Breathless

 Yesterday was a day of desperate messages on our neighbourhood e-group:

13:50: "Does anybody know where oxygen cylinders can be purchased right now? "

19:02: "Mr. B needs a ventilator immediately...his hospital does not have one to spare.."

01:14: "Very, very sorry to inform you that Mr. B is no more..."

The same tragic sequence of events is being played out in thousands of places across the country now. As the "Second Wave" of Covid-19 infections sweeps across India a major crisis of medical supply-chain inefficiencies has hit India. There has been such a sharp spike in Covid cases that 54.5% of patients during second wave required supplemental oxygen during treatment - a 13.4% increase from the peak during September and November 2020.

The irony of the situation is that there is no shortage of O2 production in the country - India has a total production capacity of more than 100,000 tons/day (7,100 tpd of medical O2 as per HT), of which over 80% goes for steel-making. According to HL Meghnani, an industry veteran, industrial O2 has to be 99.5% pure while medical O2 needs to be only 93% pure, and less than 1% of O2 produced is used for medical purposes. Yet the scale of crisis currently unfolding is mind-boggling.

India's clinical management protocol recommends oxygen therapy as the primary form of treatment: the target is to achieve 92-96% SpO2, or 88-92% in patients with COPD. While proportion of those requiring oxygen beds is still hovering around under 10%, this number is at an all time high with India's active caseload crossing 26 lakh (2.6 million). The demand for medical oxygen has increased by 18% over the last 6 days across 12 states which account for 83% of India's active cases.

Where did we go wrong? What will it take to bring this situation under control? 

One of the points made by Meghnani brings out the nature of the complexities involved rather nicely - "The current crisis arises because of a shortage of road tankers, storage tanks and cylinders... each tanker costs INR 4.5 million and a cylinder costs INR 10,000 in which you sell O2 worth just INR 300" (!) Add to this the location of the O2 plants -  mostly in Western  and Eastern India -  and the decision taken by major hospitals to outsource O2 supply instead of having captive plants, and you begin to understand why the supply-chains collapsed last week.

We are now in the process of rushing in extra cryogenic O2 tankers from abroad, and penalising those who have been profiteering during this crisis by hoarding O2, and driving up the prices.

What remains unclear is a more granular picture of O2 demand and consumption in our hospitals. How many O2 tankers are needed every day to service all the hospitals in our cities and towns? Can some of the shortage be handled by portable O2 concentrators? 

------------------------------------------------------------

REFERENCES & LINKS

* 28Apr21 - Gurumurthy S, New Indian Express - Missing Facts, Misdirected Course - https://www.hindustantimes.com/india-news/why-india-is-facing-an-oxygen-crisis-as-covid-19-cases-mount-101619268862048.html

* 25Apr21 IEexplained - What changed in the second wave? - https://indianexpress.com/article/explained/explained-whats-changed-in-second-wave-7289002/

* 25Apr21 IESunday - Falling Short O2 - https://indianexpress.com/article/opinion/editorials/nirmala-sitharaman-economic-package-migrant-workers-one-nation-one-ration-card-coronavirus-6410303/

* 24Apr21 - HT - Why India is facing an oxygen crisis - https://www.hindustantimes.com/india-news/why-india-is-facing-an-oxygen-crisis-as-covid-19-cases-mount-101619268862048.html

Life in the Altiplanos

 

This is a book unlike any I have read so far - simple, direct, brutal. 

It lends voice to many who were never heard before - the vanquished, the defeated, enslaved, and colonised; those who try to articulate themselves in the languages of their conquerors. The author won the Nobel Peace Prize of 1992, and being unlettered, dictated her life's story to Elizabeth Burgos who, in turn, edited and transcribed it as a first person account.

The book narrates a type of exploitation that has many facets, many layers. You can see within it glimpses of the caste system that was the hallmark of India's social structure for centuries,  the maoist movement which plagues parts of eastern-central India, all the way to the way we engage with our own domestic servants everyday.

Rigoberta Menchú is a Mayan from el Quiché province of Guatemala. When the Spanish conquered and colonised the Mayans a few centuries ago, hers is one of the numerous communities that were driven into the remote forests - the altiplanos. Descendants of the conquistadors now come in the form of white  or ladino landlords who try to push them off their land, further and further into the forests. 

Life is tough, food is scarce. So entire families end up as migrant labourers, working in the finca's along the coast, plucking coffee, harvesting sugarcane. Young girls are forced to work as servants in the cities, getting paid a pittance, being treated worse than dogs, and getting fired for refusing to 'initiate' their master's son's into sex... many end up as prostitutes. Those trying to seek justice are hounded, tortured and killed. Judges are bribed to ensure that protesters rot in jail. 

