To win a war, it is important to understand the enemy first. COVID 19 has devastated the World, the rich, the poor affected equally. The best of the health care facilities around the world, could not cope with the load. Efforts have been made worldwide to understand the virus, its nature, virulence, treatment options, measures needed to prevent spread, vaccine development, and economic implications.
What went wrong?
Going by the statistics which are available worldwide, the fatality rate is the same as the other flu viruses, but why did it bring the whole world to a grinding halt? The earlier pandemic H1N1 did not bring the world to a halt. This is because the CDC in the US did a wonderful job identifying the first two cases that were reported and the WHO has been alerted. This time the country of the origin of the virus has a dubious record of transparency and freedom of the press. The nature of the origin of the virus, whether from the lab or natural mutation of the virus should not be debated now, our focus should be fighting the virus together. Due to the delay in reporting the virus to the WHO, more damage occurred worldwide as the virus spread to various countries before surveillance could be done. As a part of Globalisation, frequent travel by the people took the virus to various countries. Had the WHO been intimated early, early testing of those traveling from China would have averted such a disaster. The Chinese and The WHO should be accountable for the delay in reporting the pandemic.
How did Europe recover so quickly?
The European countries are slowly opening, and they have even restarted the Soccer leagues like Primer League, La Liga, etc. The European countries were severely impacted, but they are now doing their business, as usual, they could bend the curve within 30 days of imposing lockdown. This was possible because their approach to the pandemic was scientific and done under the supervision of those concerned with the Medical Department.
Did India press the Panic button rather than being Cautious?
The government of India went into a state of panic after seeing the reports from the rest of the world, where the best of the health care facilities was put to test. There was a sense of panic among the Doctors also. The Government ordered to shut down all the private hospitals.
Why hasn’t India flattened the curve?
This is because we haven’t tried to understand the enemy. Early identification of the case, isolate the case, track the contacts is the aim, goal, and objective. For every aim, we need to have a road map. The road map is to do more tests. For the size of the population that India is having, we should be doing 5 lakh tests per day from day 1. If we had done tests on that scale in the early stages we could have identified the cases early and prevented further spread and reduced the number of cases. We could have come out from lockdown at an early stage, thereby reviving the economy at an earlier stage.
It has been more than 3 months and India, is struggling to flatten the curve, each day we are setting a new record number of cases, this is because we have ramped the testing facilities. Now it has reached a capacity of 2 lakh tests per day after 3 months of imposing the first lockdown.
Who should be the think tank in the war room?
No war has a constant strategy, it keeps changing according to circumstances and you need a think tank to do that. In India, the think tank was under the control of the Ministry of Home Affairs and all the orders are being issued by the MHA, rather than the Ministry of Health and Family Welfare. The central point of the Think Tank was from the ICMR, a premier research institute but it does not have any clinical experience. There are various associations of practicing doctors like, Association of Physicians of India, Paediatricians, ENT surgeons and Microbiology (Virology), these are the people on the ground who should have been fighting the war on COVID 19, they were nowhere to be seen and are made to be indoors at a time when they are vital in facing the pandemic.
Lacking Care and Compassion
The way the persons and family members who tested positive for the virus were treated is very crude. Two ambulances and a few police jeeps come to pick up them is a horrific scene for their kith and kin, neighbors, and colleagues. This is a disease with a recovery rate of over 97%, hence asking those who were tested positive, to self-isolate would have been sufficient and humane. This also increased more fear psychosis among the common public.
Wherever a case has been recorded, the local administrators have put severe restrictions on the movement of people and economic activity. There is no scientific basis on doing so because the virus does not travel more than 2 meters in the air. What this has done is a severe economic crisis for daily wagers, and those working in the informal sectors. Most of them are having twice a day meal, due to reduced income.
Apart from this, the administrators have been using various chemicals for disinfecting, spraying aerosols in the air, which is totally unnecessary and in fact harmful to public health. The recent article “Taking the right measures to control COVID-19” by Collaborative Innovation Centre for Diagnosis and Treatment of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China (YX); and the University of Cambridge, Department of Medicine, Addenbrooke’s Hospital, Cambridge, UK (MET), published in The Lancet, Vol 20, May 2020 stresses the above measures are unnecessary and may harm the health of the public.
Enlightening the people
The people have been under severe anxiety and stress about the virus. The teachers who have been idle should have been used to spread awareness among the public, remove the fears, teach them appropriate measures to stay safe. Most of the people still don’t know why they have to wear the mask, wash their hands, and the idea of physical distancing.
Confusion with the available drugs for treatment.
Coronavirus is a fast replicating virus like the other flu viruses, hence specific antiviral therapy, will not be effective. Various countries used drugs like lopinavir, ritonavir, favipiravir for oral therapy. The first two drugs have been in use for HIV medications for a long period of time, hence we know, what are their side effects and most of the practicing is comfortable using them. The next thing is that the first two drugs are one-tenth of the cost of the newer favipiravir. Favipiravir is costly and it is new to the doctors who are prescribing it, side effects are unknown. Remdesivir is the drug used in the patients in the ICU. Its efficacy will be known with the progress of time and more data analysis from various countries.
The virus in the body will trigger antibody response, once the antibodies are formed, the antibodies will do a surgical strike on the virus causing no harm to the host body. Since we do not have immune memory for the new virus, the body immune goes into a panic situation and causes something called cytokine storm. These cytokines are chemicals, when produced in adequate numbers and controlled neutralizes the virus. Since their production is in large amounts and uncontrolled it causes damage to the host body organs like lungs, liver, kidneys etc. In these situations, our own immune system damages our own body. In these conditions, as a part of the sepsis protocols steroids are used to reduce the cytokine storm. Of these, Dexamethasone, a low -cost drug has been found to be effective.
In the sepsis conditions, there will be a state of hypercoagulability, causing blood to clot, thereby causing damages to various organs. During this stage, anti-coagulation drugs are used.
Broad-spectrum antibiotics are to be used in sepsis patients. Organ supportive measures like a ventilator are used for lung failure and dialysis for kidney failure.
(Dr Raghava Gundavarapu MD is a practicing physician from Ongole, Andhra Pradesh)