COVID-19: Getting it wrong, and making it worse
Suranya Aiyar
Introduction
The lockdown, and all the other responses of the world
to Covid-19, have been wrong. They have been unscientific and unethical. They
have been self-defeating. They are standing in the way of our finding a real
solution to the pandemic.
We have been failed by the experts. The
epidemiologists, the World Health Organisation (WHO) and the public health experts
have all been operating on weak science, and a partial and biased view of the crisis.
Our political representatives, in every country, have not been able to
intelligently assess the advice of the experts, or to place it in its proper
context. By acting on the basis of a science which they did not understand, they
have failed the people and the science.
The crisis of a society that is beholden to science and yet knows too little about it
Above all, this is a crisis brought about by a society
that is, on the one hand, excessively dependent on science, and that, on the
other hand, has, within the lay public, political leaders and commentators, a
very weak grasp of science, at least of the kind that is in vogue among public
health experts today.
If we, as the lay public, want to get out of this crisis,
then we have to start thinking for ourselves. We have to think as if our life depends
on it, because it does. This means that we have to dig much deeper than we
usually do with a scientific subject, to understand for ourselves what the
science is saying.
What is epidemiology?
Everything began with the epidemiologists. But how many of us know anything about epidemiology even today? What do we know about the “mathematical modelling” that has ruled our lives since March? Let us try to find out.
Mathematical modelling essentially uses different
types of equations that were developed in the field of statistical mathematics.
The equations enable you to calculate the total number or size of a phenomenon
by taking into account the variables that affect it. They are supposed to help
you to answer questions like how many cars on an assembly line will be
defective, or how big is a black hole. If the phenomenon you are looking at varies
in quantity depending on what you start with, say, the number of defective nuts
(for cars), or the size of a collapsing star (for black holes); or it varies
with a time-related factor, such as the age of the assembly-line equipment; or
whatever other variables that might be relevant, you can put them into your
equation, and get a result that takes them all into account. These calculations
are used in various fields like physics, economics, business, sociology, poll
surveys and, our area of interest, epidemiology. The results of these
calculations can be plotted on a graph to give you the curves with which we
have all now become so familiar.
The actual arithmetic of this exercise is carried out
by feeding the numbers for different variables into a computer that has been
programmed to run calculations using the chosen equation. But a computer can
only run the variables according to the equation, it cannot tell you what those
variables should be, and herein lies the rub.
Deciding which variables are relevant to the phenomenon you are studying is not a mathematical exercise, but a theoretical one. Ideally, you should have a solid theoretical understanding of the phenomenon under study on the basis of which you can identify, in a rigorous, stable and complete way, the set of variables that apply. An estimation using mathematical modelling is not merely about putting a number on different elements in your equation. It is, in essence, a theory of what elements to include in the equation, and how they relate to each other.
Epidemiologists are not big on theory. There is no great understanding, in principle, of any disease or any population.
But epidemiologists are not big on theory. They don’t spend much time thinking about whether they have taken into account all the factors that drive a disease outbreak, or their relative importance. There is no great understanding, in principle, of any disease or any population. They prefer to run with working assumptions, which they keep changing as things unfold in the real world with whatever disease they are modelling.
To avoid getting caught up in questions of the biology of a disease, epidemiologists start with a simple theory: the spread of disease in a population at any point in time is a factor of the number susceptible to it (S), the number infected by it (I) and the number recovered from it (R); this is the “SIR model”.
Sounds like we have made some progress, but, really,
we are where we started, because we don’t know what are the numbers of
susceptible, recovered or infected. Each of these variables needs its own
theory for what are the further things, i.e., the further variables,
that determine each one of them: who is susceptible, who is exposed, and so on.
Since Covid-19 is a contact disease, epidemiologists took as their key working
assumption, the degree of contact with others as determining who could be
infected. But this in turn required further working assumptions, such as: what kind
of contact results in infection and what was the basis for assuming how much
contact a person has. Since you cannot do a direct count of the number of
contacts each person in a population has, you look for something by which you
can estimate average contact rates, such as travel statistics or cell phone
data, which act as an indicator or “proxy” for contact. Then there are other assumptions
that need to be made, such as how to take into account the period of infectiousness;
how to factor in the time to onset of symptoms; can people be asymptomatic, but
infectious; and so on.
In this way, you can see how at each step in deciding
what variables go into our equation, we are relying on multiple levels of
estimates within estimates, and assumptions within assumptions. Each element of
the epidemiological model is in itself a cascading series of estimates and rough
working assumptions. Any one of your cascade of estimates and assumptions that
turns out to be wrong, could throw the whole result off.
What makes all of this even more unreliable, is that epidemiologists do not even spend much time identifying the underlying estimates or assumptions when assembling their variables for their equation. So very often, it is not even a question of the assumptions that have consciously been made, but of the things that have been unconsciously assumed in the model. In other words, assumptions will be built into the epidemiologists’ models, that they are not even aware of. Sometimes epidemiologists try to correct for this by applying yet more models to their base models to “adjust” for the over- or under- estimation of its different variables. But each adjustment comes with its own assumptions and uncertainties, adding to the already cascading series of assumptions and uncertainties in the base model.
What’s wrong here is not the maths, but the science...
What’s wrong here is not the maths, but the science, or rather the lack thereof. It is said of modelling that your prediction is only as good as your data: “garbage in, garbage out”. But this really obscures the uncertainty, incompleteness and messiness that is embedded in epidemiological thinking. Your model is really only as good as the theory on which it is based, and epidemiologists have very poor theories, if at all, behind their models. Often it is a case of garbage all the way down.
To calculate the R for Covid, epidemiologists are using
the daily data put out by countries of their cases. But what is popularly
called the “daily” data, is not really “daily” in any coherent or stable sense.
They are merely the data that have been reported for the day. This may
include cases from previous days, and leave out as yet unreported cases for the
day.
This makes a big difference if you are trying to
calculate the rate of case growth using daily reported data. A key element that
gripped the popular attention with the Covid-19 pandemic was the so-called
“doubling-rate” which was said to be “exponential”. At the start of an
infection, you are still guessing where the cases might exist. Diseases don’t
have a very wide range of variation in their symptoms – fever, cold, cough and
diarrhoea about sums up the range of symptoms.
So initially you spot a few cases here and there, which
gives you a flattish line, if you’re plotting daily cases over time. As you
start getting better at identifying cases, and people begin to realise that
they might not have an ordinary ‘flu, but this new disease, more cases begin to
be detected, and so you will inevitably see a dramatic and exponential rise in
cases. This may or may not mean that cases are in fact rising exponentially. In
hindsight, you may find that there were many more undetected cases at the time that
you thought the graph was flat. If this is the case, then you would be wrong to
have predicted soaring exponential growth into the future. What your model
tells you is an “exponential” growth in cases based on daily reported case
data, could well be an exponential growth in cases being reported because of
increased testing; increased awareness of the disease, leading to more people
reporting to hospitals for diagnosis; or faster tests.
There is also a time-lag between infection and diagnosis
or laboratory-confirmation of the infection, so the cases that are reported
actually represent infections that occurred many days back, depending on the incubation
period. This means that when cases are reported to be peaking, the actual
infections, or case onset, is of several days or weeks before. You may still
have many cases, and face a serious challenge caring for all those who fall
ill, but your prediction of exponential growth based on cases detected in the
first weeks of the outbreak will be wrong.
If, like epidemiologists, you have no real theory, just some roughly thought out, tentative and incomplete ideas about the disease in question, then fitting can end up reinforcing your wrong assumptions about it. We have already seen that if your reported cases are not accurate, then the R derived from them will not be correct. This starting mistake gets compounded if, at that point, instead of looking for another more dependable basis on which to assess the R, you do “fitting” by increasing or decreasing the R, depending on the cases that you see over the next few days. If you keep doing this, you will never get to a point where you can have a reliable R. It is also dangerously circular reasoning. Essentially you are saying that the number of cases depends on the R, which in turn depends on the number of cases!
To truly understand a disease, we need to dig much deeper into the biology of the pathogen itself, as well as the way in which the human body responds to it.
This type of analysis may be helpful as an adjunct to
a more rigorous theoretical understanding of a disease, but it should not be
used to frame and lead thinking about it. The number of cases that we see for a
disease are merely its outward manifestation. To truly understand a disease, we
need to dig much deeper into the biology of the pathogen itself, as well as the
way in which the human body responds to it. If we have a correct understanding
of these things, then we can, perhaps, accurately model the disease. But
without this knowledge, modelling is a terrible way to evaluate anything. Even
if it turns out to be right, it is so only by chance.
Even at more sophisticated levels of analysis than the
one used by epidemiologists, for instance, in theoretical mathematics and physics,
there is legitimate debate over the validity and reliability of modelling.
There are questions, not just about the data and choice of variables, but about
the equations themselves, and whether it is always correct to draw your analysis
based on outcomes for which these equations give you higher probabilities. This
is not the place to go into these issues in any detail, but we need to be aware
of them to give the context for how public health experts might have gone wrong
in conceptualising pandemic disease.
To add to all these structural contradictions and
weaknesses in the epidemiologist’s approach are all the problems with data. By
now, anyone following the Covid-19 numbers must be familiar with the problems
with data. There are inconsistencies in the way a disease is tested or clinically
diagnosed, and in the way a death is attributed to a given disease. There are
uncertainties in whether testing results are accurate. Added to this are
uncertainties over whether results are accurately reported. Then there are time
lags in reporting.
Not all the problems with the data are of a nature
that better reporting can iron out. For example, the debate over dying “with”
or “by” Covid-19 is not a reporting issue, but a scientific one, and will
probably stay alive among scientists for decades to come.
So to add to all the gaps in what a model can tell us, is the inevitability of the data, on which it is dependent, not being very good. Epidemiologists try to adjust for this with more models, but again, this is an estimation. Adjustment does not clean up the data in any absolute sense.
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What the Imperial College Report said
Now let us turn from this abstract discussion of epidemiology to an analysis of one of the most influential models in the world for Covid-19. This is what came to be known as the “Imperial College Report” from the University of that name in London. The report was prepared not by the Imperial College alone, but jointly with a group of other disease-modelling institutions, including a WHO body called the WHO Centre for Infectious Disease Modelling. So the WHO is among those who wrote this report, and bears as much responsibility for it as the Imperial College. Professor Neil Ferguson, a British epidemiologist from the Imperial College, led this group. He was also advising the British government on Covid-19, and has been a consultant to the WHO for many years.
There were several reports, starting January this
year, from the Ferguson-led “Covid-19 Response Team”, which included the WHO
Centre for Infectious Disease Modelling. I am going to call them the “Covid Experts
Group”. Of these reports, the one which burst onto the world stage was dated
March 16th, in which it was predicted that if Covid-19 was allowed
to spread unchecked, 510,000 would die in the United Kingdom, and 2.2 million
in the United States of America (5).
This report came on the heels of an apparent change of
heart on the part of the UK Government in deciding to take stronger public
measures against Covid-19 than it had taken so far. The March 16th report
appears to have been an attempt to explain the change in policy: “Here we
present the results of epidemiological modelling which has informed
policymaking in the UK and other countries in recent weeks.”
But what might have been a rather dull domestic matter
for the UK, captured the world’s imagination like nothing else since the
Beatles. Within days almost the entire world was in lockdown. From India to South
Africa to the USA all work was stopped, businesses closed, travel banned, and
people were instructed to stay strictly within their homes until the storm had
passed, no one knew when.
The world ground to a halt.
Except for epidemiologists, mathematicians and a
growing array of data analysts. From New Delhi to New York,
anyone who crunched numbers for a living was churning out modelled projections
for Covid-19, and giving them to governments and journalists, or simply publishing
them on social media to, ironically for the subject, viral interest.
They predicted nothing less than millions dying,
illustrated graphically with brightly coloured exponential curves plotting
death doubling upon death, screeching upwards in a matter of days. The sight of that exponential line was like death
leaping up at you from the very pages in your hands.
Next to these projected scenarios were the “flattened”
curves of lockdown. They rose but gently, like the famous rolling hills of
England, only so high as the straight black or red line showing the point of a
country’s hospital or ventilator-capacity. That straight line would save us
from disaster, and we had to stay under it by locking down at home to stop the
spread of disease. This was how we would “flatten the curve”.
