to bubble up the cases vertically and not let them go into fission mode laterally. We have been successful so far. We could have hit cases in lakhs. That is clear.


Case Spread / Discovery Rates

The occurrence of the disease appears low in India. (see tables). Expanding testing protocols might tell a different story. Wait for data to kick in with expanded test protocols to make further inferences.


The infection rates in states tells us:-The state wise data conforms to the overall trend (table above). The Southern states appear to be stabilizing. The Northern states are on the rise. Kerala and Himachal are fattening. For the first time the number of infections were lesser than recoveries. (see graphic below). Fantastic. Let us hope this trend continues and expand to other states.  



Maharashtra and especially Mumbai is most affected. Even in Mumbai, which is the worst affected, 1761 tested positive out of 31841 samples. That is a case discovery of 5.5 % only. Not bad still  in the international context.


Testing

India is testing around 15-18000 personnel daily. This capacity is increasing. However, training of personnel for testing could be a funnel. Secondly. to test at levels of S Korea, USA, Germany or Russia we will need 8 million test kits. Equivalent to what the rest of the world needs. Hence there is a finite limit to testing despite the call of “Test, Test and Test”.  However some random testing in various likely hotspots /existing hotspots and a sprinkling elsewhere will give us a better idea.

Fatality Rate

In the absence of testing, the mortality rates are the best indicator. Even in this parameter, Indian rates are among the lowest in comparison to temperate and tropical countries.


The problem area is clearly Mumbai which accounts for 45% of India’s death cases and 1/8th of all infections. Prepare for a major outbreak while the state government controls it. The Centre should now start thinking of contingency plans for Mumbai.

As per other inputs received, deaths due to other causes have gone down by about 30% globally. There has been more than 40-60% reduction in heart attacks in New York as per NY Times of 06 Apr. Even in Delhi, cremations in Nigambodh Ghats are down by about 30%. With further data inputs, a clearer picture should appear. The evident issue is that things are going well.

Hotspots

All governments are now tuned to handle hot spots as they emerge. This will be a recurring phenomenon for the next three years. No getting away.

District Wise Spread

Not all districts are as affected. The table below indicates the number of districts per states on a case interval basis.
                                   


If district data is organised, the number of districts in a state with a level of cases emerges. Also there are several districts without any cases. The district wise case data tabulated (two days back) indicates as to how many districts and cities are badly affected. There is a   requirement of a flexible approach. Cannot be one size fits all approach.  The district wise map for Maharashtra, the most affected state confirms this.  

Co-relationship

We will not have a medicine or vaccine to deal with this Chinese Virus for quite some time. it will be endemic to our society. It cannot be eradicated with available options or resources given the Indian social structure and population density. We cannot keep sitting at home. Lock downs will lose significance and effectiveness. They will become counterproductive given our huge and soft underbelly of poverty, unorganized sector, joblessness and fragile overall economy. So what do we do? Go in for Controlled Herd Immunity. How?

A correlation ship with age, infectability, hospitalization and mortality will give the option. See graphics above. The age graphic indicates our youth bulge. Infection is maximum in the youth (This data is current). Very importantly, hospitalization is least in the youth. The youth will fight through this virus and not load the health care system. The graphic here is from USA but can be corelated here with our statistics.  The mortality is also least in the youth. It is confirmed that more than 60% of mortality is in the aged even now. Overall it must be kept in mind that the Chinese Virus has low mortality rates. Hence risks are marginalized.

Look at it from any direction. We are end played but with a clear solution. Western nations and China do not have this choice! Go in for ‘controlled’ herd immunization, minimize the losses and kick start our economy back. The alternate is let things evolve in an unorganized manner and suffer.   The motto should be to expose healthy youth to this virus and let them develop herd immunity. Isolate or protect the aged, vulnerable and co-morbid people.

Towards Herd Immunity

Achieving herd immunity has two facets. Firstly controlled exposure of medically fit youth. Secondly, protection and isolation of the aged, vulnerable and co-morbid personnel. Principally, just like social distancing, carry out social barricading  between the youth and the aged. In public places it will not be too difficult to achieve this. The real problem will be at homes. In Indian homes it is normal to have three generations staying together.