While reading Rigoberta's account you wonder how many millions more have suffered such horrors and privations. One of her brother's died of starvation, another was publicly tortured and burnt alive; her father was among the 38 who were burned to death during peasant uprising of 1980 and the consequent  burning of the Spanish embassy in Guatemala city. 

I saw in Rigoberta's stories the face of ShimaPolayan. A short, dark, muscular man who used to stay on my grandfather's land with his family, and labour in the paddy fields and estates. Perhaps his ancestors owned the area before it was forcibly taken over by newcomers who perhaps saw themselves as more civilised and entitled. Over the centuries, these people lost the confidence to fend for themselves and instead ended up at the bottom of the social pyramid, living in huts with their families and serving the 'upper castes' all their lives. 

ShimaPolayan lived in Southern Kerala and died maybe forty years ago, but during his lifetime he saw his children growing up in a more equitable world - going to school, learning the power of voting rights, and discovering that there was a better world beyond the endless toil in paddy fields.

Perhaps during his lifetime he realised that those whom he served were also slaves of a colonial power. That they may have spoken English with the correct accent, fought their master's bloody wars in lands far afield as Mesopotamia and the Flanders, and had conditioned themselves to believe that they were inferior to the white man.

The old pecking order of white-man, brown-man and black-man began crumbing after India became independent. Thanks to high literacy and democratic norms the ShimaPolayan's of the Kerala disappeared decades ago. 

On the opposite site of the world in South America the struggle still continues. How many more will it be before Rigoberta's people get back their land, and rebuild their communities?

----------------------------------------

REFERENCES & LINKS

* Wiki - https://en.wikipedia.org/wiki/Rigoberta_Mench%C3%BA 

* I, Rigoberta Menchu - Nobel laureate, 1992 - https://www.nobelprize.org/prizes/peace/1992/tum/facts/

R-Value and it's Covid Travails

SARS-Cov-2 aka Covid-19, the virus behind the current pandemic continues to be a nightmare for everybody - especially for statisticians. 

It was bad enough to have the Chinese obfuscating the truth about the original 'Wuhan virus' last year, but now we have a range of mutants (and double-mutants) that seem to be spreading in ways that are difficult to predict. This is is making the work of those who prepare statistical models much more difficult, and this in turn is affecting the quality of decisions being taken by policymakers.

Take for instance, the reproductive-value or R-Value for Covid-19. R is the number of people that one infected person will pass on a virus. 

The lowest possible R-Value is R-naught or R0. Also referred to as the Basic Reproduction Number, it is the R-value of a population that is assumed to have zero immunity against a new infection. R0 is the division of the number of new infections by the number of existing infections, or the average number of new infections over an infectious period (R0= new infections/existing infections).

Measles has an R number of 15 in populations without immunity. It means that, on average, every 10 people with Measles will infect 15 other people. For Covid-19, the latest R-value estimate for India, is around 1.30. This number is showing wide variations across states with Uttar Pradesh recording the highest infection value at 1.62, followed by Andhra Pradesh at 1.61.

The problem with the R-Value is that it gives us a picture of the past - by the time you calculate it, the number is already outdated. This is because it is based on data recorded on hospitalisations and death figures to get a sense of how many people have the virus – but the problem with this is that, since the virus’s incubation period is so long, it only gives an accurate picture of a few weeks ago.

Add to this the complications coming from recent mutations of the virus in different parts of the world, each with its own incubation period - the "UK" B.1.1.7; the "South Africa" B.1.351; "Brazil" P1, "India" variants B.1.36 (Bangalore) / B.1.1.7 (Punjab) and B.1.617 which contains two specific mutations - E484Q and L452R which is capable of 'immune escape', and infecting those who have already been vaccinated. 

Add to all this other newer emerging variants of concern (VoCs) and we have all ingredients for a statisticians' perfect nightmare. 

---------------------------------------------

LINKS & REFERENCES

* https://www.bbc.com/news/health-52473523

* https://theprint.in/health/indias-covid-r-value-increases-to-1-30-this-week-the-highest-since-april-2020/633783/

* https://www.weforum.org/agenda/2020/05/covid-19-what-is-the-r-number/

* https://www.statista.com/statistics/1101713/india-covid-19-cases-by-type/

* R0 Explained - https://indianexpress.com/article/explained/coronavirus-r0-reproduction-number-explained-6354339/

Across the Waters

 The Suez was in the news last month. A single, massive ship passing through the canal got blown by the winds and ended up getting wedged across the canal, blocking traffic for a week. During this period it effectively blocked the passage of about 400 ships and prevented an estimated USD 9.6 billion worth of trade!

How did we end up getting so completely dependent on the Suez and Panama canals? What is it that drives us to make bigger and bigger ships that need wider, deeper shipping docks and canals that cut across continents? The simple and obvious answer is global trade, and the economy of scales that drive it. If simple answers do not satisfy you, the book you need to read is David Abulafia's "The Boundless Sea".

