Covid-19 Manipur: A look beyond sambal khaba

Dr Nabakishor Haobijam *

Kakching Keithel during COVID-19 lockdown on April 23 2020 :: Pix - Shankar Khangembam

Manipur's Covid19 scenario is getting murkier day by day. The incessant reports of local transmission in the daily status reports from IDSP, and a recent point out by a State Technical committee on Covid, implies the state is at the verge of the dreaded community transmission. There are fresh reports of health care workers getting infected, some even getting serious. In addition, unofficial reports of positivity among those seeking hospital care are also on the rise.

How has Manipur, a green zone state come to this?

It was way back in March end that the state had its first positive case, followed by another in April. And for a while there was a lull, but with the advent of returnees, the imports of the disease increased manifold. As of today, the 19th of August 2020, Manipur has a total active case of 4876 total positives, 1973 active cases, 2885 recovered cases, with 18 unfortunate deaths. Officially local transmission has been ascribed as the cause of spurt in cases.

So far the government has responded with multiple SOPs, escalated testing, multiple Covid Care Centres and hospital beds in RIMS and JNIMS. Multiple lockdowns have been undertaken to slow down the transmission, the success of which is still debatable. Even during the lockdowns, the surge of positive cases is still continuing unabated.

Meanwhile the public have responded initially with leikai sambal khaba, then followed the protocols and SOPs released by state authorities, seemingly. And now with the surge again in positive cases and the possibility of community transmission, the panic reaction is gripping the population. People are resorting to their own lockdowns, and leikai sambal khaba.

It is at this stage, Manipur and Manipuris need to relook the strategy being followed to control the pandemic. The state and people need to comprehend what went wrong/right, and or what could be done more to effectively prevent a devastating stage 3. And perhaps responds than react, so as to look beyond sambal khaba?

Now is more pertinent to ask again:

What is this virus and pandemic? Why should the state and people fear it?
What are the main issues posed by this pandemic as a problem? What are we doing not correct?
And more importantly what could be the way forward?

The author will try to bring his perspective to the above questions one by one. However before doing that he wants to bring into context a background of data of the disease as of 19/8/2020, of how it is faring in Manipur. This data will also be important when we come to address the above questions.

As mentioned at the start of this article, Manipur now has a total of 4876 positive cases, 1973 still active and 2885 recovered. A total death of 18 has unfortunately occurred. The positivity rate is 4.0 % (from a total sample of 1,20,135). Test conducted per 1 million population is 38,715. And the confirmed case per 1 million population is 1,571. Case fatality rate is 0.4% against the national average of 1.94%. An average of 24 test is performed per positive case. Average growth rate is 3%.

Now with this in background, let's come to the first question.

What is this virus and pandemic? Why should the state and people fear it?

It has now become common knowledge that the pandemic is caused by SARS-COV2, which is a coronavirus. It's a novel virus, meaning a totally new one against which humanity has no immunity. Also it has the behaviour of being a highly contagious pathogen, unlike other coronaviruses. And it's this nature that is making it a global pandemic. It has caused rapid spread through droplet and aerosol transmissions.....that it has reach our remote place of Manipur.

The virus is highly contagious, but it is not a strong virus. It is in fact a weak virus, which cannot survive long beyond and outside a human host.

So why are we afraid and why it is so problematic?

The fear for this is different for general populace, government agencies and medical professionals. For the public, it creates a fear of a fast contagious infection, added with the news that there is no cure as of yet, and through misinformation can have various response from phobia, stigmatisation to nonchalance. For the government it is a new public health crisis with an associated socioeconomic baggages.

For the medical professionals, the infection creates a fear of collapse of healthcare system...especially if a massive influx of infected cases floods an unprepared health system. And in context of Manipur, with our current state of healthcare system , an uncontrolled pandemic can overwhelm our system and cause a huge issue. Hence the fear is not just of the fatality of the disease but rather the effects it can have due to its contagiousness.

For the public, though it's pertinent to remain cautious, it is a point of introspection to ask ourselves that does the 0.4% case fatality warrants a panic rather than a response? It's a matter of importance that we should understand why and what we should fear, so that we can face the problem with clear mind.

What are the main issues posed by this pandemic as problems?

The issues in this pandemic can be numerous and the list could be exhausting. However the author wishes to summarise them into the following especially with context to what we are facing in Manipur:

1. Clinical issue
2. Public health issue
3. Public awareness issue
4. Socio-economic issue
5. Educational issue

That the pandemic is primarily a medical/clinical/epidemiological issue is a long foregone conclusion. It has no cure, no vaccine, and spreads fast. And as for every pandemic, it causes a massive influx of infected which can overwhelm any healthcare system, even a well developed one. Typically for Manipur, what it causes is primarily a crisis of inadequate hospitalisation and admissions for both Covid and non-Covid patients. As our infrastructure and manpower is less optimal, the issue is going to be compounded manifold in the coming months.