Need some solutions there. The problem will be most acute in urban areas and middle-class societies. The next two weeks will give us ample time to plan for this. If we do not do so, the matter will be taken out our hands anyway. The consequences will not be pleasant. Also we need to factor in that some herd immunity is building up as we read this due to migration, unreported cases and recoveries.

Key Lines of Operation


Principles Overall the Main Principles on which we Must Operate Further are as Under

Adopt a flexible and differentiated approach. Prepare, Prepare and Prepare. The success of the oncoming phase will be dictated by the preparation which will be carried out by states, cities, districts, tehsils and most importantly individuals in execution. Overall the effort should be participatory without hidden agendas.

Action Points

Exclusions. Public gathering, including Social. Wedding, Religious, Educational, Political and any other to be banned. Sec 144 to be imposed. Schools, educational institutes, hotels, hostels, bars, sports, cultural activities to be closed till 30 July.


Personal Conduct

Lay down and enforce rules regarding mask wearing, social distancing, spitting, public urination, garbage / littering and ablution.

Essential Services

Identify and ensure essential services are maintained in the area, Identify, risks to essential services during lock down.

Communication

Use the mobiles penetration in area / district to keep public informed about lockdown regulations and stages. Give out bi/ multilingual updates twice a day. Make a two-way communication system.

Harvest

Make necessary arrangements for harvest as per local crop requirements.

Water

Summer is approaching. Plan for water. Ensure water discipline.
Local Apps.   Make local apps for local facilities through crowd sourcing.
Monitoring and Surveillance. Have a strong monitoring and surveillance system based on mohallas, areas, villages, localities and streets. These could be based on youth organizations/ NGOs.

Protection of Aged/ Vulnerable/ Immunity Compromised/ Co morbid People

Have an isolation policy for this variety. These people must be identified and kept away from youth. Separate Qs, areas, shops, times for such people can be promulgated.

Security

Have a strict security system so that offenders are arrested and dealt with as criminals. Test, Trace, Treat and Isolate as per Protocol. Train people to do these tasks.

Reserves and Reaction Capability

Identify and disseminate reserve and reaction capability at all levels. Leverage the power of Railways.

Contamination and Quarantining

Rehearse these activities as per laid down instructions. Have a plan with resources in place to carry out containment, sealing and quarantining. (https://www.mohfw.gov.in/pdf/3ContainmentPlanforLargeOutbreaksofCOVID19Final.pdf and https://www.mohfw.gov.in/pdf/90542653311584546120quartineguidelines.pdf ).

Protection of Healthcare Staff

Ensure that our protectors are protected.  

Ban Public Air conditioning

All air conditioners in public places and offices should be banned.

Population Movement Control

States must put in place a practical population and migration control system.
Liaison. With neighboring district/ localities/ states must be established.
Public Hygiene.  Carry out regular disinfection and hygiene activities. Counselling and Grievance Centers. Establish counselling and grievance centers in all tehsils.

National Restrictions  

All national restriction especially on interstate,  domestic and international travel will prevail and should be enforced.

Livelihood

The poor of India were deprived of their livelihood due to the lock down. It is unaffordable for the state and the individual anymore.  Get them back to work. No need to say more. However the return to work must be planned and monitored. Think through it lest we end up in a cul de sac. This is especially true for illegal / marginal businesses which run in congested environments. Karol Bagh and Crawford Market are just a few examples.

Conclusion

It is very clear that India has achieved a lot in the past three weeks. We are succeeding where others are struggling. USA, the sole super power seems to be in a ICU barely surviving. Clearly unable to lead the world. UK, the past superpower is in a smaller ICU next to USA. France is maintaining a fashionable distance from leadership since it is barely coping with the Chinese Virus. Russia, till recently, was on the sidelines hoping to emerge as the sole survivor.

However, the Chinese Virus has caught up to begin its havoc dance there. China is desperately trying to assume global leadership. it is too untrustworthy and opaque . Every one is looking at it as an accomplice to the virus. The big five are virtually out of the global leadership framework. It is only India which is standing tall. Very clearly, the internal power of India is shining through.

Not rich. Not prepared. Not well equipped. BUT. India is fighting an unaffordable battle to save itself ;very successfully and at the same time  it is reaching out to help others. It is emerging as a global leader beyond military or economic power. Jaan Hai aur Jahan Bhi Hai as said by our PM.  

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