COVID-19 – Lessons so far

Corona Virus pandemic has taught us a complex and contradictory set of lessons. On the positive side, the pandemic confirmed the importance of droplet and contact infection. The pandemic travelled as fast as the modern transportation could take it around, confirming that it was human bodies that spread it. 

On the negative side of the lessons from the pandemic is that it is exceedingly difficult to get an urban population to stay at home. People need to work so they can eat; parents want their children to go to school; businesses dependent on customers, whether department stores or movie theatre operators, do not want to close down.

Hence, the most practical strategy in dealing with COVID-19 is been: move quickly to isolate the acutely ill in hospital wards or at home, under professional care and roll-out an intensive public education effort about personal hygiene to everyone else.

It is learned that it is not easy to get the public to practice the rules of modern nose/ mouth/ hand hygiene. Even at the height of the pandemic, educated and well informed people broke the rules. It appears that COVID-19 has been a ‘simple to understand, but difficult to control’ pandemic. Perhaps the most demonstrably useful methods of protection are certain forms of quarantine and isolation but, under conditions of modern life these are not readily applicable. In spite of being difficult to apply and uncertain of success as it may be, the minimizing of contact seems at present to offer the best chance we have of controlling the ravages of covid-19. Our response to the next wave of pandemic COVID-19 will likely confirm these lessons.

This odd combination of futility and certainty would continue to characterize summaries of the ‘lessons learned’ from the pandemic. In the field of prevention little real progress has been made. It will therefore be justifiable to increase the emphasis already placed on the COVID-19 patient as a definite focus of infection and to adopt reasonable measures to reduce crowding and direct contact to a minimum during a period of epidemic prevalence.

The opportunities for self-protection by individuals lie along the same line: avoidance of crowds and of direct contact with COVID patients and with people suffering from the infection; rigorous avoidance of the use of common drinking glasses, common towels and the like; and scrupulous hand washing before eating. Techniques of safe coughing and sneezing should be taught to people. A careless sneeze from an infected person without a mask or a face-cover is a super-spreader.

Vaccination is a saviour but not a licence to break the discipline of personal and social hygiene.

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First published 14 Aug 21

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I Have Tested Positive. Am I Going To Die?

I am not insensitive to the grief of so many around who have already lost someone close to this terrible disease. I feel and share their grief and anger having lost not just one but many from amongst my family and friends over the last few days. While they were gasping for life, all of them repeatedly asked me this question, “Am I going to die?” Many others, who were by their side, attended by the same medical teams, also asked this question recurrently. Of them, many survived but a few could not.

Our pain is unique to us, our relationship to the person we lost is unique, and the emotional processing can feel different to each person. It is acceptable for us to take the time we need and remove any expectation of how we should be performing as we process our grief.

When we lose a loved one, the pain we experience can feel unbearable. Understandably, grief is complicated and we sometimes wonder if the pain will ever end. We go through a variety of emotional experiences such as anger, confusion, and sadness.

This post reflects my concern for those who are battling for life and for their family and friends who are equally anxious.

“I have tested positive. Am I going to die?” is a straightforward question that most people would like answered. This simple question is hard to answer. Ask this to someone who has seen a dear one succumb to this disease and the frank answer would be, “to be true and forthright, yes you are going to die, unless some miracle happens.” Ask the same question to someone who has seen a dear one survive this disease and the likely answer would be, “it is going to be a long, painful and apprehensive battle, but don’t worry, everything will be fine.”

A forthright question, “I have tested positive. Am I going to die?” is remarkably challenging to be answered by a bystander to the agony of the raging pandemic, who can only look at numbers and statistics to support his answer.

When the risk of death from COVID-19 is discussed, the Case Fatality Rate, sometimes called Case Fatality Risk or Case Fatality Ratio, or CFR, is often used. The CFR is very easy to calculate. The number of people who have died, divided by the total number of people diagnosed with the disease is CFR.

CFR is the ratio between the number of confirmed deaths from the disease and the number of confirmed cases, not total cases. That means that it is not the same as the risk of death for an infected person and, in early stages of fast-changing situations like that of COVID-19, probably not even very close to the true risk for an infected person.

Recall the question we asked at the beginning- if someone is infected with COVID-19, how likely is it that they will die? What we want to know is not the Case Fatality Rate; it is the Infection Fatality Rate (IFR). CFR is not the answer to the question, for two reasons. First, CFR relies on the number of confirmed cases, and many cases are never confirmed; secondly, CFR relies on the total number of deaths, and with COVID-19, some people who are sick and may die soon, are not counted in total number of deaths until have not died. The first reason inflates CFR while the second one deflates it.

With the COVID-19 outbreak, it can take between two to eight weeks for people to go from first symptoms to death, according to data from early cases. With CFR data available for the last 67 weeks that this pandemic has been raging, it is seen that the CFR for a country is not fluctuating as wildly as it was in the first 40 weeks and the CFR for many countries, including India, have not seen large deviations from a stable trend line over the last 18 week.

It is exceptionally important however to note that CFR for cases under Home-Isolation, under Medical-care and under critical-care are different. Further, these CFRs vary across states and locations within India. National CFR is an aggregated mean of all of this CFRs. The cases under critical care are overwhelming the health-care-system at this time, for which the CFR is logically and expectedly much higher.

With IFR being non-available, CFR is being used, albeit quite cautiously, to answer the question, “I have COVID-19. Am I going to die?” and the tremendously relieving answer to the question with a very high chance of being true, at least for patients under home-isolation and those kept in quarantine is a very loud NO. I hope the COVID-19 survivors, who constitute over 98% of the confirmed cases of COVID-19 infections will join the chorus.

