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Monday, Sep 14, 2020 12:45 [IST]

Last Update: Monday, Sep 14, 2020 07:07 [IST]

The Covid-19 Pandemic In Sikkim

The State response, socio-economic compulsions and the attitude of the community:  A   recipe for disaster in making?  Is timely mitigation possible?

DR. RINZINGDORJEE
The Covid-19 Pandemic has slowly made its way into Sikkim andhas established a strong foot hold as on this date (6th September, 2020) with the community transmission going on in the state capital of GANGTOK.  I was left wondering if weare at the brink of anexplosive growth of cases. My worry was whether we had the capacity to manage the increase in number of serious cases.
Let us look back in time as theSARS Covid 2 virus causing Covid 19 first case arrived or more accurately got reported on 30th January 2020 in India. Sikkim had its first case reported on 23rd May 2020 after a time delay of 3 months, 1 week and 4 days. Sikkim had been proactive in initiating lockdown earlier than Central Government by closing tourism earlier and with prompt action by the state health services and the administration. The job was made easy by Geography as there are only two entry points in Sikkim via Rangpo and Melli. These events occurred during the entire four phases of Lockdown from 24th March 2020 to 31st May 2020.
The situation in Sikkim contrasted with rest of India as cases spread to major cities of India. Sikkim was triumphant as it remained Covid free. Of course the national lockdown was an appropriate andeven a daring response considering India’s size and population. However, its relative success was marred by one gross oversight of the planners i.e. migrant laborers were not taken into account as they were partially invisible and neither a plan had been developed for their sustenance during this period. The pictures of migrant workers trudging hundreds of miles to try to reach home painted a sad and poignant picture etched into the Indian psyche.
The generosity of common Indians and NGO’s succoring to these migrants saved the day and prevented a major disaster. Subsequently the administration recovered from this delay. Perhaps, it was all understandable as the Covid-19 was a fairly serious disease with huge infective capacity and it had brought down to its knees;the developed countries of West and even their health systems with advanced medical care were on the verge of collapse. The only way they could save themselves was by lockdowns and quarantines.
Lockdowns are emergency measures and cannot be sustained for long for obvious reasons. They help us to buy time to prepare us for facing the pandemic in order to set up hospitals, equipments, health manpower and strategies in place.
This RNA virus is a novel virus that it is new to human beings. The place of origin is Wuhan, China. Whether it is natural or manmade (laboratory) is not confirmed but many virologists are of the opinion that it is natural and have jumped from other animal species. This virus belongs to the corona family similar to other flu viruses. The virus enters via respiratory route, nose,mouth and eyes. The virus uses its spike protein to attach to AC2 receptors present in Renin-angiotensin system of lungs, heart, kidneys and blood vessels causing disease mainly in the lungs in susceptible hosts. The virus is detected and countered by our immune system. Unlike antibiotics, anti-virals are usually less effective.
The reality is that for the past two decades the mindless so called development had accelerated and now its effects are catching up with us. The 2nd and 3rd industrial revolutions have no doubt contributed to   economic and material human development. However, on the down side our excessive environmental exploitation has reached its zenith and in a sense Mother Nature is hitting back.We have had series of epidemics like Ebola,  Swine Flu, Bird Flu, MERS, SARS Covid 1 in the past  decade with unprecedented storms, tsunamis etc.  All these are zoonotic diseases with viruses jumping across species. So it is easy to predict that such epidemics are likely to occur again. We hope it won’t be worse than Covid 19.
This pandemic is a serialized outbreaks, over timed intervals across geographies (states, countries) facilitated by easy movement of large number of people especially by Air Travel. Therefore, containment of epidemics to localized areas hasbecome extremely difficult specially if there is no surveillance. This was compounded in China by a totalitarian CCP regime which blocked vital information of this Covid 19 outbreak in Wuhan, China to the rest of the world which was caught unaware.  If the information had been shared and joint effort had taken place, the epidemic could have been contained in Wuhan, China. We could have easily avoided this terrible human and economic catastrophe.
Getting back to the epidemic in Sikkim, we were doing fairly well till we had to bring back our own people who were stranded all over the country. Along with the hosts, the viral guests landed in Sikkim in the post lockdown period. The administration and health and all related services did a commendable job in bringing our people home yet containing the virus. However,based on livelihood and economic compulsions, the cost of protective measures (Lockdowns) were quickly turning to be more damaging than the viral epidemic itself. Hence a phased unlock policy has been pursued to save lives as well as livelihoods. Over-all India under a strong and decisive leadership has done a commendable job which is based on facts viz.America despite being a developed nation has more than double number of deaths due to Covid 19  as compared to India . This is striking considering that health infrastructure in India is lacking especially in secondary and tertiary health care.
