[Music]
it was the last week of january 2020 and
i was attending the annual conference of
intensive care society
it's a conglomeration of more than 4 000
intensives across the world
we deliberate over scientific research
and clinical aspects of intensive care
management
new ideas are discussed problems faced
around the world are brought forward for
solutions
and of course we meet and meet friends
and colleagues and unwind over the three
days
of fact this academic feast one
particular aspect lingered in my
thoughts though
and that was coming from our southeast
asia colleagues they were very concerned
about this new virus from wuhan
which we all had heard of but we were
not sure how big
the problem was there was this concern
that this could take up a gigantic
proportion of a global pandemic
the thought was disturbing and frequent
to the core i but i made peace with
myself that it was not coming to my
shore so why should i worry about it
but the thought of a pandemic had
already been sown in my mind
well we came back to mumbai life
continued all through february
but by the first week of march in a
rapid turn of events
which were about to change our life came
the first realization
that a pandemic of never seen
proportions was going to hit us
there was a flurry of activity by the
government suddenly i was attending
these high powered meetings with
government officials
and epidemiology sales doctors we were
looking at strategies to tackle the
solution
in one of the initial meetings it dawned
upon me that the entire focus of this
virus and the devastating harm it was
causing
was going to be fought in the intensive
care and the high dependency units of
the hospital
icu and the people working in it we are
going to witness a new form of battle
which we had never seen or prepared for
listening to the doctors from china
reading the scientific material
social media post etc i realized that
there was a reason why i was invited for
these high-powered meetings
because even though we were a large
society there were only handful of us
who were senior clinicians who were
practicing intensive care solely
and we were going to play a major role
in this pandemic i decided for myself
that even this adversaries i was going
to look at
this as the once in a lifetime
opportunity to work in a pandemic
mind you the last one was 100 years ago
i started to prepare it
with my chin up as any other attitude to
carry
would have meant that i am going to let
the fear go better of me and stop me
from doing my duties as an intensivist
in honest truth even the financial
capital of the country mumbai had only
one infectious disease hospital and that
too in the government set up
most of us when we thought of infectious
disease thought of tuberculosis
which was endemic in our country and in
recent times h1n1
both of them we had come to terms with
their health scale professionals
and truly speaking did not pose a big
challenge to us or to the hospital
infrastructure
but this kovid 19 yes it had a new name
now
was a completely different beast to deal
with we were thinking that it was going
to be naive
to believe that even a soul one id
hospital would be able to deal with the
patient load
hence all public and private hospitals
who have been prepared
to deal with this patient screen them
and win them treat them
the process began the process began by
experts coming in for inspections to the
hospital
and no surprises found a facility to be
completely inadequate to deal with this
highly infectious virus
my hospital was no different we had to
form a quick action
team which basically started
brainstorming it
involved carving the new hospital within
