A person wearing rubber gloves handles a protective face mask. Photo: leo2014/pixabay.
I have been watching with increasing concern the trend of new daily diagnoses of COVID-19 in India over the past two weeks. To me, this reflects the general public mood, which seems to have begun to ignore the threat the novel coronavirus poses.
While the good news is that the death rates in India haven’t been as bad as in some of the other countries (we might debate the accuracy of death reporting). But with a population of 1.35 billion people, the absolute numbers are still sobering – and rural India is just beginning to get hit.
What I would like to see is reliable ‘excess mortality’ figures and a ‘p’ score that will quantify the true impact of the pandemic on deaths in India. We know that Mumbai had an excess mortality of 13,000 deaths between April and July 2020. We don’t yet have data for India as a whole.
Let’s look at new daily diagnoses trends in India, spaced a month apart (from today) for context:
March 11 – 10
April 11 – 1,035
May 11 – 4,213
June 11 – 9,996
July 11 – 27,114
August 11 – 53,601
September 11 – 96,551
These are worrying numbers.
This is when and how long we have taken to cross each million (cumulative cases):
1st million – July 17 (168 days)
2nd – August 7 (20 days)
3rd – August 23 (16 days)
4th – September 5 (13 days)
5th – September 16 (projected to be 11 days)
There are four known ways we can control deaths from this pandemic:
1. Prevent – Masks, physical distancing and hygiene
2. Prevent – Vaccines
3. Decrease transmission – Test, isolate, treat
4. Treat – Drugs, hospitalisation
Thanks to some concerted efforts, we have considerably scaled up our testing, though we could still increase the availability of diagnostic testing in tier III cities and villages. I doubt, however, that we will ever be able to conduct mass population-testing of all asymptomatic individuals.
We need to dispel myths about testing too. A popular belief is that anyone who has come in contact with a confirmed COVID-19 patient needs immediate testing. But the fact is, what high risk contacts really need is quarantine, with testing between day 5 and 14 of exposure.
We could certainly try and ramp up our treatment facilities, and rationalise hospitalisation. Triaging the need for hospital admission, oxygen beds and ICU care makes sense when the infrastructure is inadequate. However, the lesson for the future is urgent reform of healthcare systems.
COVID-19 has been a wake-up call for improving healthcare in India. Our investment in public healthcare facilities needs to at least double in the next two years, and quadruple in five years. Linking quality to government hospitals is key, making them the go-to for the common person.
Treatment strategies – in spite of the thousands of trials – have been fairly disappointing for COVID-19. With the exception of steroids (to decrease mortality) and to a lesser extent remdesivir (to clear the virus from the body faster), there have been no dramatic proven therapies.
The COVID-19 epidemic has also taught us not to jump the gun with ‘promising’ therapies. From hydroxychloroquine to convalescent plasma therapy to other drugs (including monoclonal antibodies and other antiviral substances) – all of these were touted as “proven” treatment options only to be debunked by randomised trials.
When you look at the hundreds of thousands of patients treated by these drugs, I can’t help but think what a wasted opportunity it has been. The UK prioritised the RECOVERY trial as one large, pragmatic trial where all patients would be enrolled, and see what they have achieved.
What we need to do in India is to make sure we don’t get carried away with unproven claims and allow the desperation of the pandemic to “do something” and use ineffective drugs to treat. That is just a wasteful use of resources when we already have significant constraints.
This brings us to prevention as a strategy to control the pandemic, which is clearly the best option now – and has always been so. There are 160+ vaccine candidates, and 26 are in human trials. Vaccines are great but they are not a panacea for various reasons.
First, vaccines need to be proven to be safe and effective before being used at the population level. This takes time. Second, even after a vaccine has been proven to be effective, it takes time to manufacture enough doses to cover the world’s population – and to make them available at a cost all countries can afford.
Finally, we are not really sure how effective the vaccine will be. We all hope that it will provide effective immunity to protect from subsequent infections, but we can’t base our entire strategy on that. This then leaves us with basic precautionary measures – not glamorous, not high tech, yet likely the only things we can bank on to reduce transmission, and finally control the pandemic. We need to pay attention to the three Ws – wear masks, watch your distance and wash your hands.
Strangely, and paradoxically as the pandemic has progressed, we seem to have de-emphasised our messaging on following these simple yet effective measures. When we had a thousand new diagnoses per day, we were extremely careful. We didn’t step out of our homes, wore masks when in public, maintained physical distance and washed our hands frequently. Ironically, with more than a lakh new diagnoses each day, we have thrown caution to the winds.
People seem to have equated the government lifting lockdowns to the virus not being a problem any more. But nothing could be further from the truth, as the numbers above show. We need to de-link the two.
We need to get our messaging right now. We are seeing the highest number of cases, the highest number of daily deaths than ever before in this pandemic. Now is the most dangerous phase we have had during the pandemic thus far, and this is no time to let our guard down.
While lifting the lockdown was, and is, necessary, adherence to basic precautionary measures is crucial. We just can’t afford to ignore this. We need to widely disseminate the need for the three Ws: wear a mask, watch your distance, wash your hands.
This article was originally published as a thread on Twitter, and has been compiled and published here with the author’s permission.
C.S. Pramesh is the director of the Tata Memorial Hospital, Mumbai.