It sounds good, but does it really add up? To find out,
we need to follow the epidemiologists as they make their calculations.
Central to the notion of “flattening the curve” is the
epidemiologist’s theory that if the “Reproduction Number” or “R” is at a value
below 1, the disease peters out. So long as the R is at or above the value of
1, it keeps spreading through the community. Disease control, therefore, requires
public measures that would reduce the R value to below 1.
In a paper written in 2004, Neil Ferguson and colleagues argue that R is especially useful when studying an emerging pathogen because it can be readily estimated from “the data collected from the first few hundred people infected in a novel disease outbreak” (10).
But in reality, calculating the R for Covid-19 was not
so easy for the Ferguson-led Covid Experts Group.
To estimate R, they first needed to estimate the
number of cases in Wuhan, China, as at the time that was the only known place
of outbreak. But they immediately ran into difficulties.
The Covid Experts Group did not believe the figures of
the Chinese government were reliable, so they were faced with the problem of
having to estimate the number of cases themselves. They decided to do this by
looking at the people with Covid-19 who had travelled out of Wuhan to other
countries by mid-January. At this time, this amounted to the impressive numbe
But days later they discovered they had been wrong, as
they had missed some of, indeed, more than half, the exported cases. The
correct number it turned out was 7, and not 3. So, on January 22nd, the
Covid Experts Group took out a revised report changing their estimate to 4000
cases (2). On January 25th, on the basis of these estimated
4000 cases in Wuhan, the Covid Experts Group took out a rep
The problem with this is that, even assuming the Covid
Experts Group estimate of cases in Wuhan was correct (which we will see later
that it was not), the R derived from these cases of 2.6 in a range of
1.5 to 3.5 is simply incoherent. According to Neil Ferguson’s own earlier work,
which is cross-referenced by the Covid Experts Group throughout its series of
reports, an R of 1.7 signifies a moderate rate of transmission, while an R of 2
signifies a high one (11). So the lower end
of the Covid Experts Group’s R range, at 1.5, is below moderate rates of
transmission; the central estimate, at 2.6, is just above the threshold R for a
high rate of transmission; and the upper end, at 3.5, is miles above the high
transmission threshold.
This means that the Covid Experts Group began with an
R that was in a range that gave you three entirely different types of
epidemic – low, high and “are-you-kidding” high. Now, in order to see this
immediately, you would have to be an epidemiologist. The only people who could
have pointed out this confusion in the numbers were the epidemiologists
themselves. They should have started pointing out the limitations of any
modelling for Covid-19 right from the start, when problems with estimating the number of cases in Wuhan emerged. At this point they should
have directed policy-makers to look elsewhere for answers, as the situation did
not lend itself to good modelling (assuming there is such a thing).
So it is just not good enough for some to claim, as many supporters of Neil Ferguson and other epidemiologists do, that scientists do not decide policy, and they only present the science. Yes, they only present the science, but they and only they can alert the non-scientists to the inconsistencies, contradictions and untested or unverifiable assumptions in their work. But the epidemiologists did not do so. They allowed people to believe that there was a clear signal from their calculations, when in fact, right from the start, there was not.
Even though the WHO Collaborating Centre for Infectious Disease Modelling was part of the Covid Experts Group which estimated an R of 2.6 in a range of 1.5 to 3.5 in their January 25th report, a month later, on February 28th, the WHO confirmed a much lower R, in the range of 2 to 2.5, in a Joint Mission Report with China (13). At this point, the WHO ought to have disclosed, and explained why, it had revised its estimate of R from the earlier one in the Imperial College report of January 25th, but this was never done. This is something the WHO should be asked to explain.
Two weeks after the WHO-China Joint Mission Report, on
March 16th, the Covid Experts Group also changed their R estimate to
2.4 in a range of 2 to 2.6 (5). They said this revision was based on
“fits” to the early growth rate of the disease in Wuhan. Since their January 25th
estimate of R was also based on a fit to their then estimate of
cases in Wuhan, this reference to a new “fit” to Wuhan cases indicates the
Covid Experts Group had changed their minds yet again about the numbers of
cases in Wuhan in January, but they do not say what their new estimate of cases
was. In total, this makes three different estimates of cases by the
Covid Experts Group for the same period in Wuhan, one of which is unstated.
The Covid Experts Group’s new estimate of R doesn’t last long. Ten days later, in a new report, dated March 26th, they again revise their R to 3, in a range of 2.4 to 3.3 (7). Four days later, on March 30th, they come out with yet another report with yet another initial R, 3.87, in a range of 3.01 to 4.66 (8). Observe how drastically the R keeps changing. The R in their report of March 30th is not even in the same range as their R in the March 16th report. No explanation is given for why the R has changed a fourth time; it appears to be the result of using different equations for the modelling. But, if this is the case, there is no explanation for why the model was changed, or what the implication of this change might be on the Covid Experts Group’s earlier estimates.
In this way, in the space of two weeks in the
second half of March, the Covid Experts Group change their initial R estimate thrice,
taking the total number of revisions of the initial R to four, including
their first estimate which was made in the report of January 25th. These
are the half-way-reasoned and ever-changing estimates based on which the world
went into lockdown.
Central to the logic of the “flatten the curve” policy advocated by epidemiologists like the Covid Experts Group was the question of ventilator-demand. This was a key parameter for estimating the threshold below which Covid-19 infections had to be “suppressed”. You would have thought that there would be careful analysis behind the estimation of ventilator-demand. But in the March 16th report, the Covid Experts Group seems to have simply cast about among some English doctors to get a fix on ventilator-demand; the report says that an estimated 30% of those hospitalized would need ventilators or Extra-Corporeal Membrane Oxygenation machines (“ECMOs”) based on a “personal communication” from someone called Professor Nicholas Hart. This is the chaotic and ad hoc manner in which the Covid Experts Group estimated ventilator-demand, the central parameter for their recommendation of suppression measures.
It gets more interesting. Death followed ventilators
into the Covid Experts Group calculations in a new way that might not have been
connected with Covid-19. It is well-known that ventilators are associated with
a high rate of death – 30 to 50%. This is because people on ventilators are prone
to getting VAP – Ventilator Acquired Pneumonia - and dying of that. In the March
16th report, our diligent modellers seem to have included the 50%
mortality associated with ventilators into their calculations: “Based on expert
clinical opinion we assume that 50% of those in critical care will die”. Do you
see how this may have inflated their death figures?
After losing quite few Covid-19 patients to ventilators (it was reported that 80% of patients in New York were dying on ventilators, as opposed to the expected rate of 30 to 50% (34)) doctors in the West seem to have revised their treatment protocols and held off ventilator-use with improving outcomes. In fact, as we shall see later in this discussion, ventilators left the picture in Europe and the USA almost as quickly as they had entered it, with surged critical care units in the UK and USA being wound down without seeing any patients. But we all went into lockdown to save the ventilators.
There was also a fundamental lack of consistency in the
Covid Experts Group’s approach. Key determinants were simply discarded, without
explanation, as matters progressed. For example, when the Covid Experts Group
recommended “suppression” in their report of March 16th, this was defined
as a combination of measures in which workplace contact was to be reduced by
only 25% and the rest of social distancing was for settings outside of
the home, work and school. So this
report was really calling for the suspension of social and leisure activities (for
which it recommended 75% reduction) and not of economic activity, which was to
be maintained at 75%. Suppression was explicitly described as a measure “short
of a complete lockdown which additionally prevents people going to work”. Other suppression measures recommended were isolation
at home of sick people for 7 days, voluntary home quarantine by household
members of those falling ill for 14 days and home isolation of the elderly
above 79 years of age. Schools and 25% of Universities were to be kept open. Home
isolation was also stated to result in an increase in household contact rates
by 25 to 50 percent. These measures were considered to be sufficient to contain
the epidemic by driving the R down to below 1.
But in their report of March 26th, the
Covid Experts Group set a far more severe suppression parameter of a blanket
75% reduction in contact. There is no explanation for why they abandoned their earlier recommendation about keeping workplace activity
at 75%, or the effects on their calculations of the increase in household contacts by 25-50% from home quarantine mentioned in the earlier March 16th report. In this report, they
predicted 7 billion infections globally and 40 million deaths in the
unmitigated scenario.
Some very basic questions arise here: what is the
meaning of a 75%, or any percent of reduction in contact, anyway? On
what basis are you saying that keeping people at home results in this level of
reduction of contact? What about the contact which continues for the provision
of essential services? In some countries, even in some cities in the developing
world, just the number of essential and grocery services, along with the
activity required to avail of them, would amount to contact levels equivalent
to the full contact levels of many European cities, or even entire countries. We
are thinner and thinner on explanation, but that is normal in the world of
epidemiology.
Four days after the March 26th report, the
Covid Experts Group comes out with yet another report, this time to prove that
suppression measures are working to drive the R down (8).
In this report, the Covid Experts Group say what I explained at the start of
this discussion, that epidemic parameters cannot be inferred accurately from
the case data because: “Estimating reproduction numbers for SARS-CoV-2 presents
challenges due to the high proportion of infections not detected by the health
system and regular changes in testing policies, resulting in different
proportions of infections being detected over time and between countries. Most
countries so far only have the capacity to test a small proportion of suspected
cases and tests are reserved for severely ill patients or for high risk groups
(e.g. contacts of cases). Looking at case data, therefore, gives a systemically
biased view of trends.”
This is correct, but in many of their own preceding
reports the Covid Experts Group have estimated several things using case data! In
the March 16th report, their case fatality rate and infection
fatality rate were calculated using reported case data (4, 5, 9). On March
24th, they came out with a report arguing that China’s containment
policies worked to drive down the R based on Chinese case data (6). In
their report of January 25th, they had referred to case data as a
key determinant of transmission rates: “If a clear downwards trend is observed
in the numbers of new cases, that would indicate that control measures and
behavioural changes can substantially reduce the transmissibility of
2019-nCoV.” Public opinion, experts and governments all over the world had been
influenced to adopt extreme lockdown measures based on these case number-based
calculations, and now the Covid Experts Group was saying that all this was
based on the wrong measure – unreliable case data!
At this point, the Covid Experts Group should have retracted
everything it had said in its earlier reports. But being epidemiologists, they
felt themselves under no imperative to retract anything just because their
assumptions for it were utterly wrong. They just decided to change the
determinants in their calculations from case data to death data, and moved
smoothly on: “An alternative way to estimate the course of the epidemic is to
back calculate infections from observed deaths.”
In fact, death data is subject to the same biases and uncertainties
from reporting lags and definitional disputes as are case data. We saw this
with the debates over deaths “by” vs. “with” Covid-19 and the belated discovery
of deaths in nursing homes in Europe, the UK and the USA. At the time of the Covid Experts Group’s reports of
late March that relied on mortality data, many countries like Italy, the UK and
France had not yet begun including their nursing home and other ex-hospital
deaths in their daily death reports. On March 23rd the Mayor of Bergamo
in Northern Italy had said the death toll may be four times that which was being reported
at the time (35). The United Kingdom began including care home deaths in
its daily mortality reports only a month later, on April 29th. But the Covid Experts Group simply asserts in the March 30th
report that, “Reported deaths are likely to be more reliable”.
How are you going to decide the connection between deaths
and cases – modelling again! And “fitting”: “In this report, we fit a novel
Bayesian mechanistic model of the infection cycle to observed deaths in 11
European countries, inferring plausible upper and lower bounds of the total populations
infected (attack rates), case detection probabilities and the reproduction
number over time.”
Another of the Covid Experts Group’s estimates that
kept changing was the “doubling rate”, i.e., the rate at which they said cases would
double over time. On February 15th, a month before their alarming
report of March 16th, the Covid Experts Group estimated the doubling
time of the epidemic to be 7 days based, they say, on genetic information about
Sars-Cov-2, the virus that causes Covid-19 disease (3A).
One gets a sense that all through January and February,
the Covid Experts Group were fairly confident about their calculations. But
then in mid-March there was a sudden awakening when cases in Europe exploded,
doubling much faster than had been estimated by them. In the first week of
March, alarming reports from Northern Italy began to come in of people falling ill in massive numbers. Hospitals and morgues were said to be completely overwhelmed. The
obituary section of the L’Eco di Bergamo, the main newspaper of Bergamo in
Northern Italy, had expanded from half a section in late February, to 3 pages, then
to 6 pages, and then to 10 pages end-to-end by March 10th (71). The Covid Experts Group
hints at having got a shock from Italy in its report of March 16th
when it says that its conclusions had only “been reached in the last few days”
based on the experience in Italy and the UK, and that previous planning
estimates had “assumed half the demand now estimated”. They revised their doubling
rate to 5 days based on, they said, “the observed cumulative number of deaths
in [Great Britain] or the US seen by 14th March 2020”.
