COVID-19 in a World Beyond Borders – Personal Thoughts on a New Call to Action

As a fellow of the Global Health Leaders Program at the Public Health Institute, Oakland CA, and later as its employee seconded to Medtronic Foundation, Minneapolis MN, I visited the USA 3 to 4 times a year in the last five years. Yet, my last trip there was distinctly remarkable.

In the second half of February 2020, I visited four cities in the USA, accompanied by my wife and my 12-year-old son, partly on work travel and partly on a family outing. While the family was mostly on its own, I was busy attending meetings during the daytime. After visiting Chicago, Minneapolis, and Washington DC, finally we left New York on 1st of March 2020, the day the first case of COVID-19 was declared in New York. Although the scare of the SARS-Cov2 or COVID-19 pandemic was rising, nobody had imagined the scale at which it was going to ravage the world. At that time, there had been only two COVID-19 positive cases reported in Chicago, and none in Minneapolis and Washington DC. In a weeks’ time, the number of cases had risen to nearly 90, with total deaths across the USA rising to about 20 and every city I had visited had reported a rising trend of COVID-19 positive cases every day.

In none of the airports, either in India or in the USA, did we face any active screening during the travel, except that there were announcements in the airports requesting self-declaration by travelers of signs and symptoms related to COVID-19 or if they had visited any of the few countries that had high caseloads during that period.

We returned to Bangalore, India on 2nd March, via Delhi. The country had not yet been ready with its quarantine policy or was probably still trying to understand how to organize a large scale testing strategy for people arriving from affected countries or those who started demonstrating signs and symptoms. A couple of days after arrival, I called the local helpline to inform that my family and I had just returned from New York and we would like to go for COVID-19 tests for the family. Incidentally, my mother in law and my mother, both in their 70s, live with me and both have chronic diseases including diabetes. So I was specifically interested to see if they were safe.

The helpline executive advised me to take everyone in the family either to a nearby government designated health facility for appropriate advice or to a tertiary care centre situated in the heart of Bangalore, having the only operational COVID-19 testing laboratory in the state of Karnataka at that time. Of course I was in the horns of a dilemma, on one hand, having to decide whether to take the family to any of these sites and on the other, struggling with my fear of exposing my two 70 plus mothers and my 12 year old son to potential infection in these centres, if not to COVID-19, then definitely to other prevalent infections. So finally, I decided to home quarantine all of us for not just the recommended two weeks, but an additional week, albeit with no greater logic than driven by an unknown fear, to which I shall return towards the end of this blog.

Incidentally, as India had just crossed 500 cases by the third week of March, the Prime Minister of India announced a voluntary public curfew on 22nd March followed by a nationwide lockdown for 21 days, to be further extended until 3rd May with conditional relaxation from 20th April for regions with minimal spread of the infection. Fast forward five months since then and we are living an all new world, with new norms and customs.

Till date Illinois, Minnesota, Washington DC and New York have recorded 8672, 2015, 11823 and 33170 deaths respectively. In the entire USA, of 7.4 million cases, over 200,000 have died so far. By the time this blog was written, India’s death tally had crossed 97,497 with a caseload over 6.2 million, a number only second to the USA’s. Well, it seems India is poised to soon surpass USA in this unfortunate race to become the worst affected country in the world due to COVID-19. Clinical experts, immunologists, virologists, epidemiologists and biostatisticians all have been struggling hard to understand the nature of this unprecedented pandemic with rapidly changing patterns in data across the globe and accordingly proposing ever changing explanations and therefore alternative recommendations for strategic action.

I am wondering if I could rewind the time back to March 1, 2020, possibly thinking we know enough from our experience with this pandemic over the last six months, so that we could prevent the suffering not only from the uncountable deaths but also from the massive job cuts and business slowdown. Do we know enough about what is safe behavior at home and at a public place? What if I were in the New York airport leaving for India on 1st March 2020, but more confident and conscious of what my family and I needed to know and do about an ongoing or imminent pandemic? Come September 2020; are we confident now?

Well, the unknown fear that I talked about in the beginning of this writing is still lurking around, perhaps with a more dreaded look than before, as I am still wondering how to protect my mothers and my family as much as every citizen of this world is pondering in panic. The silver lining in the backdrop of the fact that over 80% people expel the virus without clinical manifestations, is not necessarily comforting as we are not sure who belongs to the other 20%, who might be protected by some unknown “immunological dark matter” as referred to by Prof. Karl Friston, who perhaps casually made that comment in connection with Germany’s lower case fatality than Britain.

In March, with Dr. Stevan Weine of University of Illinois at Chicago, I was involved in a rapid survey of the preparedness of health facilities in 15 countries which was also published as an op-ed in The Hill adding to the speculation that low and middle income countries would be suffering from a huge crisis of shortage of beds, trained and equipped manpower to look after the surging volume of patients with COVID-19. The concern is genuine without a doubt. A survey report on pandemic preparedness by WHO member countries published in 2019  suggested that nearly half of the member nations were not optimally prepared for an impending pandemic.

However, in an altogether different perspective, although the widely publicized 2019 Global Health Security Index ranked USA and UK as numbers one and two in the first of its kind comprehensive assessment of global health security capabilities in 195 countries, both these countries have suffered heavy casualties from COVID-19 compared to many other nations that ranked far below in this list. Albeit, low- and middle-income countries were expected to be least prepared for COVID-19 that hit them without giving enough time for preparation. At the same time Australia, ranked number three in the GHS index, has apparently given a formidable response to the challenges posed by COVID-19. The same applies to Japan with a high geriatric population and a low case fatality rate. South Korea, Taiwan, Hong Kong, and Vietnam have demonstrated quite low mortality as well. While these countries have been relatively less stringent in enforcing extreme control measures such as complete lock down and forced isolation compared to others. Not to mention, response to national policies and prescriptions by the general population based on differential cultural and value based practices may have an influence in the effectiveness of government efforts and that is why Japan may have benefitted from peoples’ participation in their unique style.

The bottom line, though still cloudy for most of it, appears to me to be the emergence of a new paradigm in the field of global health. We need altogether different measures to gear up for the havoc a pandemic can wreak than what an unwavering reliance on conventional wisdom of public health experts and governments guide us to employ. This further raises the need for globalization of expertise in health risk assessment, R&D investments in health research beyond boundaries, integration of public health and evidence based measures with economic productivity in a given context of a country and so on. While developed nations continue to invest in sophisticated technology for virus isolation, vaccine research and pandemic preparedness, it is imperative to also invest in understanding how each country puts up a resilient health system against a deadly pandemic such as COVID-19 irrespective of their trades and economic status, clinical and research capabilities and cultural barriers.

As for now, we strive to reconcile with the new normal that has suddenly befallen us.

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