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Lockdown can be lifted only if hospitals can cope with surge in cases: Dr Rahul Potluri

Dr Rahul Potluri, who works with the UK's NHS, tells TNIE Editor GS Vasu that lifting the lockdown before the coronavirus can be completely beaten may only cause more long-term problems...

Published: 31st March 2020 09:49 PM  |   Last Updated: 02nd April 2020 12:58 PM   |  A+A-

Beds in isolation ward set up for coronavirus patients.

India is under lockdown since March 22. (Photo | Madhav K, EPS)

Express News Service

HYDERABAD: The Indian government might be trying to dispel notions that the current lockdown will prolong beyond mid-April, but not everybody is convinced.

In this chat with The New Indian Express Editor G S Vasu, acclaimed cardiologist and researcher Dr Rahul Potluri says that the lockdown can be lifted if "the number of deaths are not vastly increasing and if the healthcare system can cope with the number of new cases coming", but not a day before that.

Potluri, who works with the NHS in the UK and at KIMS, Hyderabad and is a pioneer in using big data in healthcare research, takes us through why he hotly contests the MIT paper on the effect of heat on COVID-19 and why he believes India is to be commended for an early lockdown. Excerpts:

You are currently practising both in the UK and in India. Is there any difference in the approach towards dealing with the coronavirus?

There are a number of differences in the way that the coronavirus situation has been handled in both the UK and India.

Initially, when the first cases came out in the UK, the policy was to test all of those who came into contact with the initial cases and after this, they thought they were in control. But a few weeks later, they found out that community spread was happening. Subsequently, they thought that they could not handle the extent of the community spread and so, they came up with the idea of herd immunity. It was only then that they calculated that 60% of the population would need to be affected before herd immunity kicked in. This would have resulted in about a quarter of a million deaths. So, they subsequently changed the policy in line with the rest of the world where they went for social isolation and a lockdown.

In India, the situation is much more different. Initially, the cases were not as much or certainly, they were not testing as much. The focus was primarily that this is a disease brought in by foreigners. The degree of community spread is not known even now. So therefore, the way the coronavirus outbreak was handled has been quite different. What is not different is the concept of social isolation and lockdown.

The reason for that is to first reduce the spread of the coronavirus from person to person. The second reason for social distancing is to buy some time for the healthcare systems so that they can cope with the outbreak, and by ‘buy some time’ what I mean is that initial modelling performed in the West, particularly in Europe and the US, has shown that if everybody gets the virus in the space of a couple of weeks, no matter how good the healthcare system is, they won’t be able to cope.

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Just to put this in perspective with numbers. In the UK, there are around 6,000 ventilators in the healthcare system in the whole country. If, even with the social distancing, there’s a peak outbreak in a couple of weeks, it is estimated that they will need 30,000 to 40,000 ventilators.

In hindsight, is it reasonably safe to conclude that the measure that India has taken of imposing a complete lockdown is a better option than what the West did?

I think we have to congratulate the Indian government for taking this step at an early stage compared to some countries in the West. They now have to ensure that the lockdown is fully adhered to. The point I am making is that social distancing and lockdown adhered to by as many people as possible — as close to 100% as possible — will limit the spread of this disease and also enable the healthcare system to cope.

But at some point this lockdown will be lifted and people will be back on the streets. The government has clarified that it has no plan to continue it beyond three weeks. Will we be safer by then without the risk of the virus affecting us or do you suspect that the virus will be back?

So, the concept of the lockdown, as I said, is not only to limit the spread of the disease but also make sure that the healthcare system can cope. There is a lot of uncertainty as to when this lockdown can be lifted and if you look at multiple arguments on the problems with the lockdown, a lot of them are around public health versus economics. For example, in the US last week, 3.3 million people were made unemployed in one week, which is a record. So you can understand the stark economic issues that many countries, not only in the West but also in Asia, are facing. So far, about 10 trillion dollars of stimulus packages have been announced around the world, particularly in the Western countries.

However, the underlying concept that most experts in the industry are reflecting upon is that if public health is not safe and if people cannot go about their daily business - for example, go to a shop without being scared that they will catch a virus - there is no economy. So, the concept that the lockdown is going to cause economic harm is not valid. Weighing economic factors against public health is always an issue. Lifting the lockdown before the virus can be completely beaten will only cause more long-term problems in the economy, in the eyes of many experts.

The lockdown can be lifted, sooner rather than later, if people adhere to the policies, and if the virus toll stays low. If — particularly in a place like India where we are not doing extensive testing — the number of deaths are not vastly increasing and the healthcare system can cope with the number of new cases coming without being at full capacity or beyond. If all of these happen, then certainly the lockdown can be lifted but not before that.

Related to this, what do you think is a reasonable time when we can conclude that India is free from a possible community spread? So far, the government has said that there is no evidence of community spread.

Your question is a good one and it has multiple answers and this links to the fact that the number of people being tested in India is low. We can’t say that there is no community spread. People who are well and in the community are not being tested and they have to be tested in the thousands. One of the misconceptions about the coronavirus is that the West, or particularly the US, has a lot more cases compared to countries where there are only a few thousand cases. But certainly, in the US, they have tested about a million people so far.

We have not tested a million people in India, not even close. If we had tested a vast number of people in the community and the number of positive cases is not high, then certainly we can come to the conclusion that there is no community spread. When we have not tested, we cannot come to the conclusion that there is no community spread. These are not only my thoughts but they are also underlined by the WHO policy where they are advocating ‘Test, test, test’.

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But even in regard to testing, there are two theories that are being propagated. One is test, test, test, while what we seem to be currently doing in India is only to test those who are showing symptoms. Which one would you side with?

