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As COVID-19 pandemic hits us full force, here’s what the systemic response should be

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In 80 percent of COVID-19 cases, the individual’s immune system is able to mount a response and the individual recovers with mild or no symptoms.

As COVID-19 pandemic hits us full force, here’s what the systemic response should be
I am neither a medical doctor with any expertise in treatment, nor am I a virologist or a chemist, and therefore have no knowledge of either the pathogen or of the variety of approaches being developed to respond to the virus.  My background is in economics and for the last several years I have been focused on trying to learn more about the designs of health systems and about how one responds in a systemic way to health issues. It is from that point of view that I hope to add to the ongoing conversation about this important question.
From what I understand, the disease transmits principally through droplets that are offered up by sick people when they speak or sneeze and can infect people who are within a 6 feet radius. The evidence that masking can therefore have an enormous impact on this because it acts as a powerful barrier, is now overwhelming and unambiguous. If the infection does enter the human body, the individual’s immune system mounts a response to it, just as it does for any other disease, and in 80 percent of the cases, this turns out to be sufficient and the individual recovers with either very mild or no symptoms at all.
The challenge in the disease relates therefore to the 20 percent who are more severely impacted and whose immune system either cannot mount a sufficient response or is taking longer than for the others to fight off the virus.  There is also the added problem with this virus that the immune system of the infected person can go into overdrive and, in a manner of speaking, over-react and significantly magnify the damaging impact of the virus. One of the reasons why Bats remain healthy despite being infected with many of these viruses (and have therefore inadvertently become carriers) is that, among other adaptations, they have also evolved a capability that keeps their own immune system from over-reacting. This is something that they needed to do in order to reduce the wear and tear associated with flight, on their bodies.
Based on all the work that has been done since the pandemic first began, we know that of the 20 percent who do fall sick, if an early response is mounted which reduces the inflammation of the airways and lungs through the use of steroids such as budesonide and dexamethasone, and low-pressure oxygen is provided as soon as the levels begin to drop below, say, 92 percent , the natural immune systems of almost 80% of even these individuals get the time they need to mount an effective response (and not over-react).  These individuals then gradually recover and do not cross the critical threshold of 85% which requires hospitalization.  Sadly, we also know that of those who do cross that critical threshold, a majority, overwhelmingly so in case of senior citizens, despite the best of care, do not recover, as the virus and their own immune systems jointly act to overwhelm their increasingly fragile bodies.
Every life is important and, no matter how slim the possibility, we owe it to every human being to do our very best to give them every opportunity to recover. And it is therefore heart-rending to see that our hospitals, despite all of their depth of capacities and a dedicated set of providers, have become overwhelmed and have had no choice but to allow people to die without even being given a chance at life. And, while because of our sheer numbers, our current situation is much worse, we have watched these exact scenes play out in cities across the world over the last year but, for reasons that are not yet entirely clear, neither we in India nor those in the global community who we turn to for guidance, decided to mount a systemic response and relied on a combination of wait, watch, hope, and denial to see us through. As far back as February 2020, doctors in Lombardy Italy, one of the best-equipped hospital systems in the world, cried on camera, wrote in the venerable New England Journal of Medicine begging the world to learn from their experience that hospitals are not the answer, but their advice fell on deaf ears.
Fortunately, this time around, there has been a keen local and global interest in attempting to craft a different and more systemic response. This has several critical components that need to be carefully understood:
  • A recognition that exclusive hospital-based responses, while necessary from a humanitarian perspective, will ultimately be overwhelmed no matter how strong they are. And, while the supply of oxygen and the availability of ventilators are proving to be the bottleneck, the rate-limiting step is increasing the availability of trained pulmonologists, intensivists, and anaesthetists, all of whom are needed to mount an effective intensive care response. This is likely to be a multi-year process and it is not yet clear that the Indian system even has the ability (or the need) to sustain this level of base capacity once the pandemic is behind us.
  • Patients who are likely to be taking up intensive care unit beds in two weeks, like most of us, are not yet infected but are at great risk for it. We need to do all we can to ensure that infection is avoided by continuing to push for the use of masks. If the infection does happen and people do not recover on their own, a rapid response as discussed earlier, using protocols of the type published on IndiaCovidSOS (https://www.indiacovidsos.org/home-care) in, I might add, several Indian languages, needs to be mounted.
  • This response needs the supply of two drugs, budesonide and dexamethasone. India makes both these drugs (and close substitutes) in large quantities and I understand that the India Pharmaceutical Alliance stands ready to fully meet the needs of these two essential medicines for the entire country.
  • Low-flow oxygen is the other important early-response “medicine” which is unfortunately in severely short supply at the moment because of the lack of interest in it over all of last year, followed by the sudden surge in demand for Oxygen Concentrators (a month ago local manufacturers were sitting on thousands of pieces in their warehouses!). However, several organisations including the ACT Grants & Swasth Alliance have taken urgent steps to redress this and thousands of these machines are on their way into India even as we speak (an Alliance consignment of 3,500 machines arrived into Delhi airport, for example, just a few days ago). Local manufacturers are also gearing up to increase the manufacture of these machines and over the next two to three weeks a veritable flood of these machines should start to pour into India.
  • They will all be much needed because these low-flow machines, when placed inside operational primary care centres, clinics, small nursing homes, and small hospitals in the remotest corners of our country, along with the necessary medicines, require very little training to use (under 15 minutes) and will not only be useful to respond to the current crisis but will strengthen the overall health systems’ ability to offer help in many other situations, including childbirth, asthma, and tuberculosis, for many-many years to come.
  • As a country, we have over 1 million government and non-government primary care providers. Many of these providers are either already ready or can be quickly trained to start to use the machines and operationalise this approach. It only needs electricity to run them and a road to transport them to the clinics. While our record on both these fronts is by no means perfect, our road density rivals that of some of the most developed nations in the world and we have made great progress on the electrification front as well.
  • We are right in the middle of this crisis and it does not look like simply keeping our head down and waiting for it to pass will help this time.  The systemic response discussed here has a great deal of power and it is imperative that we fully embrace it as soon as possible otherwise the fires that have shaken us to the core, will continue to burn. And while we should do all we can to care for those who are severely sick now,  no matter what we do our hospitals will simply not have the capacity to cope. Not in our cities and certainly not in our rural areas.
    -by Nachiket Mor
    (PhD, Visiting Scientist, The Banyan Academy of Leadership in Mental Health Senior Research Fellow, Centre for Information Technology and Public Policy, IIIT Bangalore)
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