the available infrastructure of the
hospital
separate entrances corridors segregation
of patients
people common areas to be used like i
like
ct scan mri everything needed to be
charted
and while all this was been done our
biggest challenge was to find manpower
to work in the pandemic
train them for personal protective
strategies and policies
motivate them to work ease their fears
and then realize
that just by wearing a pp suit their
efficiency dropped down by 20 to 30
percent
there was a lot of confusion fear and
trepidation amongst healthcare workers
many refused to work some of them have
some of them had genuine
some had lame excuses tried to escape
work it was a challenge to ally their
fears make them feel safe and motivate
them back to the work
it was i was supposed to travel to
australia at the same time
but because of the uncertain quarantine
and international lockdown rules
i basically stopped most importantly i
needed to be here
around the same time i got appointed a
member of the task force from
maharashtra government
it was in the recognition of my work in
intensive care and i was expected to
basically guide the state in the
critical care management aspect of the
of the pandemic which unfortunately was
the most complex one
for all of us the journey had well and
truly began
the path was uncertain and difficult
however there was one clear option that
we had to pave the road to the
destination
the destination being to see the back of
this virus which was challenging the
mankind
i personally adopted a multi-prong
approach and that was to learn
educate disseminate and learn again from
the experience
i started to interact with doctors from
china and southeast asia they were
actually seeing patients at that time
learned a lot of useful things and we
relied on the basics of icu management
which were time tested and had
established after undergoing the rigors
of clinical trial
we started educating fellow colleagues
we started disseminating knowledge
and intensive care at community at large
was relearning from each other's
experiences
the task force published his first
guidelines at the same time
and and we you know they were very well
received and i was looked upon as a
person to go in for pursuance of
any code 19 related clinical matters
our icu was soon started to be
recognized as one of the best in the
city perhaps even the state
we were looking at a lot of educational
videos and information sheets being
rolled out from our unit
the icu outcomes support for themselves
it was a unit which was not sought out
now has now been sought after
because they were sickest of the sick
patients coming in and we still had
reasonable outcomes of the patients
a lot of important political and social
personalities were treated by us
and before we knew we were actually
basking in the small success of our icu
outcomes
the press talked about it the media
talked about it webinars became the new
norm to spread and share knowledge
the information would reach thousands
within the confines of their home
though life was still at a standstill
for a common man
because of the national lockdown we as
medical professionals had in fact more
and more work to do each day
well the daily routine was never the
same it was a different challenge every
day
with increasing cases we needed to
increase capacity and we needed to find
more manpower
i was enjoying the challenge that the
pandemic had brought forward
electronic medium had become the new
norm of communication
we did icu rounds on videos we've sort
of
did it because the entire team could not
be exposed every day into the virus