 But the saving grace is that India has a strong Public health base developed since its formative years. Due to resource limitations, it was a necessity that an intentional development of strong organic linkages between public health and medical care developed. This along with years of dealing with public health issues India has vast public health intellectual and experiential human assets. In the recent years, the BJP Government has made significant improvements in health infrastructure with setting up of especially medical colleges at every districtand PMJAY scheme, all of which definitely has helped alleviate and manage the situation.
Overall in Sikkim, the ruling polity has strongly supported all the recommendations of the state task force along with fairly effective administrative response.  The state task force has given adequate leadership in the fight against Covid 19.  In fact it had shown strategic flexibility, that in unlock phase 2 onwards when  interstate movement of people was recommended by Central government,the state looking at local conditions continued with restrictions. At present interstate movement of people is allowed with screening.
The health department with its doctors, sisters and other paramedic Covid warriors has given a very good performance. The public health wing hasimplemented the screening, contact tracing and isolation of covid cases efficiently to dampen the transmission. Similarly the clinical wing hasdone excellent clinical work to reduce mortality due to Covid 19 to around 0-3 % which is approximately six times less than the national averageof  2%. We have only 7 deaths with a total case load of 1958.This on the date of sending this write-up has reached 11 deaths with 2026 positive cases pushing the mortality rate to 0.5% which is still low. Therefore, due credit must be given to the SOP which has been developed based on inputs provided by AIIMS, National Task force.
Every disease is an outcome of the interplay of three components viz.  Agent, host and environment. The disease in its course of natural history may result in cure, disability or death following the natural forces. However, Man with his tremendous intellect especially modern medicine has tried to alter the natural history of disease in favor of cure albeit to some extent successfully. Today, we are being challenged by the Pandemic Covid 19.  The medical knowledge has advanced to significant measure that we are able to slow down the transmission by knowing the paths of transmission, reduce mortality by understanding the aggravating factors. Viruses are difficult to defeat as they are intracellular parasites and their destruction is at the cost of our cells and organs. So,medical scientists have devised the route of vaccination to defeat the viruses even before they enter our cell and organs.
My whole purpose in writing this article was that I had observed certain sections of our community thinking this virus was just like ordinary cold/ flu and were behaving carelessly. On the other hand, certain sections were so scared to even step outside their homes and this fear is associated stigmatization. I have been interacting with my medical colleagues as well doing some reading throughout this pandemic  to see if  ways of defeating this virus had been found , asking about their clinical experiences , querying about vaccine status etc. The opinion of my medical colleagues in Delhi and Kolkata were that the disease was quite severewith those with age above 60, those having co-morbidities, and some apparently normal doctors and patients relatively young were dying. Further,there were post Covid injuries to lungs and heart even after recovery.  Infact, the mortality due to flu is less than 1 in 1000 population where as the mortality due to Covid 19 was 20 in 1000 population. (The reality is that in initial stages of pandemic, the mortality in Italy was around 5% (50 per thousand). Modern medicine was able to bring this mortality down to 2% (20 per thousand) by identifying and treating three major causes of mortality namely1.Hypoxia 2. Thrombo-embolism 3 Cytokinin (Bradykinin ) storm. In fact on this realization I called up Dr Suresh Madan Rasaily, Director cum HOD Medicine to congratulate him and his team for the excellent clinical work and he was very modest about it.
However, now I was worried that the sudden surge in Covid19 cases in the last 4 or 5 days coinciding with opening of interstate movement of people coupled with community behavior could overwhelm ourhospitals and the capacity of our manpower and spike  up mortality rates. It was very important to suppress the transmission and continue to flatten the epidemic curve.The epidemic curve gives a mathematical image which helps us to understand the progress and natural history of the disease, peak, cessation, herd immunityand points for intervention. The concept of herd immunity occurs in infectious diseases and interaction with our protective immune system. When 70 % or so of the population is infected naturally or immunized by vaccines the diseases stops even without 100 % coverage this is called herd immunity.
