By M.M. Janapriya –

Dr. M.M. Janapriya

We may not be 3 weeks in to lockdown yet but todays discovery of a yet another patient who seems to have fallen through the net possibly infecting about 300 more and eventually dying, prompted me to write this article and I sincerely hope President Gotabaya Rajapaksa reads this.

What has been the strategy so far? First it was enforced holidays which did not seem to have that much of an effect. Then full police curfew which is the most stringent form of lockdown. With the country almost fully locked down bar the few hours relaxation in districts other than Colombo, Gampaha and Puttalam how did the health authorities move? It was a case of wait for the patients policy. The doctors hoped for the best while preparing for the worst. This is absolutely the right thing to do. We saw how the military converted various facilities to fully equipped wards within a few days. Some even are good enough for ICUU. I salute them. 

The lockdown is a situation where we slow down the spread of the disease so that the available healthcare facilities would be enough to offer good care to the would be patients. Whilst this is happening the government took steps to better the available facilities. We know from the Chinese statistics more than 80% are mild to moderate, 14% are severe, 5% critical and 1-1.5% dying despite treatment. From what I saw on TV, I am sure there are enough beds to house the infected people throughout the country thanks to the untiring effort of the armed forces. 

The Achilles heel though, might well be the ICU care. We have got 570 ICU beds in all, as of 25/03/2020 as per Television discussion. The doctor holding the floor also proudly said ventilators are being manufactured at the Engineering Faculties of the Moratuwa and Peradeniya Universities. I fully agree we, as patriotic Sri Lankans should indeed be proud of these individuals who are innovators working round the clock. I am not sure at what stage of production they are in, right now but I do sincerely hope we have at least 1000 ICU beds by now. To come to the level of Italy we need 3500 and to come to level of the UK we need 2800 ICU beds. Even a number of 1000-1200 ICU beds with facilities for all modes of ventilation is not bad to start with but the snag is though, in the worst case scenario we will need around 1000 trained nurses to look after these per shift. 3000 nurses for the 3 shifts and a reserve of another 500 the total being about 3500 trained nurses. Do we have such a number? I don’t know. We might well have, having been trained while waiting. It is likely that about 600 of these ventilators are being locally made swiftly and hardly tested. It is also possible that they are the very basic and lack the alarm systems. Hence there needs to be a nurse with the patient standing by all the time. This is hard and risky work. I am fairly certain the DHS has already recruited and trained about 1500 nurses for this purpose. Actually one does not need a full 3 year BSc course for this. Young and healthy people looking for jobs can be recruited for this. They can be given a crash course by a group of Consultant and Senior non-Consultant Anaesthetists on how to look after a patient on IPPV (Intermittent Positive Pressure Ventilation) and other modes of ventilation. Remember this is war declared against a hardly known enemy the Novel Corona Virus-2 

Back to waiting for patients policy. We can see this policy working but just about. The best example of epic failure of this is today’s case. He went with symptoms to OPD NHSL several days ago given OPD treatment and sent home (ideal opportunity to diagnose by testing missed). He then went to a private doctor and off he went for another few days. Eventually he reappeared and was admitted to Teaching Hospital Kalubowila extremely unwell and died on transfer to IDH. This is no slur on the health department staff (who are doing a great job putting their own lives at risk) because this is what may and not infrequently does happen under wait for the patient policy. 

Being a surgeon I tend to quote examples from the field of surgery. Japan had the highest incidence of and the poorest outcomes from stomach cancer about 50 years ago. 95% of patients dying within 5 years. The policy then was to investigate once the patients presented with symptoms to hospitals and treat accordingly. As I have said only 5% survived more than 5 years under this policy. A dismal result from any standards. Japanese were very keen to turn this around, so they went in search of asymptomatic cases by a mass screening program. Within 2 decades they turned the results on its head. Now more than 95% survive over 5 years most of whom are completely cured. This is to just to show how two contrasting policies delivered results poles apart. In our case we are not going to wait years, not months and not even weeks. We got to start right here and right now.

Going in search of patients is exactly what we have to do from now on, to get the Corona virus under control. While keeping the strictures on (and relaxing as needed) more testing needs to be done. If you look at the statistics that is being given daily on TV there has always been this 150-200 odd number of suspected cases. I have written about the importance of testing these suspected cases in one of my previous articles but it hasn’t happened yet. These are possible Corona patients and longer you keep them as suspect patients more delayed we will be in taking their contacts in to quarantine. It looks that once they show more signs and symptoms they become eligible for a test. I can see where this is coming from. What is holding us back seems to be the cost. Each test kit (reliable) from South Korea is about GBP70 which is about SLR 16,000.00. Apparently there is a cheaper kit from another country affected by the virus earlier on but the UK rejected a large stock from this country just last week, as being substandard.

We need to test all suspected cases from all over Sri Lanka and be ready  test at least  5000/day (ideally 10,000) which will cost about SLR 160 million/day. Testing should be done for a while, at least for a month in the first instance which will cost the country about SLR 4800 million or Rupees 4.8 billion. This will have to be done and there is no compromise on this. Government will have to dole out this money initially but I am sure if we start a Save the Nation from Corona Fund with the Expatriates, philanthropists, all billionaires, big businesses, landed proprietors, high earning government and private sector employees donating generously and all else doing their bit this will be an easy sum of money to raise. We might even have money left for the next month if needed.

Once detected as patients on testing, their contacts should be traced and those with symptoms will have to be tested in turn. Those testing negative and the rest should be put on some kind of quarantine. Of course the positives would be treated appropriately and their contacts too tested. In this way we will get the Corona by the neck within the month and we will be able to relax the lock down a bit during this period too so that wheels of agriculture and industry can start turning again. Exports can resume and Rs.4.8 billion may not feel a lot. 

As you can see I am writing this article in a hurry because of the sense of urgency. This will be followed by a longer more complete article on the exit strategy from the lockdown in a few days’ time.