we spoke and counseled the families and
family members on the phone and video
calls
and i must say they thanked us
profoundly and even in the odd mortality
they only had words of appreciation for
the efforts which we put in
it looked like the trust deficit for the
doctors which the community had
developed
for the last few years had finally been
restored back
however as the destiny has its own way
of deciding i came down with going 19
and from being a caregiver i became a
care seeker
i was admitted to the quarantine section
of my hospital
the hospital room my team members who
are putting heart and soul to look after
me the fantastic nursing staffs the
attentive hospital management
all would seem like a perfect hospital
experience for any patient
but still deep within me i was having a
turmoil
i realized in those 14 days that what a
patient would feel
there was everything in the hospital
still so much was missing
i was realized and we were basking in
the work and the glory of
our iq success but the patients lack the
human touch
and the patient's patient doctor
relationship was completely going to be
redefined
so there was no option for a ppe kit and
we were still going to have those
astronaut looking doctors come and
examine you
and even though i knew the faces behind
the mask i still felt that i was alone
in those 14 days
not to speak of my family who must have
gone through very very two tough weeks
staring at uncertainties of the disease
and latching on to the smallest positive
news
which probably made them happy that i
was recovering
well as days ago i went by i recovered
and i was back home
and within a few days back to work but
that moment of feeling alone in the
hospital linger around
and that brought a content change in me
we looked at the entire system and
overhauled the protocols to make them
patient friendly
while the barriers of personal
protective equipment were remaining
we were looking after the patients and
attention of the detail was basically
now to make patients feel as comfortable
as they can
their hobbies were nurtured icu was soon
going to be a different place
in all this illness and patience being
sick
patients were playing flutes playing
guitar drew paintings
we had regular news updates from our
doctors and nurses
and the dietitians were tailoring food
for them so that they felt better
these were small things which were
making a difference however
we needed to be done we also
simultaneously work towards community
awareness
regular facebook lives public awareness
speeches
addressing their fears comforting them
and most importantly providing them
correct information
they were conducted by me and some of my
like-minded friends
every week in hindi english and regional
languages
it made a small difference in our life
thinking that somebody may be benefiting
from what we were talking and what we
were doing
there was so much more to do soon the
academicians across the country public
figures politicians
doctors hospitals all helped in this
initiative
somewhere with us and some were doing
their own bit so the country was
witnessing a
different way in which they were seeking
information instead of the standard
and whatsapp forwards they were now
having several platforms to seek correct
and scientific information
as days and weeks passed by we started
to know the disease well
epidemiologists at the same time were
striving hard to control the spread of
the disease and policies were
being read after the constant change
from an outsider's point of view it must
have looked like a chaos but trust me
there was a method to this process
and as we got better the process and the
