key: cord-254449-ww7iq04j
authors: Naithani, Nardeep; Datta, Rakesh
title: COVID-19: Shades of Grey
date: 2020-05-20
journal: Med J Armed Forces India
DOI: 10.1016/j.mjafi.2020.04.010
sha: 
doc_id: 254449
cord_uid: ww7iq04j

nan

Pandemics have shaped new world orders and history is full of examples of widespread death and destruction left by enemies we cannot even see. 1 Leo van Bergen, a medical historian with special interest in World War I reported that the US lost 26,277 troops in the Meuse-Argonne offensive often regarded as 'America's deadliest' in 1918. However, the toll exerted by the Spanish Flu pandemic on the US Army far exceeded this, at 45,000 soldiers around the same time. 2 Swine Flu, Ebola and Zika are only the latest in a long series of events that have ravaged the human species. COVID-19 joined this 'elite' list on 11 Mar 2020 as WHO declared COVID 19 as a pandemic. 3 The emergence of COVID-19 raised many questions about the origin, spread, infectivity, risk factors, treatment and even handling of this pandemic. This is expected, considering the dynamic nature of scientific evidence. In the limited time since the first case of a novel coronavirus was known, a PubMed search query for COVID-19 alone gives more than 6000 results. A similar search on Google scholar gives more than 13,200 results. Perhaps many more would be available in other libraries and preprint servers. While this might be encouraging, most questions still remain unanswered. It could be like a jigsaw puzzle with pieces yet to be found. To address this, Gupta et al. from National Centre for Disease Control, India, have very lucidly highlighted nine domains where healthcare workers need to find answers, in this issue of the Journal. 4 The editorial board of Medical Journal Armed Forces India (MJAFI) could not agree more. Every small bit of research counts. The overall understanding will be way more than a mere sum of parts. We have endeavoured to play our role as a peer reviewed medical journal while welcoming submissions on the entire spectrum of possible research on COVID-19 from across the world. The Journal has created a dedicated subsite (https://covid.mjafi.net) to highlight the same and accepted articles are being made open source by our publishing partners Elsevier. The submissions and peer reviews are being fast tracked and accepted articles made available online ahead of print to enable the sharing of scientific thoughts at the earliest. The response has been heartening and we hope to fulfil our role in disseminating peer reviewed translational and clinical research to help fight SARS-CoV-2. At the same time it is important for our readers to understand that what they see in one study is only a small part of the entire puzzle we are yet to see. As elegantly brought out by Pai, we need to be wary of the inherent bias and confounders when drawing conclusions out of ecological studies in epidemiology. 5 Mathematical modelling has been one of the battlefronts to help plan and organise systems to prepare for the challenge of COVID-19. It uses data to make complex predictions. The results are usually dependent on the quality of inputs and assumptions made. 6 Chatterjee et al. have made predictions on the anticipated numbers of the pandemic in India with and without lockdown and social distancing. 7 Though it is only with time that we may know the accuracy of this prediction, many such models are being developed with increasing complexity and large number of parameters. It provides planners and policy makers a set of numbers to work with in the face of uncertainty. A word of caution is however necessary in all these models. As exit polls after a closely fought election may go horribly wrong and some turn out accurate, mathematical modelling is also not without its inaccuracies. The factors which determine the course of events are complex, and undoubtedly it is not possible to model real world complexities in any equation. Regional diversities in countries like India are even more difficult to cater. Nevertheless, to carry the exit poll analogy further, mathematical models are increasingly becoming a valuable tool to equip the public health response in COVID-19. As the understanding of the transmission of the disease changes, mathematical models need to be dynamic tools to help policy making bodies. To quote Jewell et al., "Models can be useful tools but should not be overinterpreted". 8 Hopefully, the benefits of mathematical models will trickle down to local city planners and public health experts to help them make short term specific predictions.

Another aspect which needs to be considered is the mental health aspect of this pandemic. It would not be wrong to say that each one of us has felt troubled with the exponential rising numbers, innumerable social media forwards of stories of struggle and sorrow and the 'clamp-down'. The name quarantine rings an alarm with reports of people escaping quarantine and stamping of COVID-19 suspects by authorities. 9 While another editorial highlights the psychological challenges of quarantine in the current issue, mental health of both, the population and the 'Corona Warriors' is a fertile field for research. 10 Healthcare personnel are frontline soldiers in this war. In the developing world, they are already a scarce resource, and for the less fortunate patients who need hospitalisation and critical care, the only ones around. They are as susceptible, if not three times more, to get infected as has often been quoted. They are exposed to multiple patients, multiple times for prolonged durations. And at many times with only a mutual lurking feeling of suspicion and fear between the patient and doctor about being infected by each other!! To add to the hostilities, they are also bearing the brunt of unfortunate incidents of violence as reported. Guidelines, then are probably as helpful as a golf guidebook for a high handicapper trying to score a birdie ! The frequent changes in the guidelines do little to alleviate the confusions that might exist in the minds of the healthcare workers. Udwadia, a pulmonologist who has been in the thick of things since COVID-19 reached Mumbai has penned a practical perspective of protecting the protectors in this issue and shared ten lessons for the medical community to learn. 11 Undoubtedly, healthcare workers are at risk. COVID 19 should probably be viewed as an occupational disorder for healthcare workers amongst others. COVID-19 is the first new occupational disease to be described in this decade. 12 The recent ordinance to amend the Epidemic Diseases Act, 1897 by the Govt of India will hopefully help to reduce the public brunt and help healthcare workers focus on SARS-CoV-2. 13 SARS-CoV-2 has changed our world. The fight against the virus will be prolonged with its share of ups and downs. We have barely begun to understand the disease and the way it brings us down. But there is nothing in black and white yet ! These are early days and we are seeing many shades of grey. The medical community has to rise, don their battle gear and get ready for World War III. r e f e r e n c e s

20 of the worst epidemics and pandemics in history

Death from 1918 pandemic influenza during the First World War: a perspective from personal and anecdotal evidence. Influenza Other Respir Viruses

WHO Director-General's opening remarks at the media briefing on COVID-19

The missing pieces in the jigsaw and need for cohesive research amidst COVID 19 global response

A skeptic's guide to ecologic studies during a pandemic

Data-based analysis, modelling and forecasting of the COVID-19 outbreak

Healthcare impact of COVID-19 epidemic in India: a stochastic mathematical model

Predictive mathematical models of the COVID-19 pandemic: Underlying principles and value of projections

Ist 2020 11:27. Coronavirus in India: man stamped for quarantine in Mumbai caught at Secundarabad railway station

Epidemics, quarantine and mental health. Med J Armed Forces India

How to protect the protectors: 10 lessons to learn for doctors fighting the COVID-19 coronavirus

Occupational risks for COVID-19 infection

Promulgation of an ordinance to amend the epidemic diseases Act, 1897 in the light of the pandemic situation of COVID-19