India should move ahead with the undeterred resolve of adopting context-defined and regionally-differentiated strategies, undistracted by critics
Even as India is reviewing ways to nuance the second stage of the lockdown with some relaxations and looks ahead to define the path to follow after May 3, steps taken so far, continue to attract criticism from several experts and media commentators. How justified are they?
The often self-contradictory critiques harp on several themes: (1) lockdown was unnecessary or unhelpful, as India was not at high risk or is at such a high risk that lockdown will not help anyway; (2) India’s weak health system will not be able to handle the inevitable surge, so lockdown will achieve nothing; (3) only extensive countrywide testing of symptomatic and asymptomatic persons will help, without specifying the testing criteria or estimating the resources needed; (4) there is nothing you can do about it—so sit back and leave it to herd immunity, without estimating how much time it will take and at what cost of human life.
There is no doubt that a rigorous lockdown carries social and economic costs for individuals and communities. The impact on migrant workers, and the urban poor in informal occupations is particularly distressing. It would have been best to assist the migrant workers to return home, as they were very unlikely to have been virus carriers due to the low probability of their occupations or dwellings bringing them in proximity to the returning foreign travellers or their contacts. The urban poor too, could have been supported in a more humane way.
However, these lapses do not negate the logic of the lockdown. It yielded benefits in applying the brakes on viral dissemination: it did reduce the rate of rise of positive cases as a fraction of tests performed; there was no sharp surge in hospital admissions for severe acute respiratory infections (SARI); in areas where household syndromic surveillance for ‘influenza-like illness’ (ILI) was carried out, no red flags were raised to indicate a deluge; the rate of rise of deaths was nowhere close to that predicted by alarmist models.
Beyond this reining in of viral transmission, there were several other positives that bide well: public health and health system capacity emerged as policy priorities, with strong societal recognition of their value; domestic capacity is being ramped up to reduce dependence on external sources of supply for active pharmaceutical ingredients, personal protection equipment, testing kits, vaccines, and advanced medical devices such as ventilators; citizen participation and social solidarity are being fostered, best exemplified by Kerala; multi-sectoral administrative coordination has moved from being an aspirational, but, elusive chimera to a cohesive operational reality; private sector participation from both its health and non-health components was energised for providing medical and social services; an amazingly smooth Centre-state consensus-building process and a pleasing switch of warring political parties from acerbic attacks to expressions of a united national resolve boosted public confidence.
Advocates of a nihilistic approach do not see the obvious contradiction between simultaneously saying that India is at low risk and predicting that we cannot escape the disastrous surge because of a weak health system. They fail to recognise that the lockdown period offered time to better organise and scale up the capacity of our health and social systems to meet a possible surge. With OECD countries overwhelmed and modellers predicting over a million Indian deaths, a do-nothing approach would have been indefensible. If the younger age of the population is in our favour, the high numbers and early onset of risk enhancing co-morbidities like hypertension, heart disease and diabetes weigh against us. If the large rural component of our population is at less risk, there is also a duty to provide protection from unrestricted urban ingress that carries the virus.
It is also ironical that both who say that India is at high risk and those who opine that we are at low risk, fault us for ‘low testing rates’. Testing is not the only arrow in the quiver of public health. Syndromic surveillance, and hospital admissions are other sources of valuable information to gauge the spread of the epidemic. Testing has logistic constraints of kits, labs and personnel, which are being overcome. Even so, ICMR has reported that only 1 in 24 tests has yielded a positive result. The huge resource needs of case detection, through testing as the principal approach, must be realistically estimated before raising the chant of ‘widespread testing’ to a high pitch.
Enthusiastic advocates of testing also do not recognise the extent of false positives and false negatives that diagnostic tests carry in different population groups with varied prior probabilities of exposure or disease. This is a Bayesian reality that affects population-wide testing. South Korea has recently reported 190 cases which first tested positive, later twice tested negative and then again tested positive! The scientists there are unable to say whether these are ‘reinfections’, ‘reactivated infections’ or ‘false positives’ in the first place. A recent publication from China reported that 14.5% of persons, mostly young, retested positive after at least 14 days of follow-up after discharge. False positive?
Testing rates are not always good predictors of effective epidemic control. Kerala tested less than Delhi and far less than the US or the UK, but is being hailed as India’s success story in epidemic control. A striking contrast is offered by Belgium and Bolivia, which have the same population size. Bolivia performed only 2.4% of the number of tests performed by Belgium. Yet, Bolivia has had only 31 COVID-19 deaths compared to 5,453 in Belgium at the last count. Clearly, many socio-demographic and climatic differences exist between the two countries. That is why context becomes important in developing predictive epidemiological models or diagnostic tests. Fancy decontextualised models—whether in fashion or epidemiology—may walk well on the ramp, but don’t wear well in the real world.
Countrywide herd immunity will take a long while to develop. It has to happen through streamlined exposure to avoid an initial explosion of cases that will overwhelm the health system. Wang Xinghuan, head of Wuhan’s Zhongnan hospital, says that herd immunity is a long way off in China, judging from the low levels of antibodies in the general population. It is self-contradictory to advocate a passive path to herd immunity while doubting our health system’s capacity to handle a surge. Even a herd should not be stampeded by waving the branding iron of immunity. Graduated step down from lockdown and continued social distancing will be needed to achieve a safe path to herd immunity or vaccine protection, both over a year away. In the meanwhile, India should move ahead with the undeterred resolve of adopting context defined and regionally differentiated strategies, undistracted by the carping of both nihilistic and alarmist critics.
The author is President, Public Health Foundation of India
Views are personal