Phase 2: Break Out Stage
The question is who will break out? The disease or us? It is a delicate stage of the battle. The Virus can attack us from all sides outside our lock down fortress. We are exposing ourselves and our vulnerability in this graded exit. Is our vulnerability strong enough to withstand the attack? That is the test. There is loose talk of Post COVID Scenarios. That could be three years away or more. We are here and now. Let us talk of that and not look at distant unseen horizons.
The Virus is new and we do not know enough of it. There are not enough cases. Data from China is suspect. USA which used to lead the world out of trouble is itself in the dock. The Virus is not behaving like its other avatars. Not responding to known medicines. At present we do not even know if we are infected or past that. Not enough testing facilities. We do not even know whether we can develop immunity. If so for how long? Reinfections belay immunity
The new danger is asymptomatic infections and the danger of being undetected. As per reports 60-80% cases are asymptomatic, not reported. These cannot be detected due to paucity of testing facility. The medical fraternity is in a gallant stupendous fight for all of us. However they are not armed with medicines to treat us. They are flying blind. What we know is that the enemy is vulnerable to soap, hygiene, social distancing, heat, and humidity. It could be vulnerable against the BCG vaccine and Indian Genes.
It is not highly effective against healthy people especially the youth while being deadly against the old and the infirm. We must fight this Chinese evil with the weapons and knowledge we have. We must fight this the military way. In the Burma Campaign, the British Indian Army was rolled back to the Kohima - Imphal line by the Japanese. It was stricken with malaria and suffering low morale. Dysentery, Chills, Fever and Malnutrition were rampant.
Fd Marshal slim imposed strict anti-malarial precautions. Suppressive quinine treatment, sundown sleeves down, apply anti mosquito repellants, use mosquito nets, drain stagnant water, spray or wash clothing, bedding, and bed netting (but NOT your skin) with permethrin et al. Soon malaria cases reduced, morale improved and then came Defeat into Victory.
The basic tenet was discipline. Everyone had to follow precautions otherwise you simply fell sick and unfit for battle. I commanded my brigade in CI operations in the malaria prone jungles of the North East. We were all on full iron clad anti malaria precautions. Not for self alone but for our comrades also. The best subunits and units were those which were disciplined enough not to have malaria cases. Consequently they did well in operations too.
Similarly look at the Indian Army in Siachen Glacier. It is well known that in Siachen environmental casualties were higher than from enemy action. The Indian Army adopted a strict disciplinarian approach to behavior on the Glacier and casualties fell. The short point is that in the absence of medical remedies, fall back to rigid behavioral discipline. That is the only way we will win this war.
Every Indian must be made aware that he is both the Weapon and the Victim. Either he fights with discipline or all of perish. When he fights for himself, he is fighting for all others also. That consciousness must set in.
The Current Status
The current status of cases is as under.
There is a clear increase in numbers. Every day cases are growing by about 1000-1400. The welcome news is that appreciable recoveries have also started to "flatten the curve"
The Top Order
The Top Order was looked afresh from the number of active cases rather than the total number of cases. Substantial recoveries have taken place. We need to deal with the current situation than a statistical picture. Immediately the dimension of the problem changes. The graphics gives a realistic picture. Maharashtra and Delhi have been joined by Gujrat and Rajasthan. All in Five days. Reason to tighten our belt. Gujrat is worrisome.
UP and MP continue in this range. TN has dropped down from the Top Order and seems to be in control.
Lower Middle Order
Andhra and Telangana continue here but J&K has come into the picture. Worrisome.
Happily, there are many tailenders. Even more happily Kerala has dropped significantly. While the increase in numbers is not alarming, the cause of worry is that more districts are coming into the picture. The table indicates the number of districts in case pockets for some states along with hot spots. From 05 April to now there is an increase in the number of districts with higher number of cases.
Case Discovery and Mortality
The prevalence of the disease in India continues to be far less than other countries. This is based on data from 05 April. While everyone talks of inadequacy in testing, the number of cases which are popping up for the tests carried out is extremely low. The lock down has been effective. It must be seen if this scenario changes when restrictions ease. So far so good.
The situation is in control even if it is enlarging.
Heartland India is where the battle will be won or lost. The South, East and North are generally stable and under control. The problem remains an urban one. The countryside is still unaffected. The number of deaths taking place for the cases we have on hand indicates the following. The mortality / casuality rate is low in India. Our Hospitals and health care personnel are doing a good job. The disease might not be that lethal in India.
'Defeat in Victory Approach'
The only way to defeat the Chinese Virus is with the ‘Defeat into Victory’ Approach. While norms like social distancing, private and public behavioral hygiene are clear, we need to have some level of analytical approach.
Population and Case Spread Analysis
A population analysis how to control the disease is needed. Our population of 1.3 billion is 35% urban and 65% rural (see Graph below). From the earlier table we also saw that the Virus is an Urban Phenomenon. The hotspots are mostly urban.
