Covid-19 risks and response in South AsiaBMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1190 (Published 25 March 2020) Cite this as: BMJ 2020;368:m1190
All rapid responses
Thanks for the article highlighting the deficiencies of the SAARC nations particularly India. I agree that successive Govts have not the shown interest in bolstering health care. Every year the budget allocation is becoming less and less, and the corporatisation of heath sector is increasing by leaps and bounds. Very unfortunate for the country and the people. But historically India has done very well in the management of acute crisis. Present situation for COVID19, the Govt has taken the action a bit late and but sternly. Also at times it looks that it was in haste, looking at the migrant labour problem, but it had no option. Looking at the mathematical model on which every expert is predicting the disaster for India, instead of educating a scare has been created. The infectivity and the mortality figures give hope that India will not get into the situation others have gonr through. I may be wrong. But our population is still young and as the COVID19 disease picture says 80% of the infections cure by themselves.
Unfortunately the present situation of fear could have been avoided if the leaders and the experts had come out of their offices and spoken to the poor. Contribution from our premier science institutes to India health is also not that great. India has not had any major disasters in recent times. Hence preparedness and cooperation from the citizens is difficult to expect. But there's excellent response from villages for the lockdown. Success of this lockdown will be known in another two weeks. Probably there is truth in the UK chief scientific advisor's words, "for healthy people getting a mild illness would help to build up their immunity and if more people became immune it would reduce the virus transmission". This may come true for Indians?
Even the United States and United Kingdom are not following the WHO guidance, which is aggressively test, track and isolate as many cases of COVID19 as possible. Then why blame India with limited resources and health infrastructure? COVID19 incidence may act as a game changer for health infrastructure.
1.COVID-19: what science advisers must do now - Nature | Vol 579 | 19 March 2020
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The Pandemic at Our Doorstep
The COVID disaster is here. Not tiptoeing in, not insidious but loud and in our face. A mass disaster that, unlike a typical mass disaster, is giving us an opportunity to watch it replay its ravages in one country after another.
But as we await the first tide, I feel a sense of forboding. It is not the apprehension that you feel in the emergency room when a mass casualty occurs nearby and you are asked to be prepared. It is a different fear and I am a different combatant in this unusual battle. The fear arises mainly from the constantly evolving picture of this virus. Despite the trans continent threat, despite the death and sickness across the board and despite adequate warning, a coordinated world response is missing.
Several questions keep my mind busy as I visualize various case scenarios.
1. Should we spend the relatively scarce money on ventilators or on the personal protective equipment for the medical staff who will be in the trenches fighting this still relatively unknown and evolving enemy.
2. As a traumatologist, I want to participate in the response. But I worry that my years of reliance on ATLS and trauma algorithms might become a hindrance.
3. Our desire has always been to institute the current best practices in similar situations. But with anecdotes, papers, opinions and multiple social media feeds jostling in my mind, how do we find a relatively safer path for our patients?
4. What do I tell my family? There are children growing up in times of ‘jingoism’. They expect crowds egging us on, cheering us. We tell them that we may need to be ‘home quarantined’. We tell them, that we are the only ones who can fight this fight. The younger ones say that everyone wants to be a soldier during war, so what kind of war is this?
5. I want to stand alongside my colleagues and want to contribute to the defence. To fight for our patients. To contribute to humanity. But this is the rare occasion when the caretaker could become the carrier.
6. We seem to have no clear Exit Strategy. Total lockdown with the sheer logistic and economic burden cannot be carried on indefinitely. Stocks might dwindle, shortages will accumulate and then with the sick, the starving might also suffer.
7. It seems quite clear that lock downs and social distancing only flatten the curve with the numbers below the curve remaining the same. What does social distancing mean for the society in the long run?
8. The elephant in the room is the economy. Longer lockdowns and its effects on national and global economy worry me no end. Is this the end of the world as we see it?
9. Quarantine and isolation of the high-risk elderly population and those who have a history of contact seems reasonable. But it pains me to see cultures trampled and science putting out a future blue print. Are the elderly the victims of today and the Typhoid Marys of tomorrow?
