Lock down exit strategy-Hype versus reality: Is the Government caught in a chakravyuh of its own making?

It was a knee jerk reaction by the ruling dispensation in the Centre to announce the lockdown without advance notice or a proper exit strategy in place, much like the character Abhimanyu in Mahabharat entering the Chakravyuh and not knowing how to come out of it. At least, Abhimanyu knew how to enter the Chakravyuh, however the Government did not even prepare for entering the lockdown leave alone exiting it. This is becoming quite evident the way the entire narrative of the lockdown is heading as of now. Atleast, the lower and upper middle class who form a major chunk of society must understand the gravity of the situation and stop defending or justifying their ignorance.

The ‘big announcement’ and ‘credit mongering’ syndrome, a unique obsession of the Centre has created the following dilemma:

(a) of keeping things as they are – economy will suffer more and cases with still rise. or

(b) lift lockdown – cases will rise, States impose lockdown to avoid discredit, broken supply chain and economy will still suffer and lead to chaos causing civil unrest and tension leading to increase in prices of essential commodities, scarcity, famine, unemployment, fall in agriculture yield leading to severe liquidity crunch in the market similar to the times of demonetisation.

Let us examine the German and South Korean model and try to find a way forward for India

Some of the best practices followed by Germany, and South Korea in handling the Corona pandemic are given below. Note: Sweden, Taiwan and South Korea managed COVID-19 without resorting to lockdown.


(a)Germany

The coronavirus SARS-CoV-2 is posing major challenges for healthcare systems and medical institutions worldwide. An ability to rapidly diagnose the virus is of invaluable help in curbing its exponential spread in many countries. Bosch’s new, fully automated rapid test for COVID-19 can help medical facilities such as doctors’ offices, hospitals, laboratories, and health centres make fast diagnoses. The rapid molecular diagnostic test runs on the Vivalytic analysis device from Bosch Healthcare Solutions. Developed in just six weeks, the rapid test can detect a SARS-CoV-2 coronavirus infection in patients in under two and a half hours — measured from the time the sample is taken to the time the result arrives. Another advantage of the rapid test is that it can be performed directly at the point of care. This eliminates the need to transport samples, which takes up valuable time. It also means patients quickly gain certainty about their state of health, while allowing infected individuals to be identified and isolated immediately. With the tests currently in use, patients must usually wait one to two days for a result. Time is of the essence in the fight against coronavirus. Reliable, rapid diagnosis directly on site with no back and forth — is the great advantage of the solution which is an example of technology invented for life. Bosch’s rapid test is one of the world’s first fully automated molecular diagnostic tests that can be used directly by all medical institutions. What’s more, it allows a single sample to be tested not just for COVID-19 but also for nine other respiratory diseases, including influenza A and B, simultaneously. The special feature of the Bosch test is that it offers differential diagnosis, which saves doctors the additional time needed for further tests. It also provides them with a reliable diagnosis quickly so they can then begin suitable treatment faster. It is going to be available in Germany from April 2020. The COVID-19 test is based on a combination of sample preparation (including process controls): Multiplex PCR (Polymerase-Chain-Reaction), μArray-detection to allow the identification of SARS-CoV-2.

In various laboratory tests with SARS-CoV-2, the Bosch test delivered results with an accuracy of over 95 percent. The rapid test meets the quality standards of the World Health Organization (WHO). A sample is taken from the patient’s nose or throat using a swab. Then the cartridge, which already contains all the reagents required for the test, is inserted into the Vivalytic device for analysis. During the analysis, medical staff can devote themselves to other tasks, for example treating patients. The Vivalytic analyzer is designed to be so user-friendly that even medical personnel who have not been specially trained on it can reliably perform the test. 1000 tests per day on just 100 devices.

A Bosch Vivalytic analyzer can perform up to ten tests in the space of 24 hours. This means it takes just 100 devices to evaluate up to 1,000 tests per day. Given the dynamic spread of the coronavirus SARS-CoV-2, laboratories are already working beyond capacity. The Bosch Vivalytic will thus help to increase available testing capacities. (https://www.bosch.com/stories/vivalytic-rapid-test-for-covid-19/)


Germany model of COVID anti-body testing

Germany is carrying out Europe's first large-scale COVID-19 antibody testing to monitor infection rates and help prevent the spread of the virus.

According to the Robert Koch Institute, Germany's federal disease control and prevention agency, the first part of the study is to draw on the country's blood donation services, a second phase will focus on samples from regions with large coronavirus outbreaks and a third stage will consist of a representative study of the country's broader population.

Authorities say they will examine about 5,000 blood samples every 14 days, while regions like Bavaria plan to collect around 3,000 samples from representatively selected households. Antibodies in the blood indicate that someone has had the virus. The institute theorizes that these people have some level of immunity, although there is no guarantee of full immunity or how long any defence would last.

