A fiction can run around the world before the fact has got its boots on. Whom to follow, the David or the Goliath?

April 4, 2020

By – Dr Santhosh Kumar Kraleti
(Foot Soldiers for Health)

This is for discussing with you about the big picture and global figures to understand the truth about COVID19. Lot of people, especially, those who are well educated and also with science backgrounds are spreading fiction as a fact. For e.g., “The COVID19 in India is a less virulent,mutated strain whereas the strains in other countries belong to a dangerously virulent strain”.The second powerful captivating fiction is “Summer and hotter climates have a mitigatory effect on the epidemic and virus.”

We are very early in the game to predict or prove or deduce, for e.g. To rightly put across, we are right now in the first 10 overs of the first innings and trying to bet on who would win! Whoever has stated or vouched for these captivating fiction needs to do a lot of research before guiding or misguiding. “It is a capital mistake to theorize before one has data.” said Sherlock Holmes or probably Dr Arthur Conan Doyle. As far as we know, data speaks and shall speak for itself.

The spread of the COVID19 depends on these points in the same order of influence based on some hard facts enlisted below.

(1) “The more you sweat in peace, the less you bleed in war”. Are we well prepared in peace times, when there is no epidemic? Has our country learnt lessons and is it geared up after Dengue, Malaria, Japanese Encephalitis, Nipah, Swine Flu (H1N1) and SARS? “Why should we look to the past in order to prepare for the future? Because there is nowhere else to look.” said James Burke. China where the current pandemic has all begun has had a mortality of 4.1% with 3,329 deaths and 81,669 positive cases. Hong Kong, sitting next to the giant China, the epicentre of current quake has just 900 odd COVID cases and 4 deaths as on date.So,whom would you admire, the David or the Goliath? The history lessons of epidemics have always helped win the war against newer diseases. China had a bad experience in 2002-03 in the SARS epidemic where around 350 lives were lost and again in 2009-10 during the Swine Flu (H1N1) pandemic where around 900 lives were lost. Hong Kong was also hit very badly in 2002-2003 with SARS. More than 300 lives were lost and the international economic hub was affected badly. Hong Kong again had a jolt in 2009 during the H1N1 pandemic and roughly 80 lives were lost. They learnt it the hard way after SARS. Same with Singapore. They had more 33 deaths due to SARS. They also had learnt immensely from the SARS epidemic. These countries have built early responsive Health Promotion Boards so that most of the population is actively tracked to keep themselves healthy and to protect themselves from any epidemics or any co-morbidities. They have built one of the world’s best, proactive and smart health care systems. They also have strong surveillance systems. An active enrolment of all the people through their health systems and all the preparations for a disaster is done on regular basis. Regular mock drills, preparations for evacuations, earmarking the probable quarantines, keeping a reservoir of health care equipment and work force ready exactly like a reservoir of F16s which are kept ready for a war situation. To remind us all, India had also suffered and lost more than 2000 lives due to H1N1.

(2) Early responsiveness, decisive and timely steps by Governments on key decisions like Lock/Shut Down or on restrictions and social distancing. The Government and the national health team must know the right time to put a comma or a full stop to the movement of people (carrier or vector). It is a trade-off between economics and saving lives. It is a tough call. Critics would be always present and support either sides and many would be fence sitters and sway from one side to other. A simple example today is Vietnam vs USA. After more than half a century, even today, Vietnam seems to win the war. I am talking about COVID19. Vietnam has just over 280 positive cases where as USA 🇺🇸 has a mortality of 2.7% with 8454 deaths and 3,11,635 positive cases. Whom would you admire, the David or the Goliath? This was purely due to the governance and taking a tough decision to close down the borders, stop the international flights and ensure social distancing by lockdown.The largest lockdown on earth was by India and for surely is a remarkable feat in a mobile, democratic, free country.

(3) Testing more, Tracing more and Tracking more: More positive cases are to be isolated, rather than leaving them untested in the community. South Korea with a mortality rate of just 1.7%, with 183 deaths out of 10,237 positive cases is an exemplary example of decreasing the risk by doing 5200 tests per million population where as Brazil, which is on the same page as Korea but has a mortality of 4.3% with 445 deaths out of 10,360 positive cases. Brazil has a test rate of just 237 tests per million population. The surge in number of positive cases in next few weeks in Brazil can go against all predictions because of this abysmally low rate of testing. We also don’t know if the mortality rate is higher because the denominator is so small. Its’ the same story of David vs Goliath again, you can also call it “Vamana vs Bali”. The rate at which India is testing is one of the lowest in the world, 97 tests per million population. Contact tracing is being done by some countries well. Cuba, Singapore, Hong Kong and South Korea have been meticulous. Kerala has shown the same character. But unfortunately, many states in India and many countries have not been able to spend adequate amount of time in epidemiological investigations, sharing the “P-xyz” data publicly so that people who were in contact with a particular case can self-report. “In God we trust, all others bring data.” said Edwards Deming, and it is important we follow these universal principles of collecting more data, collecting accurate data and implementing the PDSA (Shewhart Cycles) to achieve success in epidemiology and infection control measures. We need a huge team of epidemiologists and public health specialists to work closely with the central and state governments.

