(22 March 2020) COVID 19 Perspective

Looking at the confusion and panic surrounding COVID19 outbreak (some of which I find strange and unwarranted), I thought I will pen down some of thoughts.  The hysteria surrounding us does not sometimes allow us to think clearly. For me the only way to clear my thoughts is to write and analyse!   I though I will share those with others who may be able to use it for themselves as well:

  • The novel coronavirus is similar to any other flu virus with the key difference being the speed at which it is spreading.
  • For most people it will cause only mild flu like symptoms after which the patient will be back to normal. To put this in perspective, imagine if you did not know that there was a novel coronavirus acting, you would have just brushed it off as just another variation of the flu. In this context, what is all the panic about?
  • There is no running away from the virus. Chances are that sooner or later it will infect you. Even after the current epidemic subsides, it can be residual in the environment and can come back to infect you later. (Note: One can argue if this will be true.  The virus may not be very stable outside the body. If we find every infected person and ensure they do not infect anybody else, then there is a chance that it can be kept out of our vicinity — but this is practically very difficult in a country like India!)  The only protection at that time will be that a) you have already developed immunity thanks to a previous infection, or b) you have received a vaccine for the same , or c) if many people around you are immune, then spread becomes harder. Chances of universal immunisation in India for the novel coronavirus seems very low in India, so option (a) and (c) are more likely.
  • When you get a flu, you just have to wait it out till your body overcomes it. There is no medication  or treatment for it — you only take medication or measures to alleviate symptoms . The same will apply for the COVID19.  So, in this context, what is the great clamour about not have drugs for treatment?
  • Every year, many Indians get the flu. Most people do not take the flu vaccine or have access to the vaccine in India. Most of them do not have a problem going about their lives without the vaccine. Most will get infections and develop immunity. So, will the case be with COVID19. So, why is there so much noise about the unavailability of a vaccine?
  • Every year lot of people die due to respiratory distress/ diseases caused by viruses or other microbes or other causes. Certain parts of our population are more vulnerable to it and they are more likely to succumb to the disease.  The same shall apply to the COVID19 as well. The vulnerable will be at risk as always and they need to be protected as always.
  • So, what should be the focus of dealing with the disease?
  • FOCUS:  Protecting vulnerable people by isolating them or through vaccines (or equivalents) or treating them with drugs when they are infected.
  • Note that trying to vaccinate everybody or assure everybody that there is a treatment (drug) available is neither the focus nor that important.
  • For a moment, let us ignore the risk of death for the vulnerable subset of our population. In which case, the best strategy for all countries would have been to quickly let everybody get infected, let them recover at their homes,  build immunity and then not worry about the virus anymore. Sooner the spread of infection, lower will the the disruption in daily life rather than having the spread get prolonged over a period of time. Lower will be the damage to livelihoods, economy, etc.
  • So, for most of us, COVID19 should not worry us and there is no real reason to panic. Panic results in poor decisions and eventually larger overall costs. A good example, is how people are panicking and rushing to their home towns in crowded public transportation from large cities. There is absolutely no sense in this panic. This will only cause faster spreading of the disease and expose vulnerable family members to even more danger.
  • So, why should we be so concerned about COVID19?  The concern is for the following three reasons: a)  Because the novel coronavirus  spreads easily and fast, it will reach the most vulnerable amongst us easier than a common flu virus and b) if all the vulnerable people get sick all at once, we will not be able to manage the health care of such numbers, and c) if we can delay the vulnerable getting sick a little longer, then there is a chance that i) we can come up with vaccines to immunise them, ii) reduce transmission by everybody around them  not being infected, and iii) we can come up with drugs in the meantime to treat the patients back to normal.
  • You will notice that all of the above are aimed at the “vulnerable” and not necessarily for most of the population.  So you are being asked by Governments to do social distancing, lockdowns etc as your contribution to help the vulnerable and not necessarily to save yourself (unless you are one of the vulnerable)! So what is the panic for?  It is time to understand issues, be calm and do what is necessary to help the system save as many of the vulnerable people as possible.
