Ground Zero
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<p>Our human compassion binds us the one to the other – not in pity or patronizingly, but as human beings who have learnt how to turn our common suffering into hope for the future.” – <strong>Nelson Mandela</strong></p><p>A teaspoon of <strong>"Hope"</strong> with “every breath” is what everybody in the world needs most now. My blood group is “B” +ve and I believe being positive helps any form of treatment and am eternally optimistic!</p><p>Today, I am penning down my thoughts on <strong>“Ground Zero”</strong> with an endeavour to fix some broken things – which may take a lifetime of work or visiting the first principles, accepting the “Ground Zero” may make it easier to fix things earlier than a lifetime.</p><p><strong>What is Ground Zero?</strong></p><p>It is probably military slang to define “that part of the ground situated immediately under an exploding bomb, especially an atomic one” or earth’s surface closest to a detonation.</p><p>India is now the <strong>“Ground Zero”</strong> of Covid Pandemic – new cases crossing <span style="color: #000000;">4,01,078 on 07th May 2021 (Active 16.76% vs Discharged 82.15%) and the number of daily deaths on the same day was 4,187 (1.09%)</span><span style="text-decoration: underline;"> </span>A lot has been written in the media about the possible causes of systemic failure, SOS calls for oxygen, hospital beds, emergency medicines, black marketing and endless pictures of the crematorium. However, all of these further lead to a sense of fear, panic resulting in the hoarding of essential medicines, oxygen and possible rush of patients who may be in mild, moderate category of Covid or normal cold/cough who can very well be managed at home – filling up Hospital beds, thereby denying admission to the genuine, severe category of Covid patients who actually need Hospital admission.</p><p><strong>First Principles thinking for Indian Healthcare Ecosystem</strong></p><p>It is always good to revisit the fundamentals to breakdown complicated problems and apply first principles thinking <Aristotle defined a first principle as “the first basis from which a thing is known.”></p><p><strong>What is the ground truth?</strong></p><p>Below is a snapshot on the Indian Healthcare ecosystem infrastructure:</p><p>“Beds will not treat patients, but doctors & nurses will” – let this statement sink in for the policy/lawmakers. There is no shortcut to achieving this overnight.</p><p>Let us see how the current Covid pandemic will affect the healthcare ecosystem and what could be the possible solutions to handle the crisis?</p><p>As on date of writing this article:</p><ol><li>Close to 20 million Indians were fully vaccinated– i.e. about 1.32% of the country’s population fully vaccinated and 8.17% with at least one dose.</li><li>More than 37,36,648 active cases of Covid have been reported with<u> </u>2,42,362 deaths<u> </u></li><li>As per ICMR reports in Jan 2021, only 21% of the population had antibodies against SARS-CoV-2</li><li>The B.1.617 variant of SARS-CoV-2 carries two mutations, E484Q and L452R – also known as the double mutant is possibly involved in the immune escape and increased infectivity. This strain is mostly dominating Maharashtra, West Bengal, Delhi and Gujarat.</li><li>The average hospital stay<u></u>with the current strain has increased to 09<strong>-</strong>12 days (from average 06 days last year) – the higher dependency on oxygen and increase in hospital stay will further aggravate the hospital bed shortage. A general thumb rule as suggested by a senior Pulmonologist, those on below will need</li><li>Nasal cannula 06-07 days</li><li>BIPAP 10-12 days</li><li>Ventilators 10-30 days</li><li>The case fatality ratio (CFR)<strong> </strong>since the outset of the pandemic last year has been around 1.3% & 0.87% for those<strong> </strong>who have contracted the infection since the beginning of 2021. However, it may surge (*difficult to comment on the under-reporting – data transparency may be a huge concern)</li><li>It is important to note that some of the fundamentals about Covid 19 have NOT changed since the outbreak of the pandemic last year:</li><li>Only 6-7% of the Covid infected cases will need Hospitalization</li><li>There are 04 broad categories of Covid 19</li><li>Asymptomatic or Pre-symptomatic</li><li>Mild</li><li>Moderate</li><li>Severe</li><li>Vaccination is not expected to prevent infection but will prevent the severity of disease, death and hospitalization</li></ol><p><strong>First