The Bhutanese Leading the way.
There is a growing voice especially on social media to do away with lockdowns and other restrictions, like for travel, with the main argument being that Omicron is ‘mild’ and there is a greater damage from lockdowns and restrictions than the virus.
So with elections in a year’s time and growing pressure if the government hypothetically lifted all lockdowns and restrictions what would happen happen on the ground is the question of our time.
Mass infection
Health Minister Dasho Dechen Wangmo said that based on their detailed projections based on experience with the past three outbreaks, vaccination status and other factors they have estimated a very conservative 5 % infection rate.
This would mean that tomorrow if all restrictions were removed then 29,573 more Bhutanese would be infected. This is compared to the 10,078 total infections since March 2020 or around the 7,000 cases in the latest outbreak.
Lyonpo said at this rate this would mean 143 cases requiring hospitalization, 10 Intensive unit Care cases and 8 more deaths.
“People are getting very shocked with 260 community cases in Wangdue reported on 16 February but once the restrictions are lifted there will be thousands of cases every day,” said Lyonpo.
Lyonpo said that this is a very conservative figure and the actual rate of infection could go up to 15 % or even higher which would mean 88,500 infected Bhutanese, 715 hospitalized and 24 more deaths.
Health System Collapse
The minister said that even at a 5% infection rate Bhutan’s entire health system would collapse and the death and sickness rate of non COVID-19 patients would also increase as they would not be able to access medical services or health professionals.
Lyonpo said that in a case of mass spread of the virus it would be impossible to keep it out of hospitals like JDWNRH, Mongar Referral Hospital, Gelephu Referral Hospital, Phuentsholing Hospital and others.
She said the virus would sweep through the wards where already vulnerable people are kept and once people with comorbidities are infected then the death rates would be even higher than those projected above. She said the six deaths so far have all been from the comorbid.
She said the virus would also sweep through the children’s ward where there are sick and unvaccinated children and that would also lead to deaths.
She said the virus would also sweep through doctors and health staff which means they would not be available which would further increase the death rates of both COVID and non-COVID patients.
The JDWNRH is currently treating around 200 cancer patients and there is only Onco Surgeon for them in the country. “Imagine what will happen if he gets COVID severely,” said the minister.
She said that similarly there a large number of critical patients suffering various ailments depending on only one or two specialists and if they fall sick then the patients would be in trouble.
Lyonpo said that people only think of COVID-19 but she said they need to remember that widespread COVID will affect all other health services from treating the common flu to cancer.
“Imagine the strain on the health human resource. If they get infected they cannot work and there will be service disruption,” said Lyonpo.
The Technical Advisory Team (TAG) said prolonged COVID spread will keep healthcare providers engaged in COVID containment measures. This will hamper essential health service delivery like immunization program, reproductive health and other public health services.
“As a result, children may die from vaccine preventable diseases and the adult population will be suffering from medical conditions,” said TAG.
COVID patients are classified as asymptomatic or mild and they are kept in isolation units in hotels, the severe cases are hospitalized and kept in isolation units in the hospital and the critical ones are kept in the ICU.
Bhutan has a total of 547 isolation beds in hospitals and 45 ICU beds with ventilators.
Lyonpo said that the easiest thing to do is to put in beds and equipment but she said that the main challenge for Bhutan is limited medical manpower.
She said in addition to the 45 ICU beds for COVID patients there are 38 regular ICU beds and the only problem is that there is only one ICU specialist to look after all this.
“When we look at the impact of the pandemic on the health system the first issue is health human resources. Even before the pandemic we were already 50% below the minimum doctor to patient ratio. We can count our specialists on our finger tips with 122 specialists, 142 general doctors which means a total of 262 doctors for the whole country,” said Lyonpo.
JDWNRH has deployed a team of 30 specialists, doctors and health staff to support the health staff in the badly affected districts. This also means that these doctors and health staff are not in JDWNRH to provide services.