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First published 11 May 2021

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COVID Confusions

COVID-19 is a new acronym coined for Corona-Virus-Induced-Disease of the year 2019. Year 2020 made some old word or phrases suddenly very fashionable and buzzing with new meanings, and injected them into active vocabulary of people. Corona, a word hitherto associated with the Sun, novelty and SARS-Coronavirus-1 was not so much in use but became suddenly a dreaded word linked to COVID-19. Positivity, a word that was generally used for the practice of being or tendency to be positive or optimistic in attitude up until then, took on the other meaning of the presence rather than absence of a certain substance, condition, or feature, now a measure of incidence of disease.

Check out some of these words or phrases for yourself, because your inability to use them in conversations may be mistaken as your ignorance – animal-human interface, asymptomatic, carrier, clinical trials, community spread, contact tracing, Contagious, Droplets, Epidemic, flatten the curve, herd immunity, HRCT scan, incubation period, Isolation, Mask, mRNA Vaccines, Mutant, Outbreak, Oxygen-concentrator, Oximeter, Pandemic, Pathogen, patient zero, PCR test, personal protective equipment (PPE), Plasma, Quarantine, Rapid-Antigen Test, Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2), Screening, self-isolate, social distancing, Super spreader, Symptomatic, Transmission, Vax, Ventilator, Viral Vector Vaccines, Zoonotic – and the list goes on.

Some proper nouns also made their way in the active vocabulary – Wuhan, AstraZeneca, Covax, Covaxin, Covishield, Sputnik5, Pfizer-BioNTech, Moderna, Johnson & Johnson’s Janssen, Novavax, Coronil, CoviSelf, Remdesivir, 2-DG, and so on; but the most conspicuous proper noun is FAUCI.

Anthony Stephen FAUCI (born December 24, 1940) is an American physician-scientist and immunologist who serves as the director of the U.S. National Institute of Allergy and Infectious Diseases (NIAID) and the chief medical advisor to the president. He has acted as an advisor to every U.S. president since Ronald Reagan. From 1983 to 2002, Fauci was one of the world’s most frequently cited scientists across all scientific journals. In the early stages of the COVID-19 pandemic, The New Yorker and The New York Times described Fauci as one of the most trusted medical figures in the United States. Currently Fauci is the Chief Medical Advisor to President Joe Biden, officially appointed in 2021.

After initially declaring in April of last year that the virus was “not a major threat to the people of the United States” and that it was “not something the citizens of the United States right now should be worried about,” Fauci repeatedly urged Americans not to wear masks early in the pandemic. Later, Fauci admitted that he had believed all along that masks were effective but said he had wanted to ensure that supplies would be reserved for medical professionals. In other words, he asserted that he had the right to lie to the public for what he believed to be their own benefit. If Fauci is correct that masks effectively contain the spread, then the cost of his misinformation as the pandemic worsened may be incalculably large, for the US community. (https://www.delcotimes.com/opinion/chris-freind-dr-fauci-needs-a-dose-of-reality/article_9bce984e-7641-11eb-8c87-4f0114a8a7a2.html )

After repeatedly dismissing the theory that the COVID-19 virus escaped from the Wuhan Institute of Virology in China, Fauci now says he cannot rule out the theory.

Fauci has now backtracked on his comments about the National Institutes of Health (NIH) funding for the Chinese lab under his leadership, that funding was not for “gain of function” research, a laboratory technique that intentionally makes pathogens more dangerous and transmissible. Gain of function research in Wuhan was indeed funded through one of Fauci’s grants.

Late last week, COVID policies stated that fully vaccinated individuals do not need to wear masks indoors or outdoors, any longer. Defending the policy, Fauci declared that the abolition of mask mandates was not a contradiction of previous policy but instead followed “evolving science” on the virus; although no examples of this supposedly new scientific evidence were forthcoming. Fauci then added to the confusion by declaring, apparently on his own authority, that young children would still be required to wear masks in school. Then, just a gay later, Fauci suggested that it was “reasonable” for businesses to maintain mask mandates even for vaccinated Americans, in blatant defiance of the CDC’s recent guidance. Whichever way one looks at it, Fauci has become a key player in the current controversy, which completes his transformation from an independent doctor into a political football, at the age of 80 years.

Fauci has also steadily moved the goalposts on the percentage of the population that will need to be vaccinated to achieve herd immunity. Earlier this year, he said herd immunity would be achieved when 60% were vaccinated; in recent interviews, he has spewed out numbers as high as 85%. At the very least, the top infectious diseases expert of the US and chief medical adviser to Biden is loose with the facts and is prone to changing his mind. To be fair, the pandemic caught a lot of people unaware, but the thing about Fauci is that he always is so sure of himself. (https://nypost.com/2021/01/24/dr-fauci-needs-to-be-held-responsible-for-mistakes-devine/ ).

India has done well in vaccinating the armed forces personnel with 90% of them having already received both doses of vaccine. India did not listen to the US guidelines (CDC) on reopening of schools, which is now being associated with untold misery that followed in Texas.

Luckily, Indian policy-makers do listen to Dr. Anthony Fauci but do not blindly subscribe to all his utterances. Good, is not it, that while being open to all the information, suggestions, knowledge and advice coming from everywhere, we have a mind of our own. When it comes to inconsistent and improvisational COVID messaging, no one can surpass Dr. Anthony Fauci.

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First published 24 May 21

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Are You Joking Dr. Lele?

Evidence-Based Medicine is a hot topic ever since the unpleasant and acrimonious spat between Swami Ramdev, also known as Baba Ramdev, of Patanjali and Dr. Jayesh Lele, MBBS, general secretary of the country’s largest lobby of allopathic doctors, the Indian Medical Association, or IMA was aired on 25 May 2021.