10. Is anyone devising systems and protocols that could be put in place for most balanced and advantageous use of the limited medical facilities available in our country, especially focusing on protecting the frontline health workers so that they can continue to carry on the thankless jobs of saving their colleagues?
11. What goes through the minds of people donning and doffing PPE? In spite of care they might not be safe. I hope my fellow professionals do not feel like unarmed foot soldiers without basic mine detectors in a mined battlefield.
These and many other thoughts swirl in my mind. I am, however, hopeful that I and my colleagues will we be able to tread the fine line between recklessness and caution that is so necessary under these circumstances.
[ WITH INPUTS FROM DR SHABIR A DHAR SKIMS MC BEMINA]
DR L PRAKASH
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This editorial is just what was needed. Our thanks and compliments to all the authors . For the South Asian region, poverty as well as the economic health of the governments are the important issues, which must be considered when we discuss, suggest, draft, or finalize any course of action.
Starting how and from where in the world COVID 19 had first started, point number one is that no one would like to eat a rotten rat, snake, left over carcasses, or a spoiled fish, if poverty wouldn't have prevented their access to fresh bread. If only people had adequate fresh food and water, COVID 19 wouldn't have started.
Our second point is that we are ignoring and discounting the expertise and experience of the doctors and healthcare personnel of this whole region, the South Asia. Experience gained from other countries will be of tremendous help. Many deaths can be prevented, and many unfortunate adverse outcomes due to overtreatment, ignorance or inexperience. Now we know that just a Paracetamol or Acetaminophen occasionally, along with rest and self isolation until 3 days after being asymptomatic, would just be fine for most patients infected with COVID 19. Use of cough suppressants is to be avoided, as that will only aggravate the congestion of lungs, which is obviously the main problem with COVID-19. Ventilators may not be useful in already packed up lungs.
At the cost of reiteration , third point is that unlike Ebola, where both the infectivity and fatality rates are very high, while COVID 19 has shown a markedly high degree of infectivity, the fatality rate is luckily quite low. It ranges from about 2 to 9 percent. Essentially, not all those infected will die, and with caution, prudence, and good care, this total may be just about 1 to 2 %, coming from the Group A (as described below).
Fourthly, we already know from a recent data that has been published in JAMA  and another one from the BMJ  as to the type of patients succumbing to this pandemic of COVID 19. Mostly some of the elderly patients have other co-morbidities as well, and thus they are more likely to take the hit. By far we also know that all those with preexisting serious illnesses, malignancy, low immunity, HIV/ AIDS, organ recipients, on immunosuppressant and steroidal therapy, morbid obesity, severe malnutrition, preexisting heart and lung diseases, compensated lung, heart, liver, kidneys, or uncontrolled diabetes, perhaps pregnancy, hospitalized patients, etc, will be vulnerable. In these cases perhaps mortality rate may be high. Let's call them as Group A for better understanding of what I have to say further. We must also include all healthcare workers and care givers into this list of those vulnerable.
Our fifth point is that, God forbid, if just for example let's assume for an instance the worst case scenario for our region is at 10% mortality. Now wouldn't it stand to reason and be more meaningful to give maximum healthcare and preventive coverage to this set of people (Group A), so that the mortality can be kept as low as possible, without frittering away our limited financial and healthcare resources as the remaining 90 % who will just be fine with mild to moderate sickness that will clear off by itself usually within 7 to 10 days. These are by and large healthy individuals, and for convenience of understanding my point, let's talk of them as Group B. From the available literature, they will likely have few symptoms that are mild, and would require rest, self isolation until three days of being asymptomatic and afebrile. However, they can always fall back on the available healthcare facilities should their condition deteriorate, which is possible, but very unlikely. It would therefore seem appropriate to allow them to continue to work as well without isolating them when they are not sick.
Now that we have nearly identified all those who will be more prone for bad prognosis, this brings us to our sixth point. Won't it be logical to identify this group first (Group A), and get them fully isolated, and make them as safe as possible, rather than imposing a full lockdown on all or on most towns, cities, states, etc.
