If Ebola struck India: Don't panic but don't be ignorant either

Over the past couple of months, we have been so consumed by important national events (RaGa vs NaMo, Srinivasan becoming the ICC head et al) that we have totally failed to notice or even give any significant importance to that little microscopic thing back in West Africa that has been steadily moving from first gear to third as it increases its mortality count.

Why should we, of course? Africa is way over there and we are safe over here. Besides, if our movies have steadfastly taught us anything over decades and decades of 'not-so-subliminal' messaging, it is that we have the pristine pure holy Ganga water and temple-bell ringing procedure to save us when all medical methods fail.

First of all, a quick recap, before we reach India itself.

Ebola Hemorrhagic Fever (EHF) - Genus: Ebolavirus. 

• First documented appearance: 1976 - Congo. 
• Worst mortality numbers before 2014: Mid-400s. Has always been confined to Africa till date. 
• Mortality in 2014: 932 dead (as of August 8, 2014).
• Transmission: Direct contact with blood or any secretions from an infected person / contaminated needles / infected meat. Infected people may shed the virus for up to 30 days.
• Most likely to get infected: health care personnel, friends and relatives of infected while treating/ looking after them.
• Modus operandi: Attacks the blood coagulation system and then rapidly spreads to other vital organs. 
• Symptoms: Once they start showing themselves after an incubation period, the symptoms generally follow the trend depicted below.

Image courtesy: Whur.com

• Fatality rate: between 50 - 90%
• Cure: None.
• Treatment options: Quarantine from general public to prevent spread

The Indian government announced earlier this week that there was no need to panic and they had everything under control for now. The fact that United Nations just declared this outbreak an International Health Emergency as of yesterday is far less reassuring.

Fine, I agree that there is a certain logic in not breeding panic. After all, if I were to do that, I would be no better than the communal hate-mongers I despise so avidly. So I would just like to engage you all in a very plausible and intellectual "what if" scenario, if you would bear with me. There are going to be a few moral conundrums as I paint this picture... hard decisions requiring a harder heart to bear.

First of all, can Ebola actually reach India? 

Hemming and hawing aside, yes. With 45,000 Indians still in West Africa in the infected regions, you are likely going to face a scenario soon where they would wish to return to India. While travelling back, if any symptoms are noticed, the person should inform the aeroplane or airport authorities and be isolated once s/he lands in India. 

Problems with this scenario:  

1. You are assuming that the initial symptoms will be detectable during that 24 hour period of travel between airports. That is not necessary as the fever may start anytime after a brief incubation period following contact with the virus.

2. You are assuming that (real life scenario) the parents are going to inform or hand over their children to authorities if they spot a mild cough. Remember the moral conundrums I was talking about earlier? Well, this is the first of them. There is basically a 50-50 chance of us being responsible enough to report and thus isolate our loved ones or (worst case scenario) have them taken away from us forever.

3. You are assuming that Indian airport authorities will screen every person coming in from Africa for a raised temperature. I certainly hope that is in place. That line drawn at the airport is literally our first and last line of defense, against a potential disaster, the way I see it.

4. More worrying is this: what if someone does get detected at the Indian airport? All those in the flight would be isolated. But would the Indian authorities be ready to fly in the next bunch waiting in Africa? And if not, how do you think their relatives here in India would react? If it were your child/spouse awaiting the next flight, how would you feel if the government told you they were not willing to bring him/her back? Would you be willing to accept that decision? Or would you go 'Cloverfield' and turn against the authorities warnings, risking everything to get the person you love back?

But of course, we just need to check flights flying in from West Africa, right? 

Unfortunately, it is not that easy anymore. Unlike previous outbreaks, this time the likelihood of the outbreak going global is far greater. The highest mortality before this year was in 1976 with nearly 400 dying. This year, so far the count stands at over 1000. The three countries primarily involved are way out of their league when it comes to managing and containing the virus. Dead bodies have been left on the street if suspected to be due to Ebola. Key doctors and health workers who were fighting the disease in Africa have died due to it this time. In multiple countries outside Africa, people have been quarantined because of coming into close proximity with infected men and women, including three Indians in Delhi who flew in from Ghana with an infected person.