But even this seems not to have matched the pattern of
the epidemic in the following days. Ten days later, in their March 26th
report, the Covid Experts Group again revised their doubling rate to 3 days based,
they said, on observed deaths in Europe.
It is based on this 3-day doubling rate of deaths that
the Covid Experts Group calculated their third new R in their March 26th
report of 3 in a range of 2.4 to 3.3. As discussed earlier, four days later, on
March 30th, they revised their starting R estimate a fourth time to 3.87.
In the March 30th report, the Covid Experts
Group sets out to prove that the lockdowns, which by then had been imposed in
various European countries in the previous 2-3 weeks, were driving down the starting
R, as they had predicted. So the increase in their estimate of the starting R from 3 to 3.87 had
the happy effect of showing an even larger decrease in the R, 64%
declare the Covid Experts Group proudly, than if the lower initial R of 3, in
the report of four days back, had been used.
In order to really judge whether the Covid Experts
Group modelling was working, they should have given us a comparison of the
observed outbreak pattern with the one predicted in their earlier reports. But
they did not do that. They came with a new model based on the observed deaths.
They said that this model was “cross-validated” because when they ran it after
withholding three days of data, the modelled forecast of deaths for those three
days was the same as the observed deaths. But given that the model itself was
fitted to produce the observed deaths, this is hardly surprising. You don’t
need to be an epidemiologist to predict that an epidemic pattern will hold for
three days into the future – not much is likely to change in just three days!
Using this new model, the Covid Experts Group say that
their back-calculation from deaths shows that the R has slowed. Even assuming
that the R has slowed, how are you going to link this slowing down to the
suppression measures? They “assume” it: “Our methods assume that changes in the
reproductive number – a measure of transmission – are an immediate response to
these interventions being implemented rather than broader gradual changes in
behaviour.” So, they are discounting any changes in behaviour, apart from
government-mandated stay-at-home, as a driver of the R. Does this mean that they are
not accounting for the normal behaviour of sick people? Seriously ill people would, by reason of their infirmity, sharply reduce their activities and levels of
contact with others, regardless of containment measures. Is the Covid Experts
Group here assuming full levels of activity and contact, even of those that
have been put onto ventilators?
These are questions that the Covid Experts Group
should be asked, because the natural case isolation that occurs when people
fall very ill is an accepted phenomenon even in epidemiological work. Even Neil
Ferguson’s own previous work, concedes this. Writing in 2008, Ferguson and
colleagues analysed three different models for the containment of pandemics,
and each model assumed that even in the absence of intervention, clinical
disease affects individual contact-related behaviour (12). This paper
also talks about the concept of pathogenicity: the probability of developing
symptoms if infected; and the natural history of the pathogen, i.e., the course
it takes in the host body. But there is nothing to show that these effects were
factored into the Covid Experts Group’s calculations of billions of cases in
the unmitigated scenario.
Apart from the question of a spreading disease automatically
resulting in reduced levels of contact, the Covid Experts Group also fails to consider other
reasons that might account for the claimed reduction in the R such as the virus
losing potency as it transmits, or finding fewer people that are vulnerable to
its worst effects. Viral burn out has been noticed in other diseases by
scientists, though there is, as yet, no scientific explanation for it (38).
Regarding the number of cases, the Covid Experts Group
says in the report of March 30th that: “The number of daily
infections estimated by our model drops immediately after an intervention, as
we assume that all infected persons become immediately less infectious through
the intervention.” How can they make an assumption of “immediate” decline in
infectiousness with a disease having an infectious period of several days and
even weeks; clinical studies of some Covid-19 patients showed viral shedding (a
measure of infectiousness) for several weeks after the onset of symptoms (21)?
These are the types of questions that we need to be asking the epidemiologists.
Even if we are to believe that the R has declined
because of suppression measures, it has come so close to the critical value of
1 very quickly considering that in their earlier reports, the Covid Experts
Group were looking at timelines of 5 and 8 months, with the epidemic taking
several months to subside, even with the highest level of suppression measures.
The closer you look at the Covid Experts Group’s work,
the more incoherent it becomes. Even when claiming success with suppression
measures having drastically driven down the R in Europe, the Covid Experts
Group says that suppression measures will have to remain in place indefinitely
until a vaccine or medicines are discovered. Otherwise, they say, the epidemic
will re-emerge on the lifting of measures: “the more successful a strategy is
at temporary suppression, the larger the later epidemic is predicted to be in
the absence of vaccination, due to lesser build-up of herd immunity” (5).
But this contradicts their starting premise that the
point of suppression is to drive the R below the value of 1 at which point the
disease will peter out. In fact, the whole argument of the Covid Experts Group for
adopting drastic suppression measures, rather than mitigation ones, was that
only suppression could drive the R below 1. If the theory of R is correct, then
why should you have to wait for vaccines or drugs to be discovered? It should
be enough to wait till the R is below 1.
But after claiming that the R has been successfully driven
down, they now say that this has resulted in fewer infections and hence there
is no herd immunity (8)! “Herd immunity” is a
theory of epidemiologists according to which if you have a certain number of
persons in a community who are immune to a disease, the disease will die out as
it will no longer be able to transmit robustly in the community. But developing
herd immunity requires exposure to the disease, which is the opposite of
the Covid Experts Group’s strategy of suppression. The whole point of the Covid
Experts Group’s strategy was to combat the disease by lowering exposure to
it.
None of this makes any sense. We find ourselves at the
end of March, and about 3 weeks of suppression measures, in the position of
having apparently driven the R down to close to 1 in a fraction of the time
that was anticipated, but no closer to the end of the epidemic than when we
started listening to the epidemiologists.
--------------------
The metaphysics of an epidemic
So where does this leave us? Is there a Covid-19
pandemic or is it all a fantasy of the epidemiologists? It’s not a fantasy, at least
not entirely so, but this tortuous journey through the morass of epidemiological
calculations leaves us none the wiser from when we began.
Do you remember where we began? With news from China
of a new and lethal disease that was racing through the populace. Lots of
people were dying. But it wasn’t just the numbers of people that caught our
attention. It was the disease: novel, incurable and lethal. For the first time
since the discovery of antibiotics, after nearly a century’s suzerainty over
communicable disease, we were faced with the prospect of an incurable and
deadly infection spreading through us.
So, in the beginning there were two things: the multitudes
falling ill, and the disease. What makes the epidemic? The multitudes or the
disease? Chicken or egg? The answer is not so obvious as you might think. Even
today, months and at least half a million exponential Covid-19 graphs on, more
people are dying from tuberculosis, diarrhoeal diseases and malaria in developing
countries in South Asia and Africa; and from heart attacks and cancer in all
countries, every day, than from Covid-19. And the difference is massive: in
South Asia and Africa annual deaths from tuberculosis and diarrhoeal diseases
are more than their Covid-19 deaths by the tens- and even hundreds- of
thousands. In African countries like the Democratic Republic of Congo, yearly
malaria deaths are in the tens of thousands, and cases can be in the millions.
Yearly deaths from non-communicable diseases all over the world, including the richest
countries, are in the hundreds of thousands, going into the millions for bigger
countries like the USA and India.
We speak of Ebola “epidemics” in West Africa, but
cases and deaths have numbered in the lower hundreds in three of the five Ebola
outbreaks since 1976. The biggest outbreak was in 2014-2016 where the cases
numbered about 10,000 to 14,000 in different countries; a fraction compared
with other diseases in Africa (140E). The number is so small, that it
does not even figure under a separate head in WHO estimates of the disease
burden for these countries.
It's not about the numbers.....
So it is not just about the numbers of people affected
by a disease, whether big or small. In our minds, that is not what makes a
disease into an epidemic. The difference between Covid-19 and Ebola, on the one
hand, and other diseases like tuberculosis, diarrhoeal disease, malaria, cancer
and heart disease, on the other hand, is that the latter are either treatable,
or not contagious.
But what distinguishes an epidemic from any other
spreading disease is not even just a question of its treatability or contagiousness.
AIDS is an incurable infectious disease. According to WHO estimates, millions
of people across the world are infected by the Human Immunodeficiency Virus (“HIV”),
and not just in Africa. According to WHO estimates nearly 10 lakh people in the
USA have HIV/AIDS; this number is about 9 lakh for Brazil, and over 1 lakh for
Italy, Spain and France (140D). These are massive numbers. But we don’t
think of AIDS as being an “epidemic”, in these countries. What could be the reason for this? AIDS takes decades to
manifest, and with antivirals you can be HIV-positive for years without falling
ill. AIDS can be managed, but Covid-19 can kill you in twenty days flat. So, the
speed at which the disease acts on the body, besides its lethality,
incurability and infectiousness, are what separates epidemic diseases, in our
imagination, from other ones.
I said that AIDS was manageable, unlike Covid-19, but although
the progress of its virus in the body is as yet unmanageable, it is
manageable in another way: Covid-19 is at least putatively manageable as we
know how it transmits, viz., through human contact.
Knowing how a disease transmits, immediately raises questions, poses moral dilemmas and engages our emotions of self-preservation in a way that not knowing does not.
Knowing how a disease transmits, immediately raises
questions, poses moral dilemmas and engages our emotions of self-preservation
in a way that not knowing does not. We don’t know where many cancers come from.
Anyone can get cancer. But the prospect, though grim, does not dampen us. We
carry on, hoping for the best. It is the same with accidents and risky jobs. And
fate. It is not just the Oriental who is fatalistic. When confronted with the
unknowable, the unquantifiable, or things that “can’t be helped”, we are all
fatalists.
But knowledge changes the equation. Once you know that Covid-19 spreads through human contact, it immediately raises the question of what to do about this. Knowledge makes control a possibility, maybe even an imperative. So even though the unmanageability and mysteriousness of a disease brings it close to the territory of the epidemic, what makes it cross into its threshold is not so much what we do not know about it, but what we do know, or think we know, about it. And even after the virus has raced around the world, infecting hundreds of thousands in the richest, most scientifically advanced places, we still think we know and can control it.
--------------------
The WHO's deep confusion about pandemics
Interestingly, although control and containment have
been the leitmotif of our response to the Covid-19 pandemic, until it exploded
on the scene this year, the scientific position was that pandemics cannot be
controlled. When, on March 11th, the head of the WHO, Director
General Tedros Adhanom, declared Covid-19 to be a pandemic, he said: “we have
never before seen a pandemic that can be controlled” (18). Previously on
March 9th he had said that if Covid-19 was a pandemic, then it would
be “the first pandemic in history that could be controlled” (17).
Before Covid-19, the scientific understanding was that pandemics cannot be controlled
Before Covid-19, the scientific understanding was that
owing to the ease and speed with which pandemic viruses transmit from
person-to-person, they cannot be controlled. The only
feasible approach in a pandemic was thought to be mitigation, i.e., trying to
limit outbreaks and chains of transmission to clusters and households when they
appeared, as we are, for instance, now doing in Delhi and Mumbai.