Lele seem to claim that COVID-19 treatment being undertaken in India by the allopathic doctors is Evidence-Based Medicine, which Ramdev was unwilling to accept due to very frequent and recurring changes in the allopathic treatment-protocols being practised, the preceding ones being abandoned citing lack of evidence while the succeeding ones being merely new conjectures.  Following the dictum that ‘absence of evidence’ is not the ‘evidence of presence’ let us dispassionately and objectively examine Lele’s claim.

The updated (revised and improved) definition of Evidence-Based Medicine is a systematic approach to clinical problem solving which allows the integration of the best available research evidence with clinical expertise and patient values. (David L. Sackett, Sharon E. Straus, W. Scott Richardson, William Rosenberg, and R. Brian Haynes. Evidence-Based Medicine: How To Practice And Teach EBM. 2nd edition, London: Churchill-Livingstone, 2000)

Speaking at the MLA 2010 Annual Conference, held in Washington DC, Mark Ebell, MD, MS, Associate Professor at the University of Georgia, and Editor-in-Chief, Essential Evidence Plus  defined Evidence-Based Practice as, “Making a conscientious effort to base clinical decisions on research that is most likely to be free from bias, and using interventions most likely to improve how long or well patients live.” (https://youtu.be/XWi7vNv2nos)

Evidence-based medicine includes three key components (see Figure): research-based evidence, clinical expertise (i.e., the clinician’s accumulated experience, knowledge, and clinical skills), and the patient’s values and preferences.

Practicing evidence-based medicine is advocated on the promise of improved quality, improved patient satisfaction, and reduced costs.

The EBM Pyramid (see figure) explains the knowledge types and the reliability of such evidence. Evidence in Level I is considered the gold standard of medical knowledge. Evidence in Level II comes from Controlled trials without randomization or Cohort or case-control analytic studies or multiple time series studies. It is often true that the best evidence available to clinicians is their own observed aggregate data. Evidence in Level III is based on expert opinion from experts who have narrowed their focus as much as possible about a complex area. Evidence in Level IV is based on personal experience. This is the least desirable source of evidence and lacks any statistical validity.

There is good evidence (e.g., from RCTs) and there is bad evidence (e.g., from personal experience). Then there’s evidence that falls in the grey area—neither clearly defined as good nor bad. It can be difficult for clinicians to know whether to use evidence in the grey area. To determine the validity of evidence, a team of clinicians with several years of experience in evidence-appraisal should review the knowledge in question. The team can then determine if the evidence is valid (i.e., accurate) and applicable (i.e., useful for the situation or population being considered).

COVID-19 is a fast moving epidemic with many uncertain parameters. In view of the lack of prior knowledge and urgency of the situation to have some understanding, clinicians and researchers worldwide are reporting rapid results in the form of Level III and Level IV evidence. There is no evidence at Level II or Level I about any treatment protocols at this time. These rapidly reported results are continuously changing as new insights on the SARS-CoV-2 virus and COVID-19 emerge.

The treatment protocols adopted by allopathy for treatment of COVID-19 have therefore been non- standardized, non-evidence-based protocols. They have been based on near real-time data, mostly of level IV and level III, to make care decisions with the sole objective of improving outcomes of treatment. Given the urgency for action, transparency, accountability, quality of care and value of care have expectedly taken a back seat.

Numerous preventative strategies and non-pharmaceutical interventions have been employed to mitigate the spread of disease including careful infection control, the isolation of patients, and social distancing. Management is predominantly focused on the provision of supportive care, with oxygen therapy representing the major treatment intervention. Medical therapy involving corticosteroids and antivirals have also been encouraged as part of critical management schemes.

The COVID-19 Treatment Guidelines have been developed by National Institutes of Health of the Government of the United States, to provide clinicians with guidance on how to care for patients with COVID-19. As per the official website these treatment guidelines were last updated on 27 May 2021. (https://www.covid19treatmentguidelines.nih.gov/introduction/ accessed on 06 June 2021). The recommendations in these Guidelines are based on scientific evidence and expert opinion. Each recommendation includes two ratings: an uppercase letter (A, B, or C) that indicates the strength of the recommendation [Rating of Recommendations: A = Strong; B = Moderate; C = Optional] and a Roman numeral with or without a lowercase letter (I, IIa, IIb, or III) that indicates the quality of the evidence that supports the recommendation [Rating of Evidence: I = One or more randomized trials without major limitations; IIa = other randomized trials or subgroup analyses of randomized trials; IIb = Nonrandomized trials or observational cohort studies; III = Expert opinion].

As on date, there is only one recommendation rated ‘AI’ for Managing Outpatients with COVID-19 while the most reliable of recommendations for Managing Patients in an Ambulatory Care Setting have not bettered the ‘AIII’ rating. Critical Care recommendations are still at rating B. Recommendations for managing hospitalised patients with varying severities of disease are still at ‘BIIa’ rating.

These guidelines have a clear disclaimer, “Rated treatment recommendations in these Guidelines should not be considered mandates. The choice of what to do or not to do for an individual patient is ultimately decided by the patient and their provider.”

The above facts clearly indicate that there is no evidence-based-practice or evidence-based-protocol for treatment of COVID-19 in the allopathic system. Based on frugal, confusing, rapidly changing and often low-quality data, clinicians are using and recommending their best educated guesses for treating COVID-19. It is true that an educated guessing is better than no guessing until such time that research becomes available but there is no evidence to show that an educated guess is any better than an uneducated guess.