  • Protecting and saving the vulnerable in the country with whatever health care systems and resources (without the system getting overwhelmed and we running out of resources )  we have is the primary agenda of any strategy to combat COVID19. Let us contribute to that without panic.
  • It is also important that people understand the purpose of Government actions well and do not confuse it with efforts to protect oneself from an infection. Otherwise, very soon there will be scepticism creeping in and as people start facing increasing levels of economic losses, they will start ignoring Government directives.
  • Some numbers — India has 1.3 billion people. Given the speed at which the virus is transmitting, If we say 60% of our population gets infected eventually, that will be 780 million people eventually (over several months). That by itself is not worrisome. A majority of those are also getting immunised against future attacks hopefully. The real issue is how many of these are the “vulnerable”. Let us say for a moment that 10% are vulnerable (just guessing — no basis). Then one is talking of 78 million people who are eventually infected and are vulnerable; so these are expected to have severe symptoms and will have to be treated by our health care system. If the death rate is say about 1% of the infected ( Note: I have reduced this number recently considering the fact that the percentage calculated using test data may be higher than the percentage calculated using real numbers — if there was a way to estimate it), then 7.8 million people eventually will die in an extreme scenario  (including both who were tested and who were  not!) . (Note that these are conjectured numbers and not based on any specific data. Also, one should not confuse this with data coming from testing cases because every country seems to be having different testing and designation criteria. The data from testing is likely to be lower than the real situation — nobody known by how much.) (Note: This should be seen in context of the fact that around 8-9 million people die in India every year; 22000-25000 deaths per day) The number of people dying will not only depend on how many people are vulnerable but also the quality of health care support in that country and many other extraneous factors.
  • The above are theoretical cumulative numbers. The number may vary significantly depending on many factors (many need to be checked) including weather (early summer and/ or monsoon), heterogeneous distribution of population in India, previous immunity status of the patients (for all you know, some Indians may have already seen something close to the current corona virus in the past and have built immunity), nutrition and health status of patient, current medications etc. I wish and hope that  the numbers are significantly lower! (And this where “miracles” kick in!)
  • If there is a vaccine, we can reduce the number of infected people (down from the 780 million mentioned above). Thus, we can reduce the number of potential deaths (down from the number of 7.8 million mentioned above).
  • If there is a drug and good medical care, then we can reduce the number of potential deaths (down from the 7.8 million mentioned above)
  • But the real practical challenge will be providing medical care to the infected vulnerable population (the 78 million mentioned above). If the entire 78 million people turn up at hospitals within a span of few months, that will be entirely unmanageable. But if we could spread this over say several months, the health care of these patients will be manageable to a better extent (but of course it depends on availability of doctors, hospitals, medical facilities and equipment, medicines etc). Question is how long can we prolong it?
  • About diagnostics —- The key goal here is to measure and track our fight against the virus in objective and quantitative terms. It is said that you cannot improve what you do not measure.  But we need to prioritise the use of diagnostics: First priority needs to guiding the course of treatment for sick patients. Second can be identifying patients who are “suspect” and need to be isolated to stop transmission. Last priority can be having better data for surveillance and planning government action. Wide spread testing or testing to quell the fears of the panic stricken would be a waste of resources at these pressing times.
  • So, here is the CALL FOR ARMS to everybody:
  • FOR MAJORITY OF THE PEOPLE:  Help slow down the spread. Do not panic. Do not hoard supplies. Do not unnecessarily imagine yourself to be one amongst the vulnerable. Identify the vulnerable and maintain a distance from the vulnerable. Leave the PPE, diagnostic/ medical equipment, hospital beds etc for the most needy and medical professionals.
  • FOR THE VULNERABLE:  Try to reduce your chances of getting infected.
  • FOR PUBLIC HEALTH PROFESSIONALS: Define clearly who could be vulnerable or not.  Define clearly how to identify “suspects” who need to be tested. Give clear instructions to common people on actions.
  • FOR HEALTH CARE PROVIDERS: Preserve all resources (supplies, equipment, PPE, beds etc)  for serving the most vulnerable.
  • FOR VACCINE DEVELOPERS: Speed to market.