A community transmission causes difficulty in identifying patients who are Covid/non-Covid. Contamination and cross infection risk can increased manifold in our existing hospitals...simply due to the fact that they are not equipped to handle a pandemic of this nature. Safety issues of healthcare workers becomes a prime concern, so as to prevent any impending problem of manpower shortage.

It is obvious that infections to healthcare workers can happen, will happen....and if this is not mitigated, then a collapse of the system can happen very fast. This will lead to catastrophic fatalities, not just because of the virulence. Already Manipur's poor healthcare system is starting to bear the brunt of the pandemic.

Administratively, for the state, this pandemic is a huge public health crisis. And because the system was not optimal before the pandemic, it's weakness will get exposed... of faulty policies and execution. The reliance on multiple lockdowns for containment, quarantine and isolation issues, and the policy of trace, track, test, treat are at any moment of time a challenge from a public administration point of view. However it's the onus of the authority to respond to the pandemic and prevent panic of the populace.

Public awareness , as far as Manipur is concerned, has become an issue over an issue. There is a widespread misinformation...even leading to information overload on the public. Reliable and usable information are not reaching as intended at the effective level to individuals. A huge disconnect is still observable in the mass about the pandemic, and how it spreads. Ostracisation and stigmatisation are being manifested as defence mechanism against an enemy which is invisible.

sambal khaba and leikai lockdowns are pure manifestation of such defence.. The failure of the state's public awareness efforts is that still people are still not compliant with efforts fundamental to break the transmission : wear mask, maintain social distance and wash hands with soaps frequently. And myths and misconceptions abound.

The socioeconomic issues caused by the pandemic is simply due to its biological behaviour which makes social collaborations a health hazard. Since the virus spread human-human in forms of droplet infection, any closed/group behaviour of humans enables its sustenance. So it pose to us to break our long tradition of social and economic activities. And that in itself is a huge problem.

Man cannot easily change his/her behaviour, so for a society/country/world to change behaviour is a gargantuan task. In fact it's a fight between this behaviour and control of the pandemic. And Manipur is like any other place. On top of this the policy of multiple lockdowns has almost grind to stop the economic activities of the state.

The education system is so much hurt by the pandemic, simply by the fact that it has not faced a pandemic at this scale. From kindergartens to university, the challenge is to how to continue the process. And at the same time prevent sustenance of the pandemic during its processes.

What are we not doing correct?

For Manipur, the things that are essentially not being done correct can be listed as:
1. Poor public awareness , that too effective ones
2. Poor coordination and collaboration of healthcare centres
3. Greater reliance on multiple lockdowns
4. In past poor management of quarantine centres
5. Low and limited testing strategy
6. Poor and non-systematic segregation of non-Covid patients
7. Poor availability of clinical data/research of Covid19 scenario in Manipur
8. Poor engagement of public, volunteers and civil bodies
9. Poor supply logistics for essentials
10. Poor awareness of long term strategy to fight the pandemic.

There can be many more, however the author wish to emphasise the above for the time being.

Looking beyond the sambal.

So now we have a problem. And we have a mixture of panic and response. The author would like to pose a question to us all, can we go beyond the sambal? Are there ways we can do forward?

Following are what the author feels that could be ways forward, and beyond the sambals.

1. Address the fear, and poor public awareness

To the author, this issue of fear of the virus, seems to be a bigger problem than the issue of the pandemic itself. The scientific fact is that the disease spread from people and solution lies in them. The problem in Manipur is the apparent disconnect from this fundamental. Hence this fear has superseded the other problems. So any effective solution or way forward has to start from addressing this issue comprehensively and effectively. This is the foundation for, even as policy wise, to face the pandemic.

There is an even greater need for mass awareness program now. And for this the leikai clubs, student organisations, civil societies, medical fraternity has to have bigger roles. In collaboration with the government, a strong effort is needed to address the fear about the disease. Use of pamphlets, dos-don'ts, audio-video programs to heightened the basic awareness of the virus and it's transmission is a need of the hour. Much so, before we plunge into anarchy of fear/ostracisation/stigmatisation.

And not just the public, the fear in important groups like healthcare workers also need focus. After-all, fear feeds on itself and will hamper each and every efforts to control the epidemic. And hence cause social stigmatisation, ostracisation even for and in these groups. Which is a recipe for a disaster in making.

The role of media is powerful here, with the strongest responsibility to disseminate proper and authentic information, prevent panic, direct the discourse. It is hence prudent that each and every individual realised that hand washing, wearing mask, maintaining social distance is part of them as frontline to the battle. Facilities for universal mask distribution should be a logistics of this awareness campaign.

