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Feature Global Health

Covid-19: how doctors and healthcare systems are tackling coronavirus worldwide

BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1090 (Published 18 March 2020) Cite this as: BMJ 2020;368:m1090

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Rapid Response:

To err is human, to dither in face of insurmountable evidence is folly

Dear Editor

As highlighted by the interview of Dr Giridhar Babu of Public Health Foundation in India in the article by Tanne and colleagues, the Indian response has, till recently, been perfunctory, dilatory and inadequate.[1]

To err is human, to dither in face of insurmountable evidence is folly. On 19th March 2020, the apex medical organization in-charge of managing COVID-19 in India, the Indian Council of Medical Research (ICMR), stated that there is no evidence of community transmission, based on 826 random samples tested, due to which mass public testing has not begun.[2] In a nation of 1.3 billion individuals, such conclusions from a small, non-representative sample fly in the face of numerous reports of people with suspected disease fleeing isolation nationwide.[3] These cases, moreover, had only begun to be documented when screening policies for all incoming travellers commenced on 4th March, prior to which incoming flyers from many currently affected countries had gone unscreened.[4] In addition, the Indian Railways, a critical transport system for people of low and middle socio-economic system, also found, on testing passengers of two trains, that COVID-19 positive cases had travelled by them prior to 19th March.[5] In light of the above facts, it is difficult to repose trust in the statement of ICMR, and thereby, the Indian response, wherein suppression of negative news seems to have been the mainstay till now. Additionally, the ICMR's approach of slow and selective testing has also publicly gone against the World Health Organization (WHO) recommendations, resembling prior handling of the severe acute respiratory syndrome (SARS) epidemic by Asian countries where public denial and administrative inaction resulted in an undue spread of the epidemic.[6,7]

Poor isolation, containment and handling facilities nationwide have resulted in a rapid on-ground spread of the infection, unfortunately still not being recognized officially, with treating physicians at my institution becoming infected.[8] Due to a nationwide lack of personal protective equipment (PPE), more such morbidity and mortality should be expected, as illustrated by the recent death of a frontline physician in Pakistan.[9,10]

While Italy, with the highest number of deaths, has faced significant challenges in resource allocation despite having a functioning healthcare system, the Indian system is already stretched thin with a ratio of one doctor per 11,600 individuals.[11] As stated well by one of the foremost epidemiologists of the country, India is likely to witness an upcoming explosion of COVID-19 cases.[12] Many of these may be anticipated to be fatal due to lack of ventilator beds; since ventilator bed occupancy has historically been over 90% in public hospitals even before the pandemic. This surge of cases, coupled with the pre-existing massive healthcare inequity, may result in the requirement of humanitarian aid. International aid agencies would do well to prepare to lend extensive support to developing countries, especially India.

References:

(1.) Tanne JH, Hayasaki E, Zastrow M, Pulla P, Smith P, Rada AG. Covid-19: how doctors and healthcare systems are tackling coronavirus worldwide. BMJ. 2020:18;368:m1090. doi: 10.1136/bmj.m1090.

(2.) Tiwari S. As Government Denies Coronavirus Community Transmission, Experts Say Too Few Tested To Know. Bloomberg Quint [Internet] 2020 Mar 20 [cited 2020 Mar 23]; News:[about 4 screens]. Available from: https://www.bloombergquint.com/coronavirus-outbreak/as-government-denies...

(3.) Furquan Ameen. Why people are fleeing isolation units in India. The Telegraph [Internet] 2020 Mar 20 [cited 2020 Mar 23]; News:[about 5 screens]. Available from: https://www.telegraphindia.com/india/coronavirus-why-people-are-fleeing-...

(4.) Coronavirus: All international arrivals to India to share travel history at airports. The Economic Times [Internet] 2020 Mar 4 [cited 2020 Mar 23];News:[about 2 screens]. Available from: https://economictimes.indiatimes.com/news/politics-and-nation/all-intern...

(5.) 12 passengers who travelled by two different trains test positive. ThePrint [Internet] 2020 Mar 21 [cited 2020 Mar 23];News:[about 2 screens]. Available from: https://theprint.in/india/12-passengers-who-travelled-by-two-different-t...

(6.) India's poor testing rate may have masked coronavirus cases. Al Jazeera [Internet] 2020 Mar 18 [cited 2020 Mar 23];News:[about 4 screens]. Available from: https://www.aljazeera.com/news/2020/03/india-poor-testing-rate-masked-co...

(7.) Jones DS. History in a Crisis - Lessons for Covid-19. N Engl J Med. 2020 Mar 12. doi: 10.1056/NEJMp2004361. [Epub ahead of print].

(8.) Lucknow doctor tests positive after coming in contact with 2 coronavirus patients.The Economic Times [Internet] 2020 Mar 18 [cited 2020 Mar 23];News:[about 2 screens]. Available from: https://economictimes.indiatimes.com/news/politics-and-nation/lucknow-do...

(9.) Pakistan Doctor Dies Amid Strike Threat Over Lack of Protection. The New York Times. [Internet] 2020 Mar 22 [cited 2020 Mar 23];News:[about 4 screens]. Available from: https://www.nytimes.com/reuters/2020/03/22/world/asia/22reuters-health-c...

(10.) Aarefa Johari. Investigation: Crucial coronavirus gear supply clouded by allegations of government ‘malintention’. Scroll.in. [Internet] 2020 Mar 22 [cited 2020 Mar 23];Investigation:[about 8 screens]. Available from: https://scroll.in/article/956866/investigation-crucial-coronavirus-gear-...

(11.) Abantika Ghosh. One isolation bed per 84,000 people, 1 quarantine bed per 36,000: Govt data. The Indian Express. [Internet] 2020 Mar 22 [cited 2020 Mar 23];News:[about 3 screens]. Available from: https://indianexpress.com/article/coronavirus/one-isolation-bed-per-8400...

(12.) Arunabh Saikia. Interview: ‘Suppression won’t work in India. Slow down the coronavirus. This will be a long haul’. Scroll.in. [Internet] 2020 Mar 22 [cited 2020 Mar 23];Interview:[about 8 screens].https://scroll.in/article/956932/interview-suppression-wont-work-in-indi...

Competing interests: No competing interests

24 March 2020
Ahmad Ozair
Medical Student
King George's Medical University, Lucknow, Uttar Pradesh, India
B-27, Street-4, Silver Oak Avenue, Dhorra Mafi