What is the big deal? We have doctors for this kind of thing, right?   

Five factors will determine how the medical faculty manage an outbreak, both globally and in India.

1. Tracing the infected.

2. Hospital isolation of the infected.

3. Quarantine.

4. Resources for health care personnel.

5. Public awareness.

Trust me when I say this, we will fail in all the above factors. 

This is India. Walk out in to the street today and see how many people are around you. One infected man, hiding his symptoms to avoid being persecuted, can potentially infect hundreds a day. From there, it's an exponential graph. 

If he comes into a government hospital and is treated initially for a regular viral fever, the sweat-soaked bed clothing directly infects all those who touch it and then touch any basic mucosal surface. Every person looking after him is at a high risk of becoming infected. That includes every mother who cannot resist hugging her feverish child and every husband who kisses his hospitalised wife on the forehead.

What about the converse? I was only speaking of the actually infected person. What about the rush of patients with a basic fever who will come in distraught that they may have Ebola? One true patient would be lost in a sea of unrelated illnesses. No easy answers here. 

To care for the infected would require us to quarantine that medical set up, be it primary or tertiary. What happens to every other patient who needs medical aid for other reasons? In a country with tragic doctor-patient ratios and even more tragic hospital-patient ratios, can you afford to give up, say, 15 - 20% of the doctors and hospitals for quarantine purposes? 

Image courtesy: Courant.com

Just how easy would it be to quarantine a hospital or a neighbourhood, albeit for just a month? Do you not see, in your mind's eye, people looking to escape and being aided by their 'friends' on the outside?

The less said about resources and medical kits available for doctors across India, the better. Again, trust me on that one. 

The level of misinformation and false cures that will pop up also worries me. And I don't mean just from quacks either. We are a health care system that is today openly promoting a 'medical guru' who once announced that he could 'cure' homosexuality with yoga, mind you.  

Worst case scenario?

The population density (people per square km) of Sierra Leone is roughly 82. Liberia and Guinea have mid 40s while Nigeria tops it at 174. Till date, there have been over 1700 people infected officially with a 1000 of them dead as of now.

See those numbers again clearly. Now, let us come to India.

Population density of Bangalore: 10,000 + people per sq km.

Population density of Delhi: 11,000 + people per sq km.

Population density of Kolkata: 24,000 + people per sq km.

Population density of Chennai: 26,500 people per sq km.

Population density of Mumbai: 29,650 people per sq km.

With 40 - 80 people per square km, countries with admittedly less medical facilities but over four decades of experience and knowledge dealing with this killer have now suffered their worst loss. They are helpless and even with international aid and awareness, are unable to:  

a) care for the officially infected as well as 

b) isolate and quarantine the potentially infected, seeing as how we are now into the 6th ( yes, 6th!) month of the outbreak.

Now extrapolate that number for a city like Mumbai, bursting at the seams with 30,000 people per square km. How many hospitals and neighbourhoods can you quarantine without somebody escaping through the gaps? And once it begins, how will it end?   

From where I see it, the only answer is preventing the outbreak. I really don't know if we will be able to contain it if it reaches us. Words like isolation and quarantine sit uneasily upon my mind when I consider the vastness of our nation. There may be some hard decisions ahead too as I mentioned earlier, ones I am not sure we can handle sensibly.

I mentioned at the outset, it is not a time for panic... yet. But being ignorant is not the answer either. You need to be aware of what may happen as well. 

There are imbeciles across the globe killing each other for land and religion, I agree. But there is a tiny invisible virus too walking free. And after forty years of isolation in West Africa, the possibility of him having left the continent for the first time in Earth's history is an actual reality this time. 

And we are not prepared for him.