Nipun Saxena

| @nipun_saxena | March 24,2020

[dropcap]T[/dropcap]HE word “novel” in the Novel Corona Covid-19 Virus is a misnomer. As part of human nature, there is a propensity to compare the deadliest of diseases and while Covid-19 does not appear to have a high mortality rate, yet the rate of exposure seems to be unprecedented.

Historically speaking, there is one disease which could match up to the exposure rate which Covid-19 is suspected to have; the disease which annihilated nearly 40 to 60% of Eurasia’s total population in the 14th century. Plague, also known as the Black Death. Some of the features that Covid-19 and Plague share are baffling.

 

The Origin

 

Both the diseases, Plague and Covid-19 has been originated in Central Asia. Like Covid-19, Plague also spread through surface contact and was singularly instrumental to have caused widespread deaths in two continents.

We must, therefore, learn our lessons from the past and apply them to the present situation. Of course, the carriers, the type of organism and the symptoms are widely different, but the exposure rates are very similar.

The Covid-19 pandemic is still in its second phase but is slowly but surely moving towards the third phase which is “community transmission” which is characterized with an exponential rate of increase in the last two days, which is typical of its nature, given the experience in China, Italy, Spain, United States of America, Netherlands and the United Kingdom which have shown similar patterns.

This exponential increase is characteristic of this virus primarily because the Rate of Exposure at this stage thrives on what is popularly termed as the precursor to “community transmission”.

 

Efforts of Government of India

 

While the efforts of the Government of India are laudable, from the Prime Minister giving a call for self-quarantine or “Janata Curfew” which was followed in letter and spirit by the public to widening the capacity to carry out tests per week ratio at par with South Korea, a commitment to increase the capacity to about 70,000 tests per day and by requesting the NABL approved private labs to carry out extensive testing, to requisitioning more number of ventilators (1,200 additional ventilator support), yet the sheer density of population in our country makes it a colossal task.

With 548 districts in 30 States/Union Territories are under complete lockdown, every effort is being pressed into service to ensure that appropriate measures are brought in place so that India does not find itself in the middle of the third phase where the infections would double up on a daily basis causing an unprecedented pressure on our healthcare.

This is when the Corona Virus will be infecting the community at large, and therefore the only plausible solution is a complete shutdown of all the services, save and except essential services.

 

Challenges ahead

 

The way Indian legal system is designed, there are three challenges that need to be addressed effectively and timely, for time is of utmost essence.

 

Regulatory/Statutory Challenges

 

In India, “Public health and sanitation; hospitals and dispensaries” features in the State List. Which is to say, that the power to make and implement laws with respect to matters falling within State List shall be the absolute and unfettered prerogative of the State Government.

The Epidemic Diseases Act, 1897 and particularly section 2 of this Enactment specifically authorizes only the State Government to make regulations to carry out prevention, testing or control of a dangerous epidemic disease.

The power granted to the Central Government under Section 3 is very limited in its import and therefore it is the ultimate discretion of the State Government to take a step by framing appropriate regulation in this behalf.

Now, even as on date, not every State has framed regulations to contain the Covid-19, and those that have made these regulations have spent considerable and valuable time in mulling the pros and cons of the same, before notifying the regulations.

In contradistinction, in the United States of America, the Federal Drug Agency (FDA) has been empowered under The Pandemic and All-Hazards Preparedness Reauthorization Act of 2013 (PAHPRA) to function as the Federal body to not only conduct a test or prescribe measures for isolation but to also take urgent remedial steps such as to even administer (with the full consent of the patient) those drugs that are currently under testing.

The scope of this legislation covers all public health emergencies involving chemical, biological, radiological, and nuclear (CBRN) agents, as well as emerging infectious disease threats. Thus, in one stroke the entire machinery is mobilized to carry out effective preventive steps, and this machinery is governed by a Federal Agency, namely the FDA which functions under a special Emergency Use Authorization program as part of the detailed National Health Strategy.

Whereas, India continues to maintain the distinction between State and Central powers, on account of the constitutional limitations imposed, which results in delayed functioning and delayed response time to public health emergencies. This is further accentuated by the fact that different States have different budgetary allocation resulting in different levels of expertise, a stark contrast in the infrastructure, and provisions for supplies resulting in overcrowding of hospitals, infrastructural deficits and the like.

Although India does have important provisions which will ensure mandatory quarantine and could be used against those patients who have attempted to flee the mandatory quarantine.

Appropriate provisions have been laid down under Chapter XIV of the Indian Penal Code, 1860 which deal with offences endangering Public Health and carry punishment under Section 269 and 270 of the IPC, 1860 in addition to the miscellaneous power for enforcing compliance and punishing non-compliance under Section 188 of the Indian Penal Code, 1860. But most of these provisions are aimed at enforcing the regulations and steps framed by the Government, I.e. they are corrective and not preventive.

 

Testing

 

It has been widely argued amongst various medical practitioners that the initial reports of the spread of the virus are usually far from the truth, and the real statistics appear to emerge within a period of 4 to 6 weeks in cases of rapidly spreading pandemics such as the present virus.

