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Letter from Chennai
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Mani M K. Letter from Chennai. Natl Med J India 2020;33:247-248
The Pandemic, The Profession, and The People
If you want to learn how to manage Covid-19, please look elsewhere. I am neither an epidemiologist nor an infectious diseases specialist, and have no expertise in this field. I am writing as a super senior member of the public. You would have read about my retirement in an earlier ‘Letter from Chennai’. It had nothing to do with the virus. My wife and I had made ambitious plans for a long stay abroad to meet our extended family and many friends, and that was abrogated in abject surrender to the virus. Instead, we are now under strict house arrest, and have not stepped out of the gate for the past 6 months. When there were reports of shortage of doctors to treat the sudden influx of patients, I felt I should go back to work and do my bit for this problem, but the thought that I am an individual at high risk and might end up on a ventilator that could be put to better use in saving a younger person has kept me from volunteering.
All of us, doctors, patients, the public, the administrators and the politicians who direct them approached the problem with a clean slate, profound ignorance. This was a new problem, with similarities to problems we have faced earlier, but sufficient differences to ensure that the solutions worked out then did not avail now. What became clear immediately was that the virus was really contagious, and many people with only minimal contact with an infected individual also went down with the disease. It could be fatal in a minority, but most people had a mild illness, and some were quite asymptomatic, which was good for them but bad for the rest of us since they could remain ambulant and involuntarily infect the rest of us.
The initial normal human reaction to a potentially fatal disease about which no one knows anything except that it spreads rapidly, is panic. Panic manifested itself in various ways. People got together to prevent bodies from being interred in their local graveyard (including that of a doctor who died after operating on an infected patient) or cremated in the neighbourhood crematorium. A doctor working with Covid-19 patients was evicted from his apartment by his landlord. Patients who were discharged from hospital after treatment were not welcomed back to their own neighbourhood. Migrant workers who returned home en masse as their income dried up due to the lockdown sometimes faced hostility, partly because of fear of the epidemic and partly because their return meant more mouths to feed.
Did we need the strict lockdown that was imposed? It certainly crippled the economy, and put daily wage earners in great difficulty. Those who could work from home might have done better than usual, as they were relieved of the daily commute, and thereby saved hours during which they could turn out more work, or have time for other activities. Would social distancing and strict discipline in wearing masks have been adequate? Sweden and South Korea have done better than the rest without a lockdown, and obviously their economy has remained in much better shape. We are not sure about China, but as far as we can make out, except for Wuhan where the disease was first discovered, the rest of the country seems to have had proportionately few patients. What distinguishes these countries is that the public has much greater discipline than the rest of the world. All of them wear masks all the time, and they maintain social distance.
Most of us displayed a lack of discipline and civic sense. We established this years ago in our reaction to rules about crash helmets and seat belts. The point is that when you refuse to wear a helmet it is your head that will break, but the refusal to wear a mask is risky not just for you but also for people around you. The police, who should have been attending to more important activities, had to spend time and energy in entreating people to stay home unless there was a pressing reason for them to step out, and to wear masks and keep two metres away from everyone else. Some youngsters felt the comparatively empty roads were ideal for them to test what speed their motorcycles were capable of. Impounding of vehicles of people violating the restrictions, and not civic sense, persuaded them to follow the restrictions imposed by the government. Most of us are now compliant, but there are still a few who move around without masks, and accumulate in groups at close quarters. Politicians and their followers feel all restrictions are for the common man, not for the chosen people like themselves.
The Government of Tamil Nadu has now imposed fines of between ₹200 and ₹5000 for not wearing a mask in a public place, for spitting in the open, for not maintaining social distancing, and for failure to maintain prescribed procedures in enclosed places where people congregate, especially bars, hair dressing saloons and gymnasia. I think this is an excellent measure to try and enforce healthy behaviour and minimize the risk of spread of infection. However, someone has filed a public interest litigation in the Madras High Court claiming that while the government could formulate guidelines, there was no legal provision to enforce them or to levy fines on people who would not follow them. I will follow the arguments in this case with interest.