Surely you are joking Dr. Jayesh Lele when you say that the treatment-protocols being practiced for treatment of COVID-19 is evidence-based-medicine. There is no harm however in your and your fellow members of IMA at least hearing C. Miller when he tells us, “why the practice of medicine is not science.” (Miller C. “Medicine Is Not Science: Guessing The Future, Predicting The Past” Journal of Evaluation in Clinical Practice, 2014, Vol 20, Issue 6, pp. 865-71).

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First published 06 June 2021

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We Are Not Letting the Pandemic Weaken

The actual number of people getting sick with the coronavirus is increasing. We know this because in addition to positive COVID-19 tests, the number of symptomatic people, hospitalizations and later, deaths, are following the same pattern. Thankfully, Doctors, clinics and hospitals have learnt to reduce the fatality rate amongst the COVID-19 patients but this is no reason for people to throw caution to the winds.

Human behaviour is the major factor. State and local administrations, as well as individual people, differ in their response to the pandemic. Some follow COVID-19 precautions, such as physical distancing, hand washing and mask wearing. Others are not as prescriptive in requiring these measures or in restricting certain high-risk activities.

In some states and communities, public places are closed or practicing limitations (such as how many people are allowed inside at one time); others are operating normally. Some government and community leaders have encouraged or even mandated mask wearing and physical distancing in public areas. Others have left it as a matter of personal choice. In areas where fewer people are wearing masks and more are gathering indoors to eat, drink, observe religious practices, celebrate and socialize, even with family, cases are on the rise.

As state governments began to reopen cinemas, bars, restaurants and stores during the last few months, people were understandably eager to be able to go out and resume some of their normal activities. Nevertheless, the number of people infected with the coronavirus was still high in many areas, and transmission of the virus was easily rekindled once people increased their activities and contact with each other. Unfortunately, the combination of reopening and lapses in the infection prevention efforts – social distancing, hand washing and mask wearing – has caused the number of coronavirus infections to rise again.

There is a lag between a change in policy, and the effects of this change showing up in the COVID-19 data. An increase in the number of COVID-19 cases or hospitalizations is seen as many as six to eight weeks after change in policy. When a person is exposed to the coronavirus, it can take up to two weeks before they become sick enough to go to the doctor, get tested and have their case counted in the data. It takes even more time for additional people to become ill after being exposed to that person, and so on.

Several cycles of infection must occur before a noticeable increase shows in the data that public health officials use to track the pandemic. Due to such delays, people become careless with their behaviour, and they start moving around more. If everyone continues to wear masks, wash their hands and practice social distancing, reopening will have a much lower impact on transmission of the virus than in communities where people do not continue these safety precautions on a widespread basis. Also, after many months of cancelled activities, economic challenges and stress, people are frustrated and tired of taking coronavirus precautions. All these are factors that are driving surges and spikes in COVID-19 cases.

About 70% of the population needs to be immune to this coronavirus before herd immunity can work. People might be immune from the coronavirus, at least for a while, if they have already had it, but we do not know for how long such immunity lasts. A widely available, safe and effective vaccine is still going to take months for everyone to get it.

There is an alarming spike in the number of cases and more COVID-19 surges are likely to occur. Letting the coronavirus circulate freely among the public would result in hundreds of thousands of cases and millions more people left with lasting lung, heart, and brain or kidney damage. We must all continue to practice COVID-19 precautions, such as physical distancing, hand washing and mask wearing. We must work with our government to ensure that everyone in our household is up to date on vaccines as soon as they are made available.

Let no one harbour the false attitude of denial that COVID-19 does not happen to them or that they are not the spreaders of the infection once they have survived COVID-19 or have been vaccinated for it. 

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused the COVID-19 disease but people are the cause of the pandemic.

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First published 12 April 21

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This is my India. I love my India.

I was one of the lucky ones among the ‘age over 60 years’ category to receive the first dose of the COVID-19 vaccine at a private hospital on 01 March 2021 itself. I am grateful to our scientists, health workers for their race against time to deliver the vaccines to people. I am equally grateful to Government of India for making it accessible to us.

Two observations from the vaccination centre while I was waiting for my turn and then being under observation for 30-minutes after the injection are interesting for sharing here. Both of them relate to the group ‘age between 45 and 60 years with co-morbidities.’

In one case, family of someone in this category of ‘age between 45 and 60 years with co-morbidities’ did not want to be vaccinated by declaring the ‘co-morbidities’ because they feared that the health insurance premium would go up if they disclosed the existing diseases.

In the second case, someone in the ‘age between 45 and 60 years but without any co-morbidities’ used a false medical certificate declaring a co-morbidity to receive the vaccine.

I am not standing in any moral judgment for either of the cases because these cases did not surprise me as Javed Akhtar had penned in his hit song FIR BHI DIL HAI HINDUSTANI. Even the experiments conducted by Dan Ariely (James B. Duke Professor of Psychology and Behavioral Economics at Duke University) in India and on Indian people and reported by him in “The Upside of Irrationality (Harper 2010)” and “The Honest Truth About Dishonesty (Harper 2013)” show that up to 6% of dishonesty is not even considered as dishonesty by us. I hope, not more than 6% of us fudge the truth about our medical conditions.

I am however anticipating something different. We being Indians are used to hiding our existing medical conditions for the fear of being social ostracized or being pitied at. However, some of us may now falsely declare to be having medical conditions to get the vaccine out of turn.

Will the post-vaccination data erroneously show that the citizens ‘aged between 45 and 60 years have unusually low or high incidence of co-morbidities’ in India or such aberrations will statistically cancel each other out?