There is a lot of work by epidemiologists, including a
large body of work by Neil Ferguson, in which they model potential scenarios
for the spread of pandemic influenza. In all of this work the conclusion is
that if you have a sufficiently contagious virus, then limits on social and
economic activity, even of a very high order, or worldwide travel bans, would
be ineffective in stopping the virus, and would at best delay its spread by a
few weeks (12, 11, 20). Even
though Neil Ferguson insisted on suppression measures for Covid-19, in a
co-authored paper from 2004, he himself makes the case for why such measures
would not work to contain a disease like this one. The paper argues that
influenza would be difficult to control even with 90% quarantining and
contact-tracing because of pre-symptomatic transmission, a feature it shares
with Covid-19. The paper says that even if you have a relatively slow virus,
if it is infectious before the onset of symptoms, then any kind of intervention
is unlikely to be able to effectively contain spread
Similar findings are made in a later work co-authored
by Neil Ferguson, in 2008, where the analysis of three different
epidemiological models for pandemic influenza is reported to show that
community and workplace social distancing have a comparatively modest effect
where the models assume either high R values, or a higher degree of
infectiousness at an earlier stage of infection, or a scenario where only a
small proportion of infections occur outside of the home, educational institutions
and the workplace; these are all features of Covid-19
This was also the position taken by the WHO about
pandemics. Since the mid-2000s, the WHO has commissioned a lot of work on pandemic
influenza. In 2006, a body called the WHO Writing Group took out a paper on
non-pharmaceutical interventions (i.e., testing, contact tracing, quarantine
and so on) for pandemic influenza, in which it says: “The principle difficulties in using
nonpharmaceutical interventions to reduce influenza transmissions among humans
include the peak infectivity early in illness” (20). So if a disease is infectious before or near the onset of symptoms, then
reduction of transmission with non-pharmaceutical measures is said to be
difficult; as pointed out earlier, these are features found in Covid-19. In
this paper, the WHO Writing Group concludes that if a novel human influenza
subtype behaves in a manner similar to the Spanish flu pandemic, then
non-pharmaceutical interventions can only delay or contain transmission during
the phase of limited human-to-human transmission, and in the pandemic phase, different
interventions for reducing impact will have to be used.
The low likelihood of non-pharmaceutical measures
being effective, given the practical realities of a pandemic, is emphasized by
the WHO in its Pandemic Influenza Risk Management Guidance published in 2017.
This document says about “Containment Measures” (Annexure 7) that: “Evidence
supporting containment at source is extremely limited, with theoretical
evidence only. Modelling studies suggest that containment may be possible in
near-ideal scenarios characterized by low to moderate transmissibility with a
basic reproduction number [less than or equal to 1.7]; very early detection of
initial cluster/outbreak (within 15-21 days); a non-urban pandemic epicenter
with limited size, density and mobility….a short period of communicability and
low rate of asymptomatic illness…..”. Covid-19 breaches all these conditions: it has high transmissibility, it was identified in China at least more than
a month (if not more) after the initial outbreak, which is much beyond
the 15-21 day horizon envisaged here, its initial R was estimated at well above the
stated threshold of 1.7, it appeared in the large and dense urban centre with
high mobility of Wuhan, and has a long period of communicability, up to several
weeks, near the time of symptom onset.
In this document, the
WHO goes on to say that non-pharmaceutical measures such as social distancing, hand and respiratory
hygiene, not by themselves, but together
with antiviral drugs, may be effective in mitigating, but not containing,
the impact of a new influenza virus in
individual countries, and that too in “smaller scale” circumstances,
such as households, and closed or semi-closed institutions. The WHO’s position
on travel bans was that they might help prevent outbreaks on small islands, but
not much more than that (20). Beyond this,
all the WHO was willing to say before Covid-19, was that the spread and overall
impact of a pandemic might be reduced if countries that “had the
resources” implemented population-wide containment measures, but that there was
“no evidence” for this. In fact, as we will see later, there was considerable
evidence going by the experience with Ebola in West Africa, that containment
measures did not work, even for a virus that had lower transmissibility than a
pandemic one.
But all these lessons and research were ignored both
by the epidemiologists and the WHO when it came to assessing the
controllability of Covid-19. This brings us back to what I said at the start about
the idea of the controllability of a disease feeding into our decisions of what
we must do about it. Of course, we cannot ignore the existence of an incurable
infectious disease once it appears in our midst. But there are a number of
possible responses, and the choice of containment as the “major pillar” of the
response, to use Tedros Adhanom’s pet phrase, was premised on a mistaken
understanding of the controllability of Covid-19.
This mistaken understanding came from a very confused
and unstable distinction that the WHO has been making between pandemic
influenza and internationally spreading viral respiratory infections caused by
coronaviruses such as Sars-CoV-2. In its March press briefings, when the WHO
was hesitating to declare Covid-19 a pandemic, Tedros Adhanom reveals the
fundamental confusion at the heart of his understanding of pandemics by drawing
a distinction between pandemic influenza and Covid-19, saying that the latter
is highly lethal, and so we should not “accept to live with it” (17 at
51.26). But pandemic influenza is also lethal; the whole point of the
WHO’s previous work on pandemic influenza was that it kills, and kills in large
numbers.
Viruses are of various kinds, the ones that cause the
‘flu are called Influenza A, B and C; and they have subtypes such as bird flu (H5N1)
and swine flu (H1N1 2009) (168); and then there are coronaviruses. The
common cold and some ‘flus are also caused by coronaviruses. In addition,
coronaviruses cause more serious illnesses such as SARS in the early 2000s and,
now, Covid-19.
The coronavirus that caused SARS, was found by the WHO
to be relatively controllable as it did not become infectious until several
days after the onset of symptoms (20). This seems to have led to the idea in the WHO that SARS was not technically to
be categorized as a pandemic, even though it was a virus that spread to several
countries at the same time. On the other hand, avian and swine flu outbreaks were
considered pandemics even though they were more confined and smaller than SARS.
Pandemic influenzas like the Spanish flu were both highly transmissible and
lethal. So this distinction between influenza and coronavirus pandemics was
never very clear; and it created a lot of confusion during Covid-19.
The WHO’s understanding that Covid-19 was like SARS in
its transmission characteristics; and was containable in the manner that SARS
was contained, allied with the Chinese understanding of Covid-19. The SARS
outbreak had occurred in China in the early 2000s, and the Chinese had found it to be controllable,
in their reckoning, with non-pharmaceutical measures. We can never be sure if
this was the case, as some experts believe that sometimes viruses just burnt
out over time (38). But, be that as it may, the entire Chinese
response to Covid-19, at least in January, was based on the premise that the
measures that worked for SARS would also work for Covid-19; and this was the
understanding accepted by the WHO.
The Chinese themselves, at least their medical
experts, seem to have changed their assessment of Covid-19 being controllable
in the same way as SARS by mid-February. On February 19th, a group
of Chinese doctors published a paper in the New England Journal of Medicine
saying that, “Our analysis suggests that the viral nucleic acid shedding
pattern of patients infected with SARS-CoV-2 resembles that of patients with
influenza and appears different from that seen in patients infected with
SARS-CoV. The viral load that was detected in the asymptomatic patient was
similar to that in symptomatic patients, which suggests the transmission
potential of asymptomatic or minimally symptomatic patients. These findings are
in concordance with reports that transmission may occur early in the course of
infection and suggest that case detection and isolation may require strategies
different from those required for the control of SARS-CoV” (163).
But the WHO seems to have not conducted any further inquiries
after hastily making up its mind about Covid-19 transmissibility in January. Even
on March 9th, by which time Covid-19 had been raging in Lombardy in Northern Italy for
several days, with obituaries in the Bergamo papers growing from half a page to
8 and more, Mike Ryan, the WHO Executive Director of Health Emergencies was
saying that the WHO was reluctant to call Covid-19 a pandemic because in their
opinion it was controllable, and they did not want countries to move to a
mitigation approach: “if this was influenza we would have called a pandemic
ages ago…..So it’s not an avoidance of the word. But the word is important
because in many situations the word involves countries moving to a purely
mitigation approach. And what we’ve seen is that moving to a purely mitigation
approach is essentially saying the disease will spread uncontrolled, in an
uncontrolled fashion…..….. unlike flu we can still push this back….
“…. In a flu pandemic you are mitigating in the sense
that you don’t have an element of controllability. You can’t stop the virus in
any meaningful way. So you focus on reducing the impact of the virus. A control
strategy says you have an element of control, and what you do is both seek to
control the virus and reduce its impact at the same time” (17 at 11.38).
Once you have a pandemic, you no longer have a choice between containment and mitigation. The virus is coming at you from everywhere, and you are left with no option but to mitigate. The steps you take may be the same non-pharmaceutical measures, but the effect will be to mitigate. If you operate from this sensible premise of acknowledging the limited impact of these interventions, then you can also weigh in the balance how widely you are going to apply them, in the sense of whether you will apply them to clusters where the outbreak appears, and for limited periods of time, or whether you go in for a society-wide indefinite lockdown.
Again, this represents a false understanding of the
choices involved in a pandemic. Once you have a pandemic, you no longer have a
choice between containment and mitigation. The virus is coming at you from
everywhere, and you are left with no option but to mitigate. The steps you take
may be the same non-pharmaceutical measures, but the effect will be to
mitigate. If you operate from this sensible premise of acknowledging the
limited impact of these interventions, then you can also weigh in the balance
how widely you are going to apply them, in the sense of whether you will apply them to clusters where
the outbreak appears, and for limited periods of time, or whether you go in for
a society-wide indefinite lockdown.
There is no difference between what Mike Ryan calls “reducing
the impact of the virus” and “stopping the virus in a meaningful way”. If you
can reduce the impact of the virus by containing clusters, and tracing the
route of the infection where it appears, which is what mitigation is, then you are
stopping it in a meaningful way. The difference is, that you realize that you
cannot contain it in the sense of suppressing and thereby eliminating it from
your population. So you don’t engage in the extreme, and ultimately pointless
exercise, of imprisoning people in their homes or, rather, in their 6-by-4-foot
shanties, as happened in the slums of South Asia.
The WHO mistakenly took the position that considering Covid-19 to be uncontrollable was to somehow duck your responsibility to do something about the pandemic. But you have to be clear-sighted about the controllability of the pandemic in order to take sensible and proportionate action, knowing that the virus will find people were they are; if you take them off the streets and put them in their homes, it will find them there; if you close businesses, but maintain essential services; it will find victims there, if you keep hospitals open, which you have to, it will spread there; if you have people living in communal settings like prisons and old age homes, it will find them there.
The WHO took the position that to say that Covid-19 was uncontainable was to somehow duck your responsibility to do something about
the pandemic. This was a misunderstanding on the part of the WHO. You have to be
clear-sighted about the controllability of the pandemic in order to take
sensible and proportionate action, knowing that the virus will find people were
they are; if you take them off the streets and put them in their homes, it will
find them there; if you close businesses, but maintain essential services; it
will find victims there, if you keep hospitals open, which you have to, it will
spread there; if you have people living in communal settings like prisons and
old age homes, it will find them there. And this, as we will see, is what
happened with Covid-19.
So the first and most fundamental mistake that we all
made, led by the WHO, was to fail to understand the fundamental uncontrollability
of pandemic virus transmission; and this led us to act on the wrong premise
that containment was feasible for Covid-19.
--------------------
The contradiction between WHO's position on containment and travel bans
The other confusion in the WHO’s approach was the way
it opposed bans on international travel, while at the same time insisting on
containment as the “central pillar” of the Covid response. They even opposed
travel bans against China in January, while at the same time insisting that so
long as the disease was contained in Wuhan, it would not breakout
internationally. But how could the disease be contained in Wuhan, or any place,
without travel bans?
The Covid Experts Group, in one of their reports,
state that between January and March, 55 countries repatriated over 8000 citizens
from Wuhan city alone (6). There would have been more repatriated
persons if they had counted those from the rest of China in that period. In
March, more repatriations occurred from Iran and Northern Italy, once Covid-19
outbreaks began to be noticed there. In many countries at the start of the
year, screening was limited to testing for fever, and we know that Covid-19 can
spread before the onset of fever. In many places, quarantine of those
repatriated was not strictly adhered to. So there was a high chance of
infection spreading through these repatriations. Tedros Adhanom was even
questioned in press briefings about the risks of these repatriations as early
as January 30th, but he shrugged at it (16).
Once Covid-19 outbreaks erupted internationally, in the
case of every country, as would be expected in a pandemic, infections were
traced back to international travel, and not just from Wuhan, but from Italy,
the USA, France, Iran and many other places, this will be discussed in greater
detail further down. So, if the WHO wanted containment, it made no sense not to
have recommended an instant travel ban.
In opposing travel bans the WHO did even more than the
Chinese, who did impose internal travel restrictions. When questioned
about the travel restrictions imposed in Wuhan on January 23rd, WHO
official Didier Houssin admits that it was a “surprise”, but then dismisses it
saying, “we also understand the decision which had been taken in the City of
Wuhan ..was not directly related to a specific evolution of the epidemiology in
the city” (14). But this shows that the WHO
completely misunderstood the Chinese response to Covid-19. In the WHO-China
Joint Mission Report on Covid-19 that came out a few weeks later in February, the
travel ban issued on January 23rd in Wuhan is emphasised over and
over as the first landmark move by the Chinese Government for disease
containment in China. So the WHO, even while praising the Chinese response to
Covid-19, does not seem to have understood the basic facts about it. At
the press briefing of January 23rd, Tedros
Adhanom even went to far as to say that he hoped the ban would be “short in duration”!