(4) Behavioural Change Management: Building the mindset of the people in a country or region or a sect can play a major role. Are they extroverts, are they travellers or revellers or people who love parties and meetings or are the people defiant and mix up a lot, not caring for their own health as well as others? Or on the other extreme are they either disciplined, or solitary or people who are culturally very particular about cleanliness. An example for the first set of people are from India, the doctor from Rajasthan in India who celebrates Holi (a festival of colours) with more than 200 friends and family even after the Prime Minister of India asks everyone not to celebrate Holi. Later the same doctor examines 6000 patients in the out- patient department of his hospital and finally tests positive. There was a similar incident in South Korea, the famous P31, where she could have infected half the number of cases of South Korea and more than 1040 cases have been directly traced to her. Another example is the “Nizamuddin Markaz” incident where a sect called the “Tabliqui Jamaat” wanted people to congregate, went against the national emergency and instructed their followers to keep breaking the law. Even though, Mecca and Medina were closed to Pilgrimage, these people instigated and accelerated the epidemic in India. India is now doubling up its’ patient load every 4 days because of the religious congregation in New Delhi. This is an incident that flags lack of knowledge and non-adherence to rules and regulations. On the other extreme is Japan,where people are very disciplined and have a habit of using masks, washing hands, using hand sanitizers, being careful and conscious of not infecting others. Both India and Japan are very ancient eastern civilisations and have strong cultural roots. Some of the ancient practices in India are similar to Japanese but have been long forgotten or considered archaic or regressive, for example leaving the footwear outside, washing hands as soon as people come in, bowing and wishing by saying “namasthe” instead of shaking hands, more vegetarian diet, yoga, pranayam (breathing exercises) and meditation. Both India and Japan currently have around 3000 positive cases and mortality rates are 2.75% and 2.45% respectively. We must see in the days to come on how the two countries progress and pan out in curtailing the epidemic and how these cultural factors play a role.

(5) Density of population and the place of the epicentre in a country can also have an amplification effect. Urban and densely populated mega cities have become hot beds for COVID19 such as Wuhan and New York. Rural communities or sparsely populated countries and country sides, social distancing is automatic and prevents spread. The density is coupled by not able to restrict movements in the early phases and allowing people to congregate and move in public transport systems. Singapore and Hong Kong are exceptions as we have already seen on how they succeeded in achieving their initial victories in the very first battle against COVID19 due to battle preparedness which is more crucial than urbanization. Urban planning, housing, water and sanitation, transport, and effective implementation of facilities in slums will be the key drivers. In many countries in Europe, North America, Australasia and countries like HK, Singapore and Japan, the urban population is more than 50% and, in some countries, it could be more than 80%. But the average size of the house is large enough for a home or self-quarantine or segregation. The people can also adhere to social distancing and there would be no need to congregate for water and essentials. Whereas in one of the world’s largest slums like Dharavi in Mumbai, India or Khayelitsha in Cape Town, South Africa or Neza in Mexico City, the density of the population can sometimes reach 50,000 to 75,000 people per square kilometre. They would need to congregate for food, milk and even drinking water and toilets. The average size of living for these families is less than 200 square feet for a family of four. It would be a ticking time bomb if anyone gets infected.

(6) Age is an important co-influencer and other co-morbidities will play an important role in mortality and disease progression rather than on spread of the disease. These factors are behind the “bombshell effect”. Is your population obese or malnourished or healthy? Are there a lot of smokers? Their general health indices (e.g. diabetes and hypertension) will play a huge role during clinical management and in critical care. As it was discussed widely in many blogs and papers already about Italy, whose mean age is around 45, which has wreaked havoc in the older population. France, Spain and many European countries are losing their elderly populations due to COVID19. We still have to see in countries like India, whose mean age is just 28. Though the mean age is low, the denominator itself is very high and hence the geriatric population in India could be more than the total population of Italy! The mortality in Florida, USA is being linked to obesity and associated co-morbidities; The global average clearly shows that age and co-morbidities have been the greatest liabilities for our critical care teams. There is a clear 2% to 3.5% higher fatality in COVID cases when compared to NonCOVID fatality in patients with pre-existing conditions such as Cardio-Vascular diseases, Diabetes, Hypertension, COPD, Cancers as we can see from published data in China 🇨🇳 from the Report of the WHO-China Joint Mission published on Feb. 28 by WHO.

