THE CORONA COMBAT : REVIEW OF THE SITUATION IN INDIA By Lt Gen P R Shankar(R)

The battle is truly joined with Corona Virus from Wuhan, China.  We Indians are at Day 5 of the battle. Let us review the situation and see what lies ahead holistically. Every one of us is under attack - Individually and collectively, under the pump. We are in a battle for our lives and the way we live it. The battlefield is your house, mohalla, area, taluk, district, state, the nation and most importantly our health care infrastructure and professionals. The viral enemy is ubiquitous.  We are under siege. How do we defeat this Virus?  The military way.  Since all of us are battling the enemy together, this review will be in military style.

Enemy

Transmission and Fatality. Corona Virus transmits through respiratory droplets (sneeze or cough or talk)[1] which can infect other people via the eyes, nose, or mouth—either when they land directly on somebody’s face or when they’re transferred there by people touching their face with contaminated hands. Direct person-to-person transmission normally only happens when people are in close contact—within about six feet of each other. Most transmissions are among family members or between patients and health workers[2].  The virus survives on smooth, nonporous surfaces for up to 72h (doorknobs, handles, toilet seats, etc.). It transmits, under the radar, stealthily. Carriers could show mild, limited, or no symptoms[3]. It is highly contagious with a very high basic reproductive number R of about 2.4. The Swine Flu R was 1.5. Due to stealth and high R, it spreads exponentially and explodes on us one fine day. There is no antidote or medicine against it.  A vaccine is more than 18 months away. However, it has a slow fuse and gives time for cure. It is a slow and long illness[4]. Infection to ICU time could be up to a fortnight. Fatality rates are 0.5% - 4%. Fatality is high in the aged. (see Chart[5]). Fatality rates increase since the health care system cannot cope with cases. India’s high population densities can exponentially increase the rate spread to a flood.   Death occurs less due to severity but more due to inability to cope with the flood of cases[6]. The key is to reduce the cases so that our hospital system can always cope with it.

Climate. One-degree rise in temperature and one percent increase in relative humidity lower R by 0.0383 and 0.0224, respectively[7]. (see chart below). Countries with relatively lower temperature and humidity (e.g. China, Korea, Japan and Iran) have experienced more severe outbreaks compared to warmer and more humid countries (e.g. Singapore, Malaysia and Thailand).[8] [9] Overall people in temperate warm and cold climates are more vulnerable followed by those in arid climates. People in the tropics will be least affected[10]. Some hope for India.  However. even in warm and humid conditions quarantine is needed to reduce transmissions and protect the vulnerable. Asynchronous seasonal outbreaks are still possible. Hot and humid weather will reduce the infection spread but will not stop it. Moreover India has had milder temperatures than normal. Most of India is likely to remain below normal for the next two weeks. If we get past mid Apr, and temperature rise, we can hope for summer to suppress the disease. John Hopkins University estimates that, we can expect a R of 1.8 in India.

The Virus is vulnerable to soap and direct sunlight. Use this weapon.  The uncertainty is how will it mutate and evolve in future. Let us now deal with the known. We can mutate also in time.  

Own forces

As of today, there are 867 active cases, 25 deaths, and 86 recoveries[11].  Cases have increased steadily. We should expect a case explosion in future despite an effective lockdown. Lockdown has given us time to think and plan. We are fighting this battle far better than richer and better equipped countries[12].

SWOT Analysis. We must fight this battle on Indian conditions, realities and terms. Hence a SWOT analysis is in order. The SWOT table in point form without detailed explanation gives a holistic picture. More points are welcome for follow up by those in charge of operations. The mantra is - leverage strengths, exploit identified opportunities and focus on marginalization of weaknesses and threats.