Lyonpo said that one of the main reasons that Bhutan cannot ‘live with COVID’ is because unlike other bigger and richer countries it does not have the option of several government and private hospitals and large medical manpower that can be used if some hospitals get infected.
Phuentsholing has been the worst hit area in terms of COVID spread with around 2,200 cases as of Sunday.
Lyonpo said the health team down there are exhausted providing not only COVID related services but also regular medical services. “But when I talked to them they said they will do it and can do it,” said Lyonpo.
Omicron not like flu
There is a growing perception that Omicron is like a ‘flu or a cold,’ but this is not the case on the ground in Bhutan.
Lyonpo said that demographically Bhutan is a young country and there is a high vaccination rate and so far that has worked in Bhutan’s favour, but she said that despite this the Omicron cannot be compared to the flu and is more deadly.
She said there are people who are asymptomatic or have only mild symptoms, but there are also people who suffer from stronger symptoms despite the vaccines.
She gave the example of a male health worker who tested positive and despite the booster dose he over the phone informed Lyonpo that Omicron is not mild at all and he was getting severe joint pains.
Lyonpo said that there was a total of 7 cases requiring Oxygen support.
The TAG team said that while they have not seen as many severe cases as would be expected with previous variants, but people should not get the idea that this disease is not severe.
Of the 7 that required Oxygen and continuous monitoring 4 were elderly at 84, 85, 90 and 99 years. One from Mongar has been discharged, one is in Gelephu, two are in RIGSS.
One 21-year-old with underlying medical conditions was managed in RIGSS and is now referred to JDWNRH for specialist care.
There is a 103-year-old lady from Samtse with underlying medical conditions being monitored closely.
Of the two on Oxygen is a 60-year-old female with hypertension and heart failure from Samdrupcholing referred to Mongar and a 47-year-old male who is a case of end stage renal disease on dialysis at RIGSS passed away on Sunday.
Lyonpo said that Omicron is not only more transmissible than flu but it is also more deadly.
She also said that while there is a lot of data on the influenza virus and how it will behave there is still very little known about Omicron.
The minister said that so far while COVID deaths have been with COVID there is literature to show how COVID worsens the condition of comorbid people with various kinds of ailments.
Despite Omicron being prevalent, the combination of vaccine hesitancy, refusal to follow COVID protocols and lack of measures by authorities lead to more Americans dying of COVID-19 in the last two weeks of January 2022 than 3 years of flu deaths.
COVID and children
There is also a growing perception that children will not be affected much by COVID-19, including in the unvaccinated ones below 12.
Lyonpo said that there is very limited data on children, and it is only in this outbreak that large numbers of children below 12 are getting infected. She said that as of friday 745 children below 12 have been infected and of this figure 292 children are in the 0-5 age group.
She said while there is limited literature in children studies from the UK and USA are showing the presence of long COVID in children. She said in the long term she both professionally as a minister and personally as a mother cannot take a risk in letting the virus run through the children only to discover later long term health consequences.
The TAG said that if more and more children get infected, we will see higher risk of children with severe disease.
Lyonpo said that 130,000 children are not vaccinated and thus they remain at a risk of severe illness.
TAG said that there are increasing evidences of long COVID in children including them being prone to other ailments in the future like heart ailments.
TAG said the disease should not be assumed to not be severe for children.
Lyonpo pointed out that JDWNRH only has 12 pediatric doctors of which there are only 7 in the hospital has five of them have been deployed in Wangdue and the southern Dzongkhags due to the high numbers of children getting infected there.
The international examples and advice
A lot of people and countries have pointed to Denmark which starting from February 2022 is one of the first countries in the world to remove all restrictions with an aim to live with the virus.
However, Denmark despite having an overall vaccination rate of 82 percent has seen a high surge in cases, hospitalization and deaths. Experts within Denmark themselves acknowledge they do not know what will happen when the virus spreads more in the older and vulnerable population and the impacts of long COVID.
