THE CORONA COMBAT – FIFTH REVIEW. THINKING BEYOND LOCK DOWNS BY LT GEN PR SHANKAR (R)

Fourth Review @https://palepurshankar.blogspot.com/2020/04/the-corona-combat-fourth-review-on-to.html

Phase1Successfully executed.

Phase 2New guidelines issued by government of India as outlined by PM.
Battle continues without a pause.
Voices and articles questioning the lockdown are surfacing. Hindsight is always clear. It is so clear that you can conclude that Trump, Subramaniam Swamy and Rahul Gandhi have the same IQ. One must listen to the media briefing of the Governor of New York to get clarity to realize where we are. New York daily gets cases more than Delhi has had so far. Daily deaths in New York is as much as our daily number of cases. New York has run out of resources. It is broke. USA was two weeks ahead of us in the Corona timeline. That is the reality we have evaded. In foresight, two weeks from now we will be discussing our path to economic recovery while New York will continue to be plagued and struggling. We are on top the curve when we examine this ‘sight’ through our heads and not through our ‘hinds’.  

Economy will take a hit. There will be a global recession. No brainer. Is there a single country which will escape economic contraction, including China? Despite its mask diplomacy and predatory economics it will have huge issues. India has the best credentials to recover since we have our people intact. However we cannot live in a lockdown forever. That is fortress mentality. We need to move ahead with plan till such time we have a vaccine. The present guidelines have some conditionalities which are contrarian. These need resolution.

EnemyThe Chinese Virus has not mutated but shown traits of re-infection. A Second wave is expected in winter. In the meantime there is a study in Germany gives some hope. It suggests that lifestyles might not need to be as Brahminical as is now. We need to wait for the full findings of the study.  

Own ForcesClimate.  April- May will get progressively hot. After that, the South will experience monsoons while hot summers will continue in the North. Eventually once the monsoons set-in all-over India, we will see muggy humid conditions. This is the time when transmission rates of the Chinese Virus will be the least. The time window till September is critical for us to move to long term solutions.

SWOT Table. A new SWOT table has been evolved based on Phase 1 experience to help us navigate through Phase2.

STRENGTH

SOCIO ECONOMIC

SOCIAL ADAPTATION TO ADVERSE SITUATIONYOUNG DEMOGRAPHIC.
INBUILT IMMUNITY OF TROPICSEXPERIENCE AND KNOWLEDGE GAINED BY OTHER COUNTRIES.
VOLUNTARY PARTICIPATION IN EXTENDED LOCKDOWN.

MEDICAL
LOW INCIDENCE, TRANSMISSION AND FATALITY. GAINED TIME.
EXPERT HEALTH CARE PROFESSIONALS POOL.
MODELS OF SUCCESS – KERALA AND BHILWARA.
EXPERIENCE IN HANDLING EPIDEMICS AND DISASTERS.

NATIONAL
LEADERSHIP – DECISIVE, CLEAR, INFLUENTIAL AND CONSULTATIVE (PM &CMS).
RESPONSIVE GOVERNMENT.
PREPARATION AND CAPACITY ENHANCEMENT.
INDIAS INNER STRENGTH (X FACTOR)STRATEGIC COMMUNICATION
WEAKNESS

SOCIO ECONOMIC
LAW OF DIMINISHING RETURNS OF LOCKDOWNSCURRENT LOCKDOWN IS A PARTIAL SOLUTIONPOPULATION DENSITYDIFFICULTY IN MAINTAINING SOCIAL DISTANCING.
AWARENESS LEVELS ARE POOR AT LOWER STRATA OF SOCIETYPUBLIC HYGIENE (PUBLIC URINATION AND SPITTING)
 
MEDICAL
AGED/ VULNERABLE / CO MORBID PEOPLE.
MALNOURISHMENT AND LIFESTYLE DISEASES.
LACK OF INDIGENOUS RESEARCHLACK OF MEDICINE OR VACCINATIONLIMITATION OF TESTINGLIMITED KNOWLEGDE OF DISEASE BEHAVIOURLIMITATION OF TESTING EQUIPMENT.

