By M.M. Janapriya –
Being a senior medical professional and a concerned citizen studying and following the flow and ebb of the Corona stream, in my beloved motherland I am greatly perturbed by the way Corona raised it’s ugly head again and how this surge is being managed at the moment. I have absolutely no doubt in my mind that there is indeed community spread now. Even though the health authorities and the media are making a valiant attempt to connect the hundreds of cases scattered over most of the country to one or another of the existing clusters they have failed in style according to a PHI who came on Ada Derana TV on the 26th October 2020.
This is a very serious matter indeed and worse is the fact that the health authorities have been economical with the truth. Please watch the clip here from 6.29 minutes to 6.51 minutes. This man is an apology to a proper head of a very important preventive health Department. Listen to him carefully. The journalist is asking “Hand on heart can you say that there is no community spread of this disease at the moment? The doctor says “Yes of course I can say there is no community spread as at present. There is no necessity for us to hide such a thing because community spread is a situation where we cannot link one patient to another. As at present only 90.7% of the allotted bed capacity has been utilized. Ten percent of the beds are still available for use.” He is paradoxically referring to the measly 10% of Corona beds left as if it was 90%. This man’s reply is completely illogical, incoherent and incomprehensible to most of us proper medical doctors.
On the same clip the Public Health Inspector comes on next and says “ Covid 19 resurgence that has occurred in relation to Divulapitiya and Minuwangoda also called the second wave has got to a very unfortunate level by now. Together with the sub-cluster recorded in Peliyagoda, cases connected with this resurgence are being reported from all over Sri Lanka. Also at this moment in time several cases whose source of infection cannot be determined are being reported from parts of Sri Lanka. Therefore the situation in the country is dire.” Please watch this video between 6.53 minutes to 7.34 minutes.
The doctor clearly is holding back the truth the question being is he doing it at his own volition or is he being a puppet of someone or indeed is he genuinely incapable of analyzing the situation and coming out with a scientific inference? If any of these is the case he should respectably resign from his job and pave way for a better person to come in. Also it is evident from the recent happenings that the special Presidential task force headed by the Army (ironically not the head of the health sector) which, up until now seems to have done a sterling job, has been caught napping.
What happened and how it happened
Friends, Colombians, Countrymen, lend me your ears;
I come to bury mother Lanka, not to praise her.
The evil that men do lives after them;
The good is oft interred with their bones;
So let it be with my darling mother. The noble Brandics
Hath told you mother Lanka a woman of ill fame:
If it were so, it was a grievous fault,
And grievously hath she answer’d it.
Here, under leave of Brandics and the Rest–
For Brandics is an honourable organization;
So are they all, all honourable men–
Come I to speak in mother Lanka’s funeral.
She was my darling mother, who gave unconditional love to me:
But Brandics says she was a woman of ill fame;
And Brandics is an honourable organization.
It hath brought many a kill home to Colombo
Whose Dollars did some coffers fill:
Did this make Brandcs seem ‘untouchable’
When we, the poor cried, mother Lanka hath wept:
A woman of ill fame should be made of sterner stuff:
Yet Brandics says she was a woman of ill fame;
And Brandics is an honourable organization.
(Might be worth listening to this Mark Antony funeral oration by one and only Charlton Heston in the film Julius Caesar. I watched this as a 3rd year medical student on one of the few 70mm screens in the country at that time at the Odeon theatre, Kandy.)
This is a summation of the events that led to the most recent Sri Lankan Covid-19 debacle in which some powerful business people must have felt that the nation was an expandable lot. Also this poetic narration might give the confused Sri Lankan public an opportunity to delineate who Mark Antony was and who indeed was Brutus. SARS COV-2 is having a field day here on Sri Lankan soil courtesy utter and miserable mismanagement of the infection by the special presidential task force in which subservient doctors play either the second or third fiddle.
From what is happening around us it is obvious even to a second standard school child that
Corona is everywhere. The “test little trace with passion and isolate with a vengeance” strategy
of the task force has been defeated hands down. They are still being commandeered by the
Army and the learned (or not so learned) doctors seem to be just toeing the line. The
description below describes it all. With apologies to Lord Tennyson,
“Forward, the Lankan Brigade!”
Was there a man dismayed?
Not though the Nation knew
Someone had blundered.
Theirs not to make reply,
Theirs not to reason why,
Theirs but to do and die.
Into the valley of Death
Dragged the unsuspecting nation.
Corona to right of them,
Corona to left of them,
Corona in front of them
Volleyed and thundered;
Stormed at with droplets and spray,
Unwillingly they were dragged,
Into the jaws of Death,
Into the mouth of hell
Dragged the hapless nation.
This is the current situation. Like in ‘Sama Jathakaya’ we will defer investigating how this came about for the moment and get on with what remedial measures should be called in to action in order to resurrect Sri Lanka and unlike in ‘Sama Jathakaya’ we will pressurize the government to bring the culprits to books once the dust settles.