Strength A young demographic to withstand the Virus. Leadership – decisive, clear and influential. Preparation on track. Decisive and responsive government (economic and poverty alleviation schemes) . Inbuilt immunity of Tropics Experience and networks in handling epidemics and disasters. Expert health care professionals pool. The Brains and numbers. Indian innovation cum jugaad at all levels. International experience and knowledge gained by other countries.     Timely imposition of curfew and unprecedented public response and adherence.   India has an inner strength to surprise itself (X Factor) . The strength and steel Armed Forces and Railways Ahead of the Curve Syncretic Culture

Weaknesses Population Density and difficulty in social distancing. Huge numbers specially of the aged Malnourishment and lifestyle diseases Awareness levels are poor at lower strata of society Poverty levels and unorganized sector Poor health care facilities and lack of numbers Fragile economy Social Awareness and Public Hygiene (Public Urination and spitting) Divisive Culture

Threat Indiscipline and non-adherence to laws when lockdown is lifted. Population can overwhelm. Approaching summer – water stress in all mega cities and what if the virus mutates to survive Summer? Internal Migration Break down of essential services Inadequacy of Economic and Poverty mitigation packages Ideological politics

Opportunity Time gained   Climate and on coming summer will weaken the Virus Indian economy might be poor, Indians individually are rich (tax Free low interest Bonds?). India can show the way to the developed world Development of herd immunity Low oil prices.

Key Lines of Operation

The key lines of lines of operation in this battle are as under.  

Practice Isolation. Isolation is the key to defeat the enemy at every stage of battle. The extent and degree of isolation/ quarantine is a matter of the situation. The enemy will constantly try to de-isolate us. Self -isolate when in doubt. Do not let entry of the Virus into your immediate periphery. Remember the Laxman Rekha principle. Isolation flattens the curve and buys time.

Maximize Social Distancing.  Probably the most important concept. In the Armed Forces it is a matter of routine to maintain distances between man to man, gun to gun, tank to tank so that minimum number of casualties take place in one attack. Social distancing minimizes attack potency (transmutability) of the virus.

Enhance Private and Public Hygiene. Washing hands, public places hygiene, disinfection etc. kills the enemy. Normally people wring their hands in despair. Wringing hands with soap brings hope now.  

Build and Recreate Capacities. Enhancement of our medical infrastructure is the prime need to meet the oncoming rush and there will be a need to recreate / redeploy it.  

Institute a Strong Testing, Tracing and Treatment Regime.  While a lot has been discussed about it and action is also being taken, we need to look at the long-term methodologies and reinforce this action.

Protection Priorities and Policies. Nationally we must have a priority for protection. This would involve protection of the protectors and protection of the vulnerable (aged, infants and the chronically ill). Simultaneously it will involve burying the VIP culture. Saving the old from the young will be a key policy.

Building Awareness.  Building awareness and education of the masses to increase compliance of preventive measures will be a key to defeating the enemy. Door to door awareness campaigns and monitoring for compliance can be considered. issues to be communicated are symptoms, self diagnosis and treatment procedure including helplines,  

Migration Control. Migration control and facilitation will be critical in our country. Staging centers can be opened. Special routes and mode of transport can be instituted. This must be thought through better than now.

Managing Other Diseases and Ailments.  Routine diseases and ailments cannot be ignored beyond a point. Hence this must be given thought before all medical facilities become centers of transmission or other ailments are ignored to our detriment.

Response Development.  There is a need to develop a flexible response capacity to cater for emergencies and evolving situations. It implies building up reserves and moving underutilized facilities to hot spots on an as required basis. We have an extensive railway network. Special Corona Relief Trains fully equipped with ICUs and medicines and isolation facilities can be mobilized. This will be a surge capacity of immense value. Many of them are AC too. Ideal for patients. 

Surveillance and Monitoring. A very important aspect of disease control is getting to know the ground situation so that adequate responses can be generated. A parallel overlay system of surveillance and monitoring is the need of the day. In the Army, all Artillery officers function one up with their own communication. It duplicates normal systems and often works faster. It enables simultaneous and nonlinear responses. It also brings in truth in reporting. Replicate it.

Mobilize Funds. India might be a poor country. However Indians are rich individually. Their funds should be mobilized either as donations or as tax-free long-term bonds.