The spread of cases in districts approximately is as under:- 50+ cases – 65 -70 districts25-50 cases – 80-100 districts0-25 cases - 200-225 districts.Nil cases – 325 districts (approx. as per GOI).
It stares at us. Protect the districts.
A three-pronged approach is required.
1.Contain hotspots and districts with more than 50 cases through lock downs, sealing, red zoning etc,
2. Eradicate the disease from districts less than 50 cases. With onset of summer and strict measures it can be killed.
3. Do not let the Virus enter Corona free districts at any cost.Each district must have a different strategy suited to it.
Population and Disease Co- relationship
Age and Mortality
The table below is data of 6839 deaths in New York city. If there are no underlying conditions, the death rates are drastically low. The immediate conclusion is that we need to protect or shield the high-risk people from this disease.
High Risk people are all above 70 and those with underlying conditions like Diabetes, Lung Disease, Cancer, Immunodeficiency, Heart Disease, Hypertension, Asthma, Kidney Disease, and GI/Liver Disease. These people should be put under lockdown / isolation / extreme care / zoned out. The concept of ‘Expose the youth and Protect the High Risk’ is to be based on this data. Commence the concept of "Social Barricading" high risk people.
Infection and Hospitalization
A relationship between infection and hospitalization is that of all detected infections, approximately, 80.9%, are mild, 13.8% are severe and 4.7 % are critical. Infections which do not need hospitalization (moderate/mild/asymptomatic infections) are 95.6%. Infections that lead to hospitalization, but not critical care are 3.08%.
Infections that require critical care are 1.32%. Experience also indicates that a “20-something has about a 1% chance of illness so severe it requires hospitalization, and that risk rises to more than 8% for people in their 50s and to nearly 19% for people over 80”. This data enables planning for medical infrastructure in an area and population.
All this data is nice. How does one use it at practically at various levels? We need to have an idea of the magnitude of the problem at each level from the grass root Tehsil/ward level to the highest level in the GOI. We start the population distribution graph and table below. .
The population distribution must be co related with the details of underlying diseases to get a fair idea of how many people are high risk in an age group. As per India’s health statistics the prevalence of underlying diseases is Obesity – 155 million, Diabetes – 50 million, Hypertensive – 12.5% (in 15-49 age group, Cancer- 175 million, Heart diseases – 50 million.
This data must be dis-aggregated to various age groups from relevant information available in authorized repositories of such information. An educated guess can be taken based on common sense and life experience. My educated guess is as under
|SERIAL||AGE GP||PERCENTAGE||CUMULATIVE||NO OF PERSONS IN AN AGE GROUP HAVING LIFESTYLE / UNDERLYING DISEASES (this needs endorsement/amendment by appropriate authority)|
The next step is to appropriate this distribution to various groups and divide them into high risk and low risk groups.
|SERIAL||AGE GP||PERCENTAGE (a)||CUMULATIVE||NO OF PERSONS IN AN AGE GROUP HAVING LIFESTYLE / UNDERLYING DISEASES (b)||LOW RISK GROUP (%) (a– (a x b)) (a)||HIGH RISK GROUP. ALL ABOVE 60 ARE IN HIGH RISK GROUP. (%) x(b)|
After this the data can be converted to any population group. For a basic brick of 10000, the distribution is as given in the table below
|SERIAL||AGE GP||PERCENTAGE (a)||CUMULATIVE||NO OF PERSONS IN AN AGE GROUP HAVING LIFESTYLE / UNDERLYING DISEASES (b)||Low risk group (%) (a) – (a x b) (a)||Low risk group (%) (a) – (a x b) x(b)||Low risk people in 10000||High risk people in 10000|
We now know that in each age group how many high-risk individuals are there in a brick of 10000 in various age brackets. They can be dealt with or protected as per local situation. The flaw in this data is the assignment of lifestyle diseases to each age group. This must be assigned based on better statistical data available. Once that is done this matrix will be very solid aid.
A District Magistrate armed with this data can get basic medical tests done at tehsil / gram panchayat level and then he will be able to handle each village of his district easily. A secretary at state/ national level can get the macro data for his planning. There is need to know whom to segregate and how, if needed. This is a planning tool. This model can be used at any level for many purposes.
If all low risk healthy individuals are infected in a group of 10000, the casualties will be around 50 -75 people if the percentages of casualties from New York are taken as a guide. However if all high-risk individuals are exposed and get infected then we should expect about 90 % of them will die. Hence protection of the High-Risk People is a mandatory part of any plan.
From this table one can plan for their protection as per local conditions. This must be enforced with some logic and sense and some amount of discipline in the society. It can not be enforced at the PMs office, but from grass root levels on a widespread participative basis. This is a matrix which can also be used for herd immunization eventually.