It is difficult to pass on the sense of epidemiology to non trained individualsbecause of technical words, however concepts are not too difficult to understand.  The whole purpose of above write-up is to come to some practical applications in the field:
1.    Understand that the unlock and opening is due to livelihood and economic reasons. The virus is still with us and the disease it causes is quite serious with morbidity and mortality.
2.    Therefore, we need to continue to strictly follow proper masking, social distancing and frequent hand washing especially when coming from outside. These are in combination as effective as vaccination.
3.    Continue to test, track and isolate Covid patients and their contacts to suppress transmission. Have rational tests and screening based on incubation period and disease infectivity. Sikkim still needs to ramp up the antigen tests.
4.    Be careful but do not be fearful as fear will increase your cortisol levels which will bring down your immunity. Our current situation is with regard to clinical treatment is excellent with mortality around 0.5% which is positive.
5.    Understand that trying to achieve herd immunity quickly is foolish as it will overwhelm our health services both directly through Covid 19 as well as non Covid causes. Make every effort to flatten the epidemic curve by application of Sl. no 1 and 2.
6.    We are still at the first phase of the Epidemic curve and therefore to know our status we need to do serological tests by random sampling every fortnight or so.
7.    There are 6 or 7 vaccines in phase three(3) clinical trials and indicate good antibody development. They are likely to be in the market by 1st quarter to 3rd quarter of 2021. So we can be immunized safely if the epidemic curve is flattened.
8.    The health infrastructure and health system in our state needs to be further improved to face such likely challenges in the future. In 2015, to the earlier government I had submitted 6 such proposals. However only one materialized in 2018 i.e. rationalization of health manpower by segregating the Doctor’s cadre into General and Specialist health services. The remaining issues, I will submit to the new government in due course.
9.    The health sector needs to be prioritized by allocating 5% of the GDP.
10.    The issue of migrant labor in control of infective diseases has been faced by the health department in Sikkim earlier in respect to Leprosy and TB since a long time. We need a mechanism to record, monitor their status to ensure proper health check up as well as social support in crisis times. Also, it will help us to check movement of anti-social elements. A pan India policy with program is required.
11.    I have kept the best for the last. There is clear evidence that supplementation of Vitamin D is helpful in preventing and clearing complications of Covid 19. (Vitamin D supplementation has to be taken under medical supervision). Therefore, a community level intervention cum study would contribute to resolving the Covid crisis as well as enhancing our knowledge of the Covid 19. Anestablishment of a Medical Research Centre is of paramount importance for the health of Sikkim.
The final SWOT analysis:-
STRENGTH:
 1) An excellent clinical team with well developed SOP.
2) Sufficient public health expertise albeit faltering recently.
3) Good leadership with adequate administrative skills.
WEAKNESS:
 1) Though having excellent primary health care, infrastructure and manpower, there is limited and constrained secondary and tertiary level health manpower and resources.
2) Health systems & hospitals management are inadequate and outdated.
3)  Certain sections of the community not practicing containment practices e.g. proper masking, hand washing etc. along with stigmatization.
4) Overdependence on central guidelines: need for local strategic flexibility to use time bound and geographical bounded lockdowns to suppress high transmission periods e.g. Gangtok Municipal area lockdown for one week.

OPPORTUNITIES:  
1. The crisis has given insight into strength and weakness of health infrastructure, health systems, manpower & equipments for correction.
2) Possibility of initiating Vitamin D supplementation intervention program for Covid 19 prevention and reducing mortality as a pioneering state.
THREATS:
 1) Covid 19 virus continues to be a serious disease in those people with co-morbid conditionsalong with high infectivity.
2) Vaccine delivery timeline prediction is difficult along with ensuring vaccine safety and efficacy.
Finally it is both for public (community) and government to work together as a team using our strengths, skills and opportunities to navigate this difficult period.

(The writer is retired Principal Director, Health department, Govt. of Sikkim. Email: r_dorjee@yahoo.co.in)

Sikkim at a Glance

  • Area: 7096 Sq Kms
  • Capital: Gangtok
  • Altitude: 5,840 ft
  • Population: 6.10 Lakhs
  • Topography: Hilly terrain elevation from 600 to over 28,509 ft above sea level
  • Climate:
  • Summer: Min- 13°C - Max 21°C
  • Winter: Min- 0.48°C - Max 13°C
  • Rainfall: 325 cms per annum
  • Language Spoken: Nepali, Bhutia, Lepcha, Tibetan, English, Hindi