Deploy Armed Forces. They are the steel of the nation. Deploy them before it is too late. Act now all over in all districts.

Visualized Phases of Battle

Phase I. Lock Down Period Up to Apr15.  The current lockdown has bought time for India so that the curve is flattened. This is a period when India is doing the following.

Isolation. The Isolation exercise is going on remarkably well despite some migration related hiccups.

Preparation. There has been an extensive effort at preparation which must continue. Preparation includes building up numbers in protective gear, ventilators, ICU beds, oxygen, emergency response, monitoring and reporting, national requisition of private capacities and development of software app-based solutions. Preparations for last rites of the dead should not be overlooked.  

Awareness. There must be a regular official briefing twice a day which all media and channels must carry. Very much like the time of OP VIJAY when a composite team from Services, MOD, and MEA used to brief people. Also an extensive awareness and educational campaign must start for the masses who might still not be up to scratch on these issues.

Individual Effort. Everyone at all levels must take self -care of selves of regular diet, exercise and ailment management. Stay fit.

Test, Trace, Quarantine , Treat. This regimen should be simply upped in the same trajectory as is being done now.   

Phase 2. Summer – Monsoons.  The current lockdown will go a long way to flatten the curve. However once the lockdown is lifted many of us will behave like uncaged animals and undo everything in one go. This will be a tricky and an extension of testing period for all of us.

Lockdown. The lockdown period may be extended or be partial. Release must be gradual. Immediate lifting of lockdown is out of question. Strict rules for isolation and assistance of the vulnerable should be evolved. Large functions, marriages, restaurants, bars, public gathering and unnecessary travel should be reduced. Schools, colleges and universities should remain closed and reopen after summer. 

  

Decongestion. There is a clear case for urban decongestion. It should be done through controlled migration in this period.

Herd Immunity. India must develop herd immunity to the Virus in a controlled manner through the young and fit. It involves deliberately separating those who are being exposed to the virus and monitoring them. Experts must look into this.

Monitoring Mutation. The Virus is mutating. There is no doubt about that. This must be tracked scientifically.  

Phase 3. Monsoon to Winter. This is a grey zone period for which action and response will evolve with experience gained in summer. However, in this period, our hills will be vulnerable to the Virus since they will be experiencing temperate climate.

Phase 4. Winter. Expect a recurrent wave. Deal with it with the experience gained. This Virus will not go away.

Conclusion

The Chinese Virus can be defeated with a military approach and thinking by all soldiers (nee citizens). We will defeat it unitedly at one level and individually at another. We must continue to do it now, tomorrow and well into the future. We need to launch a multipronged counterattack with the tools and knowledge available to us. When the vaccines and antibodies come, we will see. Till then fight with what you have.  Stay safe. Keep morale high. We as Indians need to discover our inner strengths. Jai Hind.  

If you feel there is sense in what has been outlined , please send it to all our friends who are in the thick of executing plans. they should be as well armed as possible. if you have any suggestions please do not hesitate to add. it will save our lives better. 

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[1] https://www.healthline.com/health/coronavirus-transmission#spread-without-symptoms

[2] https://www.the-scientist.com/news-opinion/how-covid-19-is-spread-67143

[3] https://www.livescience.com/coronavirus-undiagnosed-spread.html

[4] https://www.theatlantic.com/health/archive/2020/03/how-will-coronavirus-end/608719/

[5] https://epidemic-stats.com/

[6] https://webcache.googleusercontent.com/search?q=cache:Q7S18eyhhpgJ:https://www.mohfw.gov.in/

[7] https://arxiv.org/ftp/arxiv/papers/2003/2003.05003.pdf

[8] https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3556998

[9] https://www.technologyreview.com/s/615381/coronavirus-spread-could-slow-with-warmer-weather/

[10] https://www.medrxiv.org/content/10.1101/2020.03.12.20034728v1.full.pdf+html

[11] https://webcache.googleusercontent.com/search?q=cache:Q7S18eyhhpgJ:https://www.mohfw.gov.in/

[12] https://www.worldometers.info/coronavirus/