The opposition to travel bans during pandemics is a long-standing WHO position that predates Covid-19. But this was premised on the understanding that containment is not feasible for pandemics, and so, in responding, we had to think beyond such bans and other non-pharmaceutical interventions. But Tedros Adhanom failed to see how his position on travel bans totally contradicted his position on containment.
The opposition to travel bans even during pandemics is
actually a long-standing WHO position that predates Covid-19. But this was premised
on the understanding, explained above, that containment is not feasible for
pandemics, and so, in responding, we had to think beyond such bans and
other non-pharmaceutical interventions. But Tedros Adhanom failed to see how
his position on travel bans totally contradicted his position on containment.
Even when announcing, on January 30th, that
Covid-19 was a Public Health Emergency of International Concern (PHEIC), which
WHO officials like Soumya Swaminathan later claimed was the date when countries
should have implemented full emergency protocols (39), the first recommendation that Tedros Adhanom made in that very same PHEIC
declaration was, “First, there is no reason for measures that unnecessarily
interfere with international travel and trade. WHO doesn’t recommend limiting
trade and movement” (16).
What protocols did the WHO have in mind for containment if not travel bans? Was it plausible for the WHO to advocate pandemic
containment with handwashing and cough hygiene, but no travel and trade
restrictions? The truth is that it was the WHO itself that was not convinced
that this was a pandemic, and they thought that the whole thing would be
contained by the action China was taking internally. Even when Tedros Adhanom
was forced reluctantly on January 30th to announce a PHEIC, he kept
repeating that this was only being done to enable countries with weaker health
infrastructure than China’s to prepare for a possible outbreak, and that “WHO
continues to have the confidence in China’s capacity to control the outbreak”.
Tedros Adhanom doggedly persisted in this utterly
mistaken and unscientific belief even when, contrary to his confidence in
Chinese measures stopping Covid-19 from going pandemic, it burst forth with
unprecedented ferocity in Northern Italy in March. This is what he says at a
press briefing on March 9th when newspapers at the Covid-19
epicentre of Bergamo in Italy were running obituaries of 10 pages and more
owing to this disease: “We’re encouraged that Italy is taking aggressive
measures to contain its epidemic, and we hope these measures prove effective in
coming days” (17). Far from proving
effective, Italy went on to become the worst affected country for weeks, ending
with over 2.4 lakh cases and nearly 35,000 deaths. So, ironically, even when
the WHO was lecturing us to take Covid-19 more seriously, they themselves did
not have a grasp of just how uncontrollable it was and how, therefore, unsuited
their SARS-based containment-approach to it was.
They also failed to understand basic things about the
transmission of this virus, for instance via healthcare workers. Maria Van
Kerkhove, designated the WHO Technical Lead for Covid-19, said in the March 9th
press briefing that “transmission in healthcare facilities and among healthcare
workers has not been a major driver of transmission for this particular pathogen”
(17 at 19.19). Even as she was
saying this, Italian doctors were writing articles about how, in Italy,
Covid-19 was primarily a hospital transmitted (nosocomial) disease.
Maria Van Kerkhove was also either ignorant about, or
deliberately ignoring, the fact that in China it was hospital doctors who
forced authorities in Beijing to take note of the Covid-19 epidemic after
dozens of them began to fall ill and die from what was at the start known only
as an “atypical pneumonia” sweeping through the hospitals of Wuhan. Even Tedros
Adhanom was simply wrong when he said on
January 23rd that it was the Chinese SARS surveillance system that
spotted their Covid outbreak: “This outbreak was detected because China has put
in place a system specifically to pick up severe lower respiratory infection. It
was that system that caught this.” In fact, the SARS fever clinics in China did
not pick up on Covid-19, and the local authorities in Hubei ignored, and might
even have actively suppressed their doctors warnings about it for weeks in
December, 2019 (33, 21).
Maria Van Kerkhove also showed a deep confusion about
Covid-19 transmission when she made the surprising statement in late June that
it does not transmit from asymptomatics, or only very rarely. But not only was
the stay-at-home of healthy people ordered on the premise that asymptomatics or
pre-symptomatics could be infectious, when the WHO had been forced reluctantly
to declare Covid-19 a Public Health Emergency of International Concern on
January 30th, even though it had decided against doing so only a few days
previously on January 23rd, was that a case of asymptomatic
transmission had been detected in Germany (164, 14-16).
One of the big lessons of the Covid-19 pandemic is the
way this kind of pandemic disease enters a population from many places at once.
Donald Trump’s characterisation of Sars-CoV-2 as the “Wuhan virus” is not only
xenophobic, but also inaccurate. We cannot, as yet, be sure where or when this
virus first originated. As I write this paper, there are reports from Italy,
Spain, Brazil and the USA of Sars-Cov-2 having been detected in corpses and
sewage samples from way before the Wuhan outbreak of November/December, 2019.
When the virus was identified in China in January, most countries issued
airport screening and travel bans for people flying from China or the Far East.
But if you follow the first cases in different countries, you see a pattern of
transmission from other countries and people with no travel history to China.
More countries had their first imported cases from
Italy than from China; these countries are spread on all continents, and
include India, Bangladesh, South Africa, France, Iceland, Germany, Norway,
Russia, Mexico, Cuba and Brazil. Many European countries that detected a few
initial cases traced to Wuhan in January, did not go into a severe outbreak
until cases were discovered in late February and early March from Italy. In
Spain, the first cases were detected in the Canary Islands and Tenerife, and
these were imported from Germany and Britain; in mainland Spain, the first
cases were imported from Northern Italy to Catalonia and Madrid. In France, the
first cases in February included cases imported to Haute Savoie by a British
national returning from Singapore, and the first major outbreak in early March
from the Church gathering in Mulhouse in Haut Rhin where, till date, no cases
appear to have been connected to Wuhan.
In the United Kingdom, early cases included imports from Singapore. In Kenya, the first case (mid—March) was of someone returning from the USA via London. In Iceland, early cases included an import from Austria. In Italy, early cases included imports from the Philippines, Singapore, Romania and Norway. In Pakistan and India, early cases were imported from Iran. In India’s first hotspot of Mumbai, early cases mostly came from the USA. In the rest of the state of Maharashtra (whose capital is Mumbai) the first cases came from London, Scotland, France and the Netherlands, among other countries. In Ahmedabad, an early hotspot in India, it has been speculated that President Donald Trump’s state visit in late February, which was with a large team from the USA, might have imported cases there.
In Sweden, early contact tracing focussed on people with a travel history to Italy owing to some early cases having been connected to travel there. But Swedish officials later announced that while they were focussed on Italy, cases were being imported “below the radar”’ from many other countries. This is a very clear example of how contact tracing and other containment measures can be misleading in giving the early impression of the infection coming from just one or other place (186).
Tracing back to early cases in different countries, it immediately becomes clear is while everyone was focused on Wuhan, the virus was already global and being introduced to populations from multiple countries. No one had really grasped the degree to which pandemics are in fact pandemic. Although the WHO and pandemic thinking in general has for decades been emphasizing the connectedness of the world as the main risk and driver of pandemics, everyone reacted in a very un-pandemic way by focusing only on Wuhan or China.
Tracing back to early cases in different countries, what immediately becomes clear is that while everyone was focused on Wuhan, the virus was already global and being introduced to populations from multiple countries. No one had really grasped the degree to which pandemics are in fact pandemic. Although the WHO and pandemic thinking in general has for decades been emphasizing the connectedness of the world as the main risk and driver of pandemics, everyone reacted in a very un-pandemic way by focusing only on Wuhan or China. In a globalised world, it makes little sense to speak of contagion as coming from a particular city or country. By the time you see it somewhere, you have to assume that it is everywhere.
It is also pointless to waste time waiting for scientists
to figure out whether human-to-human transmission has begun. China’s first
announcement in mid-January was of 40 cases, but this was its
laboratory-confirmed cases at the time. Once they were able to tabulate all
their cases in mid-February, it became clear that at this point there were over
1,000 cases at least, and rising (App-A and B). So once you cross a few
dozen cases, the sensible thing is to assume human-to-human transmission. SARS,
MERS, Ebola, HIV, H5N1, all are viral infections that showed human-to-human
transmission, there is no reason to assume that any new viral disease will not
be the same.
So those interested in containment have to understand that in order for travel bans to be effective, they will have to be worldwide and implemented early in the outbreak, even before we are completely certain about the nature of the pathogenic agent, whether there is community transmission, and so on. This immediately raises the question of the practicality of such measures; and the potential for all these efforts being wasted if it turns out that the pathogen subsides before going pandemic.
It doesn't work. We have to forget about containment, and take sensible mitigation measures where possible, keeping the main focus not on containment, as the WHO advocated, but on treatment and support. We will discuss this in detail as we go along in the discussion.
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The mistaken focus on ventilators
So the WHO’s incorrect and incomplete grasp of the
facts, and its deep confusion about pandemics, coronaviruses and their
controllability, set us on the wrong path in
responding to Covid-19. The other big mistake in our response to Covid-19 was the
early and decisive formulation of the key medical intervention for this disease
being ventilators. The “flatten the curve” strategy of reducing infections to
match hospital resources assumed that saving lives was a matter of providing
Covid-19 patients with ventilators and critical care. But ventilators left the
picture in Europe and the USA almost as quickly as they had entered it in March.
By early April, doctors there began to report that ventilators were not helping
all Covid-19 patients, and might even be harming them
Very quickly, once they actually started seeing patients, doctors in Europe and the USA found that they had to think beyond ventilators for treating Covid-19
So very quickly, once they actually began seeing
patients, doctors in Europe and the USA found that they had to think beyond
ventilators for treating Covid-19. They began looking at delaying intubation
and also at less invasive therapies for breathing support. The focus expanded from
ventilator-care to other treatments, as doctors began to understand the way in
which Sars-Cov-2 attacked the lungs and the body's immune response to it. The shift in attention from ventilators to the way the disease progressed
in the body, opened up investigation into anti-virals to inhibit Sars-Cov-2 from
multiplying in the body, and also to enzyme-inhibitors to block those aspects
of the body’s natural immune response to it, that were exacerbating the damage
caused by the pathogen itself. This is a living example for the world of what
clinicians say – that medicine is a practice. It is not just about machines and
equipment.
The Americans and Europeans were slower off the mark with anti-virals and other drugs than the Asians, Russians and Africans. This may be partly because doctors in Asia and Africa who regularly treat tuberculosis, meningitis, diarrhoeal diseases, dengue and malaria, among other infectious diseases, are more experienced with these drugs than Western doctors. We will go into this aspect in detail further down.
Eventually, even the US sent an anti-viral preparation called “remedisivir” for approvals, which was in the market by late June. At around the same time, UK scientists claimed to have improved results with a drug called dexamethasone with intubated patients. There does not appear to have been much innovation from Continental Europe or the Nordic States with drug therapies for Covid-19. Indeed, as we go through our survey of Covid-19, the decrepitude and dullness of these places contrasts sharply with the youthfulness and dynamism of Asia.
Some of the effects of severe Covid-19, such as blood clotting, noticed as new and atypical by Western doctors, are similar to those observed in patients in the final stages of any illness when they are headed to sepsis and septic shock (41). Some of the worse cases of Covid-19 sound similar to patients in the last stages of Ebola in West Africa, or dengue in India. Anti-coagulants like heparin for critically ill patients were included right at the start in India’s National Clinical Management Guidelines for Covid-19 (42). Chinese doctors cataloguing the clinical course of illness in hundreds of patients in Wuhan hospitals in January, emphasized the observation of thrombosis (blood clotting) in critical cases and noted that elevated levels of a substance called d-dimers correlated with cases that proceeded to become severe (21, 22).
