13 May, 2020

COVID 19 Chronicles: How Could One Virus Impact Our Destiny (COVID): A Black Swan Event!

My concern is also the attitude of patients with chronic disease about visiting health care facilities – which would be perceived as a repository of this dreaded disease and a place best avoided presently

A Black Swan Event

I write this piece on the 44th day of India’s lockdown – variably described in terms ranging from adulatory to castigating, by a bevy of commentators, local and international, some well -informed and others clearly clueless. I shall therefore prefer to present a narrative of events in India and try my best to resist the urge to infer from or pass judgement on these observations.

India’s first administrative response to the (then yet to be designated) COVID-19 pandemic was thermal scanning of passengers on flights coming from China and Hong Kong with effect from 17th January, 2020, a fortnight before our first patient, a medical student returning from Wuhan – landed in Kolkata, took a domestic flight to another city, and then surface transport to the final destination. This set off a saga of contact tracing which has since been replicated hundreds of thousands of times, putting immense strain on the limited cadre of India’s Epidemic Intelligence Service and the Integrated Disease Surveillance Program. Social distancing, hand hygiene, limited social congregation, travel restrictions and screening of passengers on all international flights were imposed in due course.

Three weeks in to March, by when India had reported less than 400 cases of COVID-19, there was a significant escalation of effort, with cessation of all domestic and international flights, and soon thereafter all inter-city and within city travel by any mode of transport – road, rail, metro – was brought to a halt. On 22nd March, 2020, the Government of India did a “trial” run – advising all citizens to stay indoors from 9 am to 9 pm, and this transitioned to a “complete lockdown” commencing 25th March, 2020, which remains ongoing even today, albeit with a reduced level of stringency from earlier this week. This relaxation is based on the “color code status” of the districts – green zones indicating low risk and no cases, orange minimal risk and limited cases and to red indicating high risk and larger number of cases.

A month in to the lockdown, the analysis suggested that the actual cases were about a quarter of the anticipated number, and that the doubling time rose from somewhere between 3 and 4 days to a more manageable double-digit figure of approximately 11 days. While this remains the status even today, we have noticed a recent spike in cases such that by now India has recorded just under 53,000 cases, and nearly 1800 lives have been lost to COVID-19. We take some comfort in these numbers, given both our population size and urban density, but like all nations we would have been delighted if our efforts had resulted in fewer cases and mortality. Current information also suggests that the hospitals, ICUs, ventilatory capacity and stocks of PPEs have not been overwhelmed, and we hope it stays that way.

Our research site, located in District SBS Nagar, in the state of Punjab, reported its first patient in the third week of March, who was admitted in the District hospital, one of the facilities we were operating from. As a result, we decided to cease all field activities on 19th March, 2020 and these remain suspended even today. Clearly, this has caused a major hiatus in our efforts, especially because we were to commence a new phase of activities at that point in time. Just prior to lockdown we had also decided to introduce additional strategies for ascertaining impact of our implementation, and this lockdown period has been gainfully employed in working out the nuances, instruments and processes of this additional component of our project. Multiple rounds of discussion, feedback from field-level research staff, multiple iterations of the documents and we can just about see a glimmer of light at the end of that tunnel – one shudders to think how we would have managed all this in a pre-Zoom world!

We wait for a graded emergence from the “lockdown” – not sure when and how. Punjab which had been doing exceptionally well, recently received a contingent of returning pilgrims from another part of India, and have reported a surge in new cases. This suggests that we are unlikely to commence field operations any time soon, and continue to make preparations in anticipation of that occurrence. This is also a reminder that the specter of SARS-CoV-2 will loom over our communities and field work even after the re-opening of India.

Apart from the immediate impacts, there will be inevitable long-term challenges (and potential opportunities) in the post-lockdown world. My concern is also the attitude of patients with chronic disease about visiting health care facilities – which would be perceived as a repository of this dreaded disease and a place best avoided presently. Efforts are already afoot to develop, enable and regulate telemedicine as an alternate way of delivering care. While stable patients with chronic disease may opt for this model till such time that the pandemic abates, the absence of any immediate strategy to integrate tele-consultations with the in-person out-patient care framework we are testing in our Hy-TREC project is an additional source of anxiety. Reopening of health care facilities to deliver “business as usual” also remains uncertain, given the infection control norms which will not only be expected but also demanded by health care workers and patients alike.
Crystal ball gazing not being one of my talents I shall refrain from speculation about what the future holds in store for us, but it does appear that we are accursed as captured in the English expression – “may you live in interesting times” – peace and tranquility seem quite a distance ahead!