results started to show up for
themselves
many people started to predict how the
how the virus would basically behave
and what part path it would take up some
would say that it would decline in 100
days some would say it would be
different
most got it wrong some may have probably
got it right as well but the truth is
that every pandemic wave decreases
it follows a different trend across the
world while in some european and
american continent it may peak in winter
in india it decided to peak in monsoon
and by the towards the end of the season
by around september end
stages started decreasing finally the
life was looking bright again
it felt like sunshine the economy was
moving
the bazaar gurus in the share market
must be finding it very very
good for them that the share market was
going up
and for a common man though it was back
to work and support the family
it often amazes me that the countrymen
we have a lot of resilience
and as a whole country we try to stand
up in in despite all the adversities
that we face all the time
there were smiles on people's faces
while some families may have lost their
loved ones
it was basically still trying to put up
a put up a brave face
by hiding those memories in the deep
corner of their heart
authorities were happy people were happy
soon diwali came through
festivities came through there was this
wedding season which started up and
almost
everybody wanted to forget that a virus
called corona even existed
in midst of all of this the scientists
of our country and world were working
very hard to create a vaccine
they knew that the only effective way to
deal with was to vaccinate people
and this was learned from the history
from the smallpox and the polio viruses
and many more
we were all looking for the wildfire
forward for the vaccine announcement
and when it came through it looked like
there was going to be some solution for
this difficult problem
we as medical frontline professionals
felt as if a safety armor was
formally going to be surrounding us and
protecting us
and because the patient was still coming
and we still needed to work in icus
i sensed a small twinkle in my mother's
and wife's eyes
as the indian vaccination program kicked
off they must have thought that at least
some protection for me now
well as a healthcare professional i was
fortunate to be one of the first ones to
be vaccinated
all news channels and papers carried
vaccination drive in an extremely
positive way
and indeed would be 2020 had started on
a positive note
the big step forward however quickly
turned
into a into a hesitation as a news a few
complications from vaccine came through
and all along the vaccine and the
problem which we were trying to deal
with
was now basically to deal with the
vaccine hesitancy a new terminology for
me
a large part of our time was felt now
was spent now in dispelling these
doubts in the people's mind be it at
work media platform social media
whatever it was
after all it's very difficult to
understand what human mind thinks
and when we started to to sort of try
and change the thought process
after all it was going to be a very very
difficult task to do
but the history had shown that the only
effective way to deal with the various
is to actually have vaccination program
go ahead
with hard work from various quarters and
push from government officials and
scientists
finally the vaccination program came
back on track
but i have mentioned before that we
don't take learnings from history
seriously
the previous spanish pandemic which lie
with spanish flu pandemic which was
there 100 years ago
had clearly shown us that a second wave
was coming