 NATIONAL
POVERTY LEVELS AND UNORGANIZED SECTORFRAGILE ECONOMYDIVISIVE CULTURE
 THREAT

NATIONAL
ACCEPTANCE OF FOREIGN PRESCRIPTIONS/IDEASAPPROACHING SUMMER – WATER STRESS IN ALL MEGA CITIESECONOMIC STAGNATIONOVER CENTRALISATION

SOCIO ECONOMIC
INDISCIPLINE AND LAWLESSNESS.
HUNGER AND POVERTYIDEOLOGICAL POLITICSLOCKDOWN FATIGUEREVERSE MIGRATIONOUTLIER EVENTSPERSONAL INDISCIPLINELACK OF COMMUNICATION

MEDICAL
A BREAKOUT CAN OVERWHELM FACILITIES.
MUTATION OF VIRUSSECURITY OF HEALTHCARE PROFESSIONALSSECOND WAVEREINFECTIONAGED AND VULNERABLE
OPPORTUNITY

NATIONAL
INDIA CAN SHOW THE WAY TO THE DEVELOPED WORLDYOUTH AND HERD IMMUNITY.
LOW OIL PRICES.REBUILD ECONOMY

SOCIO ECONOMIC
LEARN FROM EXPERIENCE

MEDICAL
TIME GAINEDCLIMATE AND ON COMING SUMMER.
WEAKEN THE VIRUS LOW MORTALITY.

Current Status. The current status of cases is tabulated below. While cases and mortality has increased, recoveries have also happened. This data needs to be dis-aggregated to get a clearer picture.

State of the States. A look at the State of the States will tell us where we are. The graph below is of the “Top Order” of infection – Maharashtra, Delhi and Tamilnadu. These states have high numbers now. Equally they have high capacities. However they are showing signs of stabilization and there is a glimmer of flattening of their graphs. 

The graph below is of the “Middle Order” – Rajasthan, UP, MP and Gujrat, popularly also known as the ‘cow belt’. While the numbers are presently low in these states, their graphs are on the rise. In my opinion, tough times are ahead for these states.  

The graph below is of the “Lower Middle Order” – Kerala, Andhra, and Telangana. Their trendlines are declining and curves flattening appreciably. Special mention of Kerala is in order. Its number of daily cases is lesser than recoveries and the curve is dipping. Needs emulation by other states. 

The rest of the states are mercifully the “Tail Enders”. Hope they stay that way. Hope a pinch hitter does not emerge.  Overall, heartland India needs focus. The South, East and North are generally stable and under control.      Case Discovery and Mortality. The percentage of cases detected for the tests carried out and the percentage of mortality/ deaths for the cases detected is compiled from 05 Apr, till date. It is given in the graphics below in comparison with other countries and for some states taken as a random cross section.  

It is noticeably clear from the graph above that the prevalence of the disease in India is far lesser than other countries. As the number of tests have increased, the figure is tending towards stabilization. It further emerges that the infection/ transmission rates in India needs to be studied post haste. The mean Transmission rate (Ro) needs to be fixed for each region. This has a long-term implication.  As states have increased the testing rate and have tightened their responses, the rates and number of cases have changed. We must expect undetected / unreported transmission which could break out in clusters. The rates detected now, are likely to increase as lockdown is eased, despite best efforts. Outlier events have contributed to increase in cases. The effect of the outlier event at Bandra will surface in about ten days. Prepare for more outliers. This is India.

The overall fatality rate continues to be one of the lowest in India. Even in individual states, the rates are low. However when one looks at numbers closely, Maharashtra, Delhi, MP and Gujrat seem to be on the higher side. These states need to introspect.    

OptionsWhat are the options ahead? Prior to that let us see a few issues.

Vaccines and Drugs. A detailed and illuminating assessment on progress of drugs for management and cure as also vaccines has been done by Reuters. (https://uk.reuters.com/article/us-health-coronavirus-lifeline/reasons-for-hope-the-drugs-tests-and-tactics-that-may-conquer-coronavirus-idUKKCN21V1YR/ ). While there is lot of research going on, it is amply clear that a Vaccine is far away. A cure could be in the offing a little earlier.

German Study. The study carried out in Hinesburg (Germany’s Wuhan)  by virologist Hendrik Streeck is interesting. As per him 15 % people in Hinesburg have experienced an infection or are currently infected. This is based on antibody testing. In effect the process of herd immunity has already begun.  According to current estimates, the people under study are immune for six to 18 months. Mortality rate was .37%. Virus found on doorknobs and surfaces was dead and could not lead to infection. Hence lifestyle changes might not be so drastic. This study needs to be followed up and corelated with our environment to get to a correct and deducible picture.   