What mistakes did we do?
- Victory in the first leg made us believe all was well
- Task force seemingly didn’t meet for 2 months
- Didn’t realize struggling India next door could pose a real time threat
- Viral genome sequencing of the second wave virus seems wanting
- Realistic numbers of random tests are not being done
- Politics seem to have come before the country
- Public is being misinformed. Why?
- Stringent enough measures have not been instituted yet
Victory in the first leg made us believe all was well
Be it our innate immunity, herd immunity, successful BCG vaccination of the whole nation, hot climate, airy housing or the virus that came our way being a deleted mutant, I will without hesitation give a lot of credit to the task force for a job well done as per the first wave despite a few lapses it showed from time to time.
It felt almost surreal that we did so well with only 11 people dying all of whom having had other co-morbidities. We were jubilant and quite rightly so. Unfortunately this jubilation led to the authorities taking their ‘eye off the ball” the consequences of which were disastrous. Letting the Navy sailor go home on leave for New Year without completing the quarantine period was foolhardy and also was high handed. This sailor developed Corona and very likely infected a large number on the way home crossing borders of many districts. Together with him there were several other sailors let loose recklessly who too were found to have the infection. Then came the infamous 3 sporadic positives from staff NHSL, from streets of Rajagiriya and of Kolonnawa which predictably became negative within 24 hours in order to maintain ‘no community spread’ status.
Thondaman’s funeral came next. This took place violating every health guideline and more sending a very bad message to the public. Health authorities and the task force wouldn’t care less. Former advised the government it was safe to hold elections without excluding community spread by either doing PCR on large enough random samples in all provinces or indeed checking antiviral antibody levels in these samples or both. This is the reason why the servile doctors were not allowed to head the task force. The powers that be had made a good assessment of their capabilities and assertiveness.
Task force seemingly didn’t meet for 2 months
Basking in the new sunshine the Task Force apparently missed out on meeting for two long months. I cannot vouch for the authenticity of this statement but this is an accusation society seems to be levelling against the administration. If this is indeed true it is an unpardonable ‘mistake’ on the part of all the members of the Task force especially the medical members who should have advised the hierarchy on the prudence of having regular meetings till the virus threat was completely gone.
It is military practice to jealously guard the territory recaptured from the enemy with all their might. The present Sri Lanka Army and its top brass no doubt will have first-hand experience in this regard from the war against the northern terrorists. It is however deeply regrettable that this principle was not adhered to, in the Army led attack against the viral illness.
Didn’t realize struggling India next door could pose a real time threat
India after a reasonable start lagged severely behind in the race against Covid-19 infection. Infected number is astronomically high and number dead is staggering too. This is fathomable because under the booming economy is a faction of the community amounting to about 50% of the population or more that is desperately poor and is invisible to the rulers. They are malnourished and probably have not had all the prescribed vaccinations. It is very likely that a significant number of these people would not have had their BCG vaccination at all.
This and other reasons may have made this group very vulnerable indeed. We have been having a great deal of interaction with our big brother neighbor especially in the field of garment industry. Even though it is obvious that the powers that be should have been very strict with people coming from India it looks as though the authorities have had only a ‘sweet heart’ relationship leaving room for infected people to be smuggled in.
Viral genome sequencing was not done?
From the very outset people were yelling from the rooftops that the second wave virus may have come from India. Judging from the speed at which the infection is spreading and the fact that 6 people have already paid the ultimate price, this assumption seems to be not without merit. The only way this suspicion can be put to rest is by genome sequencing of this virus for which facilities are available in Sri Lanka but this has not happened for some unknown reason. Had we established this sooner and deployed stringent anti-spread methods in double quick time we might not have been in the predicament we are in today.
Realistic numbers of random tests are not being done
It is being said over electronic and print media that a large number of PCR tests are being done daily. These seem to be mainly on suspected cases and their contacts. It was told on ITN news last morning that there were 431 cases found after testing over 10,000 individuals. Going by this alone, the current prevalence is over a million people but the real number is going to be a multiple of this which can only be established or refuted by testing much larger numbers. The constant plea from different Medical Organizations and concerned individuals to increase the number of test done per day though has been heeded to half-heartedly, is nowhere near what is needed to realistically catch all infected people and isolate them.
Following are the key reasons why testing large numbers matters.
- Some studies estimate that presymptomatic and asymptomatic transmission accounts for approximately 50 percent of cases and testing is required to ensure that carriers of the coronavirus are not unknowingly passing it on to others.
- People generally seem much more likely to co-operate and isolate themselves if they are confirmed as virus carriers.
- To break chains of transmission, public health officials need to know where the virus is and who has been exposed to it. In addition, close contacts of virus carriers must be informed so that they isolate themselves, meaning colleagues at work, people in the same apartment building, or those who have been in the same cafes, shops, trains, or planes. This is already happening to some extent but the test numbers are small, there seems to be a pecking order for tests to be done and the results take days to come. Hence the intended outcome of breaking chains of transmission falls by the wayside. In this respect quick access to testing and releasing results quickly are clearly mandatory improvements that need to be made and made quick.