According to the Indian Council for Medical Research (ICMR) Advisory dated 17.03.2020, titled Strategy for Covid-19 testing in India there appears to be an Orthodox testing pattern while conducting tests: This is limited to three categories of people only, that is:

  1. those people who have travelled to a foreign country and were previously asymptomatic (do not exhibit any symptoms) but who start exhibiting symptoms;
  2. those people who have been in contact with the cases that have been confirmed by the laboratories, and;
  3. those doctors, nurses, paramedical staff that have been treating categories 1 and 2

The latest and revised strategy for testing Covid-19 dated 22.03.2020 in India has included two more categories of individuals who are mandated to undergo treatment, and include:

  1. All patients who are complaining of Severe Acute Respiratory Illness (including fever, shortness of breath, cough and cold), and;
  2. Asymptomatic direct and High-risk contacts (meaning those who live in the same household or those who have treated a confirmed case) of a confirmed case.

It is interesting to note that initially unless a person starts exhibiting the symptoms, he has to maintain a self-quarantine/isolation for a period of 14 days. Thus, it is left to the individual to quarantine herself/himself.

Most of the infections that have passed on to the community fall within this domain where a person failed to observe the mandatory stay at home quarantine and decided to mingle with the crowd. The regulations to enforce mandatory quarantine while a person is asymptomatic are still not in place, and that has resulted in a steep rise in the graph of the spread of infections.

There is one important feature, the testing was limited to only these three categories of individuals is primarily because the Government does not have enough testing kits available. As per the Strategy for Covid-19 testing in India, ICMR Pune is in the process of requesting an additional 1 Million or Ten Lakh kits.

A similar request has also been made to the WHO seeking additional testing kits. In a press briefing by the Secretary Health on 22.03.2020, it has been observed to scale up the procurement of FDA approved test kits to achieve the potential to carry out 70,000 tests per day, which is at par with the status in South Korea.

However, a realistic assessment would also entail that the population, as well as population density in South Korea vis a vis India, is stark. Therefore, in the event of community transmission, India must in the very least, must be capable of carrying out a far greater number of tests than a mere 5 lakh tests per week, which by India’s population standards might be grossly inadequate, keeping into account the rate of transmission of this disease is unprecedented.

The testing net has to be widened on an urgent basis and has to follow a liberal pattern, such as that followed in Hong Kong, Singapore and South Korea, which have demonstrated better results. This testing net must now include all the individuals who have a history of travel in the last two months (irrespective of whether they are symptomatic) and their family members.

Every effort must be made to trace their contact history and every person must be quarantined and subjected to testing. In addition to that, steps must be taken to prosecute and punish those who try to create any obstacles by fleeing, refusing to quarantine or refusing to cooperate with the public health official.

Furthermore, every effort must now be made to contain the local community transmission since India stands in the deeper end of Phase II with a spiralling number of infected cases on a daily basis.

ICMR Testing labs are inadequate to contain the spread of the virus and it is essential to request the assistance of all NABL approved testing centres, whether Private or Government. This has to be done immediately, and the Government must also ensure that sufficient kits are available to them before the pandemic spreads to other cities.

It is only in 21.03.2020 that the Ministry of Health and Family welfare in the exercise of its powers under Section 10 of the Disaster Management Act of 2005 has laid down elaborate guidelines for the purposes of authorizing private medical labs to carry out the tests.

However, in so doing, the observance of the guidelines by private labs are of utmost significance. This assumes particular significance since the virus is extremely contagious and may cause a biosafety hazard, if not handled properly. It is thus extremely important that every stage of the test, from sample collection to the sample storage and ultimate disposal of biowaste is done with utmost care and caution. The private laboratories will, therefore, have to induct and train competent staff at blitzkrieg momentum so as to play a pivotal role in testing in the few weeks to come.

 

Infrastructure

 

In a letter written by the President of the Indian Medical Association Cochin Chapter, it has been regretted that given the Exposure Rate of Covid-19, the rate of spreading infection would be unprecedented. The mortality rate of the disease is pegged between 2 to 3 % and therefore it is of crucial import that the hospitals (both government and private) are brought up to speed and are armed with critical life-saving infrastructure with pulmonary assistance capabilities.

As per various news reports, China had to construct dedicated hospitals for Covid-19 patients, and the Spanish Government had passed a law bringing all the Private Hospitals under its ambit. Sadly, there is no equivalent provision in India which empowers India to take similar measures bringing health care service providers under its control for a limited period of time. However, the need to have an adequate number of the isolated ward, and ICU beds cannot be stressed enough. It is only then that a possible spread of infection could be effectively curtailed.

It is also for us, the citizens to understand the gravity of that which is asked of us. In our misplaced excitement to observe the quarantine for a minimum number of hours, we must not step out in gatherings after 5 PM, nor must we fall prey to any reasons other than scientific to act. This also appears to be the underlying reason why section 144 of the Criminal Procedure Code was invoked in different cities after 9 PM on 22.03.2020.

However, it is for us to take all necessary and measured steps towards prevention so that we can afford a fighting chance to our health care system. Let us observe what has been asked of us, a simple act of self-isolation so that the possibility of further contamination is averted. Every day that we quarantine will deal a severe blow to the chain of transmission and will help the doctors save a life.

 

Image courtesy: The Week 

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