There are two things and I think you have to do both.

The reason that you are only testing the people with symptoms is because we are a country of 1.3 billion people. How are we going to test everyone? We know even in the US, particularly in the first two to three weeks, there was difficulty in obtaining the testing equipment. Now, things have eased slightly there. Many countries across the world, including the UK, are having difficulties in obtaining the testing equipment. In India too the story is no different.

The second thing is, what are you going to do if you test somebody and they come out positive? Are you going to isolate all of them or millions of them? There is no capacity to do so.

Therefore, testing the people who have symptoms or who are unwell seems to be a reasonable policy in the context of social distancing and lockdown because even if people who are asymptomatic or have had mild symptoms are now positive, what is advised, at least in the UK, is to stay at home until the symptoms resolve.

So, the concept of test, test, test is not so simple. There are obvious benefits. Well, if we look at experts and the World Health Organization, and if you take the case study of South Korea for example, in early March, they had a number of cases all at once. They subsequently undertook a test, test, test policy. And if you look at the curves of South Korea, they have drastically reduced. They have managed to test a lot of people, they have kept people apart and the cases have largely been contained.

A thing everyone needs to consider is what to do when we come out of it on the other side. How do we find out who is infected and who is not? If you don’t have such an exit strategy, all the things we have talked about, such as economy, health... nobody knows.

Then, a different type of test is required. Not only a test to see who has got the virus but also a test for who has had the virus and who is immune. This is particularly relevant to a potential vaccination in the future too. If somebody has already got antibodies to the virus, are you going to vaccinate them again? Are there risks to such a policy? Because a lot of vaccines, and I am speculating, are live attenuated vaccines. And as such, they may have risks if you give them to people who have already been infected by the virus or are immune to it.

Therefore, the testing element will definitely come into it, in a large extent at some point. It is just that in the near future, with everybody involved in testing for a disease that didn’t exist three months ago, it is very difficult to test everyone at once.

There are two arguments being made and both of them have turned controversial — one, the virus that travelled to India is less virulent and then, there is a study reportedly presented by MIT professionals that the virus may not survive in hot conditions. Is there enough scientific data to back these claims?

I am aware of both of these studies and I must say that both of these are very preliminary studies. The MIT paper looking at temperature and the coronavirus is only an abstract that was presented. There is no full paper. The abstract is somewhat peer-reviewed but not to the extent that a full paper would be. That is the first caveat. And the second caveat, they looked at the cases in early to mid-March and correlated this to temperatures. It is a purely computational model with correlation. It remains to be seen if temperature has an effect on the coronavirus but certainly, this is not what this study has shown.

Because the coronavirus started in colder places and then, spread to other colder places, and it is only now coming to spread in hotter places like Africa and Asia where the number of people being tested is low, we cannot automatically come to the conclusion that the number of cases is lower in those countries. That is by no means proven yet.

The second paper you are talking about  - on the race differences in coronavirus virulence - has not been peer-reviewed and has not been published. It has been uploaded to a pre-print server and I must credit the authors for doing so because it puts the study into public view. But the authors themselves claim that further work is required before they come to any conclusions that the strain is less virulent in India.

This study just looked at a few of the early cases and the genomic patterns of these cases. There are a lot of methodological weak points in this study and the authors themselves acknowledge this. The main ones are that there is no differentiation as to the ethnicity of the samples they have taken from various countries. For example, if they claim to have taken a sample from Wuhan, did they take a Caucasian living in Wuhan or an Indian living in Wuhan or an Indian living in the USA? None of this data is recorded in their study.

The second thing is, the main point that I took from their study, is the genome of the virus is similar in 99% of the cases across the spectrum and they are certainly not saying that it is different in India. That is not the conclusion. We have to be careful when we come up with such conclusions from very preliminary data and it remains to be seen whether this is the case but certainly, we cannot come to that conclusion now.

As someone who has also seen this situation in the UK, any advice you would like to give to people back in India in dealing with the crisis?

The main advice is don’t take the coronavirus as ‘not a serious problem’. The coronavirus is a serious problem. We have not seen the likes of it for over a 100 years since probably the Spanish flu pandemic. People are dying.

To put this into context, in places such as Italy and Spain, on a daily basis for the past week, 800-900 have been dying. If you extrapolate that to one month, that is about 2,00,000 to 2,50,000 lakh people dying in each of those countries. In the UK, about 200 to 250 people are dying on a daily basis. The projections and the mathematical models are that this will extend to around 1,000 people per day in the next couple of weeks and this is a very difficult statistic to deal with.

Let me just tell you what is happening on the front lines in these countries. Doctors from various specialities are being forced by the situation to act as COVID-19 doctors. So, orthopaedic surgeons who have little or no experience in dealing with medical problems are suddenly being thrust into the front lines to deal with this COVID-19 crisis.

That is not because they want to do this, it is because they have no other choice because of the overwhelming number of patients who come through the front door who are really sick. And if you take a city such as New York for example, there was news out that they will run out of medical supplies and capacity in less than a week and those numbers are changing.

I’ve been in touch with many colleagues in North America and the UK and life for the doctors is very difficult and uncertain there at this point. They have faced difficulties in terms of having personal protection equipment (PPE) and they are also putting their own lives on the line to treat patients in the wake of a very serious illness.

So, let’s not make any mistake, this illness is very serious. I’m glad that so far in India we are not seeing those sort of death rates and I hope that it continues that way. Everybody has to play a part to keep it that way and that is to maintain the lockdown and maintain social distancing. The more people that participate in that, the less people will die and the less this disease will spread and the less we will see these terrible consequences.

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