- As we have already experienced, certain parts of a country can become hot spots with a high number of cases and with even super-spreaders. This is being done at the moment thanks to testing of contacts in and around suspected places like in the case of Brandix. This is not enough. It is important to test third and fourth layer of contacts too. In addition if we test large numbers in given areas randomly, while getting to know the prevalence of asymptomatic disease in the community, emerging hotspots too will become visible at a much earlier stage than otherwise. It makes a huge difference if a country has 50, 500, or 50,000 cases. Without accurate numbers, governments and doctors are trying to fight a fire without knowing how large the blaze is, or where unseen embers are still burning.
Statistically the number of tests needed to get a very accurate estimate of the prevalence of the disease and to catch all of the active patients, is a 20,000/million population which means we should be testing 400,000/day. I am sensitive to the fact that we are a poor country and don’t have the financial capability to afford so many tests daily. We should somehow try to reach at least 25,000 tests/day till the present wave is gotten under control.
Politics seems to have come before the country
With the virus rampaging across the country as shown by the number of cases discovered per day even with a modest degree of testing, the powers that be did not seem to have paid a great deal of attention to this problem. For days on end they were preoccupied with getting the 20th amendment to the constitution passed in parliament for which there need not have been such an indecent hurry. This simply shows that for politicians of all colour, the wellbeing of the nation is only a secondary issue.
Public is being misinformed. Why?
I have almost come to the end of my tether at telling the authorities of the importance of providing authentic information to the public to win public confidence as, well informed public would tolerate strictures that would be incrementally imposed through the epidemic till new detected numbers recede. Trying to curb the epidemic without public co-operation will no doubt prove a steep mountain to climb. In several of my previous articles I have shown how health and other authorities have misinformed the public and therefore do not intend going deep in to the matter again. However as a last ditch attempt to drive some sense in to the impervious brains of the authorities I have broached this topic again at the very beginning of this article. It is well known that countries which have done well in this pandemic have kept their people updated with authentic information. Amongst such countries are New Zealand, Australia, South Korea, Singapore, Hong Kong but Germany would walk away with the medal.
Stringent enough measures have not been instituted yet
Hundreds of cases being discovered daily and 6 of them paying the ultimate price already authorities should have known the matter is serous. But not to be. They are pressing ahead with the ‘test, trace, isolate ‘policy without significantly increasing the number of tests done per day. As such this epidemic is likely to go on for a lot more time to come.
What should be done here and now?
Under this subheading I have just enumerated what needs to be done as elaborating on each point will entail a laborious process which would leave a voluminous article which would put off even the avidest of readers. Besides, most of the points are self-explanatory.
- Accept that there is community spread. This is a great point to start doing better in earnest.
- Lot more testing to find asymptomatic people who keep spreading the infection. Roughly 50% of PCR positives are asymptomatic but can spread the disease. To catch these it is recommended that one has to do 20,000/million/ population/day. i.e. for SL 400,000 tests /day. No financial capability. So do as much as possible, may be 25,000/day
- Co-opt more people from the forces, university students grama arakshakas and volunteers to trace and isolate
4. Hospitalize only symptomatic cases
- Asymptomatic positives to be quarantined at their own homes where feasible. These homes must have several rooms and at least two toilets/bathrooms so that the Covid-19 positive person can follow health guidelines with ease.
- All people self-quarantined should be visited by a PHI or other co-opted for the purpose at least every other day. They will look for worsening signs and if detected refer the patient for admission.
- Better still have ‘Corona taxis’ like in Germany. Teams of doctors and nurses in full Personal Protective Equipment in cars visiting all self-isolating patients to assess their progress.
- High risk cases to be admitted to specially designated tertiary hospitals. These would be the elderly and the others with illnesses like, Diabetes, heart disease, high blood pressure, chronic lung disease etc.
- Moderate risk cases be sent to other designated general hospitals with medical specialists
- Low risk cases to be managed in designated district hospitals and peripheral units. Eg.Fit and young sufferers
- Medical specialists all over the island should be kept updated through ‘zoom’ meetings.
- All schools to be closed
- Government departments and private sector must have minimum staff attending in person
- Encourage working from home
- Film theatres hotels, pubs, taverns and all public gatherings to be banned
- Home parties be banned
- Two families even should not get together
- All practices so far followed viz. wearing face masks, hand washing with soap and water and social distancing to be continued at all times
- Showering on returning home with clothes going to the washer
- Lockdown the districts with hot spots
- Reappraise after I week and if progress is slow
- Enforce Island wide curfew
It is my fervent opinion that the government gives due consideration to my suggestions to put the Corona genie back in the bottle.