2. Care the vulnerable As it was mentioned in the beginning, the main problem with this pandemic is that, even though it is less virulent and case fatality is low, it can affect the vulnerable in the society in a more damaging way. The experience of Italy et all suggest that higher death rates are observe in the elderly, co-morbids. This can happen from the disease itself, or from compounding the effects of the co-morbid conditions, or from inundation of hospital beds leading to inadequate hospitalisation of these groups.

In fact, the main healthcare problem of this pandemic is - the care of this vulnerable group and prevent their fatalities.

So how can we do that?

o By mapping and maintaining register of the vulnerable groups (start at leikai levels)
o By Planning for their hospitalisation, medication, testing, isolation, so that no hurdles are created in their care.
o Streamlining their care with a collaborated efforts involving volunteers, CSOs, state and healthcare centres so that they get the fullest support they can get.

3. Adopt more aggressive policy for trace,track,test and treat, and use technology

The current testing policy can be seen as suboptimal, as we have 24 test per positives. And taking into context that majority of the test was done on returnees, it become obvious that a more aggressive testing is the most appropriate policy right now. Rapid cluster testing, active door-to-door testing, sentinel testing in medical centres etc needs to be ramp up.

Testing for the frontline workers like HCPs, police, and other essential service providers needs to be streamline and frequent. They are, being in the frontline, more exposed to the risk of getting the virus. The facilities of Covid care, Covid hospital, needs to be focused more with an expectant demand from increased infection. Home Isolation should be made a viable option to relieve pressure on the care centres, logistics and community involvement. However the public awareness hurdles in these options needs empathic handlings.

A more aggressive contact tracing and testing is still applicable now, even though community transmission is on the verge. This will also bring out testing statistics which can help develop a predictive model, which may help in calculating or estimating the disease loads in the coming months. As much depends on flattening the curve, this testing lies on the crux of the problem.

The aid of technology using apps, websites will help dispensing necessary and authentic information. This can also address medical issues in treatment etc when used as telemedicine.

4. Involve the public, leikai clubs, civil societies, non-essential services' government servants

As the pandemic progresses towards more to community transmission, the fight cannot be left alone to the state and government mechanism. Decentralisation of logistics will be needed. Disbursements of information, supplies, care of vulnerable etc will need the involvement of all. However training them with proper SOP will remain the onus of the state health department and government.

5. Streamline the collaboration and cooperation of medical facilities/centres both private and public.

Recent issues like non-Covid deaths due to non-availability of hospital admissions reeks of a failure of collaboration between the healthcare system. Dedicated communication channels, proper referral system, and seamless transfer system of patients can be streamline with more cooperation between the bodies, including private/public.

6. Evidence base clinical data of Covid scenario in Manipur

There is a serious absence of any evidence based approach , especially in the context of data about the virus and epidemic. There is a usual statistics of positive, active, recovered cases. However this datas are not usable or important in context of clinical treatment. The medical fraternity needs to play a greater role in dispensing scientific and evidence based facts about the virus and it's behaviour in context of Manipur.

This can have dual advantages, in the sense that it can address the undue phobia , panic and fear of the masses, and also help the healthcare providers themselves with a better understanding of the clinical scenario for the disease. Successful treatment modalities needs to shared wide and transparently. After-all we are not limited to tertiary institutes for Covid management.

7. Stringent safety concerns for frontline workers

As community transmission progress, it will be dangerous for any healthcare centres to not treat anyone coming to them as positive cases. Hence for medical centres like hospitals needs to amend SOPs for this eventuality. In fact testing every patient will be the new normal for hospitals. Regular testing of healthcare workers will be a necessity in the near future for their safety and prevention of cross transmission from them.

And much like healthcare workers, police , and essential services workers will now need a regular testing protocol, simply due to the fact that they are more risk prone to exposure of the virus. Weekly testing may become the need of the hour.

8. Prepare for unlocking

Since the national SOP and policy is there, not much can be done outside their policy. However within the policy, a more customised approach suitable to address the issues of the pandemic needs to be chalked out.

9. Prepare for possibility of secondary wave

As the virus is resurfacing in countries like New Zealand which was recently >100 days free from corona, it is obvious that we need to have a strategy and plan for such eventuality. And for this testing will play a big role. Identify weakness or transmission leaks and test, trace, track and treat them. Herd immunity is still a questionable solution.

10. Strengthen the collaboration between public, government, healthcare and essential workers.

Having written about so many solutions, some specific and some vague, success will depend on a single principle. And that common principle for whatever policy, strategy to fight this virus will remain - a collective responsibility . So utmost collaboration between all sections of the society is a must condition . Much will depend on the collective address of behavioural change of the society itself.

And therein the individual's responsibility and common sense will play the pivotal role in our collective covid19 fight. To conclude this write up, the author wishes that more efforts are initiated as collective efforts to address the lacunae of poor public awareness of the virus and the pandemic. And banking on that, collaborated processes need to be built upon so the rest of the solutions be streamlined upon. May we all overcome this pandemic.