A lot of the issues raised by Italian and American doctors in March and April, when they were first hit by Covid-19, about being careful of lung damage from intubation, keeping patients “dry”, i.e., being conservative on fluid replacement as this can cause further lung damage, and on the timing of intubation for patients showing severe respiratory distress, are covered as a routine matter in the Indian National Clinical Management Guidelines for Covid-19. This may well be the case for other Asian and African countries, as well. By mid-April there was a recognition even in the West that the blood-clotting, and other “atypical” reactions they were observing in Covid-19 patients, might be part of the general deterioration into sepsis is as seen with other severe viral diseases, and, eventually, Western doctors also began to talk about adding anti-coagulants like heparin to the treatment (47).
So what you have is a very different picture of
treatment than the one envisaged in the “flatten the curve” model, where
everything hinged on ICUs and ventilators.
By mid-May, ICU facilities that had been “surged” by rich Western countries, as frantically recommended by epidemiologists, were being shut down, many without seeing any patients.
By mid-May, ICU facilities that had been “surged” by rich Western countries, as frantically recommended by their epidemiologists, were being shut down, many without having seen any patients. In England, the NHS had taken over convention halls in five cities, converting them into open-plan ICUs, with thousands of beds, complete with ventilators and other critical care equipment. These were called “NHS Nightingale Hospitals”. The one in London was opened with great fanfare by Prince Charles himself (48). By mid-May, three of the NHS Nightingale facilities were closed without having seen a single patient. The London facility, which had a capacity of 4000 beds, was closed after having seen only 54 patients.
The same story was repeated in the USA. The Engineering Corps of the US Army had been seconded to set up thousands of hospital beds in convention centres and other big venues around the country. However, many of them did not see a single patient, including in New York, which was the worst affected city, not just in the US, but perhaps in the world at the time. By early May, all of these facilities were being scaled down (49).
A British Medical Journal report from the time quotes
some British doctors as being extremely critical of all this. Richard Sullivan, the director of the Institute of Cancer Policy, King’s
College, London is quoted as saying, “The trouble is that Neil Ferguson’s modelling was
wildly exaggerated. You cannot rely on a model to predict what happens with a
pandemic. There are too many variables.
“You need good local intelligence to work out what
transmissions rates really are; this did not appear to have happened.”
Another doctor, who tellingly for the repressive atmosphere of the times, wanted to remain anonymous, questioned the disproportionate focus on intensive care capacity, given the massive spread of Covid-19 in prisons, old age homes and dementia wards, which was not anticipated, and went unnoticed for weeks, with tragic consequences in the UK (50).
Interestingly, ventilators were not front and centre
in the Chinese response to their Covid-19 outbreak. The WHO-China Joint Mission
Report gives ventilators and ECMOs (Extra Corporeal Membrane Oxygenation machines) only a passing reference, “in critically ill
patients can improve survival”, along with a range of treatments used for
Covid-19 including chloroquine, phosphate, antivirals and traditional Chinese
medicine (13).Ventilation and ECMO were given
to only a quarter of the “severe” and “critically” ill patients. According to
this report, 18.8% of patients were severe, and 6.1% were critical, so 25% of
these patients amounts to 4.4% of the total Covid-19 patients being ventilated,
as opposed to the figure of 30% taken by the Covid Experts Group. The report
says that oxygen supplementation was given to the rest of the severe and
critically ill patients.
Oxygen supplementation also requires equipment, but of a much simpler variety than ventilators and ECMO machines. Some of them can be used at home, and are available for hire. They don’t even require oxygen cylinders, as they operate by concentrating the oxygen from the air. All of this is much less costly than hospital intensive care. A fraction of unlucky patients who might become critically ill may require full ICU intervention, but there were many more options for the rest that the epidemiologists clearly had no idea about. What this tells us, is that epidemiologists really need to spend some time with actual doctors and patients. It is absurd for them to go about making predictions by models alone, without knowing anything about the actual practice of medicine.
The emphasis by epidemiologists on ventilators was dubious from the start. Anyone who has seen a relative being moved to intensive care knows that ventilation is not a cure.
The emphasis by epidemiologists on ventilators was dubious from the start. Anyone who has seen a relative being moved to intensive care knows that ventilation is not a cure. It is a measure of last resort, taken when all other treatments fail. Most of us who have been through the hospital grind with older family members see ventilators not as a life-saving therapy, but as a death knell. Spouses tell each other that when the time comes, they would rather not be put on a ventilator, but end their lives peacefully at home. There is a popular belief that once people go on a ventilator, you may never see them again, and research for this paper revealed the scientific truth behind that popular belief – 30 to 50% of ventilated patients don’t make it.
A lot of patients may have been lost in Europe and the USA because of the over-use of ventilators at the beginning of their Covid-19 outbreaks. Not having enough pulmonologists and ventilator-trained nurses to take care of the sudden surge in ventilated patients, doctors from other fields, and untrained medical students and nurses, were deployed in places like New York (51). This is in contrast to the Chinese approach, where they designated separate hospitals for severe patients, to which they deputed teams of pulmonary specialists (13).
High-tech ventilators are complicated to use. Intubation, being a highly invasive procedure in which a tube is sent deep into the patient’s body, requires a high degree of training and experience. The machines have different settings for air pressure flow and need to be carefully calibrated to the capacity of the individual patient’s lungs to withstand the pressure of the air being pumped in. Even basic things like turning over an intubated patient (which has to be done every two hours) and feeding them through a tube requires skill and experience to avoid internal damage. It was probably a mistake to use untrained personnel for ventilated patients in New York and other places.
In Italy and the USA, ventilator protocols that were initially used for
Covid patients, were the ones that had been developed for acute respiratory
distress syndrome (ARDS). Based on the ARDS protocols,
patients were being sedated and put on ventilators depending on their oxygen
levels. But doctors reported that this was often causing a further
deterioration in the patient (52).Some
doctors disagreed with patients being actively sedated and intubated according
to ARDS protocols when their breathing was relaxed, their heart rate was not
high, and they were able to speak in coherent sentences.
Dr Kyle-Sidell, an emergency and critical care
specialist in Brooklyn, New York, started off a discussion at the end of March over
the need to change ventilator protocols with an impassioned YouTube broadcast.
He said that Covid-19 patients were not behaving like typical patients
suffering from lung collapse, and there was a need to change the way in which
they were being looked at – what he called the treatment “paradigm” - which was based on ARDS at the time (53, 54). We discussed earlier the way in which the
experience with SARS clouded judgment on the part of China and the WHO as to
the most suitable response to Covid-19. The ventilator protocol for ARDS is
another example of how assumptions from prior experience were not working for Covid-19.
Doctors in Italy, led by a world-renowned critical
care specialist, Dr Luciano Gattinoni, reported that the pressure at which air
was pumped into patients with lung collapse from ARDS was too high for Covid-19
patients, some of whom showed good lung function despite lower oxygen
saturation levels. They said that although such patients should be watched for
future intubation in case their breathing became laboured, many patients did
not progress to that stage and should be given other breathing support. Intubating
such patients was also exacerbating the problems from vascular damage caused
around the lungs by Covid-19. A paper by Dr Gattinoni and colleagues warned
that even when patients were intubated, attention should be paid to treating
fluid collection and inflammation around the lungs caused by Covid-19. This
gives us a hint that perhaps these aspects of Covid-19 disease had been missed
with the early excessive reliance on ventilation
The decision about what treatment to use involves a much more subtle calculation than the epidemiologists’ one of matching the numbers of patients to the numbers of ventilators. Where you do not have the staff to man complex equipment, it is better to start looking for other forms of treatment, and this is what doctors began to do.
What emerges is that critical care is not, as
envisaged by the epidemiologists, a simple matter of ventilators and oxygen-supply.
Such a simplistic understanding of critical care, even endangers patients as it
fails to account for the importance of training and experience in their use.
The decision about what treatment to use involves a much more subtle
calculation than the one that the epidemiologists were making, of matching the numbers of patients
to the numbers of ventilators. Where you do not have the staff to man complex
equipment, it is better to start looking for other forms of treatment, and this
is what doctors began to do.
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The novel thinking required by a novel disease
An interesting comment from Dr Kyle-Sidell at this
time, which throws light on how a novel disease situation demands novel thinking,
beyond the established rules and divisions of medical practice, is his description
of how as an emergency care specialist he was able to see Covid-19 patients in
different stages and degrees of illness – from the emergency room, to the hospital
floors, to the ICU - and how this gave him a wider picture of the progress of
the disease, unlike the ICU doctors who were only receiving patients “on breathing
tubes” (56).
As they worked through their Covid-19 epidemics, critical care in rich Western countries saw both a quantitative as well as a qualitative change. The protocol for Intensive Care Units in First World countries is one-nurse-per-patient. This is quite different to intensive care units in India, where a nurse would serve more than one patient. In India, intensive care units are built on an open plan with beds arranged on a perimeter around the nurses’ station, so they can have a 360-degree view of the patients at all times. But things changed dramatically in rich countries once Covid-19 reached their shores. For instance, in the UK, NHS Nightingale ICU facilities were opened with thousands of beds, but just a few dozen staff. So much for the one-nurse-per-patient rule.
Professor Charles Knight, a senior doctor and
functionary in the British National Health Service (NHS) system, who was
seconded to the London NHS Nightingale as CEO, spoke of the importance of
cutting bureaucracy and expanding NHS hospitals’ in-house intensive care units
in a manner that used fewer resources
If you follow the discussion in developed countries among doctors around Covid-19 treatment, what comes through is that the issue they had to contend with was not so much ventilator-availability, as the inflexibility of top-down treatment protocols devised by hospital administration. The entire thrust of hospital organization is for adherence to consistently applied protocols. But this might be making them less agile than is required in a novel disease outbreak. The reality of big hospitals, with worries about litigation claims and maintaining insurance cover, is that what should be a purely technical matter for doctors, i.e., what treatment protocol to use, is not in reality so......a big hospital becomes a place for churning out medical services as a sort of assembly-line of treatment. It is not a place for thinking. Consider how futile, and even dangerous, this makes the hospital in a time when we are confronted with a novel disease that defies the rules. How can a new treatment be found without innovation, receptibility, openness, and giving some space for trial-and-error?
If you follow the discussion in developed countries
among doctors around Covid-19 treatment, what comes through is that the issue
they had to contend with was not so much ventilator-availability, as the inflexibility
of top-down
Listening to Dr Kyle-Sidell in interviews where he talks about the need to reconsider ventilator-protocols, one gets the impression that
while some colleagues may have supported him, changing hospital protocols is no
easy matter. In the end, Dr Kyle-Sidell was moved out of the ICU because he said that he could not, in good conscience, follow protocols that he believed were
harmful, and the hospital was unable to change them.
The reality of big hospitals, with worries about
litigation claims and maintaining insurance cover, is that what should be a purely
technical matter for doctors, i.e., what treatment protocol to use, is not in reality
so. To steer clear of litigation and insurance trouble, a big hospital has to
diligently follow set procedures. In this way, a big hospital becomes a place
for churning out medical services as a sort of assembly-line of treatment. It
is not a place for thinking.
Consider how futile, and even dangerous, this makes
the hospital in a time when we are confronted with a novel disease that defies
the rules. How can a new treatment be found without innovation, receptibility,
openness, and giving some space for trial-and-error, something that has become
an anathema in advanced countries with their risk-averse, insurance driven,
litigious culture? Will the media and lay public give doctors and public health
authorities the space to experiment, or will every death, every failure be
blamed on them, to a chorus of condemnation from news broadcasters all around the
world? In this atmosphere of hyper-vigilance, why would doctors be encouraged
to think and try new things? They would be safer to follow the protocols.
Dr Kyle-Sidell was forced to come on social media as
he was unable to persuade his hospital administration to allow him calibrate
ventilator-use to what he saw in his patients. Hopefully, his honesty will not
prove be career-destroying. His and Dr Gattinoni’s interventions sparked off an
energetic debate on ventilator protocols, and protocols in general, among doctors
in New York who were at the frontlines of the Covid-19 outbreak. While some
doctors took a more conservative approach, expressing their dissatisfaction
with working on anecdotal evidence without widespread clinical trials, many
doctors reported that within weeks of these events, hospitals had pulled back
on their initial response of rushing Covid-19 patients to intubation based on
ARDS protocols (58).
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The Clinical Trial: A gold or gilt (or guilt!) standard?
Rigid protocols might also have played a role in retarding
the search for drugs for Covid-19 treatment in the West. While Western experts
continue to debate the use of hydroxychloroquine, and the WHO has been
plodding along for months with its “Solidarity” trial for this and other drugs,
the Indian medical authorities advised this drug as treatment and preventive for doctors and high risk contacts of patients.