The unfortunate trend in the interaction of patients’ relatives with their doctors has been for them to assault the doctor if a patient dies. The usual victim of this violence is the junior doctor, especially in public hospitals. I would like to pay a tribute to the work done by them. They work under adverse conditions, often without adequate personal protective equipment, and sometimes with a colossal patient load. The government should certainly look after them better. Many of them had to work long hours with inadequate food, and their having to face physical violence speaks poorly of the administrators and the public. Some of them had to agitate to ensure the presence of security personnel to keep them from harm, and now these attacks seem to be dying down. Health workers were recruited on an emergency basis by the government and the municipal corporation, and they have faced the same risks as doctors and hospital staff. Salaries have not been disbursed on time. This particularly hits the low-income groups who have no cushion to protect them against these delays.
Politicians in the opposition are quick to take the opportunity to attack the government for lack of equipment, and when equipment is purchased they are equally quick to accuse them of corruption in the process of acquiring them. Large funds have been spent on acquiring ventilators and critical care monitoring equipment. We hear of irregularities pointed out by auditors and accountants, but rarely do we hear of anyone in authority being punished. It is an ill wind that blows nobody any good.
Our usual avenues of social interaction and relaxation outside the home are restricted. Clubs are now open for outdoor activities, and the one to which I belong has also reopened in a restricted way, but I am discriminated against for people over the age of 65 years are not permitted to partake in even these limited activities and have been asked to stay home ‘according to the recommendations of the government.'
With time on our hands, many of us are now hooked on the internet. The availability of openings in the media to express opinions freely has led to large numbers of experts pronouncing their views on the disease. What should you do, what should you not do, eat or drink. Almost everyone with an internet connection or a smart phone and entry into some group or the other pronounces himself or herself an expert on the matter. One doctor actually says, ‘I have vast experience of treating this condition and know more about it than others.' A large variety of foods are recommended, others are declared taboo. No iced water or ice cream. Various vegetables and fruits are helpful in combating the virus. Vitamins, tonics, minerals of different kinds improve our immunity and keep all viruses at bay. I wonder how I have lived to my eighties having a special liking for cold water and ice cream and never taking any of these supplements. Maybe my liking for fruits and vegetables has helped. We are advised not to touch anything. The virus can survive on various surfaces for days or weeks. It was reassuring that an infectious disease specialist announced that the spread through fomites could be discounted. It is the air we breathe that carries the virus and could kill us.
Every now and then we learn of someone who isolated himself or herself from the world completely, discouraged all visitors, ate only hot cooked food, and yet got infected with Covid-19. It is hard to live in complete isolation from the world around. You need food, and unless you grow all your requirements you will have to obtain some items from outside, and someone must bring it to you. Beware of asymptomatic carriers, we are cautioned.
With all our attention being diverted to the virus, I am worried that our usual patients are being neglected. Transport being restricted means they cannot come to the hospital easily. Many are worried that going to hospital would expose them to the risk of a superadded infection, so they stay away even if they could go to the doctor. Telemedicine has helped some of them, but you cannot feel a liver or a spleen, or auscultate for crepitations over the internet. Ideally, we should ensure that some hospitals should be maintained Covid-free. Patients with fever should go to specially designated fever clinics and hospitals, and other hospitals should take only non-communicable diseases. I do not believe this has been done in any city. Obviously smaller places with only a few hospitals cannot afford this separation.
As in every disaster that has hit us, this one too has some redeeming features, some hope for the future of India. Everywhere we hear of groups of people who have banded together to help people in need. Some have cooked and served food for those who were deprived of a regular income, some have helped to educate children who could not go to school and could not avail of distance education. Above all, they have performed the last rites of many whose own relations were afraid to come anywhere near the body of the deceased. And this has been truly secular. The helpers have been from every religious and social group, and their service has gone to people of any community who needed it. Muslims have helped to cremate Hindus, and Hindus have helped Muslims. Disease and deprivation do not discriminate between us, and these angels did not either.
Today’s newspaper carries encouraging information. The daily incidence of new cases in Chennai has fallen below 1000 for the first time in several weeks, and the whole country is also seeing a declining trend. Maybe I could venture to invite you to Chennai sometime next year, when we have returned to our original state of affairs. I have always confidently said this is a great city, and you can always be healthy here as long as you do not eat the food, drink the water or breathe the air.