Germany, which produces most of its own high-quality test kits, is testing for COVID-19 on a greater scale than most countries: an estimated 1,20,000 tests a day in a nation of 83 million(1 million= 10 lakhs, hence 830 lakhs). The high level of testing has helped Germany slow the spread of the virus and keep deaths low. Authorities estimate more people in Germany now recover from the virus every day than are infected by it.

Germany has an another powerful weapon in the battle to contain Covid-19-a wealth of private laboratories that are helping it test more than 50,000 people a day.

The country had already tested about 920,000 people through late March and checked more than 350,000 people in the past week ending April 2, 2020, as per the report of the Robert Koch Institute public health group. That may still understate the country’s total effort, since not all the laboratories that have done assays have yet submitted numbers.

Germany’s widespread testing — still not as comprehensive as many there would like — has enabled better tracking of the coronavirus’s spread than in many other European nations. The country benefits from other health-care advantages, including one of the continent’s highest rates of hospital beds in relation to population size. Germany is testing about 6,000 of every million citizens, about three times the rate in the U.K., according to an analysis from the BBC. Critics have pointed out that the U.K. was slower than some other countries to make labs available for processing.

German health authorities saw in mid-January what was coming and were “maximally prepared” with a plan for the pandemic. That was certainly the case for Bavaria, which had one of the first Covid-19 clusters outside of China. In January, a Chinese employee of auto-parts supplier Webasto SE visited the company’s headquarters south of Munich without realizing she was sick. Upon returning to China, she was confirmed to have the virus — and soon so did nine Webasto workers in Bavaria along with some of their family members. Since then, Bavaria — with a population of 13 million(130 lakhs) — has performed more than 1,10,000 tests, according to their state health ministry. The region has expanded its capacity to do 13,000 tests a day, with about 11,000 of those performed in private labs. The aim was to get clarity as fast as possible when it comes to possible cases as it is important in order to curtail infections.  The German government will extend a global travel warning until June 14 and cannot promise that it will be dropped after that date.  The German Chancellor, herself a physicist has identified the reproduction factor — known by epidemiologists as R-naught — as a means of gauging how successfully countries have kept the virus in check and how much stress it could place on health services. Germany’s R0 has declined to 0.75 from 0.9 according to their public health authority. That means that each person with the virus infects an average of 0.75 other people.


(b)South Korean case study(without resorting to lockdown)

Since its first confirmed case of COVID-19 in late January, South Korea has shown a determination in the face of the virus that appears to be paying off. From a sudden spike in the number of cases to its decision to implement widespread testing, South Korea has shown itself able to respond quickly and decisively. The fast rate at which the pandemic moved surprised the authorities in South Korea. The first 30 cases identified in South Korea were handled in a steady and diligent manner. Between January 19, 2020 and February 18, 2020, South Korea had recorded a total of 30 cases and no deaths. That slow increase in infections soon changed –February 18 was the day it recorded its 31st case. But that all changed with the appearance of Patient 31. Within 10 days, there were more than 2,300 cases. Patient 31 was what is known as a super-spreader – someone who passes the infection on to a larger number of people. She was then involved in a minor traffic accident and checked into hospital, and while a patient there she attended church services on two occasions and went for lunch in a hotel with a friend, despite developing a fever. In just a few days after she was diagnosed with the coronavirus, hundreds of people at the church she had attended and in the surrounding areas tested positive. Super-spreaders like Patient 31 enable a virus to take hold and act as fuel for an outbreak.

Although the rapidity with which COVID-19 took hold in South Korea initially surprised authorities, well-established strategies were soon put into place. But we need to plan and to stay one step ahead. An all-government approach was envisaged. The Prime Minister of South Korea created a task force of all government ministries and, crucially, all regional and city governments, too making it more a devolved democracy and all inclusive strategy. This joined-up strategy, involving the different regional authorities around the country soon paid off. When one region ran out of hospital beds other provinces were asked to open up beds in their hospitals. When it ran out of doctors in one region, the other region doctors were asked to help.


Crucial role to testing

South Korea also explains that being open with people and securing their trust is vitally important. The key to our success has been absolute transparency with the public – sharing every detail of how this virus is evolving, how it is spreading and what the government is doing about it in totality.  In 2015, the country experienced a sudden and unexpected outbreak of MERS – Middle East Respiratory Syndrome, which is also caused by a coronavirus. It was the largest MERS outbreak outside of the Middle East, and led to 185 confirmed cases in South Korea. It also led to a firm belief that testing should form a central part of any response to a viral epidemic. So when COVID-19 hit South Korea, testing became the course of action that seems to have set the country apart from other nations. Testing is absolutely critical with a fast-travelling virus like COVID. South Korea has tested over 3,50,000 cases so far – some patients are tested many times before they are released, so we can say they are fully cured.