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First published 02 March 2021

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Some Unsought Advice for the Prime Minister Shri Modi

The situation where you are running from pillar to post to find a hospital bed or an oxygen cylinder for your loved one, and there is nowhere to go, you feel frustrated, helpless and angry.  If you are the lucky one to find some place, the ban on visitors makes you more edgy because you could not be with your loved one to offer comfort and support when he/she needed it most. The thought of not being able to see or comfort a loved one who is living with an advanced illness is heart breaking.

Time seems to freeze when you learn that someone you love has slipped from medical care to critical care in a COVID-19 facility. Maybe you instinctively pushed the news away, or perhaps you cried, or swung into action. You and your loved one may have pursued promising treatments and perhaps enjoyed some respite from the illness over the last few days.

The loss of a loved one is life’s most stressful event and can cause a major emotional crisis. All kinds of emotions, denial, disbelief, confusion, shock, sadness, yearning, anger, humiliation, despair, guilt, can flood people’s minds.

SUCCESS, WHICH THE GOVERNMENT IS TRUMPETING

The data given out by Ministry of Health and Family Welfare website https://www.mohfw.gov.in/.

COVID-19 CASES IN INDIA as on: 15 May 2021, 08:00 IST (GMT+5:30)

Active – 3673802   Discharged – 20432898    Deaths – 266207    

Until date (15 May 2021), 24372907 people have been identified to be infected, of which 15.07% (3673802) are Active cases right now, 83.83% (20432898) have successfully survived the infection but unfortunately, the balance 1.09% (266207) could not survive and have died.

Yes, your government is right that Indian has done exceedingly well, on an aggregate basis, in management of the COVID-19 crisis as compared to any of the countries in the world. Nevertheless, the fact remains that the mismanagement of second wave of COVID is hidden behind the exemplary management of the COVID. Your government was successful in flattening the curve of cases and deaths of the first wave over a period of 11-months, something which the Western world could not do. The same cannot however be said for the second wave.

FAILURE, WHICH OVERWHELMED INDIA

You do not have to go to any other source of data to see this. Failure, which overwhelmed India, is buried, not too deep, in these very numbers.

Please have a relook at the data given out by Ministry of Health and Family Welfare website https://www.mohfw.gov.in/.

COVID-19 CASES IN INDIA as on: 15 May 2021, 08:00 IST (GMT+5:30)

Active – 3673802   Discharged – 20432898    Deaths – 266207    

COVID-19 CASES IN INDIA as on: 15 April 2021, 08:00 IST (GMT+5:30)

Active – 1471877   Discharged – 12429564    Deaths – 173123    

Of the 24372907 people identified as infected so far (over the last 15 and one half month – the first case was reported on 30.01.2020), 10499082 (43.08%) cases came during the last one month. Out of 266207 deaths recorded so far, 94122 (35.36%) deaths occurred during the last one month.

This is not a joke or a mere spike. It is a deluge.

Of all the cases – 43% came in last one month;

Of all the people dying – 35% died in last one month.

COVID-19 began hitting way too close to everyone’s home. What were merely numbers for people during the first wave, started turning into names and those names 𝗂𝗇𝗍𝗈 real 𝗉𝖾𝗈𝗉𝗅𝖾 whom people know?

WHAT WENT WRONG

With micro-situations continuously evolving and rapidly changing, managing Pandemics at the ground level is a very complex phenomenon involving case-by-case tactical and urgent decisions that need ‘thinking fast’. However, the policy level, at which the office of the Prime Minister sits, the foresight and strategy based thereon, is an important decision that allows wider consultations, reviews and ‘thinking slow.’

At the strategy level, dealing with pandemics involve only two sub-strategies, ensuring that the pandemic does not spread (Restriction strategy) and ensuring that those infected are able to recover from the disease (Treatment strategy).

Restriction is about reducing the number of cases, which is accomplished through controlling the spread of infection (Appropriate Behaviour and immunisation through vaccines). Where the disease is contagious, isolation and quarantine of the prospect (contact tracing) and the suspect case (symptomatic cases) is as important as that of the confirmed case. In case like COVID, where not every infected person shows the symptoms of being infected (asymptomatic cases) the inter-people-contact has to be clamped down.

Treatment is about reducing the mortality rate among the cases through proper and timely diagnosis and treatment.

YOU HAVE RIGHTFULLY TAKEN CREDIT FOR MANAGING THE FIRST WAVE

You had the foresight and the promptness in March-April 2020, in using the Restriction strategy, when the first wave of the pandemic broke out, which resulted into definitive reduction in spread of infection and reduction in the mortality rates. Numbers speak for themselves.

However, the second wave, which started knocking at our doors towards the end of February 2021 and is peaking now, has left much to be desired at your level.

SHOW THE GRIT IN ACCEPTING THE DISCREDIT FOR MISMANAGING THE SECOND WAVE

COVID-19 patients tend to be sick for a long time, spending weeks in the intensive care unit in some cases. Patients improve up to a point, and then it can be several weeks before one would see them continue to improve. Families need to prepare for that, as well as peaks and valleys seen so often in the sickest patients. Hospital restrictions that prohibit visiting COVID-19 patients have been major stressors for families, as well as those in the hospital. In the unfortunate events of patients losing the fight against COVID-19, not every one of their families and friends have the emotional strength of suffering the pain sagaciously or silently. Patients, their families, and other caregivers have little patience or tolerance, and their short fuses can explode on the very people trying to care for them.

Doctors and nurses are withstanding the worst of a much angrier, more frustrated, and weary bunch. Medics falter when they witness rudeness and other bad behaviour. It interferes with their working memory and decreases their performance. Frustrated patients are making health care workers’ jobs even harder.

No medical-care infrastructure, in terms of both physical dimensions and human dimensions, can have the capacity to deal with such deluge.  No society can cope with such agony and death. Yes, Treatment Strategy has limitations in dealing with such tsunami of cases.