International Trend line. On one hand the Chinese Virus is threatening our lives. On the other we might end up losing them due to the economic deprivation which we have to face because of protecting ourselves against the Chinese Virus. A ‘lives vs lives’ debate has commenced. The international trend is now to look at life after lockdowns. Many countries are looking at herd immunity seriously since that is the only option. Sweden has gone in for it. “On Monday 6th April 2020 Denmark announced plans to open kindergartens and schools and a staggered return to work, Austria plans to lift Covid-19 restrictions, Germany may reopen schools if infection rate stays low. On the 11th April, it was reported that France and Germany are discussing herd immunity as a strategy to help lift restrictions. Without a vaccine and with a hemorrhaging economy, the fact is many countries have, or are looking to, promote a controlled spread of COVID-19 in the healthy population to achieve herd immunity.Humanity needs to accept that a vaccine will be not available in time for this current wave of COVID-19 and that herd immunity is not an option; it is the only option. No one supporting herd immunity supports a rapid spread of COVID-19 in vulnerable populations.  Herd immunity is a controlled distribution of COVID-19 among groups that are least at risk and involves introducing restrictions and suppression measures as necessary”. Many more countries are on this line of thought. (https://www.carahealth.com/health-articles/immune-food-allergy-infection/coronavirus-covid-19-countries-adopting-herd-immunityhttps://www.sciencemediacentre.org/expert-comments-about-herd-immunity/

Short Term- Lock Down.  In the short term, we can continue with the lockdown – loosening or tightening it as planned per the color codes. Of course this will be accompanied by short term containments, sealing, hotspot management and quarantining routine. Testing, tracing, isolation and treating will continue aggressively. Social distancing, masks, hygiene, and sanitation will soon be the norm. All these help in reducing transmission rates and keep the infection in check. However the infection will not be eradicated. It will rear its head in different places at different times. This will continue till the next three years.

Long Term – Herd Immunity   Herd immunity was used to eliminate smallpox virus and almost wipe out polio. So it is a main line option. Whether we like it or not we will develop herd immunity by infection. Uncontrolled development will overload our healthcare system beyond capacity and take a toll on high risk individuals. So the only alternative we have left is Targeted / Controlled herd immunity. We need to seriously start thinking about it and plan to move towards herd immunity beyond 03 May.

How Do We Go About It? Herd immunity is guided by a herd immunity threshold which is 1-1/Ro. Where Ro is the rate of transmission. The global estimate of Ro for the Chinese virus is 2-3. Johns Hopkins estimated Ro for India was 1.8 (based on environmental factors). At a Ro of 1.8, 45% of our population will have to be infected to achieve herd immunity. Too much. That is prior to lockdown. However the lock down (partial or full), behavioral changes, social distancing, mask wearing, and other interventions would have lowered this figure. If the Ro figure is 1 then the threshold is zero, implying that herd immunity is achieved. If Ro is 1.2/1.3/1.5 then 17%/23%/ 33% must be infected to achieve herd immunity. So the primary inescapable and essential task is to fix a Ro for India with its attached conditionalities. After that there must be a plan to keep the Ro there and achieve Targeted Herd Immunity

Targeted Herd Immunity. Targeted herd immunity is a long-term process. It will be an extension of the current lockdown and must be meshed with the calibrated exit policy. It will involve the following.

Principle. The fundamental principle is to expose the healthy young and protect high risk people.

Set and Control Transmission Rate. Set a transmission rate and take measures to achieve it based on climate, experience, and data of outlier events. This must be controlled through methods adopted during lockdown. The trick is that transmission rate should be below or match healthcare facilities capacities. If the desired R0 is achieved , we will know how much of the population we need for immunity.

Youth Exposure. Based on medical evaluation and testing expose healthy youth to normal activities. If affected, treat them, and put them back into circulation. It includes setting up special quarantine hostels and hospitals.

Increase Low Cost Testing Procedures. Evolve low cost testing methodologies indigenously toascertain asymptomatic infected people and those youth in circulation. This is critical.  

Introduce Social Barricading of High-Risk People.   The government advisory for the aged is only a start point. Protect the high risk through isolation, separate enclosures, separate flights, buses, parks, cinemas, railway compartments, hospital times and so on. Apart from Social Distancing, start talking of Social Barricading.

Data Collection. Rigorous data collection and research must be initiated for monitoring the implementation process of herd immunity.

Mainstream Outliers.  Outlier events like that of Tablighi, Migration fracas and Bandra station chaos have already contributed to the spread to the Chinese virus and has in fact contributed to Herd Immunization indirectly. This data must be mainstreamed.

Unreported Infection.  In our country there is a lot of infection which is happening but unreported. This must be uncovered and factored including recovery. In turn it means extensive testing.

Recorded Infection. The official recorded cases also have contributed to herd immunity. Factor them in.

Schools and Colleges.  Opening and attendance in schools / colleges should be based on medical examination and monitoring.

Preparation for Outliers. Some outlier event will occur. Prepare for it. 

Conclusion
The haul is long and hard. The choice is stark. Our economy will recover only if the Chinese Virus Situation is in control. Henceforth the Chinese Virus situation will be in control only if our economy is recovering. It is a catch 22 situation. It comes back to the fundamental issue. This is a fight that we have to fight together irrespective of caste creed or religion. All for one and one for all. So far we have done that admirably. There is no reason to think that we will not do it hence forth.  

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