  • FOR DRUG DEVELOPERS: Speed to market
  • FOR MEDIA OF ALL KINDS:  Do not create panic.
  • FOR THE GOVERNMENT:  Plan and coordinate to slow down the spread at minimum socio-economic cost.  Do not take it to a situation where people need to weigh human life (of the vulnerable) against the socio-economic costs to all!!

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Notes on 26 March 2020:

  • Alternative numbers for India based on the case of Italy:  Italy’s population is about 60 million. It has reported roughly 74,000 confirmed cases. And 7500 deaths so far.  There are parallel reports it is very likely that >60% of Italy’s population has now been infected with the Coronavirus and so how “herd immunity” will kick in. (There is no way to confirm it since one cannot test everybody.) If this is true, then >3.6 million people are infected in Italy. Of these 3.6 million people, around 2% were tested and confirmed COVID-19 positive.  In an advanced economy like Italy, if testing rate is 2% of the infected population, then in India it will be probably lower —- say assumed 1%. In fact reports suggest that India is doing about < 0.5% testing of the infected population.  That will be 3-8 million confirmed cases in India. So chances are that at its peak, India may report say upto 3-8 million confirmed infected people  (that is those who were infected and were confirmed to be infected by testing).  If Italy’s numbers are anything to go by, then 10% deaths amongst those tested confirmed will mean ~500,000 deaths confirmed and attributed to COVID-19. If one argue that India’s death rate will be lower for various (yet unproven) reasons including weather, younger population, previous immunities of some kind, etc etc — say 1% deaths in India.  Then still numbers will be ~ 50,000 deaths attributed to COVID-19.
  • Understanding Lockdowns:  Lockdowns can work if implemented well. Here is how? If a population has Group A (minority in early stage of epidemic) that is infected and Group B (majority in early stage of epidemic) that is not, then a lockdown aims to keep Group B away from Group A. In Group A, the following sub-parts will be there: Group A1 (majority) will see minor symptoms (if any)  and recover, build immunity against the virus and their bodies will destroy the virus within the lockdown period. Group A2 will fall sick and hopefully be identified and treated appropriately.  Hopefully, Group A2 will be managed in such a way that they recover, build immunity against the virus and their bodies will destroy the virus in a controlled, isolated environment within the lockdown period or may be even longer.  Group A3 (small fraction) will die without infecting others (since they are in isolation).  If this happens well, then the virus should go out of the population by the end of the lockdown period —- at least for the time being and until a new/ fresh  attack happens begins in the population. So, in principle, an effective lockdown can stop the epidemic. For it to work —- i) Lockdown needs to be long enough for Group A1 to recover fully, ii) separation of Group A and B has to be effective,   iii) Society needs to ensure that Group A2 and A3 are identified and isolated during the lockdown period and then kept in isolation (if required for a longer period) till they fully recover or die. The real challenge in India is (ii) and (iii) above. We will have to see if we can do this well.  Handling (ii) is a nightmare in India. Handling (iii) is easier when the proportion of Group A to Group B is smaller. So an earlier Lockdown is better than later.
  • How do we know who is “vulnerable”? Scientists and clinicians are collecting data on this still but they have announced that those with relatively weaker immune systems are more vulnerable — a) elderly, b) seriously sick with other diseases, c) people with immune deficiency, d) people on immune suppression medication, e) malnourished and people with a history of respiratory diseases – a) COPD, b) excessive smoking etc. Children do not seem to be very vulnerable.
  • People are hoping against hope that Indians are saved by the following possibilities (all speculative — no basis): a)  younger population, b) previous infections and resultant immunity, c) warmer weather, etc etc
  • Weak points for India — a) Very large population and high density with lot of poverty — easy  forCOVID19 to spread, difficult to enforce lockdowns etc, b) poor healthcare system, c) poor nutrition, etc
  • My list of priorities in that order: 1) Enforce lock down as well as possible, 2) PPEs for medical professionals, 3) life saving devices and hospital care for sick patients, 4) drugs (very difficult but more important than vaccines at this time), 5) vaccines (more doable but longer term solution).