Pandemic preparedness starts now

The time is not about playing blame games and looking for scapegoats, but about seriously going about identifying the lacunae in our responses

By Dr R Neerunjun Gopee

There’s no country or government that hasn’t been caught with its pants down when Covid-19 sprung upon the world at the beginning of last year. Except perhaps for New Zealand.

As suddenly, several countries including ours were flooded by a proliferation of lay experts in medicine and public health, whose non-expert opinions drowned the sober, evidence-based advice that the frontliner researchers and health professionals were tendering in the right places and in the established medical and health publications and forums. Given the rapidly changing manner in which the disease was manifesting across different geographies and demographics, these frontliners were also sharing more directly among themselves whatever new – and little but cumulative — experience they were gathering as they managed their patients. Nobody knew any better than the other, and every bit of new information in real time even if not yet peer reviewed as yet could help someone or the other to reduce severity of disease, or perhaps avert one more death.

Many of the complex technical discussions regarding Covid such as, among others, its pathophysiology in causing the phenomenon ‘happy hypoxia’ (low oxygen levels in patients with Covid who were going about with hardly any symptoms) went above the head of non-specialists in the field. Their attempts to get a grasp on it sent them back to look up their medical college notes and texts on lung physiology, and update that with the newer terminology so as to make better sense of what they were reading. Like I had to check up with physician friends to get a handle on the subtler aspects. This reminded me of the reply a very senior late orthopaedic colleague of mine many years ago, when asked whether he could lend me from time to time a copy of the British Medical Journal which I knew he had been receiving regularly since his return from the UK.

‘Well, you know what. I have stopped subscribing to the BMJ because, apart from one or two of the leader articles in the editor’s section and the obituary pages where I sometimes come across a write-up about one of my former teachers, I can hardly understand anything!’

The point is that advances are taking place so fast in medicine, with new vocabularies for newer conditions and concepts leading to hyperspecialisation, even keeping up in the subspecialties of one’s own field can prove daunting – and time consuming. Not to speak of the challenges posed by greying cells even in, admittedly, a brain endowed with plasticity! In other words, the genuine experts in their respective domains, who tend to be humble as they gnaw at their problem (s) like the beaver, are those whose opinions should matter. Not those who belong to the Whatsapp university. Though, at times, there may be some reliable or valuable information present there, all of which must be used judiciously.

These reflections came to me on pondering about the current surge in India. In such times of acute crisis, it is natural for people to react with their guts, so that it is the country’s leader who has to bear the brunt of criticisms to the extreme of shouting for his resignation, as if this will solve the immediate problem.

More objectively, the scientific approach is to analyse the different aspects and challenges of the situation, and then formulate new or modify existing responses. One paper that throws light on the new wave is ‘Why variants are most likely to blame for India’s Covid surge’ by Rajib Dasgupta Chairperson, Centre of Social Medicine and Community Health, Jawaharlal Nehru University, published in The Conversation of April 28, 2021.

It begins with ‘India’s government has blamed the people for not following Covid-safe public health directives, but recent data shows mask use has only fallen by 10 percentage points, from a high of 71% in August 2020 to a low of 61% by the end of February.

‘And the mobility index increased by about 20 percentage points, although most sectors of the economy and activity had opened up. These are modest changes and do not adequately explain the huge increase in cases.’

The author then suggests that ‘a more likely explanation is the impact of variants that are more transmissible than the original SARS-CoV-2 virus.’

He then goes on to discuss the variants in India, as viruses keep changing and adapting through mutations.

‘The Indian SARS-CoV-2 Genomics Consortium (INSACOG), a group of ten national laboratories, was set up in December 2020 to monitor genetic variations in the coronavirus. The labs are required to sequence 5% of Covid-positive samples from states and 100% of positive samples from international travellers.

‘The United Kingdom is currently testing about 8% of its positive samples and the United States about 4%. India has been testing about 1% altogether. INSACOG has so far tested 15,133 SARS-CoV-2 genomes. This means of every 1,000 cases, the UK has sequenced 79.5, the US 8.59, and India only 0.0552.

‘…The current second wave started in the northwestern state of Punjab in the first half of February and has not yet plateaued. One of the advisers to the Punjab government confirmed that more than 80% of the cases were attributed to the UK variant.

‘Significantly, the most affected districts are from Punjab’s Doaba region, known as the NRI (non-resident Indian) belt. An estimated 60-70% of the families in these districts have relatives abroad, mostly in the UK or Canada, and a high volume of travel to and from these countries.’

It is established that variants are more highly transmissible and cause more severe disease, and epidemiologically this translates into a higher number of deaths the larger the population.

Responding to this article, Peter Cobbold, Professor Emeritus, University of Liverpool adds that ‘The Indian crisis has a more convincing explanation than virus variants.’ Citing a paper by Dr John Campbell, he advances the following: ‘This is the low level of Vitamin D3 in the Indian population, despite the sunnier climate, and this has a negative impact upon disease transmission and severity’. He suggests that ‘the answer for India is sunbathing, exposing the total area of skin can supply 10,000IU per day. Aerial pollution absorbs UVB so city dwellers will need supplements,’ concluding that ‘the science is sound, the implementation by medical and political authorities dire.’

Regarding the critical issue of oxygen shortage, another article in the same issue of The Conversation: ‘What steps must be taken to secure oxygen – for COVID-19 patients and into the future’ opens by noting that ‘new waves of the Covid-19 pandemic in countries, such as Kenya and India, have exposed the poor management of oxygen supplies’ and gets the insights of Professor Trevor Duke, ‘an expert on [oxygen provision] and editor of the World Health Organisation (WHO) guidelines on oxygen therapy for children, about …what countries, with limited resources, can do to secure better supplies.’

The issues covered are: Why is oxygen so important for treating Covid-19? What are the challenges getting oxygen to patients? What can be done to improve the situation? Can any immediate steps be taken?

The recommendation is that ‘the priority should be scaling up oxygen and quality of care and monitoring. There are ways and models to do this, in even the least resourced health care settings.’ And the conclusion is that ‘Covid-19 is a long-game; the best time to start implementing effective oxygen systems may have been several years ago, but the next best time is now.’

In the same vein is the recommendation in the article by Rajib Dasgupta, ‘Setting up a genomic surveillance system and consistently testing 5% of the positive samples is an expensive but important tool in the journey ahead. This can help us identify emerging hotspots, track transmission and enable nimble-footed decision-making and tailored interventions.’

So too, for us: the time to start preparing for the inevitable next pandemic is now. It is not about playing blame games and looking for scapegoats, but about seriously going about identifying the lacunae in our responses and the strategies to correct them pre-emptively and proactively, with the Fact Finding Committee being an important first step in this direction.

* Published in print edition on 30 April 2021

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