Unlike Italy, China, the UK and parts of the US, there was no lockdown in South Korea. It did, however, close its schools. There have been postponed attempts at reopening them, but would reopen eventually on April 6, 2020. Even in South Korea, the right to an education is a crucial part of their social values.

South Korea also sounds a note of caution. Beating the outbreak does not mean the coronavirus no longer poses a threat, it’s not going to be normal like things were before the coronavirus. Normal after the virus is going to look very different. This will be with us for a long time.

The world should look to South Korea’s handling of the coronavirus outbreak as a way to emerge from the pandemic without severely affecting economic growth. South Korea saw a rapid increase in cases starting late February and by mid-April, daily reported cases of infection fell well below 100 due to mass testing and strict social isolation measures. As a result, it contained the virus outbreak without suppressing economic activities. South Korea saw a rapid increase in cases starting late February when the flu-like disease spread rapidly among members of a religious group. By mid-April, daily reported cases of infection fell well below 100. The country embarked on mass testing efforts and strict social isolation measures but didn’t totally shut down businesses. As a result, it managed to contain the virus outbreak without suppressing economic activities. The world should look at South Korea as an exit strategy because it has institutions in place to trace and quarantine. South Korea has started easing some of its social distancing measures.

To summarize the South Korean success story without lockdown is  (i) Despite a sudden spike in infections, South Korea is now winning the fight against the COVID-19 coronavirus. (ii)Regions shared doctors and opened their hospitals to each other’s patients. (iii)Testing is at the heart of the country’s coronavirus strategy.


Successful case studies in the Indian Scenario

(a)Kerala model

Kerala model in handling the floods, the nipha virus and now the COVID-19 is a successful case study in itself. The State leading in high rates of literacy had already invested on education and health care infrastructure over the decades, the proactive approach of the State Government from the time the first case reported till now and the emphasis on testing, timely delivery of essential commodities to the house holds through the law enforcing agencies, testing, treating and quarantine, preparing food from a common kitchen and delivering the food packets to the needy and the migrant labour work force all have worked wonders and the results are there for everyone to see. The decision making at the apex level in the State having daily press briefings with the State health minister and the entire beuracracy  running like a well oiled machine. The State was the first to release a Rs 20,000 crore financial package and sought assistance from the Centre which gave a very negligible sum to that State without any scientific reason or logic. The Centre’s step motherly treatment to the States was evident and did not respond to multiple requests for payment of dues and financial assistance by the opposition ruled  States. On the contrary, the Central Government must come forward with a stimulus package for all the States and hand hold them till the States’ economies are not back on track. State friendly, proactive policy decisions is expected of the Centre. All dues that are payable to the States by the Government of India need to be cleared in one go instead of the piece meal basis.

 

The indicators which shows that Kerala model is a success are

(a) Lowest death rate

(b) Highest recovery rate among Indian States

(c) Highest number of COVID-19 testing in India based on population density-Ten centres in Kerala

(d) Establish COVID-19 testing Kiosk(WISK)

(e) Went for Plasma Therapy

(f) At least two COVID-19 special hospitals in every district

(g) Promulgation of law on epidemic control-The Kerala Epidemic Diseases Act

(h) Provide telemedicine and consultation for Indian diaspora

(i) Start 1400 plus community kitchens across the State

(j) Has the highest number of migrant labour camps and shelters in the country-19,902

(k) Appoint 300+ doctors and 400+ health inspectors on war footing within a day

(l) Declare stimulus package of 20,000 crore financial aid

(m) Provide one month food irrespective of Above Poverty Line(APL)/Below Poverty Line(BPL)

(n) “Break the Chain” campaign for hand washing, sanitizing and social distancing

(o) Exclusive mobile application named GoK Direct and an SMS system to provide authentic information to the public

(p) Expanding Internet bandwidth and connectivity for the lockdown situation

(q) Conduct daily situation analysis

(r) Daily situational briefing on public health and protective measures and programmes by CM, Health and Revenue ministers and Chief Secretary

(s) An Indian institution to get membership in the world virology network is in Kerala.(Institute of Advanced Virology in Thiruvananthapuram has gained membership in the Global Virus network)

(t) All arrangements for the expatriates returning after lockdown-Space has been identified to accommodate around two and half lakh people and 1,29,000 beds have been arranged in all the 14 districts of Kerala

 

(b) Rajasthan model (Bhilwara model)

Rajasthan too had its Bhilwara model and was effective in containing the pandemic.  The essence of this model was ruthless containment, strict compliance of the curfew and screening of the whole population of the district. This model was unique that the corona infection was found in the doctors and other staff of a private hospital and without any knowledge, the doctor continued with patient consultations in large numbers and the source of the infection was also untraceable. The biggest challenge was the screening and testing of the population of more than 30 lakhs and to identify people who had come in contact with the infected persons and quarantine them. For this, extensive counselling of people had to be done.