The Indian advisory for Hydroxychloroquine as
Prophylaxis states the position clearly and simply: “Hydroxy-chloroquine is
found to be effective against coronavirus in laboratory studies and in-vivo
studies. Its use in prophylaxis [prevention] is derived from available evidence
of treatment as supported by pre-clinical data. The following recommendation
for the use of hydroxy-chloroquine as a prophylactic agent against SARS-CoV-2
infection is based on these considerations, as well as risk-benefit
consideration, under exceptional circumstances that call for the protection of
high-risk individuals”
For the treatment of severe Covid patients, India’s National Clinical Management
Guidelines for Covid-19 say: “No specific antivirals have been proven to be
effective as per currently available data. However, based on the available
information, (uncontrolled clinical trials) [Hydroxychloroquine combined with
Azithromycin] may be considered as an off-label [meaning without clinical
trials] indication in patients with severe disease and requiring ICU
management” (42). So the guidelines they take a practical view, given the limited options and
severity of Covid-19 disease.
Certainly, the use of hydroxychloroquine carries a
certain risk; in India, in the early days of our Covid-19 epidemic, two doctors
who were said to have been self-prescribing hydroxychloroquine died from
suspected side effects. But its use among doctors here is now fairly wide, and
there has been no explosion of bad reactions. Its use may even explain the
relatively low incidence of hospital outbreaks of Covid-19 in India, compared
with hospitals in Italy and the USA. Doctors have even been giving hydroxychloroquine
in India as a preventive to patients with heart disease, under careful
supervision, of course.
The risk profile of drugs like hydroxychloroquine may
need to be re-calibrated by taking into account their potential for prophylaxis
and treatment, given the limited options available in the current state of
science for Covid-19. Even the idea of the clinical trial, which keeps
rejecting therapies that doctors at the bedside find are working on patients,
might need an overhaul.
There can be no neat answers; ignoring protocols also has
risks. Some clinicians will object, quite reasonably, that intervening in this
way will “complicate the clinical picture”, i.e., the true progress of the
disease in the body, and the search for effective interventions. These are all
valid considerations. Perhaps, instead of looking for neat, universal
solutions, we just have to have an open-ended, incremental approach, being very
conscious when we take a conservative line, of the risk of missing out on
innovation in treatment, and equally being conscious of the risk of abuse, when
we take an unconventional approach. This is a state of mind that comes
naturally to many in the developing world – a kind of dialectical approach to
life. The WHO has only added to the confusion by conducting its own ‘Solidarity”
clinical trials. Instead, the WHO could have shown real leadership by spotting
these oppositions and encouraging countries to evolve a way of negotiating them,
in finding solutions for the Covid crisis.
Private enterprise is doing better with encouraging
new thinking. Online physicians’ platforms, like Sermo, began to publish data
on the use of hydroxychloroquine and anti-viral drugs by physicians around the
world. On Sermo, you can already see the emergence of a new language and a
groping for new standards for drugs-testing to deal with the new realities of Covid-19.
In their “About” section they use the term “Observational Study” which is described in these words:
“They are called observational studies because the
investigator relies on the physician’s self-reported or observational reports
of treating patients without manipulation or intervention. This is in contrast
to randomized controlled clinical trials, which are designed experiments where
investigators intervene and look at the effects of the intervention on an
outcome.
“While
randomized, placebo-controlled clinical trials are still the ‘gold standard’
for assessing the safety and effectiveness of therapy, observational studies
are a fundamental part of epidemiological research” (44).
Sermo’s
focus on physicians’ experience, even its disclaimer to the media listed under
the title “How Sermo studies compare to the scientific standard of polling”,
show the first the glimmers of a paradigm shift in standards and the emergence of a
new scientific language to deal with the new challenges of Covid-19.
Lines are being crossed in other ways too. For all the blame-game between China and the West over Covid-19, doctors from these countries immediately got into a conversation with each other over treatments for Covid-19. Doctors across the US spoke of the need to consult with Chinese and Italian doctors to learn from their experience with this disease. Established journals like the New England Journal of Medicine, the Lancet and the British Medical Journal published Covid-19 case studies and findings by Chinese doctors and national research institutions; and Chinese medical journals also published Covid-related research, meticulously translated into English. In fact, readers would be interested to know that the exchange of views and research through medical journals has been going on for years between China and the West.
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A Foucauldian moment for the medical world
What you have in all these developments is the breakdown of established systems of hospital organization, medical practice and pharmaceutical standards. While this may throw up new questions, the process of questioning the fundamental principles of hospital and medical practice is of long standing in the medical field. The study of these questions is part of the regular curriculum for medical students, many of whom would be familiar with the philosopher Michael Foucault’s seminal work, The Birth of the Clinic. In this book, Foucault chronicles changes in the field of medicine just before and after the French Revolution, using these changes both as a metaphor and an example in philosophizing about how systems of thought, institutions and modes of practice come into being and change.
There are important lessons for the present time in Foucault’s exploration of the different ways and objectives with which hospitals and clinics were organized at different times; emerging, as he argues, out of the play of ideas between medical expertise, social, political and economic concerns about medical practices and institutions, and the lay sentiment towards hospitals and doctors.
There are important lessons for the present time in Foucault’s exploration of the different ways and objectives with which hospitals and clinics were organized at different times; emerging, as he argues, out of the play of ideas between medical expertise; social, political and economic concerns about medical practices and institutions; and the lay sentiment towards hospitals and doctors. Foucault engages in this interrogation of changes and new developments in the medical field without, in any manner, denying or diminishing the validity of medical science as science: “I should like to make it plain once and for all that this book has not been written in favour of any one kind of medicine as against another kind of medicine, or against medicine and in favour of an absence of medicine. It is a structural study that sets out to disentangle the conditions of its history from the density of discourse, as do others of my works.” This is precisely what makes Foucault’s work on medical science all the more compelling for present times in which are always being told (especially by non-scientists) to “follow the science”. You can follow the science and still question its institutions, and currently favoured trends of thought.
At a very simple level, Foucault tells us that we
don’t have to be tied to established categories and systems of organization. If
the current best practices for hospital protocols or clinical trials are not
working to help Covid-19 patients, then we can break them down, mix them up,
abandon or invert them. If established divisions between areas of medical specialization
are obscuring a full understanding of the disease, then let those divisions be
dissolved. Covid-19 has changed the game, and this is the time for questioning,
not compliance. Only through the recognition that the old truths no longer hold,
can we have the free and honest scientific enquiry that this moment demands.
Italian doctors were quick to intuit the misalignment of their current medical practice, with the exigencies of a highly contagious disease like Covid-19: “Coronavirus is the Ebola of the rich…..The more medicalized and centralized the society, the more widespread the virus…” (23); “the Coronavirus epidemics should indeed lead to a number of reflections on the organization of healthcare and the way contemporary medicine has lost sight of some diseases, such as infectious ones, that were, probably prematurely, seen as diseases of the past…..many hospitals, including ours are reorganising and “industrializing” out-patient care, building large open spaces where multiple specialists will furnish hundreds, or perhaps even thousands of consultations per day….We are now slowly realising that this “super-efficient” factory-like program is incompatible with the periodic occurrence of epidemics, a scenario many experts consider likely, whose consequences will probably be more severe because of globalisation. While economies of scale seem to favour “hospital factories”, events like Covid-19 infection, risk compromising their ability to function….We have definitely not won the fight against infectious diseases, but we have probably forgotten about them too soon. In a high-technology setting, it is all too easy to forget the overwhelming, often dark power of nature” (24).
We do not know what new ways of medical thinking might run up against which commercial interests in the pharmaceutical, research or medical insurance field. Even non-commercial actors in the health sector, like developmental or philanthropic organisations, such as the WHO and the Bill and Melinda Gates Foundation, may push back against new ways of doing things as a result of institutional inertia, the fear of losing prestige or the fear of other, earlier interventions being questioned. A radical re-think is discomfiting for all established players in the field.
The medical world can take this as its Foucauldian moment and ask for radical changes in confronting Covid-19. Those who do, should expect resistance, as happened with Dr Kyle-Sidell. Each way of organizing systems comes with its own hierarchies and privileges, which will resist change. We do not know what new ways of medical thinking might run up against which commercial interests in the pharmaceutical, research or medical insurance field. Even non-commercial actors in the health sector, like developmental or philanthropic organisations, such as the WHO, Medecins Sans Frontieres, and the Bill and Melinda Gates Foundation, may push back against new ways of doing things as a result of institutional inertia, the fear of losing prestige or the fear of other, earlier interventions being questioned.
The politicisation of the Covid crisis has also worked
against a sober and fair scientific assessment of the situation. Only through open
scientific debate will better ways of treating Covid-19 emerge. Some doctors
and academics were quick to see this. They have already begun to chip away at
the established protocols and treatment paradigms. Prestigious universities and
affiliated hospitals have set up online forums, like the Oxford Covid-19 Evidence
Service, run by Oxford University and Nuffield Hospital. This portal puts out
research pointing out gaps in the scientific understanding of Covid-19, as well
as contradictions and uncertainties in the data and epidemiological analyses of
the pandemic. Many medical journals, assisted by publishers like Elsevier and
researchgate.com, made papers on Covid-19 available free to the public on their
online portals. Some papers were put out while they were still in review to facilitate
quick and open discussion of Covid-19 research, even at the cost of the peer
review controls of normal times.
These were
not exactly dispassionate exercises, entered upon purely for an objective
discussion of the science. The outrage of some scientists at the mainstream
view, the preference for this or that approach, a greater or lesser emphasis on
certain aspects of the many issues that arise, are all fairly evident in the
work that has been put out. Not all the work that has come out will stand the
test of time, and positions will be softened as tempers cool down. But what is
important for us as the lay public to understand, is precisely the contested,
contingent and tentative nature of the science of Covid-19. It is from the
churn of ideas that a better understanding of the disease will emerge, but this
needs patience and restraint from the watching public.
The idea that the science somehow “settles” itself, is something only non-scientists believe. In reality, science is peppered with paradoxes, unsolved equations and unproven assumptions.
Above all we have to be open to questioning everything. Query whether there can be any science without questioning? The idea that the science somehow “settles” itself, is something that only non-scientists believe. In reality, science is peppered with paradoxes, unsolved equations and unproven assumptions. They are even given names, like Quantum Uncertainty, the Reimann Hypothesis and Fermat’s equation, which was only solved a few years ago, after over three centuries. Scientific research is pervaded with debates that have no “settled” answer. Albert Einstein did not believe in the existence of black holes, even though the idea of black holes is posited on his own theory of relativity (60). Interestingly, the idea of black holes came from a form of mathematical modelling. In general, Einstein seems not to have been greatly impressed with modelling as a method of reasoning. He even said of quantum physics that “God does not play dice with the Universe.” (61). This is the elevated level to which have to return in the sciences. From Galileo to Isaac Newton to Einstein, none of the paradigmatic shifts or fundamental breakthroughs in science have come from the bean-counting exercises of modelling and number-crunching. Many great mathematicians like Ramanujan, and physicists like Stephen Hawking, saw the answer first, and then spent their careers trying to demonstrate it in mathematical terms. So the idea or the understanding or intuitive insight is, in a way, greater than the science. In a sense, the science only follows the understanding, in its raw and instinctive form. No supercomputer can ever do what Isaac Newton did, when observing an apple falling from a tree.
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Hospitals as hubs of disease during epidemics
In The Birth of the Clinic Foucault describes how hospitals in 18th century France had become such a hub of disease that people, especially the poor, came to see them as places of contagion where people went to die. Two hundred years later, exactly the same thing happened in Covid-struck countries around the world. In China, Italy, France, the UK, USA, Russia and many other countries it was doctors, nurses and hospitals that became the first great spreaders of Covid-19, catching it unawares from early patients who came in for treatment with flu-like symptoms. A big chunk of Covid-19 in Lombardy in Italy, New York in the USA and England in the UK was found to be from hospital infection (33, 45).
