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Covid-19: weathering the storm

BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1199 (Published 26 March 2020) Cite this as: BMJ 2020;368:m1199

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COVID 19: The last straw that broke a weak camel's back

Dear Editor,

These are testing, telling and trying times. For now, it is 'weathering the storm' [1]. Dr. Godlee has aptly brought up many important points which warrant a thorough exploration and appropriate follow up action as well. Such times do make us sit up and take notice of our weaknesses and lacunae. Otherwise wasn't it hunky-dory so far.

If one steps back a little, and takes a panoramic view of the whole situation, it's seems to be a matter of weakened response to onslaught by this new Corona virus, the COVID 19. Long ago, during the HIV epidemic, I remember the severe infection with a pathogen Toxoplasma gondii in only those who were weak and had very low immunity levels. On the other hand, it couldn't work its way through in any of the healthy and immuno-competent persons, and thus confirmed its status as an opportunistic pathogen.

We must not forget that this is a time that is generally considered the season of flu. COVID 19 infection remains a mild disease in most individuals. However in the weak, frail elderly, this infection by COVID - 19 might just be that last straw that broke the camel's back. Kindly visualize this. Until now, before COVID-19 made an entry, even the elderly, frail, sick, and weak persons might have been coping up well with all these common respiratory viruses. Thanks to the influenza and pneumococcal vaccines, that are used universally in the west. However many of these viruses do have their propensity of damaging the protective ciliary action of the respiratory linings and of affecting the mucus glands. While the healthy will usually continue to fare well, it will be the frail, weak, elderly, especially those suffering from multi-morbidities and reduced immunity who may become more prone for severe attack by COVID-19. These prior events could provide suitable milieu for COVID -19 to launch an opportunistic infection.

Since the time COVID 19 has came along, there has been some panic as well. Large population is exposed to the risk of infection. But not all those who get infected by COVID-19 are going to end up in ICU, or be struggling with scarcity of ventilators, and just 2% or less have been found at risk of fatal outcome [2-3]. Here during this pandemic we are dealing with really large populations, and we are trying to take the total population under complete protective net, overlooking the availability of present resources and capabilities, and omitting the fact that not all require a protective net. This will not only make the task at hand difficult, but be wasteful as we already know that COVID-19 has been a whimper whenever it is facing any healthy individual. Doctors and other medical staff who have fallen down in the line of their duty, may have caught COVID-19 really deep in the respiratory bronchioles and beyond. This only redoubles the requirement for their personal protection, adequate rest, relief from stress, and sufficient insurance.

Let's take an example of a shipwrecked sea for better understanding . By and large it is already known that seafarers are by nature quite courageous and have a great foresight. They would also know that if unfortunately a ship packed to the brim by people starts sinking, those responsible for them would probably channelize all their energies and limited resources available at that point of time to rescue and save people who will not be make it to the shores safely by themselves. It is rather a given that many who are hale and hearty will surely be able to swim easily back to the shores and to its safety. Therefore the Captain of that ship would probably use the resources available with prudence, prioritizing them for the most needy first. Likewise, prudence is what is really called for right now, rather than frittering away the limited resources on even those who will surely be able to swim back easily to the shore all by themselves.

Imagine the plight of persons who are barely managing to stay afloat with malignancy or transplant procedures, major surgeries. septicaemia, HIV / AIDS, weakened immune system, prolonged bed ridden patients, and its consequences. major heart, lung, kidneys, liver, hematological, nutritional, endocrinal problems, etc. Modern medicine has been of help, but for how long. COVID -19 seems to be that last straw. In our haste to nail down COVID-19, we might be ignoring other factors and infections , like flu, which may be priming for bad prognosis following COVID -19 infection. Essentially all of them, Tom, Jack, Harry, and COVID-19, might be culprits in small measures, but during this pandemic, we just might be getting inadvertently biased towards labeling COVID-19 as the prime underlying cause. This new corona virus infection, COVID-19, although quite insignificant in most healthy individuals, seems to be just the last straw that appears to be breaking the camel's back.

Is it too difficult to understand who will require help and isolation until this pandemic settles down [4-5]? Certainly not the whole population. It would be logical to identify who all will require support and care, and use the limited resources without squandering them all, under duress and inability to handle panic and unreasonable demands arising due to fear. Many studies have come up pointing as to where the maximum fatalities are expected. So, won't it be reasonable to try and protect this group first ? Simultaneously iIt is also a given that outside this group, surely anyone who might require help and care won't be denied.

By now it is more or less clear who will require special care and management and isolation. Surely the healthy and all those with adequate immunity can easily be excluded. It is not that every elderly is at risk of a bad prognosis, and not that only the elderly are at risk. By identifying individuals at risk, which will be about 10% or so of the whole population, we can identify this group that is likely to have bad prognosis should they get infected by COVID -19. Since so far the fatality rate has been under check, being less than 2% in most treatment facilities, wouldn't it be therefore logical that by identifying this group who are actually at risk of bad prognosis, they be the ones who are isolated for weathering this storm? This could also be easier on the overall financial burden, while providing maximum care and the much needed protection to all those needing it.

Best regards.
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

References:

1. Godlee Fiona. Covid-19: weathering the storm BMJ 2020; 368 :m1199

2. 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

3. 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

4. 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 01 April 2020

5. Chauhan Rajesh. Covid-19 : Catch the tiger by its tail.
BMJ 28 March 2020. Available at : https://www.bmj.com/content/368/bmj.m1190/rr-1 Accessed on 01 April 2020

Competing interests: No competing interests

01 April 2020
Dr (Lieutenant Colonel) Rajesh Chauhan
Consultant Family Medicine, Geriatrics,Industrial Health, Disaster Management
Dr. Ajay Kumar Singh, MD (Med); Dr Shruti Chauhan, MDS
Family Healthcare Centre, 154 Sector 6-B (HIG), Avas Vikas Colony, Sikandra, AGRA -282007. INDIA.