However, you have faltered in making use of the Restriction Strategy once the coming of the second wave was clearly visible towards the end of February 2021. This failure has resulted into the ‘unforeseen’ deluge of cases and deaths. In ability to see these coming, is itself a failure of leadership and his advisors.

Overtly or covertly, this failure is being attributed not to any lack of your foresight regarding COVID, but to your political ambitions in West Bengal and other states. I am not a political strategist, but the results tell us a story.

FAILURE IN STATE ELECTIONS 2021

Ever since you brought in the US Presidential style of electioneering to Indian politics in 2014, people vote for the leader as much as they vote for a party. Your inability to win Rajasthan, Punjab, Maharashtra and Madhya Pradesh had shown an association in your inability to project an unambiguous leader who could campaign in the same style in the state as yours in the national elections.

When you or any of your central leaders campaign in a state election, the electorate asks themselves – are you or any of those central leaders going to be their Chief Minister? Even when they wish to vote for your party, they do not know who is going to rule them. As they say, a known foe is better than an unknown friend is, the electorate ends up making choices, which may look poor from a larger perspective, but they are the best picks that the electorate could make from within the choices available to them.

Let us not forget that a day after the first round of polling took place on 20 May 1991, former Prime Minister Rajiv Gandhi was assassinated while campaigning. The remaining election days were postponed until mid-June and voting finally took place on 12 and 15 June. When the surge in COVID cases was so visible by the end of March for everyone to see, not postponing the elections was neither good strategy nor good politics. The votes polled in your favour in successive rounds of polling have shown a negative association with the rising COVID-cases in the country. Who knows, if the state elections were postponed for a better time, their results for you could have been better.

WHAT NEXT

Dear Prime Minister! As a leader, please accept the fact that you won the battle against the first wave but lost the battle against the second wave. You do not win all the battles. It is important that you win the war – war against COVID-19.

You won people’s mandate because they trusted you. You used your high visibility and high credibility in winning over their emotions. Trust is after all an emotion.

All Indians are one but they are not the same. Similar people are grouped into states. That we have 29 states shows similarity of people within the states but dissimilarity of people across the states. Indians are not like Americans, who have little diversity in language, culture or religion.

The unified central-command structure of decision making which you could use so successfully in running the Government in Gujarat may not be an optimal design for running the Union Government. Please remember that the entire bureaucracy that you handled in Gujarat was a unified Gujarat cadre but when you handle the union Government, your bureaucracy is not one cadre. The rules of engaging with the opposition leaders and bureaucracy within Gujarat are not suited to engaging with the opposition leaders and bureaucracy in the matters of the Union.

They still trust you but the untold agony and death, which they have seen over the last one month, has broken them emotionally. Fear & grief of COVID-19 is overwhelming ordinary people and your political rivals and bruised media (you have taken away many of their free bees) are adding fuel to this fire. Emotions are contagious. Our brains are wired to mirror the body language and emotion of others. In an era of social media, opinions occlude information and truth becomes matter of opinion. Absolute truth makes way for pre-truths, half-truths, developing truths, post-truths, my truths, your truths and no-one-knows whose-truth.

There is no denying that you are suffering from a loss in your credibility. Your high visibility and waning credibility is untenable in public space. You cannot be complacent or disheartened. You need to make a serious course-correction.

You have to rise as a leader and restore the confidence of people in their ability to overcome and succeed under your leadership. Please work towards decreasing the COVID-19 test-positivity rate & case fatality rate and increasing the EMOTIONAL POSITIVITY among the people of India.

To everyone locked inside their homes, in fear or anxiety, and to everyone locked out from the joys of life as usual, please put a confidence in them that the sun will come again. Remind them of the vibration that passed all over their lives, make them remember everything that they shared with their loved ones, thank the Gods who helped them face the untold grief over the last one month.

You have to rise from the ashes of the second wave. YOU HAVE TO WIN ALL THE FORTHCOMING BATTLES AGAINST THE THIRD AND THE FOURTH WAVE. YOU HAVE TO WIN THE WAR.

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First Published 17 May 2021

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Na Dainyam Na Palayanam न दैन्यं न पलायनम्*

There is no reason to believe that any Indian political leader is anti-India. They all mean well and wish well of the country. They all have illusionary visions and Indian spirituality.

The phrase ‘Vasudhaiva Kuṭumbakam’ (Sanskrit: वसुधैव कुटुम्बकम्) consists of several words: vasudhā (transl. ’the earth’); ēva (transl. ’is thus’); and kuṭumbakam (transl. ’family’).

अयं निजः परो वेति गणना लघुचेतसाम्। (ayaṃ nijaḥ paro veti gaṇanā laghucetasām)

उदारचरितानां तु वसुधैव कुटुम्बकम्॥ (udāracaritānāṃ tu vasudhaiva kuṭumbakam)

The original verse appears in Chapter 6 of Maha Upanishad VI.71-73. Also found in the Rig Veda, it is considered the most important moral value in the Indian society. This verse of Maha Upanishad is engraved in the entrance hall of the parliament of India.

‘Vasudhaiva Kuṭumbakam’ belonged to the world where there was only the Vedic Civilisation and is no more valid in the times of ‘I, me, mine and ours’ ethos. A Hindu may believe that the whole world is ‘one family’ but the rest of the 85 percent of the people of the world may not think so.

Nehru misread China, Shastri misread Pakistan, Indira misread Khalistan, Guljari Lal, Morarji, Charan Singh, VP Singh, Gujaral, Devegowda, and Chandra Shekhar were unable to read anything, Rajiv misread Sri Lankans, Narsinha Rao misread Italians, Vajpayee misread Pakistan, ManMohan did not read anything, and Modi has misread China.