This book is a serious piece of work - over 800 pages of which nearly half is references and citations! And yet, it is eminently readable, especially in the e-book format where the act of picking up a book of this size does not remind you of visits to the gym :)

The book covers a wide canvas. Starting from the oldest records of those who ventured out to explore the seas and oceans, all the way to the obsessive search for trading opportunities and power-play between countries that marks our relations with the not-so-boundless seas today.

I particularly enjoyed reading the sections on Polynesian navigators and explorers, trade during the Harappan period; the spread of Buddhism by sea; the Cholas, and the spread of Omanis deep into southern coasts of Africa. Towards the end, details of the arrival of the Europeans on the scene, and their depredations in Africa, the Americas and Asia makes for depressing reading. 

At the end one has to admit that if it were not for the bloody competition between the European powers that completely transformed the world through slave-trading and migrations, the world would have been a completely different place. 

-------------------------------------------------

LINKS & REFERENCES

* 2021 Suez Obstruction - https://en.wikipedia.org/wiki/2021_Suez_Canal_obstruction

* 

Covid Shielded

The lady who helps us with the housework is from a remote coastal village in West Bengal. Yesterday she got a call from her parents and the news was that they were both suffering from fever. A few thousand kilometres away, near the capital city, we too were afflicted by the same symptoms - the expected after-effects of a vaccination national drive against Covid-19. 

We were among the four million+ people who got vaccinated in India today. While the fever and the dull pain of an intramuscular injection abates, it is quite amazing to think of superlative effort that has gone into creating, testing and delivering these vaccines all over the world.

The vaccination program started its rollout in India couple of months ago. First for those over 65 years of age, and for those who were vulnerable due to 'co-morbidities'. At first people were wary, and senior citizens had to be coaxed and cajoled to the vaccination centres. This changed on 1 April 2021 when the government decided to expand the coverage to those over 45 years of age.

The sheer scale of this effort does not hit you until you participate in it. It is a four step process is driven by information technology in which each dose can be traced back to a specific vial at a specific vaccination centre:

(1) Registration at CoWIN site - a single phone can be used to make four bookings at either government 

(2) Selecting a vaccination centre - Based on your postal PIN code you can opt for either the nearest government centres (free of charge) or private hospitals / clinics (fixed at INR 250) 

(3) Vaccination - At the hospitals a queuing system ensures that people maintain social distance. Each vaccine station has three staff  - two for writing out the registration details, one  for preparing the vaccination card, one for checking the CoWIN id, uploading the confirmations online, and a nurse who administers the vaccine. The whole process takes about 8 minutes. After the jabs people are expected to wait for 30 minutes of observation before returning home. 

(4) Certificate - within a few minutes of getting vaccinated an SMS message leads you to an online certificate (PDF) which can be used as proof while travelling.

(4) Follow-up - each vaccinated person is given a card which specifies the vaccine type (Covidshield / Covaxin), the date for the second dose (min. 28 days), emergency helpline numbers and a list of five possible after effects (mild fever, pain and swelling, etc.,)

One thing I have learnt along the way is that the government machinery seems to be far more efficient than the private sector. In my immediate neighbourhood all the hospitals were booked until 14 April, so I expanded the generic Noida PIN code and booked two slots on 1 April at Metro Hospital from a list of about 10 hospitals. 

However my experience at Metro Hospital left me quite disappointed. It is a large hospital in Sector-11 Noida. When I found my way to the entrance the staff seemed paralysed by chaos - there were over a 100 angry, impatient people already crowding inside, with the guards telling the newcomers that they would need to wait for three hours!

I went back to the CoWIN site and got my appointment rescheduled to the  next day at the District Combined Hospital, a government facility in Sector 30. Over here the whole process was a breeze. There was ample parking outside; masks, hand sanitisers and social distancing was compulsory; tokens were being distributed at the main gate and security guards were systematically guiding people through waiting halls while giving priority to the elderly and infirm.

Millions of tiny vials from Oxford-AstraZeneca / Serum Institute of India, Sputnik and J&J have now set out to deal with a virus from China that had the world paralysed for more than a year. Hope is in the air, and in our blood streams.

-----------------------------------------------------

LINKS & REFERENCES:

https://www.livemint.com/news/india/covid19-vaccination-over-36-lakh-people-get-the-jab-on-april-1-the-highest-so-far-11617335903675.html

https://www.bbc.com/news/world-asia-india-55748124 - Covishield and Covaxin: What we know about India's Covid-19 vaccines

On the remarkable role being played by Co-WIN and its developers (19 April 2020, Indian Express) - https://indianexpress.com/article/india/co-win-platform-coromnavirus-vaccine-india-modi-govt-7279432/