we as clinicians had fears about it but
somewhere the message about it got
diluted
in all the backpacking and how we at the
country had done exceptionally well in
controlling the pandemic
we probably lost that message and well
it may have been forgotten 100 years ago
but we didn't even bother to look at the
europe and the american countries where
the second wave was well and truly
happening as we were trying to improve
from where to come out of the first wave
neither the authorities nor the common
man or doctors were actually expecting
what was coming
a little lag of time and the second wave
hit us like never before
within a span of six to eight weeks from
february 2021
india was reeling with cases again this
time the numbers rose spectacularly fast
and our healthcare system was stretched
to the limits
there was a shortage of life-saving
things like oxygen
drugs it almost felt like deja vu but it
was multiplied by three faults
as we are currently in the midst of this
second wave we are fire fighting for
essential life-saving things
while some cities and states are doing
much worse
some have started to show some
improvement the hope currently is that
the second wave which comes like a storm
probably should vanish like a storm as
well
again the mathematical models predict
that it could be 100 day cycle
we will have to see how accurate they
are this time around
i would like to summarize by saying that
i'm most certain with hard work and team
effort we shall again
come and be victorious in this wave as
well
the extent of damage to human life and
economy it causes
will remain to be seen just like the
first wave
the second wave would also go down but
the ferocity of that
would still be unknown because we just
need to wait out
while what we can do is that we probably
need to take the learnings from the
history
it is often said an experience that when
the second wave comes third one is
already staring at you
let's take a pledge that we will not let
our guard go
go down now the second wave when it
declines we will mask up and vaccine up
that would be the mantra the government
needs to step up
surveillance testing tracing traiting
and microcontainment in a more effective
way when the wave actually goes down
at all cost avoid the third wave and all
it needs is that the government to
invest
more and more in healthcare and for us
to behave like responsible citizens of
the country
jai hind
you
{{
[音乐]
这是 2020 年 1 月的最后一周，
我正在参加重症监护协会的年度会议，
这是一个由全球 4000 多个重症监护室组成的集团，
我们讨论了
重症监护管理的科学研究和临床方面的
新想法 世界各地面临的问题
都被提出来寻求
解决方案
，当然，我们会见并会见朋友
和同事，并在这三天
的学术盛宴中放松身心
非常
担心这种来自武汉的新病毒
，我们都听说过，但我们
不确定
问题有多大，
担心这可能会
占全球大流行的很大一部分，
这种想法令人不安，并且频繁
出现在核心我 但我对
自己和解，它不会来到我的
岸边，所以我为什么要担心它，
但想到一个 大流行
已经在我的脑海中播下，
我们回到孟买，生活
一直持续到 2 月，但到 3 月
的第一周，即将改变我们生活
的事件迅速转变，
第一次
意识到一场前所未有的大流行
突然间，我正在
与
政府官员
和流行病学销售医生一起参加这些高强度会议，我们正在
寻找解决解决方案的策略
，在最初的一次会议中
，我突然意识到， 这种
病毒的全部焦点及其造成的毁灭性伤害
将在重症
监护室和医院重症监护病房的高度依赖
病房以及在其中工作的人们
进行战斗，我们将见证一场我们从未有过的新形式的战斗
看过或准备
听来自中国的医生
阅读科学材料
社交媒体帖子等我意识到
我是有原因的 被邀请参加
这些高权力会议，
因为即使我们是一个大
社会，我们中也只有少数
高级临床医生
专门从事重症监护
，我们将
在这场大流行中发挥重要作用，我为自己决定
，即使这个 对手，我将
把这看作是一生一次的
机会，在大流行病中工作，
你最后一次是 100 年前，
我开始
用我的下巴准备它，因为任何其他的态度
都意味着我是
让恐惧变得更好，并
阻止我诚实地履行作为重症监护者的职责，
即使
是该国的金融首都孟买也只有
一家传染病医院，而当我们
认为时，政府也设立
了我们大多数人 传染病的
想法
是在我国流行的结核病和
最近的 H1N1
，我们都已经与
他们的健康规模专业人士达成了共识，
并且确实做到了 不会
对我们或医院基础设施构成大挑战，
但这个 kovid 19 是的，它现在有了一个新名称，
现在
是一个完全不同的野兽来
处理我们
认为即使是一个灵魂一个 id
医院也太天真了 将能够处理
患者负荷，
因此所有准备处理该患者的公立和私立医院
都
对他们进行筛查并赢得他们的治疗
过程开始 过程由
专家到医院检查开始
，没有发现任何意外 设施
完全不足以应对这种
高传染性病毒
我的医院也不例外 我们必须
组建一个快速行动
小组，基本上开始
集思广益 它
涉及在医院
的可用基础设施内建造新
医院
单独的入口走廊 隔离
病人 像我一样使用的公共区域
ct 扫描 mri 一切都需要
绘制图表
，而这一切都已经完成 我们
最大的挑战是找到人力
在大流行中工作
培训他们制定个人防护
策略和政策
激励他们工作 减轻他们的恐惧
然后
意识到仅仅穿上一件 pp 套装他们的
