The Narendra Modi government’s ‘Janata curfew’ exercise, in its concerted effort to combat COVID-19, is without much historical precedence. The curfew, which forces everyone to relinquish their individual civil liberties for the greater common good for a period of 14 hours, serves as a symbol of moral recalibration that India will face, as we prepare for the invisible war that is slowly, yet steadily, embarking on our shores.
It is true that a 14-hour curfew will not likely have a discernible impact on the viral transmission nor the overall trajectory of its outcome. However, it will stand as a testament to the Indian government’s commitment to get health services, public health, and public policy to work towards a common goal. In addition to the ‘Janata curfew’, which will certainly serve as a kickstart to our immense social responsibility that lies ahead, I discuss five things that the Modi government ought to be considering to tackle this problem effectively and decisively.
Heterogeneity of exposure and criticality of testing
An accurate understanding of burden of disease is critical to be prepared during times like this. The notion of heterogeneity of exposure stems from the understanding that population distribution involves both the exposed and the non-exposed. In the case of SARS-CoV-2, pre-symptomatic transmission has played a significant role in disease transmission all around the world, thereby contributing to exponential rise in cases as testing becomes readily available. Every individual identified early in the disease process through testing and quarantine will prevent further transmission. A failure to do this will decimate the health services on the tertiary end. R0, which is the rate of reproduction of a disease in a population, is roughly 2.6 for COVID-19. In China, these numbers were as high as 5.5. This simply means that an average infected person will infect 2.6 individuals.
In the case of COVID-19, there are also ‘super spreaders’, who transmit the infection to several individuals, being unaware of their own exposure status. Therefore, our primary public health intervention should be an attempt to universally test our subjects. Though a small country, South Korea managed to test close to 20,000 individuals a day. This has been largely attributed to their remarkably low mortality of less than 1 per cent compared to 8 per cent in Italy, though other demographic characteristics may have also played a role.
‘Shelter in place’ to become the new norm
The term ‘shelter in place’, while not specific to risk mitigation in pandemics, simply means ‘stay at home’. Commensurate with the ‘Janata curfew’, the idea of ‘stay at home’ will have to become more normative until we have better control of the spread of the disease. Currently, several parts of the world, including Italy, parts of California and New York have state government directives for ‘shelter in place’ with more joining suit in the coming days. While most governments allow essential services to remain open, this does involve significant restrictions and sanctions to daily independent living. The effective understanding between people and state is profoundly important as people become important stakeholders in this shared obligation towards curtailing the spread of disease. In close proximity to the idea of ‘shelter in place’ is ‘social distancing’. This is particularly relevant for those who tested negative to keep them non-exposed. This, in turn, will keep R0 at a low number, as those who test positive will be automatically quarantined.
Effective home quarantine and safe house
The idea of home quarantine for the exposed and social distancing for the non-exposed accrues some interesting challenges in the Indian context. Only 15 per cent of the 170 million households in India have one room for each member of the household. Coupled with relatively higher population density, the risk of unabated transmission is significant in India. Italy has the highest population density in the western world and that has been attributed as one possible mechanism for high transmission rates, in addition to their high older demographic. While this reaffirms the importance of early testing, the Modi government should set up safe houses within each district or municipality to safely quarantine positive cases with mild symptoms who need to be isolated and monitored for worsening of symptoms. This should be reserved for those who are unable to home quarantine as a contingency. The 15 per cent of subjects who can isolate themselves at their own home should exercise home quarantine, per guidelines.
Shutting state borders and enforcing lockdowns
As we have seen already in India and many parts of the world, viral shedding has been observed during the early pre-symptomatic period. With open state borders, contact tracing, which is an effective public health intervention to swiftly identify those who came in contact with the exposed, will become all the more difficult. Hence, shutting borders will help mitigate spread of COVID-19 across state borders. While these can certainly be eased once comprehensive testing has been deployed, it is imperative to enforce state borders to mitigate spread as well as asymptomatic transmission in the interim. The population of several states in India compares to the populations of South Korea, which is 52 million. Enforcing a strict lockdown will direct the attention of each state government to ensure the availability of all essential resources and personnel for its populace. With some states more heavily affected compared to the other, absence of migration between states will ensure containment as well. States will have to take responsibility in coming together to address a common enemy, which in this case is the virus, while supporting each other in enforcing restrictions.
Infrastructure, personnel and resource allocation for tertiary care
India is home to about 105 million people above 60 years of age. Most epidemiological data from around the world puts them at highest risk of mortality from COVID-19. In addition to elderly, health care workers, who are at the frontline of this infection, are further affected by cumulative risk of exposure, leading to high degrees of mortality among them. Two important considerations that need to be addressed include:
Eighty-one per cent of individuals tested positive with COVID-19 seem to make a near complete recovery, while 14 per cent develop severe disease and 5 per cent become critical with a proportion of them dying as well. The mainstay of supportive care for the severe and critically ill is by the use of ventilators. India is home to roughly 30,000 ventilators, though these are estimates based on best available evidence with some degree of state differentials. Given the transmission rates in the US and Italy, any comparable influx of cases will completely decimate India’s health system. Hence, proactive measures have to be taken by the Modi government to equip all secondary and tertiary care centres with adequate ventilators and, if required, every effort needs to be made to fast-track them into production. The time for such an intervention would be NOW.
b) Personal protective equipment
The unsung heroes around the world fighting the coronavirus pandemic, steadfast in their commitment to greater good, are the health workers. There is ample evidence from around the world regarding increased mortality among health care workers. Equally distressing — and what has remained a repeated call for help — is an impending shortage of personal protective equipment (PPE). This includes N95 masks, gloves, gown, face/eye shield and so on. The Modi government should pro-actively be ready with PPE anticipating a significant influx of patients into hospitals. The responsibility of the government to safeguard the health and wellbeing of the populace should not be overcome by its obligation to protect the wellbeing of all providers.
The virus, though originated in a small Hubei province in China, traversed much of the world before coming to India. These past few months have given us a wealth of information and empowered us with an invaluable resource — time. As people live through apprehension and anxiety, there is no reason why we should not be hopeful as we prepare to fight this together, as one nation. It will remain a test of our moral compass and social obligation, for the virus knows no discrimination — of language or religion or colour. To the COVID-19, we are nothing but a desirable host.
Dr Ravikumar Chockalingam is a psychiatrist and a public health scholar with the US Department of Veterans Affairs, Saint Louis, MO, USA. Views are personal.