The State Government of Rajasthan was proactive in making all possible arrangements to ensure that not a single person remains hungry on any of the days. It purchased wheat from FCI at a market price of Rs 21 per kg and distributed it free of cost to 60 lakh needy persons. The State declared an economic package of Rs 3000 crore for the poor and the destitute. Provided 10 kg wheat per person for two months to the BPL, State BPL and families covered under the NFSA. Besides these, economic assistance of Rs 2500 had been provided to 33 lakh poor people who are not covered under the NFSA and social security pension schemes. These included construction labourers, daily wage earners, street vendors, rag pickers and other deprived people. These people were also provided packets of dry ration or food free of cost.

To bring the State economy on track and ensure growth at a faster speed, a task force was constituted headed by a retired finance secretary to Govt of India. There have been continuous discussions with experts and stake holders of all the sectors. Permitted activities were supported during modified lockdown to ensure resumption of operations without many obstacles.

 

Some indicative strategy for lifting the lockdown in a phased manner in the Indian scenario based on the  German and Korean  experience:

  1. Healthy people with no underlying medical conditions should be allowed to socialise together in small groups, while family members will be permitted to attend funerals.

  2. Further, next step would depend on factors such as how the rate of infection evolves, the number of intensive care beds available, compliance with social-distancing rules, aggressive testing, including defining concrete thresholds on how these measures are effective and can be evaluated from time to time.

  3. Aggressive regime of coronavirus testing has to be ramped up. This would help in slowly unwind the lockdown and avoid further economic meltdown.  The Government has to set itself a goal of carrying out at least 200,000 samples per day. So far since the outbreak in India and during the lock down as on April 30, 2020, only 8,30,201 samples have been tested according to ICMR. Britain proposes to test 100,000 samples a day, France plans to test 700,000 samples a week.

  4. Once a person tests positive, tracing would begin to identify, test and isolate all those who had been in close contact with the individual.

  5. The tests have to be made free of cost by the Government, furthermore the process to get tested should be made easier , as of today if someone voluntarily wants to get tested , it is very difficult

  6. A suitable fresh emergency practical economic-support plan has to be worked out and delivered encompassing all sections of the social economic spectrum in the society that would soften the impact of the virus. The detailed economic support plan would be a subject matter for a separate article.

  7. The return to normalcy must not lead to a relapse and lock down enforced again which would have severe repercussions on the Indian society.

  8. Expediting the vaccine for COVID on a fast track mode so that we achieve the level of maturity similar to that of polio drops.

  9. Privacy, vulnerability, surveillance, security, data storage, costs, technical issues of Arogya Sethu including source code needs to be addressed on top priority as it has led to similar rogue applications that are a high security risk. The source code must be open to independent audit. It must not be made mandatory till the aforesaid issues are resolved. It must not be used as an surveillance application as it invades the individual’s rights of privacy.

South Korea is one of the major sources of testing kits for India – the anti-body test kits as well as RT-PCR or Reverse Transcription Polymerase Chain Reaction test kits – for the detection of the novel coronavirus disease. India has sourced around 450,000 test kits from South Korea so far.

Two South Korean firms making the diagnostic kits are M/s Humasis Co Ltd Korea and M/s SD Biosensor. M/s Humasis have signed an agreement to supply 500,000 covid-19 test kits, expected to help in early detection of the disease. These kits would be delivered to the Indian Council of Medical Research in four lots starting from April 30,  2020 according to a statement from the Indian embassy in Seoul.

SD Biosensor started manufacturing rapid antibody test kits in its Manesar plant after getting the necessary go-ahead from the Indian Council of Medical Research and from the Drug Controller General of India. The State Government of Chhattisgarh used the SD Biosensor kits for COVID testing in the State.

The Chinese companies too sent RT-PCR test kits, rapid antibody tests, thermometers as well as personal protection equipment.(PPE) including 6,50,000 testing kits. The major consignees were Imperial Life Sciences, HLL, Matrix Labs, Invex Healthcare, Max and companies of the Reliance, Tata, Adani group besides the state governments of Karnataka, Assam, Tamil Nadu and Rajasthan. But, some of the Chinese kits proved defective. The cost too were contested in the Indian courts after which the Central Government cancelled the order based on the Court’s direction on pricing.

So in short we should ramp up our testing facility ( which the govt should have done in last 45 days), we should learn from South Korea , TEST TEST TEST  should be our mantra . The more we test the more we should be able to identify and isolate .

To sum it up it is suffice to say that the Government’s response in this crises has left a lot to be desired. It should stop behaving like Abhimanyu caught in a Chakarvyuh and start behaving like Arjun to get out of a Chakarvyuh of its own making.

First published in Sabrang India.
The writer is a medical doctor, MBBS, MD practicing in the national capital region, NCR