UNLOCK 2.0 — Lessons for India
The existential philosopher Søren Kierkegaard said, “Life can only be understood backwards, but it must be lived forwards”. So this information while important to know. Is but rear view window data. Indicating path travelled and on going ambient efforts .But not metrics which sets the forward direction and path. Or windscreen view on its way to proceed to unlock
As India sets in motion steps to unwind Lockdown in its many versions (five in all). And charts a path to fully Unlock, hopefully with fewer versions. And more clarity and precision.
A few pointers are in order as to what semblance such an UNLOCK dashboard should look like, and what measures taken to wind down from the few months of Lockdown.
Once again metrics such as Total Positive Rates (TPR), Infection Fatality Rate (IFR), number of antigen /RT PCR tests, numbers of antibody (sero) tests, Contact Tracing nos (CT), house to house surveillance nos, swabs taken, patients screened,case loads, recovery rate, etc should not muddy the waters.
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The first step is in (1) establishing the right metrics. And (2) the criteria ( threshold) value against each metric to determine whether it satisfies the condition for graded Unlock or Gating criteria
And (3) to keep this simple, and as an objective , something which can be updated everyday transparently on to website for public consumption. Like Dharavi where public knowledge about it’s war on Covid was readily available and shareable by BMC at all times. And Delhi’s belatedly realisation on need for transparency in data as a means to be on top.of the virus and create trust in public authorities.
𝗠𝗲𝘁𝗿𝗶𝗰 #1—Decline in Total Hospitalizations. The Ward/Zone/District/Municipal Limit must show a decline in the seven-day smoothed curve of total net hospitalizations (defined as the total number of people in the hospital on a given day) over the course of a 21 day period. . Alternatively, if daily net increase in total hospitalizations (measured on a 7-day smoothed curve basis) does not exceed a certain pre set number say X.
𝗠𝗲𝘁𝗿𝗶𝗰 #2. Decline in Deaths. Though Mumbai shows doubling rate going up (now around 90). It’s fatality rate is still ~5.75% above the National (2%) & State levels (3.7- 3.85%). This must show a sustained decline in the 5/7-day smoothed curve of daily hospital deaths over the course of a 14/21-day period. Alternatively, the region can satisfy this metric if the seven-day smoothed curve of daily new hospital deaths does not exceed a number say Y.
𝗠𝗲𝘁𝗿𝗶𝗰 #3 New Hospitalizations. The Area must experience fewer than new hospitalizations per million population, measured on a seven-day smoothed curve basis. New hospitalizations include both new admissions and prior admissions subsequently confirmed as positive COVID cases.d
[Since there is day to day variability in data. It is better to apply the statistical method of cubic spline or “ smoothed curve “ instead of the traditional rolling average ]
𝗠𝗲𝘁𝗿𝗶𝗰#4 Hospital Bed Capacity. Area must have at least 20% of their hospital beds available. So, if Mumbai has say about ~16,000 beds earmarked for critical+less severe (DCHC & DCH) covid cases. Then 3200 beds should be available at any point of time. Delhi has a unique “problem of plenty” in that they have 13,348 hospital beds at present, of which 6,259 are occupied and 7,089 are vacant. Even as it’s health care system is under severe stress. It’s more a lack of a proper market or adminstrative clearing system. Due to assyemtric information.
𝗠𝗲𝘁𝗿𝗶𝗰#5—ICU+Ventilator Bed Capacity. An area should have at least 10% of beds available. So if Mumbai has about ~1700 ICU beds. Then 170 should be spare. And if they have ~1000 ventilators, then 100 should be free. It seems there are now a surplus of ventilators in Mumbai. On the other hand ironically Delhi has 708 have ventilators of which 460 are occupied and 248 are vacant. Even if it’s health care system is under severe stress.
[One can also choose to use a 5 -day smoothed curve over a 14 (5–14) day period. With 14th day incidence being less than 1st day. But I have chosen the 7–21 format, as one finds a discerning secular trend line on a longer time period. As to the pre set ‘ X’ number that has to be set by Municipality based on what has been the trend from beginning till now ]
𝗠𝗲𝘁𝗿𝗶𝗰 #6 — It’s a well known saying in Public Health circles that “Beds don’t cure patients. Doctor’s and Nurses do”. It is absolutely critical to therefore track at any point the number of doctors, nurses, ward boys/ class IV workers on- duty. And ratio of such frontline health care workers (HCW) to beds. Deaths on account of lack of staff between 1 a.m — 5 a.m near Oxygen beds is a key factor in cause of death in a hospital. Even when beds are readily available the admission is delayed leading to death like in Mumbai recently. On account of staffing shortage. Bangalore is in a somewhat similar rock and hard place. Surplus of beds. But no doctors. Telengana on the other hand has the opposite. No beds. A higher ratio would obviously speak well. And lead to lower fatality rate. This is not just only a comfort metric. But is a critical indicator of the overall coping capacity of the healthcare system. And needs to be immediately Dashboarded.
