As the coronavirus disease (Covid-19) spreads rapidly across the world and India, and health care systems are being brought down to their knees, the general sense is that social distancing (SD) will contain the virus. But the evidence shows that in India, SD may not produce the results we want. At the moment, the educated understand SD, but those who lack the requisite educational background and belong to the marginalised segments are unable to grasp its importance and practice it. This is why we need to go beyond SD. The advice coming from China, Italy and other affected countries, processed and packaged by epidemiologists and data scientists, has led authorities to prepare for the worst-possible situation. Moving rapidly, they have instituted a level of prevention we have never seen earlier in health care. Bear in mind that India is a country where primary care and preventive medicine has always been inadequate.
Let’s first critically examine the ground reality before we assume we are on the right track, as the stakes are high and failure is potential devastation. Here are the challenges. One, while SD will go down as the phrase of the decade, we are still not sure about the extent of SD needed to create the desired effect. What is the threshold that humans have to be kept away from each other to stem the spread? Is shutting down schools, offices and malls enough? If you walk around, you will see that people continue to mingle at uncomfortably close levels. This happened even during the janata (people) curfew on Sunday. Social distancing is difficult to implement among the poor where masks, sanitisers and any duration of isolation is a pipe dream, and home/community over-crowding is a way of existence. Two, what is the duration for which SD needs to be maintained? The answer changes based on the information of the spread coming daily, which is a function of how successfully SD was done and testing. If SD is successfully done, the disease will be curtailed, and if done half-heartedly, SD will not produce positive results.
Three, there is evidence to show that Covid-19 maximally impacts the elderly and those with chronic diseases, but the spread in various socio-economic strata, especially the poor, does not appear to be defined. In India, this is our nightmare with similar terrors such as tuberculosis, malaria and dengue being marginally controlled at best due to overcrowding and poverty. We do not have a great track record of controlling infectious diseases.
Four, we also do not have enough kits in the country (or anywhere in the world) to find the true disease denominator. With a 1.3-billion population, a policy of “limited utilitarian testing” has been recommended, which is changing rapidly. The disadvantage of the policy is that we are not only undermining the information we need to define this pandemic’s penetration and nature in our country, but also isolating people who may not have the disease.
Five, we have a heterogeneous and ill-defined health care system that varies in infrastructure, skills, and economic strength. Nursing homes, small hospitals, government hospitals and corporate hospitals are dissimilar in their services and quality, a major factor impeding planning in a pandemic such as this — we have to factor this in the planning process. And six, caring for sick in-patients is by far the weakest link in managing the disease. Infrastructure, health care personnel and personal protective equipment (PPE) are the three pillars of management in the in-patient setting. If we reach the stage for massive deployment of health care, there is negligible isolation infrastructure, no comprehensive health care personnel plan for deployment and attrition, and not enough PPE available. An intact health care community is imperative to tackling the crisis, and without PPE this is an impossible task. What are the measures we need to take to get the PPE train in order and have Covid-19 centres that can deliver safe and quality services? Radical measures include ramping up PPE production and supply. Managing Covid-19 centres, due to the need for trained health care personnel, PPE and high infectivity are more challenging than running even the best of hospitals.
In the backdrop of this unprecedented worldwide crisis, here is what is necessary.
The first is a central PPE distribution system with military precision and implementation to ensure there is no waste. The second is an emergency PPE law enacted for production, distribution and utilisation. Third, as drugs and vaccines develop for this infection, a similar strategy needs to be followed to ensure they get to those who actually need it.
Fourth, Covid-19 centres must be audited and approved by an external team of experts to ensure no short-cuts for personnel/PPE have been taken. Fifth, the judicious use of all resources to plan for the long haul, as the epidemic may stretch for weeks as in other countries — we are seeing burn-out in Covid-19 facilities worldwide. Sixth, the system has to allow patients with non-Covid-19 issues to be taken care of without the risk of cross-infectivity. And seventh, there is an urgent need to create an ombudsman for Covid-19 preparations. The ombudsman must be empowered and supported by the government and people alike.
The time to move is now like never before.