效率就下降了 20% 到 30
% 医护人员中的许多困惑 恐惧和
恐惧
许多人拒绝工作 其中
一些人有一些真诚
一些人有蹩脚的借口 试图逃避
工作 这是一个挑战 联合他们的
恐惧让他们感到安全并激励
他们重返
工作 我是不是应该同时去
澳大利亚，
但是由于不确定的检疫
和国际封锁规则，
我基本上停止了，最重要的是，我
需要在
大约同一时间来到这里，我被任命
为马哈拉施特拉邦政府工作组的成员，
那是 为了表彰我在重症监护方面的工作
，我被期望
在
重症监护管理方面基本指导国家
不幸的是，这场大流行
对我们所有人来说都是最复杂的一次，旅程顺利而
真正地开始
了道路是不确定和困难的，
但是有一个明确的选择是
我们必须铺平通往
目的地的道路。 看到
这种挑战
人类的病毒的背后
我个人采取了多管齐下的
方法，那就是学习
教育传播并从经验中再次学习
我开始与来自
中国和东南亚的医生互动，他们
实际上正在看病人 时间
学到了很多有用的东西，我们
依靠 ICU 管理的基础知识，这些基础知识
经过时间考验，并
在经历了严格的临床试验后建立了
我们开始教育同事
我们开始
在整个社区传播知识和重症
监护正在从每个人身上重新学习 其他人的
经验 工作组同时发布了他的第一个
指南
，我们你知道 w 他们很
受欢迎，我被视为
一个可以从事
任何与 Code 19 相关的临床事务的人，
我们的 ICU 很快就开始被
公认为该市最好的 ICU 之一，
甚至是
我们正在研究的州 我们单位推出了许多教育
视频和信息表
ICU 结果为他们自己提供支持
这是一个
现在没有被寻找的单位，现在已经受到追捧，
因为他们是进来的病人中
病情最严重的，我们仍然有
合理的 患者
的结果 许多重要的政治和社会
人物都接受了我们的治疗
，在我们知道我们实际上正在享受
我们的 ICU 结果的小成功
之前，媒体谈论它 媒体
谈论它网络研讨会成为
传播和传播的新规范 分享
知识 尽管由于国家封锁，普通人的生活仍处于停滞状态，但这些信息将
在他们家中传播到数千
人
事实上，作为医疗专业人员，我们
每天都有越来越多的工作要做
大流行带来了
电子媒体已成为新
的交流规范
我们对视频进行了 icu 轮次我们已经
这样做了，因为整个团队不可能
每天都接触到
我们所说的病毒并为家人和家人提供咨询
在电话和视频
通话中
，我必须说他们深深地感谢我们
，即使在奇怪的死亡中，
他们也只对
我们付出的努力表示赞赏，
这看起来像是
社区
最后发展起来的对医生的信任赤字 几年终于
恢复了，
但是由于命运有自己的
方式决定我到了 19 岁
，从照顾者变成了
ca 重新寻求者
我被送进了我医院的隔离区
病房 我的团队
成员全心全意地照顾
我 出色的护理人员
细心的医院管理
对于任何患者来说，这似乎都是一次完美的医院体验，
但仍然很深刻 在我的内心深处，我感到一阵
混乱，
在那 14 天里，我意识到
病人会感觉到
医院里的一切
仍然缺少很多东西
缺乏
人情味
，患者的医患
关系将完全
重新定义，
因此没有个人防护装备套件的选择，
我们仍然会让那些
看起来像宇航员的医生来
检查你
，即使我知道面具后面
的面孔 我仍然觉得
在那 14 天里只有我一个人，
更不用说我的家人了，他们一定
经历了非常非常
艰难的两周 了解这种疾病
并抓住最小的积极
消息
，这可能让他们很高兴
我恢复得很好，就像几天前一样
医院流连忘返
，这给我带来了内容
变化 尽可能让患者感到舒适
他们的爱好得到培养 ICU 很快就会
在所有这些疾病和耐心中变得不同
正在为他们量身定制食物
，让他们感觉更好，
这些都是小事
，但
我们n 必须完成 我们同时
努力提高社区意识
它对我们的生活产生了一点
影响，认为有人可能会
从我们的谈话中受益，我们
正在做的
事情很快就会有很多事情要做
全国各地的院士 公众
人物 政治家
医生 医院都在
我们的某个地方为这项倡议提供了帮助 有些人正在尽
自己的一份力，因此该国正在
见证
他们寻求信息的不同方式，而
不是标准的
和 whatsapp 转发。随着时间的流逝，我们开始
拥有多个平台来寻求正确
和科学的信息
流行病学家同时了解疾病 时间在
努力控制
疾病的传播，从局外人的角度来看，
在不断变化之后，人们正在阅读政策，
这
一定看起来很混乱，但相信我
，这个过程有一种方法
，随着我们变得更好，这个过程
结果开始自己显现
许多人开始
预测病毒的基本行为方式
以及它将占据的部分路径 有些人
会说它会在 100
天内下降 有些人会说它会有所
不同
大多数人知道了 错误的有些人可能
也做对了，但事实是
，每一波大流行病都会减少，
它在世界范围内遵循不同的趋势，
而在某些欧洲和
美洲大陆，它可能在冬季达到顶峰，而
在印度，它决定在季风
和 到了
9 月左右的季节
末期开始减少最后
生活看起来再次明亮
感觉就像阳光经济正在
推动集市 我们在股票市场上
一定会发现
股票市场正在上涨对他们来说非常非常好
，对于一个普通人来说，尽管它已经
恢复工作并养家糊口，
但我经常让我惊讶的是，我们的同胞
有很大的韧性
和 作为一个国家，我们努力
挺身而出，尽管
我们一直面临着所有的逆境，
人们的脸上洋溢着微笑，
而有些家庭可能已经失去了
亲人
把那些记忆
藏在内心深处，
当局很高兴人们很高兴
排灯节很快就过去了
庆祝活动来了，这个
婚礼季节开始了，
几乎
每个人都想忘记一种叫做冠状病毒的病毒
甚至存在
于所有的
我们国家和世界的科学家们都在
努力创造一种疫苗，
他们知道唯一有效的应对方法
是给人们接种疫苗
，这是从fr学到的
从天花和脊髓灰质炎病毒的历史
以及更多
我们都在
寻找疫苗公告的野火前锋
，当它通过时，
似乎会有一些解决方案来
解决
我们作为医疗前线专业人员
认为的这个难题 就好像安全盔甲
正式将我们包围并
保护我们一样
，因为病人还在来
，我们仍然需要在重症
监护室工作 我认为
现在至少对我
以及作为医疗保健专业人员的一些保护我很
幸运成为第
一批接种疫苗的人之一
所有新闻频道和报纸
都以非常积极的方式进行了疫苗接种活动，
而且确实将在 2020 年
开始 积极的一面
是向前迈出的一大步，但很快
就
变成了犹豫，因为有消息
传出疫苗引起的一些并发症
一直以来
，我们试图处理
的疫苗和问题现在基本上是处理
疫苗犹豫不决对
我来说这
是一个新的术语，我们现在大部分时间
都花在消除
人们心中的这些疑虑上 它在
工作 媒体平台 社交媒体
不管它是什么
毕竟很难
理解人类的想法
，当我们开始
尝试改变思维过程时
，毕竟这将是一项非常非常
困难的任务，
但是 历史表明，
解决各种问题的唯一有效方法
是让疫苗接种计划真正
推进
，各方面的
努力和政府官员和
科学家的推动
最终疫苗接种计划
重回正轨，
但我之前提到过，我们
不要认真地从历史中
吸取教训 如果我们知道第二波
即将到来，
我们作为临床医生对此感到恐惧，但在
某个地方，关于它的信息
在所有背包旅行中被淡化了，以及我们在该
国如何在控制大流行方面做得非常好，
我们可能失去了这一信息，
而且可能 100 年前就被遗忘了，
但我们甚至懒得去看看
欧洲和美洲国家，那里
的第二波浪潮确实
发生了，因为我们试图
从第一波浪潮中走出的地方进行改进，
无论是当局还是
普通人或医生实际上
预计会发生什么
，但时间有点滞后，在 2021 年 2 月后的 6 到 8 周内，第二波
以前所未有的方式袭击了我们，
印度这次再次遇到病例
，数字上升得非常快，
而且 我们的医疗保健系统已经
到了极限
氧气
药之类的救命用品短缺 这几乎感觉像是似曾相识但
它乘以三个 f
由于我们目前正处于
第二波浪潮之中，我们正在为
拯救生命的基本事物
而战，而一些城市和州的情况要糟糕得多，有些城市和州的
情况
已经开始有所
改善，目前
希望第二波浪潮来得像 风暴
可能也应该像风暴一样消失
数学模型预测
这可能是 100 天的周期
我们将不得不看看这一次它们有多准确
我想总结一下
我最确定的努力工作和 团队
努力我们将再次
到来并在这一波中取得胜利，
以及它对人类生命和
经济造成
的损害程度还有待观察，就像第一波一样，
第二波也会下降，但
其凶猛程度
仍将是 未知，因为我们只
需要等待，
而我们可以做的是，我们可能
需要从
历史中吸取教训。人们常说，
当第二波第三波来临时 一个
已经在盯着你
了，让我们发誓，我们现在不会放松
警惕
第二波下降时，
我们将掩盖和接种疫苗，
这将是政府
需要加强
监视测试追踪特征
和 当波实际上下降时，以更有效的方式进行微控制
避免第三波，
它所需要的只是政府
在医疗保健方面的投资越来越多，让
我们表现得像负责任的国家公民