The Health Minister said that under the guidance of His Majesty, Bhutan has taken a very conservative approach to dealing with COVID-19 for three reasons.
The first is that in a nation of around 700,000 people, it cannot afford to experiment with its approach. She said that given the social networks in Bhutan even a few deaths would plunge the nation into national remorse.
She said that given the size of the country it can observe and learn from others by taking its own time and under the guidance of His Majesty come up with a very homegrown and indigenous approach to dealing with the virus that is good for Bhutan.
Secondly, the minister said that it is not known what kind of mutations will happen to the virus and how it will behave.
Thirdly she said that Bhutan does not have the medical infrastructure of countries like Denmark or others to manage a large number of infections and cases.
Lyonpo pointed out that the WHO advice is still saying that it is too early for relaxations as the pandemic is not over, and the aim should be to contain the spread of the virus.
Apart from Omicron killing and making people sick, Lyonpo said a key concern for WHO is the mass spread of Omicron will give it the perfect breeding ground for the next variant and such a variant could bypass vaccines and it may not even be detectable with the current test kits.
Lyonpo said that while it is in the interest of the virus to mutate to become less virulent and more transmissible it is too early to say that this is the final stage of the virus.
The other dangers of taking COVID lightly
Internationally there has been some research on long COVID. A 2021 study by Oxford University found that 1 in 3 people who recovered from COVID-19 are getting long COVID while a 2022 Center for Disease Control Study (CDC) finds that 1 in 10 people are getting long COVID.
In the absence of any long COVID study in Bhutan this paper in January 2021 interviewed 7 mainly young and middle aged Bhutanese who recovered and found that five of them are still suffering from long COVID months and even a year after testing negative.
The long COVID was in the form of the sense of taste and smell not working properly, fatigue, difficulty breathing, brain fog, memory issues and anxiety. At the time of the second outbreak even for people who were asymptomatic their multiple inflammation markers were very high and 25 percent of all lung X-rays showed the lungs developing pneumonia like conditions.
The WHO itself recognizes long COVID and lists multiple body organs and systems that can be impacted by it and says it may also increase the risk of long-term health problems.
The health minister said that while the ministry has not done a long COVID study in Bhutan, the anecdotal reports indicate that recovered patients are suffering from long COVID in the form of chest tightness, joint pains and people generally not feeling well.
In India, until recently, around 20 percent of COVID-19 cases were found to be the Delta variant and these were found to be driving deaths and hospitalization cases.
Given how Bhutan’s cases are imported from India the Health Minister said that delta cases coming in undetected also cannot be ruled out though the gene sequencing so far in the latest outbreak has only detected Omicron.
Here too there is a word of caution as the health minister said the Omicron variant sub-lineage detected in Bhutan is BA.2 which is the most infectious of the Omicron sub-lineages.
While people are starting to take COVID-19 lightly this has been enabled mainly due to the high vaccine coverage which has prevented mass deaths and sickness and also the various measures by Bhutan like sealing border, mandatory quarantine and lockdowns.
Compared to Bhutan’s 6 deaths for 756,129 people, Peru has had 6,417 deaths per million of its population, Bulgaria had 4,985 deaths per million, UK had 2,386 deaths per million, USA had 2,386 per million.
Even in Bhutan’s neighbourhood, where deaths are thought to be vastly undercounted due to a poor reporting system Sri Lanka reported 729 deaths per million, Nepal saw 416 deaths per million and India saw 373 deaths per million.
There is no telling what will happen if the vaccine protection wanes without booster doses, and if all controls are taken away or if the restrictions are removed and a new virulent strain finds its way into Bhutan and goes after 130,000 unvaccinated children, the 90,000 vulnerable with comorbidities and the 56,000 senior citizens above the age of 65.
Lyonpo said that Bhutan must work to protect the above as every home would have a child or parent.