Our seventh point is that rather than spreading thin all the resources, let them be concentrated on about 30 to 35 % of the population that comprise our Group A, who might have a bad prognosis if not given special care right from the start. This way the governments will not go overboard on their precarious budgets. Unnecessary panic will be lessened as complete population will not be mandatorily isolated.
Our eighth point is that policy makers must realize there is no vaccine or any cure in sight as yet. Vaccines, whenever they come, will be coming at a cost. It will be required for Group A, but do we actually see a need for a vaccine for those in Group B, where 90 % patients who will be already OK by the time we count the seventh day of this sickness. Here the sickness is anticipated to be mild, as has been the experience elsewhere in otherwise healthy individuals.
The ninth point, and also the final point as of now, is that gradually we will be going to have a huge population forming up Group B, who would eventually gain active immunity, and would be the harbingers of the much needed "herd immunity" against COVID-19. This in turn will be protective for the frail and the weak of the Group A. This herd immunity, attained actively, would possibly work well for the posterity as well.
The general population somehow feels that anyone catching this infection is bound to die. This is also the reason for the chaos and panic. We need to put it straight to the masses that more than 90 to 95% of those found positive for this COVID 19 and all their contacts will get well and recover fully within a week or so. Total mortality will be just about 1 to 2 %, or maybe a little less. It will be prudent to advise the policy makers to let the people of Group B continue working, rather than confining them by a lockdown. Should they catch COVID 19 infection, they will need to accept treatment under a healthcare professional's care and guidance, plus self isolation until afebrile and asymptomatic for a continuous period of three days. On the other hand, limited and therefore manageable Group A can be given special protection and care, right from the start.
Dr (Lieutenant Colonel) Rajesh Chauhan
MBBS (AFMC), Master in Medicine (CMC Vellore), PGDGM (Geriatric Medicine), PGDDM (Disaster Management), AFIH (Industrial Health), DFM (Family Medicine), FISCD, ADHA (Hospital Administration) & LLB
Dr. Ajay Kumar Singh, MD (Medicine)
Asst Professor, Department of Medicine,
Index Medical College, Indore. India.
Dr. Shruti Chauhan, MDS
Reader, Index Dental College, Indore. India.
1. Bhutta Zulfiqar A, Basnyat Buddha, Saha Samir, Laxminarayan Ramanan. Covid-19 risks and response in South Asia BMJ 2020; 368 :m1190
2. Chauhan Rajesh. COVID 19 : Fresh approach, initiative, and opportunity. BMJ 24 March 2020. Available at : https://www.bmj.com/content/368/bmj.m1141/rr-4 Accessed on 26 March 2020
3. Onder G, Rezza G, Brusaferro S. Case-Fatality Rate and Characteristics of Patients Dying in Relation to COVID-19 in Italy. JAMA. Published online March 23, 2020. doi:10.1001/jama.2020.4683
4. Chen Tao, Wu Di, Chen Huilong, Yan Weiming, Yang Danlei, Chen Guang et al. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study BMJ 2020; 368 :m1091
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Bhutta et al's editorial highlights not only the "glaring gaps in public health preparedness for infectious disease outbreaks in South Asia" but a general neglect of health systems in the region. The countries of SAARC have one of the poorest health and social indicators in the world. India and Pakistan may be nuclear powers, but for over 70 years they have been locked in a senseless and never-ending conflict over Kashmir and a cycle of hate and malevolence that has drained vital resources that could be invested in health and social development. "Sharing accurate information and best practices in real time" is unlikely to happen unless there is peace and understanding in the region and a political framework that allows free communication and movement of people in the region.
In his book "The Plague" published in 1947, Albert Camus wrote that “It may seem a ridiculous idea, but the only way to fight the plague is with decency.” If there is any lesson to be learnt from this crisis, it is that all lives are precious and ethics, morality and "decency" must take center stage in all our decision making. There is no place for narrow minded nationalism or religious fanaticism in this interconnected and globalized world.
Competing interests: No competing interests