Bracing Ourselves for an Explosion of Cases in India — Reflections on Covid

(Posted on Friday, April 3, 2020)

India and its 1.3 billion residents are on a three week lockdown to curb the spread of Covid-19. The move was in response to troubling new predictions that suggested that without aggressive actions up to 500 million Indians could be infected and up to 50 million could experience severe illness.

A friend of mine is a practicing physician in Hyderabad, India who is also deeply involved in public health reforms and policy development in the country. Here are his thoughts, which he shared with me via email.

The epidemiological behavior of the virus is being closely watched in India to come up with predictions on the impact here and to enable planning. There are a few factors that are in India’s favor: our mean age is 28 years and nearly two-thirds of the country are below 30 years of age; less than ten percent of our population is above the age of 60. The relatively low number of cases here is puzzling in many ways. Some attribute it to a data cover up, but even anecdotal evidence from hospitals reinforces the fact. Doctors are not seeing a surge in cases. I have thousands of cardiac patients, who are at high risk, and my team is in touch with them constantly — I have yet to see any surge. Doctors across the country are also very active on social media and there has been no surge in anxiety levels among them. I hope this is not a false lull before the deluge!

Still, as the epidemic in India now enters a new phase of community transmission, we are all bracing ourselves for a potential explosion. I come to the hospital every day to meet with our review teams and ensure that our facility is fully geared up and ready to meet an incoming storm. Our patients with underlying cardiovascular disease are at the greatest risk. Our top priority is our high risk patients. We are in touch with them and have given them access to us via mobile phone or messaging services like WhatsApp 24 hours a day, seven days a week.

Hospitals and general practitioners have stopped outpatient services and elective services to prevent crowding and in preparation for the deluge, if it happens. Doctors are all now giving patients access to their mobile numbers and WhatsApp accounts for any essential consultation, which is free. The government also issued guidelines on telemedicine, making it accessible to all. Pharmacies are open. Online drug deliveries are being permitted. Home diagnostics and drug delivery services were already becoming popular prior to the epidemic and now people are relying on them even more. Dedicated facilities are being notified to segregate Covid patients from non-Covid patients and plans are afoot to teletrain the healthcare workforce on how to manage Covid patients. Railway coaches are being modified to act as makeshift healthcare facilities that can reach remote areas when the need arises and the military is on standby to step up capacity, if needed.

Luckily, essential supplies are still available. We are fully absorbed in preparations to ensure that we don’t run out of the materials that we need, like personal protective equipment, masks, ventilators, oxygen, and so much more. I have seen a lot of crowdsourcing of novel ideas, what we call jugaad solutions — a way of using limited resources in innovative new ways to meet the need. I saw one group who was able to offer basic ventilators for just Rs.7500 (USD 100)! Another is working on 3D-printed circuits to hook up a single ventilator to two patients. Others are working on serological testing so patients can know their immune status. Larger organizations are also stepping in. Maruti Motors and Hyundai have come forward to manufacture ventilators.

Existing antiviral and antimalarial drugs are being tested under the supervision of the Indian Council for Medical Research to assess their efficacy. Government research facilities and industry are coming together to fast track the development of new drugs, diagnostic tests and vaccines. India meets one third of all global vaccine needs so we have the capacity to ramp up manufacturing once a candidate vaccine is ready.

Public Health Response

The government has also been managing our public health response — they started early screening of those traveling to India from affected countries and even when people tested negative for symptoms upon arrival, they were still checked to see whether they exhibited symptoms later. If someone did test positive or show symptoms, the government extended their surveillance measures to all those who came into contact with the individual. The borders were initially shut to only those affected countries but, since then, the border has been entirely closed down.

Schools were among the earliest public gathering spots that were shut down. This later extended to all places where people gather — gyms, cinema halls, malls, religious places — and then to all nonessential shops before the full countrywide lockdown was imposed. Even before our Prime Minister’s call for the official shutdown, a symbolic voluntary shutdown was already under way.

We’ve encountered some problems along the way but we are fixing them. Initially it was a struggle to figure out the right methods to employ to make sure that everyone would retain access to groceries, food, and medicines. Mobile rythu bazaars have been created, where fresh vegetables and fruits are brought directly from the farmers to the local communities, are improving access to perishable food items. Money is being directly transferred into the bank accounts of the poorest to help them buy essentials, sometimes even leaving rice and dal on the doorsteps of those who need it. The government and local community organizations have also organized shelter and food delivery for those living on the streets. The sudden scramble of migrant workers wanting to go back to their villages took the system by surprise and we are still trying to cope with this problem. One thing is certain, the system will have to keep a close watch on these people when they return back to their villages to make sure they don’t fall ill or infect others. Frontline health workers will continue their surveillance in these villages just as we are doing in the hospital. Now anyone admitted with acute respiratory illnesses are screened for Covid-19 to determine whether there has been any community transmission.

Economic Hardships

There is no telling yet what the economic impact will be. As a first step, the government announced a Rs.1.4 trillion (USD 18 billion) economic relief package. Banks have been asked to automatically defer loan payments for three months and to extend loans to small and medium sized industries to continue to pay employee salaries. This means that brick and mortar businesses are still paying staff and online business are still trying to stay operational. The Reserve Bank of India (RBI) has reduced the cash reserve ratio which is bringing more liquidity into the system. People are also making voluntary contributions to a variety of special funds and companies are doing the same. Savings from the fuel import bill as a result of the plunge in oil prices is also being used and diverted towards relief.

Social Life

People are adjusting to this new life. Internet traffic has increased manifold, as has TV viewing. The government owned television channel started rerunning old episodes of Mahabharata. When the show first aired in the nineties the streets used to be empty during the hour it was on TV. Youngsters born later are now being exposed to India’s ancient wisdom through the show. Older people find comfort and spiritual solace viewing the shows again. There is, however, one unforeseen negative social response that is unfolding slowly. In many communities and homes, people are shunning healthcare workers out of fear they will bring the virus home.

Online helplines are being provided for those who find their mental health is not strong because of the lockdown. Online education portals are doing roaring business, as classes shift from schools to homes. Culturally, elders in India have a different perspective on the grim prospects of death. Their immune systems have been ever ready for battle given the type of environments they grew up and lived in. These host factors may come to their rescue now. We have observed this phenomenon among the beneficiaries of our state public health insurance program who come from villages and city slums. The incidence of hospital-acquired infections is very low among those groups compared to people who are born and grow up in more hygienic environments, validating the so-called Hygiene Hypothesis.

It is impossible to know what the future will hold for India or for the rest of us. But I am trying to be optimistic in my approach to the epidemic. The human race needed a reminder from Mother Earth. If we heed her warning it, this could be good for the future of all of us.

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Originally published on Medium (April 2, 2020)