All politicians know and understand that ‘poverty’ is India’s biggest problem. Most of them want to correct it but they do not have it in them to deal with the problem directly. Indian political leadership has conclusively proven itself consistently deficient in its foresight and capability in policy-making and action taking over the last 75 years. 

If India lost the 1962 war with China, due to lack of appropriate weapons and ammunition in the hands of our soldiers, India may lose the 2020-21 war against this virus due to lack of appropriate weapons and ammunition in the hands of our doctors.

A wiser political leader Vajpayee had written:

कर्तव्य के पुनीत पथ को
हमने स्वेद से सींचा है,
कभी-कभी अपने अश्रु और—
प्राणों का अर्ध्य भी दिया है।

किंतु, अपनी ध्येय-यात्रा में—
हम कभी रुके नहीं हैं।
किसी चुनौती के सम्मुख
कभी झुके नहीं हैं।

आज,
जब कि राष्ट्र-जीवन की
समस्त निधियाँ,
दाँव पर लगी हैं,
और,
एक घनीभूत अंधेरा—
हमारे जीवन के
सारे आलोक को
निगल लेना चाहता है;

हमें ध्येय के लिए
जीने, जूझने और
आवश्यकता पड़ने पर—
मरने के संकल्प को दोहराना है।

आग्नेय परीक्षा की

इस घड़ी में—
आइए, अर्जुन की तरह
उद्घोष करें:
‘‘न दैन्यं न पलायनम्।’’

A ‘Murali-Dhar’ does not remain a ‘Murali-Dhar’ but goes on to become a ‘Giri-Dhar’ and a ‘Chakra-Dhar’ as the situation requires.

If ‘Maha Upanishad’ gives us, the value of ‘Vasudhaiva Kuṭumbakam,’ ‘Katha Upanishad’ gives the inspiration to Swami Vivekananda to give us ‘Arise, awake, and stop not till the goal is reached.‘ The words “Arise, awake…” can be found in the 1.3.14 chapter of the ‘Katha Upanishad’, where Yama is advising Nachiketa

उत्तिष्ठत जाग्रत प्राप्य वरान्निबोधत, (Uttisthata Jagrata Prapya Varannibodhata)
क्षुरासन्न धारा निशिता दुरत्यद्दुर्गम पथ: तत् कवयो वदन्ति| (Kshurasanna Dhara Nishita Durataya durgama Pathah tat kavayo Vadanti)

Arise! Awake! Approach the great and learn.
Like the sharp edge of a razor is that path,
so the wise say—hard to tread and difficult to cross.

* न दैन्यं न पलायनम् was the motto of my school that I proudly wore on the badge of my barrette cap.

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First published 27 April 2021

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Non-Academic Staff in Higher Educational Institutions

Non-Academic staff members are professional employees who contribute very significantly to the success of Higher Educational Institutions. They bring to the Higher Educational Institutions an important repertoire of professional skills, possess a wealth of institutional knowledge, provide essential resources, and work alongside of faculty and Administration in realizing the Institution’s mission. Many have served through several administrations and numerous leadership changes at the departmental level. This long-term experience gives them invaluable expertise and lends consistency to the daily operations of the institution.

The contribution of non-academic staff highly influences the student experience at Higher Educational Institutions. While faculty supports students academically and in research, the staff makes equally important contributions toward the success of students through many critical support and operational services.

There is evidence to show that the number of non-academic administrative and professional employees at established Higher Educational Institutions in India has more than doubled in the last 25 years, vastly outpacing the growth in the number of students or faculty. The disproportionate increase in the number of staffers who neither teach nor conduct research has continued unabated in years that are more recent.

Those commenting on higher education often ask whether the proportion of administrative and support staff is higher than it should be, with the unspoken assumption that a percentage less than hundred is ideal. This is a good starting point; since without administrative and other support functions Higher Educational Institutions are always at some risk that they cannot adequately provide student services and high value research.

There is just an overwhelming amount of money per student that is being spent on administration. This raises a question of priorities.

Institutions have added these administrators and professional employees even as they have substantially shifted classroom-teaching duties from full-time faculty to less expensive part-time adjunct faculty and teaching assistants. Institutions have increased their hiring of part-time faculty to try to cut costs.

Institutions can undertake a critical examination of their costs to tell exactly how much the rise in administrators and professional employees has contributed to the increase in the cost of tuition and fees, which has also almost quadrupled in the last 20-years. This is a higher price rise than for any other sector of the economy in that period, including healthcare. The unrelenting addition of administrators and professional staff has driven this steep increase.

The continued hiring of non-academic employees belies the very idea that institutions are doing everything they can to improve efficiency and hold down costs.

While the rest of the economy has been shrinking overhead, higher education has been investing heavily in more overhead. Staffing per student is a valid way to judge efficiency improvements or declines. The ratio of non-academic employees to faculty has also doubled. There are now two non-academic employees at public and two and a half at private institutions and colleges for every one full-time, tenure-track member of the faculty. In no other industry would overhead costs be allowed to grow at this rate; executives would lose their jobs. The doubling of administrative and professional staff does not seem to have improved the performance of Higher Educational Institutions.

In any long-term plan for Higher Educational Institutions, among other goals, the institution should learn to value non-academic staff as crucial for the central missions of the institution. This requires that the non-academic staff be supported as a crucial human resource for the institution. Careful attention needs to be paid to the creation and maintenance of a healthy workplace. Career development should be fostered through advancement opportunities. Internal mobility should be actively encouraged.

Valuing non-academic staff also requires the rational, transparent distribution of staff across units, and a careful consideration of their duties. Regular review of staff roles and responsibilities should be implemented.

