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Rapid response to:


Covid-19: India imposes lockdown for 21 days and cases rise

BMJ 2020; 368 doi: (Published 26 March 2020) Cite this as: BMJ 2020;368:m1251

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Rapid Response:

Re: Covid-19: India imposes lockdown for 21 days and cases rise

Dear Editor

It is quite clear now that that the process of self-isolation/lockdown only flattens the curve. The area under the curve remains the same. In other words, the same number of patients will fall sick but over a longer period of time. So, the current plan is to reduce the load on the health services only. Perhaps try and push part of the curve towards summer and hope for the best.

Basically, an effective medicine or a vaccine is needed.

Also, as viruses are relatively unpredictable, it might decide to mutate and disappear. This is the imponderable or unpredictable. That is where prayers come in.

But the developing world, where I live and practise, presents its own challenges.

We must remember that in the developing world we are not able to save patients with high injury severity scores under normal circumstances. In comparison this is a greater challenge in numbers and perhaps in severity.

Naturally, under such circumstances, our triage threshold will become significantly lower. This is worrisome because of the numbers that we are talking about in the subcontinent.

Most of the hospitals in our part of the world are not aware of their surge capacity. It needs drills and assessment and planning in ‘peacetime’. I have a sneaking suspicion that we, in the developing world, might already be working above our hospital surge capacity on routine days.

One might suggest some means by which the pandemic might be combated better in our circumstances.

1. Clear plans of management and clear chains of authority at the hospital, state and country levels. We might have leaders who are obeyed by most people. At the same time, we certainly have many doctors especially public health specialists and infectious disease specialists who could explain the future course of the disease better. It is a difficult choice. Should the popular figures speak or the more inherently knowledgeable ones? Perhaps it is time to share the stage.

2. As India and Pakistan apply opposing strategies to combat the virus, a lockdown appears to be the better bet at this moment. However, how does a country exit the lockdown without risking another surge? Perhaps it is important to allow some geographically isolated states to come out of the lockdown first whilst deploying medical resources there. This model could be applied to the rest of the regions gradually. After all herd immunity is the only exit strategy at this moment.

3. Religion. It is the only thing that will keep doctors and paramedics working at the frontlines. A significant number is scared. As part of the healthcare system here one feels a palpable sense of dread in a part of the medical community, especially considering the figures coming out of Italy. Heroes are good, as long as they are on the other side of the fence in these circumstances.

4. Rather than go for spectacular innovation in ventilators and high-end equipment as many propose, it would be better to innovate in low end personal protective equipment. This would include innovation in plastic barriers between a suspected patient and the screening doctor, low cost plastic mask frames, plastic shoes and coveralls.

5. Finding and instituting best practices. In an era where social media can ferment riots, the barrage of forwards causes great confusion in the average medical practitioner. It is important to have a single source at the state level which can provide relevant information and address pertinent issues. This should be constituted by a mixture of medical specialists and bureaucrats. The bureaucrat heavy approach can be tangential at best. At present social media is adding to the confusion in the midst of an avalanche of information. It feels like drinking from a fire hose.

6. Involving psychiatrists. The era of rumours seems to be back. The primitive response of trying to save oneself at a visceral level is visible in the areas where the patients or the doctors at the forefront of this fight reside. It is important to put forward the viewpoint of the patient. The public should know that there is a huge difference between Isolation, quarantine and ostracization.

Competing interests: No competing interests

26 March 2020
Shabir A Dhar
SKIMS MC, Bemina, Srinagar, Kashmir.
SKIMS MC, Bemina, Srinagar, Kashmir. INDIA.