A Tilted Discourse on Covid-19

A Tilted Discourse on Covid-19

A view of a hospital ward set up for Covid-19 patients in Assam | Anjan Borah (Wikimedia)

A comment on 'India's Tryst with Covid-19'

The Covid-19 pandemic has ushered in desperate times for India. On the one hand, a seemingly unstoppable coronavirus threatens lives in a country with widespread destitution and frail public-health services. On the other hand, the lockdown has exacerbated poverty and unemployment, compromising livelihoods.

In this moment of desperation, several commentators have challenged India’s policies for controlling Covid-19, particularly the decision on the lockdown. An example is Vikram Patel's "India’s Tryst With Covid-19" (17 April 2020). Here I take on some of his arguments and those of others.

A common slipup has been to point at the high number of deaths due to certain other diseases. Malnutrition or other respiratory infections lead to mortality and morbidity considerably exceeding that due to Covid-19 today. This has been used to argue that our response is an overreaction.

There cannot be a bigger fallacy than these claims. What they fail to appreciate is that in epidemics or public-health emergencies, comparing the number of epidemic-related deaths with those due to other causes is an absurd and futile exercise—precisely because of the distinguishing traits of an epidemic. The very essence of epidemic response is to halt the numbers from reaching disastrous levels, not to defer action till the numbers start to match those of widely prevalent endemic diseases.

 It is the endemicity of these other diseases that keeps them from becoming hyper-acute challenges for the health system and direct threats to health personnel themselves, as Covid-19 has become. There is no denying that such endemic conditions pose significant public-health challenges and entail massive economic losses, towards which our response has been sluggish and inadequate. But comparisons of this kind downplay and warp the very notion of an epidemic. Questions such as why lockdowns are not applied to curb significant challenges like road-traffic accidents or air pollution indicate a detached interpretation of numbers rather than a holistic consideration of the problem at hand.

Another argument centres on speculation. It has been advanced that over-speculation led to the lockdown and that the case for Covid-19 aggravating mortality in the absence of a lockdown is purely speculative.

Again, such speculation, albeit an educated one, is what guides epidemic response. Can we afford to hold back action in an emergency till concrete evidence surfaces and the threat goes out of hand? We have to prepare for the worst-case scenario, not a conservative estimate.

The uncertainty surrounding how Covid-19 would unfold in the absence of the lockdown has been conspicuously overblown. There is no reason to believe that Covid-19 would have taken a course in India considerably different from that in other regions. For every point in India’s favour, such as a favourable age-composition, there are not-so-favourable ones like overcrowding and a weak healthcare infrastructure. There is no evidence to back claims of an innate Indian immunity to the coronavirus. We even lack strong evidence for lifelong immunity among those infected and subsequently cured.

In such cases, there is no choice but to reorient the public-health apparatus, weak as it may be, to tackle the epidemic. Certainly, the unsavoury concomitant is that care for regular diseases gets compromised. But this is a fault of a weak health-system, not of the epidemic response.

What is the alternative? Allowing total normalcy in accessing healthcare in times of flaring Covid-19 would portend an unimaginable disaster. It then becomes necessary to conceive insulated alternative arrangements to deal with usual illnesses amidst the pandemic—and the government is envisaging such arrangements. However, a certain amount of compromise is always built in. Perfect negotiations are impossible in an emergency. It will only be fair to acknowledge that the brunt of the epidemic will invariably have to be borne by both the afflicted and the non-afflicted. We can only try to assuage it as much as possible.

Patel draws an analogy between the lockdown and prophylactic mastectomy for rare breast cancers, suggesting that such preemptive strikes are unwarranted in medicine. But such pre-emptive action is what forms the cornerstone of emergency response, particularly when there is good reason to suppose that the epidemic could overwhelm the system. Preemptive strikes may not be justified in medicine, but they are indeed in public-health emergencies. Perhaps the author has conflated the two!

The impact of the lockdown on livelihoods has undeniably been severe, but there is a widespread assumption that allowing normal activity in the face of the pandemic would have left livelihoods undisturbed. Considering the patterns exhibited by Covid-19 till date, there cannot be a more fallacious presumption.

In fact, allowing a free pass to the virus by not imposing a lockdown would have led to a twin burden: of flaring disease and a disrupted economy. Can livelihoods sustain in the midst of the panic and chaos engendered by a flaring epidemic? The United States is an instance of how such a twin burden would look like.

There are two differences between the US and India to consider. First, unlike in India, in the US it is the individual states which are authorised to impose lockdowns, not the federal government.
Second, there is strong public backlash in the US against lockdowns, given the wide preference for personal liberty at all costs. On the contrary, in India, the rapid spread of Covid-19 and the attendant chaos could have resulted in strong public rebuke of the government for not imposing a lockdown, especially when most affected nations have imposed such measures.

It is for similar reasons that the strategy of herd immunity, by insulating the elderly and allowing mobility for younger people, appears problematic. To educate and convince India’s vast young population on basic precautions while venturing out is a daunting task, especially when they are not totally immune to risk. Consider the example of the United Kingdom, which initially went for a similar strategy. Projections suggest that even if the herd-immunity strategy was carried out perfectly, cases among 20–40-year-olds needing intensive care at the peak of the epidemic would be twice the UK’s intensive-care-unit capacity.

The ensuing controversy compelled the UK to change course. It is anybody’s guess how baleful things could be in India. Ensuring that the elderly are adequately insulated while others resume activities slowly while practicing social distancing, is highly aspirational in a country like India which sees pervasive disregard of even a draconian lockdown.

It is improper to interpret the lockdown as merely an instrument to hold down the numbers of those who die. That a majority of countries worldwide have had to resort to this unprecedented natural experiment, in some form or the other, is enough testimony to its need—especially when India could not pull off a Taiwan or a South Korea. It could have been better planned and utilized. Gaps still remain and urgently need to be filled. More importantly, as the pandemic recedes, we must derive long-term lessons.

Soham D. Bhaduri, a medical doctor and editor of the medical journal 'The Indian Practitioner', Mumbai.
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