So where is Mumbai on these metrics?
The overall bed capacity at the time of this writing across all categories in Mumbai (DCHC, DCH & CCC, CCC-2) is probably 18,000.
But the key metric — Metric #5, is track the critical and less severe capacity. Which in the case of Mumbai is around ~ 9500. Because this determines the fatality rate. And the idea is to ensure that the fatality rate keeps declining. And Deaths Per Million (DPM) for Mumbai (265) comes to the 9 city urban agglomeration average (79) or below. Though total cases may well be increasing.
[Hopefully by then, at a decreasing rate]
Going by the above metrics. Mumbai (not MMR) is on the margin of technical cut off criteria to Unlock. Nearly there. Though the situation shows improvement across some wards. The overall ICU beds occupancy situation is is ~87 % across the board. With O2 beds at 44 % availability. [It’s worthwhile to note that New York City at similar point of its UnPause had 30–40% spare bed capacity, much above their p͟r͟e͟ s͟e͟t͟ threshold of 30%, with ICU beds at between 41–56% available capacity. While on the opposite spectrum Miami is operating at 119% of its capacity!]
Be that as it may.
So, how should one approach UNLOCK 2.0 — Lives Vs Livelihood
Firstly, demarcate the high infection and low infection wards or PIN codes. Whichever provides for seamless physical contiguity and ease of definition & administration. For e.g Mumbai has around 24 wards, with 9 of them in the acute range of positive cases (>4000). With 8 of them in the high range (> 3000 cases). And rest < 3000. One can figure out if these areas are primarily ‘Business’ or ‘Residential’. Or, number of buildings under containment orders in each ward/zone. And if low residential-high business. Then ‘Businesses’ stays open. If Low -Low, then open, if High -High then probably closed. High residential- low business. Closed.
Alternatively, look at doubling rates of each ward. Anything over 90 > should be fully opened. With no fine print. Or, wards with rolling growth rate of cases for last 7 days of <0.9%.
So on and so forth.
(2) allow green- to- green zone inter and intra travel travel bubbles by all means. Incl point to point trains and metros. Without stopping in intermediate yellow or red zone stations. And without administrative fencing of trips beyond a certain radii of residence. Or daily medley of new directives which basically just creates more chaos and incertitude amongst the public.
(3) Identify the sub category of high risk retail businesses and low risk ones in each zone/ward. And allow the low risk categort businesses to be open regardless of whether they are deemed as essential or not.
E.g beauty, barber, nail spas and gyms are hi risk...as too are coffee shops, bars during peak hours. While Fine dining is relatively low and can be proscribed by the physical layout & bookings. Though buffets would be high risk. As too well could be doctors, physiotherapists, dentists clinics, chemists, specially post Lockdown!
Urban planners can best help in zoning and gating based on footfall, density and contact proximity nature of flow of activities & duration. One can then allow them to be open or closed, without defining whether they are essential or non essentials. Timings, odd-even day opening are other aspects to maximise social distancing which can be tinkered with to allow for maximum optimality in m͟a͟i͟n͟t͟a͟i͟n͟i͟n͟g͟ b͟a͟l͟a͟n͟c͟e͟ between urgency of economic livelihood and criticality of public health.
(4) And finally incentivise good behaviour. Not penalise alone. The first de jure measure for mandarins is “penalty & punishment”. Or what I have begun to call as the “ danda ka funda". This alone does not work. Indians have advanced and God given degrees in gaming the system. So best is to penalise, but also reward desired behaviour. If I was mandarin. Would call in e.commerce and new age loyalty cos to quickly design flurry of incentives around good behaviour. With high visibility recognition. Same was done during demonetization, GST, past Income tax filings, or unaccounted wealth/income, bank deposits, amnesty schemes, immunization programs programs, school delinquency, etc.
Cant see why it can’t be done now.