Principles for Covid Pandemic</strong></p><p>Let us now apply the “First Principles” thinking for the current Covid crisis – what can be done in the immediate <90 days>, mid to short term <365 days> and the policymakers favourite <05 year plan></p><ol><li>Immediate <90 days plan> “Deconstruct then reconstruct” – First, accept the current failures – change and solution only begin after that…</li><li>Vaccination – There is an 85% reduction in hospitalization after being fully vaccinated. Improve the efficiency of the vaccine supply chain, availability and administration – this will ensure that at least the Hospital Bed/ICU/Oxygen crisis will start reducing in the next 6 to 8 weeks</li></ol><p>> Is Govt the most efficient supply chain player?</p><p>> Why not rope in the likes of Amazon, Flipkart, Swiggy, Zomato etc? Let the already over-burdened, stressed, fatigued healthcare & front-line staff focus ONLY on the vaccine administration, post-vaccine monitoring and surveillance – the rest of the back-end supply chain, logistics can be probably better managed by non-healthcare industries. Probably, shift vaccine centres to locations other than PHC, Hospitals (maybe schools, post office, banks?) – for primarily 02 reasons:</p><ol><li>It unlocks the healthcare staff at OPD, Clinics and Hospitals to focus more on managing a severe category of Covid cases only</li><li> The current 2nd strain is more infective, transmissible – hence, if the place to administer vaccines (imagine India still needs to cover 99% of 1.35 billion in the next few months) and the long queues to get vaccination are also the same places where the mild, moderate and severe cases of Covid or suspected cases will go for testing, treatment and admission. Looking at India’s history of adherence to crowd management, queues aren’t we staring at a vaccination site being a hotbed for acquiring Covid infection?</li></ol><p>> Was there a need to change the success formulae of previous vaccination campaigns of Pulse Polio etc?</p><ol start="2"><li>Role out Tele-medicine for Mild, Moderate Covid category of patients + Syndromic Surveillance via Digital Health Tools on a war footing</li></ol><p><strong>> </strong>Majority of the population who have to travel to consult a doctor at PHC, OPD of a Hospital or Fever Clinic – will further put the doctors, nurse and fellow citizens at-risk. For every reported Covid positive case there are 2-3 not reported and at least 10 asymptomatic or pre-symptomatic cases.</p><p>Rolling out Tele-Medicine as the Choice of First Consult for Covid Mild, Moderate category of patients will reduce the burden on already over-crowded Hospitals which should be only limited for Severe Category of Covid cases. This will also ensure that the healthcare staff deployed at OPD, Fever Clinics, Hospitals will have lesser contact with potential Asymptomatic/pre-symptomatic cases.</p><p>> The challenges associated with RT-PCR and Rapid Antigen Tests (False Negatives and False Positives, Timing of the Tests, Skilled WorkForce) – have resulted in flip-flops over policies to label a patient as Covid positive and who may or may not need Hospital Admission. Irrespective of the Lab Test results – there is an old adage: you do NOT treat a lab report but a patient based on his history, signs, symptoms and clinical presentation. Adoption of digital health tools such as remote monitoring of vitals such as (Heart Rate, Pulse, Respiratory Rate, BP) etc will play a critical role in the current pandemic, especially when combined with Tele Medicine – as a layer of syndromic surveillance before the 6th/7th day of exposure may give lot of insights and lead indicators in contact tracing, who may benefit from lab testing, imaging and who can be managed at home-isolation, who will need Hospital Admission etc.</p><ol start="3"><li>Enforce The Prevention of Terrorism Act, 2002 (POTA)on those involved in black marketing of Hospital Beds/Oxygen/Emergency Medicines/Ambulance – anything related to Covid crisis.</li></ol><p>> Once the black marketing of Hospital Admission/Oxygen/Emergency Medicines etc is resolved – fear, panic and hoarding will stop</p><p>> The above will ensure that only genuine severe category of Covid patients rush to the Hospitals</p><p>> Ban Whatsapp, social media, News Channel Coverage of Covid Diagnosis, Treatment Guidelines – the “Mis-Infodemic” is killing more patients than the real Pandemic.</p><p> </p>
KR Expert - Dr Satish S Jeevannavar
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