By Glenn C. Kharkongor
Predicting the future is hazardous at best. Crystal ball gazers and clairvoyants have kept away from the Covid scene. Some church goers quote Bible verses to claim this is a curse from God, to which Bah HH Mohrmen has posed the right question, and to paraphrase him, “If this pestilence is from God, why are we taking measures to curb it, instead of humbly accepting our just punishment?”
For the rest of us, Covid lies in the realm of science and it is here that we must look for answers. Science is not always precise and predictable. Indeed, debate and doubt are important tools in the scientific method, and the constant peeling away of the unproven and disproven enables a clearer core of factual information to emerge.
Covid is here to stay
Do viruses that cause contagious pandemics go away? Probably not. Once the wave passes, the virus lurks quietly somewhere, dormant till favorable conditions arise again. Only a few viruses have been truly eradicated, like smallpox and rinderpest, polio is on the cusp of elimination. Several of the recent pandemics or local outbreaks of SARS, MERS, and Zika have been contained, and the numbers have diminished, but spikes occur now and then. So like with HIV, an uneasy equilibrium is reached with most viruses.
There have been cascading predictions for the peak of the epidemic, first April, then mid-May, now we are hearing August. These are futile prophecies, and Niti Aayog made a big hash by declaring that after May 16, there would be no more cases. That offending power-point from Dr VK Paul, a retired professor from AIIMS, has since been removed from the website.
Pre-symptomatic spreaders are identified once they get symptoms, so the biggest unknown is the number of asymptomatic cases. These innocent individuals may be quiet spreaders, having never been tested. Thus with every stage of unlock, there will be a spike of cases. These are not preventable and must be immediately subjected to isolation and tracing of contacts. Migrations of labour and other home returnees like students caused a spike. Another predictable spike will occur with the opening of schools. Fortunately children are very low risk.
A wave is somewhat different from a spike. It means a resurgence of virus spread, maybe from new mutations, or environmental factors such as seasonal temperature and climatic variations. But definitions are subject to shades of meaning.
What about testing?
Unreasoned demands for more testing are a simplistic approach. Even if it was logistically and financially possible to test everyone in India, the yield would not be very useful. Millions would be found to be negative. An unknown but probably large number would be asymptomatic positives. This may be a feel-good thing, because it would tell us that most people with the virus don’t get sick and it would also provide a denominator that would indicate a very low fatality rate, i.e., not that much to worry about, compared to compared to TB, malnutrition, suicides etc.
It would be impossible to trace the source of infection of every asymptomatic positive case and would confirm by default, that there is community spread. A better strategy would be to test more in hotspot areas, and definitely all contacts.
Up to this point we are talking about RT-PCR, finding out if a person has the virus and can be a spreader. Antibody testing has a different purpose. Antibodies to Covid appear 6-12 days after infection and merely show that a person was exposed. It has little role in treatment.
Antibody testing is a public health surveillance tool that tells us about prevalence in the community and will influence later policies and decisions about control programs, such as vaccination, drug requirements, treatment protocols and public awareness.
Vaccines
Hope and hype do not help the cause. It takes at least a decade to develop a vaccine. Even though Nipah vaccine efforts got an early start, the vaccine is still years away. Compressing the time frame is fraught with complications. The fastest vaccine was developed in 4 years, for mumps in 1967. MERS appeared in 2012, but intense work on a vaccine is still in progress. Whether a vaccine will come at all is not a given. In spite of 30 years work, there is no effective vaccine for HIV. Best efforts have yielded no vaccine for dengue or chikungunya.
Even if a good vaccine is developed, anti-vaxxers will pose a considerable threat. In 2019, the World Health Organization named vaccine hesitancy as one of the top 10 threats to global health. Deaths among unvaccinated persons are steadily rising, worrisome especially for innocent children. Their parents subscribe to fringe theories such as links with 5G,and claims that Bill Gates is using vaccine microchips to track humans. The anti-vaccination movement uses social media to amplify its message. Facebook told the British Medical Journal that it has removed hundreds of thousands of posts containing harmful misinformation relating to Covid-19 and a potential vaccine.
Meghalaya may fall victim. The vaccination rate among rural children in the state is 58.5%, lower than the all-India average. A published survey on vaccine-hesitation, by the Indian Institute of Public Health, Shillong in 2018, reported a multi-factorial situation. While many parents were worried about efficacy and side effects, there were cultural and religious reasons also. Like with Aadhar, there is some distrust of government schemes. Biometrics is considered by some to be anti-Christ.
Medical officers have reported refusals based on religious grounds, and one government doctor said that he had invited religious leaders for a discussion, but nobody showed up. In the course of a nutrition project conducted by MLCU, it was found that in one village, not a single child had been immunized because of warnings from a pastor.
Drugs
Hydroxychloroquine has been virtually abandoned, studies on ivermectin have been discredited. Plasma transfusions from infected patients do help but will never be available on a large scale. Plasma is the golden yellow sticky fluid that oozes from healing wounds, the liquid residue when the red blood cells are removed. It contains antibodies. Steroids have been given a magical glow, but they are natural hormones occurring in the body and have general immune benefits that cover a wide range of illnesses in a non-specific manner. Steroid drugs can have harmful side effects, both in the short and long term.
The first anti-viral drug manufactured in India for Covid is favipiravir, announced on June 20. It will help those with mild and moderate disease, but not those with severe disease. Each tablet is Rs 103.
For the prescribed 14 day course, the expense will be Rs 11,866. Not many will be able to afford this, and no scheme for poor patients has been announced.
What should Meghalaya do?
A phased unlock is the right strategy, but not to be unduly dragged out. Border checking should be continued for registration and home isolation. Testing at state border areas won’t tell us much, because people from containment zones cannot move, and those who are allowed to travel are expected to be asymptomatic anyway. Testing at the entry points can be restricted to those from high case cities and persons with symptoms. Institutional quarantine should be only for those with positive tests and symptoms.
Educational institutions must open, albeit in a phased manner. For schools, first the higher classes, for colleges and universities, only the final year batches. Other batches can join a month later, when precautionary systems are in place. Assembly, convocations and other large campus gatherings must wait. Teaching in shifts is logistically difficult, and will entail double faculty time. Students from the other Northeast states will come to Shillong, but are unlikely to cause a spike in cases.
Tourism can re-open for the post-monsoon season. Because of a general fear, the numbers will be small to begin with, and so crowding at popular spots is unlikely. One USP that can be marketed is the low Covid prevalence. Maybe this is the idea of ‘resilient tourism’.
The unlock will be covered by the Rapid Response System. Chief Minister Conrad’s idea sparkled briefly, but seems to have been shelved. A vigilant and agile system of testing and contact tracing for every positive case can now be put in place.
We will have to live with Covid like we live with TB, malaria and the flu.