Medicine and Vaccination
Everyone is looking forward to medication and vaccination as the solution to the Virus. While medication is ok, we must think through the vaccination business: -
It is Big Numbers and Big Money. There are already issues of ethics propping up.
Can a vaccination be given to an infected person? The disease might get complicated. An infected person with vaccine is double infection.
How long will the immunity last? There is no clarity on natural immunity.
When will the clarity on vaccinated immunity come? Given the number of asymptomatic cases coming up, how does one know whether it is safe to take a vaccine. Hence each vaccine might have to be preceded by a test. It only complicates the issue. What are the side effects of each vaccine? Incidentally, all vaccines have side effects.
Will we Indians accept Chinese vaccines given the substandard nature/ quality of even medical equipment being supplied by them all over. That might be a bio war channel. I will not accept it. It is a matter of trust or lack of it. By the time all these issues are resolved, the infection might have spread to all people and herd immunity might have been achieved. Hence is the vaccine necessary at all?
The Virus could have mutated making the vaccine redundant.
If after the first phase, the Virus is seen not to be as lethal in India as it is proving and can be managed with a curative medication, should we go in for a Vaccine at all? All these issues are being raised because vaccines are forlorn hopes for now. We must fight this Virus like Malaria; with what we have- The Defeat into Victory Way. When the right vaccine comes along we can use it.
While natural herd immunity is fine conceptually and can be the goal, there are issues with it as under: -The number of cases is far too less to attempt herd immunity at national level at this stage. When the total number of cases are just less than 20000, we can not think of exposing 1.5 billion to it. Insane. However we must be cognizant of a substantial number of asymptomatic and unreported cases in the environment which can force our hand.
It is not clear if persons who are infected once are immune to this Virus. As of now it is all an educated guess. In the absence of clarity on that issue, attempting any kind of herd immunity is out of the equation. Targeted / controlled herd immunity must be attempted as a pilot project along with establishing immunity parameters and population control measures.
Once results from the pilot project are clear, we can go in for Herd Immunity in a targeted, controlled, and phased manner. Herd immunity also means letting people get infected deliberately and being prepared for the consequences. In such situations Herd immunity progress must match the medical capability of the nation and region. The haul is clearly long.
Principles of Operation
While the key lines of operation must be continued with as mentioned in earlier reviews, we need to veer towards certain underlying principles to handle the situation in the long term. These are as under.
Contain Urban Areas and Firewall Rural Areas
The three-pronged approach as outlined earlier must be taken to contain and restrict the Virus in Urban areas. We should be prepared to go through cycles of suppressive lockdowns, lifting, containment and sealing actions. We should now put in place a movement monitoring and restriction plan so that affected areas do not contaminate clear areas.
Protect the Aged / High Risk/Infirm and Expose the Youth
Exposing the youth is not an issue. However we must be prepared to handle it medically. The infrastructure to handle the disease even if it is mild must be put in place. The major issue is that the aged need to be protected. Social Barricading of high-risk people must be a norm for the next 2-3 years. There is no choice. We are now talking of separate transport systems, enclosures, shopping facilities, and almost everything. A parallel way of living must evolve.
Reduction of transmissibility will be a major challenge in India. The crowds are self- defeating. Unless a sense of self discipline is built in, we will all lose. Individual measures of transmissibility reduction save the self and others also. This consciousness must be built in through strategic communication.
Public measures of reducing transmissibility must be thought through, re-engineered and implemented. Workplaces must be re- imagined on a 24x7 basis. If our economy must revive, there is no other choice but to reduce crowds and movement in public places so that we can work and educate ourselves. Immigration into India must be very stringent. Travel and work places have to be seriously focused upon.
Strengthen the Testing Capacity.
We need to expand our testing network. We must go indigenous. It is hoped that the effort of Sri Chitra Thirunal Institute for Medical Sciences comes good. Unless testing is made widespread, affordable, and accessible, our fight against this Virus will be hampered. Testing helps us to put in place monitoring systems. Surveillance and monitoring go hand in hand.
Prepare for Controlled Herd Immunity
Ultimately, we must go in for Herd Immunity. However we need to prepare for it based on research and study. We also need to have extensive testing capability to trace and map the extent of the spread of the virus if we attempt controlled herd immunity. It will be a very long process at the cost of repetition.
In a metaphoric sense we have been thrust into this battle unarmed. We have reached this Frontier Sans Medicines. We have to defeat this with what we have – “The will , determination and oneness of the Indian people as a whole”. If we do the simple things right, we will succeed. We have done that so far. These could be some hiccups. That is what life is all about. There is no reason to believe that we will not succeed in future. We must put our shoulder together and say 'altogether heave' and do it the Gunner Way as you can see in this photograph below. It is of a 25 Pounder Gun with its vehicle being dragged up slope in SeLa Seector in 1962 by our determined Gunners - All Together Heaving!.