As the institution advances, it must take care to maintain necessary staff levels and skill requirements. An institution should however never lose sight of the primacy of its purpose, functions of teaching and research, and not let the flab of Non-Academic Staff grow. The institution cannot be unmindful of the non-academic responsibilities, which it entrusts upon the academic-staff.

The financial stress on the institutions of higher education caused by COVID-19 pandemic has led to focus on productivity and cost-cutting, which in certain cases has led to denial of tenures to faculty and non-renewal of teaching contracts. At a so-called premier b-school in Gurgaon, the annual workloads for the teaching faculty have been increased by over thirty percent without any increase in their compensation. Of course, academics are the front line staff who provide the teaching and research functions that represent the institution’s core business. Unfortunately, there seems to have been no talk of pruning the non-academic staff by any percentage.

It is astounding to hear a very senior professor from the institution saying that non-academic administrators were a cancer in their academic system. It is more alarming to notice that many others are greeting such a statement with mutters of approval. It seems probable that eventually, there would be an open or covert warfare between academics and non-academics at this institution where legacy systems have sustained the covert bossing by the non-academics over the academics.

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First published 07 April 2021

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When, Where and How Will We Get the Vaccine?

Indian society has a tendency to understand risk in all-or-nothing terms as has come into sharp focus during the COVID-19 pandemic. It is a realm where individual liberty takes primacy over collective responsibility.

The experience of the last 10-months shows the focus of the government on the risk of spread of the infection from an infected to others, rather than the risk that the infected person faces through the infection.  Public health messaging through ‘Aarogya Setu’ app refers to “high-risk” “moderate-risk” or “healthy or low-risk” individuals. Public-service announcements on radio are framing ‘using sanitisers’ ‘wearing of masks’ and ‘social-distancing’ as “virtuous” thereby semantically differentiating the refusal to do so as admirably masculine and nonconformist.

India on Saturday 16 January 2021 kicked off the world’s largest immunisation exercise against Covid-19. If all goes to plan, 30 crore people may be vaccinated against the contagion by July end. This mass-vaccination project, unfortunately, for the moment targets barely 2% of the population, 30 million persons out of a population of 1400 million. In first 4-days, less than 1% of these 30 million targeted-persons have actually received the first of the two-shot-regimen. Nearly one-thirds of the targeted-persons did not turn-up to get the vaccination done. At this pace, even this project will take next 100 weeks for completion. 100 weeks is 2-years, which means well into 2023. What would become of the rest 98% of the population is not clear at this moment. The Government of India’s moral, international and legal obligations make it imperative that COVID-19 vaccines are free and universal. There is no doubting the sincerity of the intentions of the government, but the implementation of the intentions leaves people in a limbo.

Social shaming and punitive enforcement of public health measures are both ineffective and unethical. Shaming and policing tactics shift undue responsibility for contagion management from institutions to individuals, and places further burdens on communities that, in the case of COVID, already suffer disproportionate rates of infection.

The risks are never unidirectional and that risk management always involves weighing multiple factors. COVID-19 is not the only risk people have to consider when they make decisions about most aspects of their daily lives. An inability to work from home means very real, material risks like losing income, losing housing, losing the ability to provide and care for families. Shaming people for their risk behaviours is not just unethical and ineffective. Such behaviours are not a binary matter of “risky” or “not risky,” but one of choosing which risks to take.

It is critical for the Government to correctly diagnose, manage, mitigate, and treat COVID-19 as it occurs. , and to do their best to keep it from having major. It is an even more critical thing for the government to consider communal consequences, with regard to COVID, which is far more easily transmissible and whose uncontrolled spread has massive costs for nearly every aspect of public life.

It is important to find ways to help people live their lives during the pandemic. Nevertheless, doing so must not come at the expense of other people’s ability to stay alive, let alone be in public at all. The more inconsiderate those nondisabled people are about containment measures, the longer many disabled and chronically ill people will have to maintain the strictest possible measures simply to stay alive.

It is true that all social activities bear some level of risk. It is equally true that, to a certain extent, we must each decide how to balance the risk of contracting and transmitting the virus against the psychological, social, economic, and often competing medical risks of limiting various kinds of activity. The evil complexity of risk management during this pandemic requires all of us to be better, more considerate social actors. When we as individuals make decisions about what risks to take, we should look at the details soberly and seriously consider how our choices affect what choices are available to others in our communities.

We should direct our frustration at institutional failures instead of individual ones. The amount of COVID-related talk that is exclusively about individual risk management is neither accidental nor inevitable. It is a consequence of the massive disregard of duty on the part of the governments to give clear information and distribute the resources necessary for everyone. It is equally a consequence of the ways our political and healthcare systems already make it gratuitously difficult to access vital care and resources by way of inadequate health coverage.

Putting it bluntly, the almost exclusive focus on individual risk that has characterised governmental speech on COVID persists because institutions tasked with reducing the risk burdens of individual cannot or will not do their jobs.

This emphasis on individual attention to risk-mitigation is especially poignant and unsettling when one realises that this governmental discourse is occurring in tandem with their awareness that the infrastructure necessary to manage that status lies in ruins.

Our public institutions have the obligation to manage and mitigate the infection risk in ways that allow everyone to flourish. We must not lose sight of where the burden of risk management ought to fall. We must not fall prey to the temptation to punish individuals for institutional failures.

We are unable to figure out how to proceed amid caring for one another and watching more and more of our number suffer or even die. Even if we have the ability to pay for the vaccine, willingness to pay for it, ability to reject taking the vaccine and the ability to raise our voice against the system, we do not seem to have the ability to get the vaccine in reality.

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First published 19 Jan 2021.

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