Now, let’s analyse the rumours based on some hard facts and statistics as on April 4th:

Spain has a mortality of 9.5% with 11,947 deaths and 1,26,168 positive cases. Italy has a mortality of 12.3% with 15,362 deaths and 1,24,632 positive cases. Germany has a mortality of 1.5% with 1,444 deaths and 96,092 positive cases. France has a mortality of 8.4% with 7,560 deaths and 89,953 positive cases. United Kingdom has 4313 deaths out of 41,903 positive cases with a mortality percent of 10.3. These are one of the world’s strongest economies and best healthcare systems. They all are collapsing like a pack of cards. The mortality varies from 1.5% in Germany to 12.3% in Italy. Does this mean Germany has a less virulent strain and Italy a more virulent strain? Do Italy and Germany have very different climatic conditions? Do they have different densities in populations? They have almost the same climatic conditions and similar temperatures. Germany has a density of 240 per square km and Italy has a density of 206 per sq km, lesser than that of Italy. It is more about the first two points when we compare both these countries, early response and disease/war preparedness.

Some more important examples are Indonesia which has a mortality of 9.2%, with 191 deaths out of a total of 2092 positive cases but just 0.9% of mortality in Thailand where only 20 deaths have been reported out of a total of 2067 positive cases. So, do you suggest that temperature has a role to play? Indonesia and Thailand almost have the same climatic conditions! What separates and differentiates both the countries is very evident, Thailand has a much robust primary care and has a very smart, responsive healthcare system.

Let’s not make our people victims to rumours that India is safe. There are numerous statements which are not authentic stating that “We have a less virulent strain and high temperatures will save our country”. These are not to be believed unless proven. We (India) need a second lock down to beat the epidemic and probably a third one before the rainy season. We all know what had happened in the Spanish Flu in 1918-19. The difference in mortality between St Louis and San Francisco was implementation of multiple lock downs. The steps taken by Vietnam, Hongkong, Thailand and Singapore can also guide us. Let’s all join hands and fight it scientifically rather than believing in rumours.

The Prime Minister of India has taken a very bold and commendable decision even after the critics have widely spoken about economics and linked the lockdown to “Notebandi”. Very soon, there would be numerous critics and cynics who would unite and the Government would be criticized for loss of lives due to either the pandemic or will also be criticised for a slowdown in economy and loss of jobs for the daily wagers. To lockdown a country of this size and proportion and develop a team spirit, a camaraderie in a 1.3 billion people with more than 30 provincial governments, 1000 mayors and half a million village Panchayats (village administrative unit) is not easy. It is truly uniting, aligning and connecting a gazillion minds. A country and its’ leadership would be praised, revered and will leave a mark in world history as a nation which cares for the lives of its’ citizens. The true definition of humanity is “kindness and benevolence”. I would give the benefit of doubt to our leadership as of now and they done a few things right compared to the west. I agree we still have a very long way to go and lots of things need to be done. But in the current circumstances it would be unfair to not acknowledge the many positives Indians have shown in these testing times. (1) Successful Janata Curfew, (2) Effective Implementation of lock down (though I felt it could have been done a week earlier), (3) No panic buying or hoarding by the masses, (4) Public distribution of food grains and essential commodities to the people below the poverty line (BPL) along with direct benefit transfers to BPL, and the most crucial of all, (5) Majority of the people following the lock down religiously and People’s participation in supplying food, water, milk to the daily wage labourers homeless, elderly and the disabled. Thousands of good Samaritans are even supplying food to the police, the doctors and the healthcare workers. Many hoteliers have given their hotels to the police and doctors to stay as they cannot go home. These are some of the examples of the resilience of the people and its’leadership.

Though the lockdown and the disaster management will be undertaken aggressively as the whole country and world is under an adrenaline surge. What after some time, let’s say after six months or a year? Will the world and India care to build a strong Preventive, Promotive and Primary Health care system? Will India ever care to learn from its’ mistakes, ride high and also understand from its’ victories over small pox and polio that tertiary care, large fancy hospitals are nice, but the ASHA (ground health force in India) workers, functional SubCentres, functional Primary Health centres, smart and active surveillance systems are the need of the hour. India doesn’t need a 20% GDP expenditure on health with everything parked in the tertiary care. We need something like Singapore, Thailand and South Korea. Let’s look east. These are the models to be replicated and scaled. We need David, not a Goliath. We need a resilient healthcare system that can take shocks of this kind rather than go into a stupor after a slightest fever. “By failing to prepare, you are preparing to fail.” said Benjamin Franklin and I hope we begin to prepare.

I thank Dr M Rajender Reddy and Mrs Vijaya Lakshmi from Hyderabad for giving their valuable inputs.

Dr Santhosh Kumar Kraleti is a public health specialist who has worked extensively in Primary Health Care settings on Adolescent Health, Urban Health, Maternal and Child Care, Govt Social Health Insurance Platforms, Quality Improvement, Blindness Control and Disability Prevention. He is based out of Hyderabad and is CEO of Foot Soldiers for Health. He is an Advisor to Union Ministry on Blindness Control, Mental Health and Costing of Health Packages in GSHIS.

He can be reached @ 8977788350 and drsanbharadwaj@gmail.com

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