The Birth of the Clinic also describes how the phenomenon of hospital-acquired infections led to a discussion of “de-hospitalisation”. People began to advocate for patients to be treated in their homes. This was said to have the double benefit of keeping the patient in the more affectionate environment of his family, as well as preventing his illness from being complicated by hospital infections. Two hundred years later, Italian doctors from the Covid-struck hospitals of Northern Italy echoed these ideas: “a factory-like hospital is intuitively far from the ideal of personalized medicine, and such a system may prove incapable of providing specific, personalized contact with caregivers, a point that is often important for chronic patients” (24); “we are learning that hospitals might be the main Covid-19 carriers, as they are rapidly populated by infected patients, facilitating transmission to uninfected patients…. Home care and mobile clinics avoid unnecessary movements and release pressure from hospitals.” (23); “In Lombardy [Northern Italy] Sars-CoV-2 became largely a nosocomial [hospital acquired] infection…..The lessons relevant to other countries are the need to avoid bringing patients with suspected Sars-Cov-2 infection to the hospital, except when they clearly require hospital care” (25).
Countries like Japan and South Korea who were conscious of the tendency of hospitals to become hubs of disease in epidemics, built into their disease-response strategy the prevention of Covid-19-spread through hospitals. In Japan, to keep hospitals clear of infections, municipal authorities were asked to set up specialised consultation centres for testing. Experts early on expressed a concern that hospitals were at the risk of becoming contaminated from too many people with symptoms of cold coming in for testing. People were requested not to over-crowd hospitals and to quarantine and take treatment at home for the first few days if they developed cold or fever. They were advised to report for testing only after they had had symptoms for four days (62). In Japan there was also, unlike countries in the West, early recognition of the danger of spread of infection in old age facilities (63).
To keep hospitals clear of infection, the South Koreans made wide use of telemedicine and testing outside of the hospital setting, such as with drive-by tests. They set up digital apps for communicating tests results and prescriptions, and organising home-delivery of medicines (46). Though Japan and South Korea did have Covid-19 outbreaks in some of their hospitals, the overall size of the outbreak in these countries was smaller than in other places.
Fear of hospitals gripped the populace wherever it was hit by Covid-19. We did not attempt to understand the effect on the people of the policing role that healthcare workers and hospitals take on under a policy that emphasizes disease control over treatment of the sick.
As in 18th century France, the fear of hospitals gripped the populace wherever it was hit by Covid-19. The Chinese government had adopted a policy of putting everyone suspected of Covid-19 into hospital isolation. Covid-19 suspects in Wuhan were “cohorted” in isolation wards with others where infection might have spread (13,64). Videos surfaced on social media of people in China being dragged, kicking and screaming, to forced hospital isolation (65).
There were stories of Covid-19 patients running away from hospitals in Russia and Iran; and screaming to be let go of when being admitted to hospitals in New York. Quarantine centres in India came to be feared equally for their squalid conditions, as for the risk of infection.
If we had not been so fixated on epidemiologists’
reports, a historical survey of epidemics past could have helped us to
anticipate the vulnerabilities of hospitals during epidemics. We would not have
had to go so far back as 18th century France to learn about this. A
deep fear and resentment of hospitals and quarantine centres have been a
running theme in each and every one of the five Ebola outbreaks in West Africa
since the mid-1970s. The WHO is so disliked there, that it has had to advise its
workers not to wear its logo when doing community outreach
But we did not even think to look at the material on
hand about epidemics. We did not attempt to understand the effect on the people
of the policing role that healthcare workers and hospitals take on under a
policy that emphasizes disease control over treatment of the sick. Instead, led
by the dehumanized, decontextualized, de-historicized containment approach of
the WHO, we terrorized and alienated people, we used force on them, and exposed
them to infection in the name of “protecting” them from it.
There is no escaping the chaos of the epidemic.
Awareness of hospital infections would not in of
itself have protected from its happening. As we saw, even countries that had anticipated it and took prevention measures, had hospital outbreaks. There is
no escaping the chaos of the epidemic.
Even de-hospitalisation creates problems. In Japan,
the focus on keeping people away from hospitals left them feeling vulnerable
and neglected. The specialised testing centres had waiting
queues and the system was criticised for missing people with Covid-19 pneumonia
who needed urgent help. This brings us back to what I said earlier about there being
no neat solutions in an epidemic.
What Covid-19 taught us about growing old in wealthy countries
Another problem with de-hospitalisation is that in developed
countries there may be no home and no family to de-hospitalise into. In Sweden,
40% of households are single-person without children (67). Where is the family that 18th century French doctors spoke of to
care for the ill, as described in The Birth of the Clinic? Can you send
a sick person to his house alone? What about the fact that so many of the elderly
in developed countries are not living with their families, but in care homes?
In a telling passage in one of its reports, the Covid
Experts Group writes: “The average size of households that have a resident over
the age of 65 years is substantially higher in countries with lower income
compared with middle- and high-income countries….Contact patterns between age-groups
also differ by country; in high-income settings contact patterns tend to
decline steeply with age. This effect is more moderate in middle-income
settings and disappears in low-income settings…indicating that elderly
individuals in these settings [lower-income and middle-income countries] maintain
higher contact rates with a wide range of age-groups compared to elderly
individuals in high-income countries” (7).
We should have paid attention, not just to the entry of contagion, but also to dispersing it once it took root, instead of, as in the case of old age homes, actually assisting the further spread of disease by locking residents in place, rather than allowing them to leave, where feasible.
The Covid Experts Group uses this to argue, in its
usual jaundiced way, that this makes the elderly less vulnerable to infection
in high income settings. They were completely wrong, as they failed to account for
the increased exposure of the elderly to infection in the communal setting of
the care home. This reveals one of the mistakes of only thinking in terms of
“flattening the curve” by locking down to stop the entry of the virus. The
virus inexorably found its way to wherever people were to be found. There was a
recklessness in thinking, knowing what we did from the start about the highly
contagious nature of Sars-Cov-2, that suppression would work. We should have
paid attention, not just to the entry of contagion, but also to dispersing it
once it took root, instead of, as in the case of old age homes, actually
assisting the further spread of disease by locking residents in place, rather
than allowing them to leave, where possible.
The risk of infection from communal living
arrangements in old age and nursing homes was exacerbated by the fact that owing
to the “flatten the curve” focus on hospitals, the risk of the spread of
infection in these facilities was overlooked. Care home staff were not a
priority for the allocation of personal protective equipment (PPE). With the
culture of lockdown taking hold everywhere, the sole Covid-19 response of many
old age homes was to stop families from visiting their residents, leaving them
ever more alone and unspoken for. In many states in the USA, a further layer of
risk was added by nursing homes being requisitioned to house convalescing
Covid-19 patients, who might have still been infectious. New York’s Governor
Andrew Cuomo and other state governors have come under attack for sending elderly
Covid-19 patients to nursing homes from hospitals for recovery (69).
De-hospitalisation can only work in a society that has multigenerational homes, where caring for the sick and elderly is woven into the fabric of family life, and not considered purely a matter of care homes, and hospital beds and machines. Western epidemiologists were right to the extent that they were operating on the very real premise for them, that in their societies the ailing often have nothing but machines and beds to serve them. But these are not conditions that apply in developing countries, at least not in Asia and Africa. This is something that the WHO as a world health organisation ought to have appreciated before sentencing us all to lockdown. News reports of old people found dead in their beds by the army in Spain, of old people in the UK found starving alone at home under lockdown, of no one coming to claim the bodies of the Covid-19 dead in New York, give us hints of something much wider and longer-standing than the outbreak of Covid-19 being at play.
News reports of old people found dead in their beds by the army in Spain, of old people in the UK found starving alone at home under lockdown, of no one coming to claim the bodies of the Covid-19 dead in New York, whose burial in marked mass graves was relayed across the world by the international news media, give us hints of something much wider and of longer-standing than the outbreak of Covid-19 being at play (68). How alone must these people have been, and for how long? They did not simply happen to die alone in the midst of a lockdown; they were already alone when they fell ill; they already had no one to call them when they took to their beds. These deaths were not just an accident of the Covid-19 epidemic. They tell us something about the anomie life in advanced societies, and of the price they pay individualistic values.
The loneliness of life in Sweden with 40% of households comprising just one person, casts its much remarked upon “no lockdown” policy in a new light. Isolation is so woven into the fabric of life there, that it did not need official imposition.
The loneliness of life in Sweden with 40% of
households comprising just one person, casts its much remarked upon “no
lockdown” policy in a new light. Isolation is so woven into the fabric of life
there, that it did not need official imposition. At least the Swedes showed a
greater self-awareness than other Western countries, by intervening to mediate
this isolation by facilitating a limited social life, even under the spreading Covid-19
disease. We, in the developing world, also need a lesson in awareness. We need
to be more aware of the differences between life here and in the West, before
adopting Western models for our societies.
Part of the problem with Covid-19 spreading amongst
the elderly in developed countries arose, in a sad irony, from the better
health standards in these places. These societies have greater longevity and
widely available sophisticated operations for advanced cancers and other
non-communicable diseases. This means that a lot of older people can get
life-saving medical interventions, like tracheostomies. But these complex
operations also leave them in need of special care for the remainder of their
lives. Some of these people have to be kept in nursing homes, with advanced
medical equipment and trained staff.
In the end, Covid-19 ravaged old age homes in Europe
and the Northern America. In Canada, this has been the disease of the old age homes, with an
estimated 85% of Covid-19 deaths by late June having been of residents of long-term
care, retirement homes and assisted living facilities. By mid-May in France,
Ireland, Belgium, the United Kingdom, Spain and the USA, over half the deaths were
said to be of care home residents, who died either in care homes, or in hospitals
and nursing homes. These figures had changed somewhat by early July to 49% in
France, 63% in Ireland, 64% Belgium, 41% in England and Wales, 52% in Northern
Ireland, 44% in Scotland, 34% (confirmed) to 68% (confirmed + probable from
Covid-19) in Spain and 45% in the USA. In the USA, in some states, the proportion
of deaths from nursing homes and long term care facilities reported by mid-May was
even higher – 81% in Minnesota, 78% in Rhode Island, 77% in New Hampshire, 70%
in Connecticut and 60% and over in Massachusetts, Delaware and Kentucky, among
others. By late-May, New York, which was among the early hotspots in the USA, was showing
20% deaths from this category, but it was probably much higher earlier in the
epidemic. It was 51% in neighbouring New Jersey by late-May. Even in countries
with relatively lower Covid-19 deaths in Europe, such as Germany, Sweden and
Norway, old age home deaths were a high proportion of the total. By the third
week of June, 39% of the Covid-19 deaths
in Germany were reported in communal settings, including prisons and nursing homes;
in Sweden nearly 47 % Covid-19 deaths were of care home residents; and in
Norway 59% of Covid-19 deaths were of residents of care homes and other institutions
We should not let these rich countries off the hook by allowing them to point to age and “comorbidities” as excusing the deaths of the elderly from Covid-19.
We should not let these rich countries off the hook by
allowing them to point to age and “comorbidities” as excusing the deaths of the
elderly from Covid-19. Firstly, the fact that the vulnerability of care homes
was not anticipated, points to a high degree of neglect of these homes. In
Sweden, while all the attention was on what competing epidemiologists were
saying and whether the limited public and school activity permitted there was
right or wrong, it was the elderly in care who were dying, overwhelmingly, by
the largest numbers. There were some very worrying reports in the press of the
elderly being ignored, or even being denied oxygen and other treatment in
Sweden (174). Even prisons received more
attention on this point, with prisoners in Norway and the USA, among other
places, being released in order to reduce crowding and the risk of infection.
“Co-morbidities” sounds less like an authentic clinical description, and more like the finessing of a lawyer or insurance company.
Secondly, the whole idea of “comorbidities” has to be
vigorously interrogated. You see this expression in all the medical literature
on Covid-19, starting with Chinese journal publications. But what are these
so-called co-morbidities? Cardiovascular disease, diabetes and high blood
pressure are really just concomitants of increasing age. They are not
comorbidities in any useful sense, because almost any person above the age of
50 starts developing some degree of these. Those in their 70s and 80s would
generally have some degree of all three conditions. “Co-morbidities” sounds less
like an authentic clinical description, and more like the finessing of a lawyer
or insurance company to make excuses for lost patients, and in all likelihood has its origins as a concept from there.
All these questions should be actively pursued, now that it seems that the age
of infectious disease is back upon us.
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The horror of hospital isolation
One of the most alarming stories to emerge over
Covid-19 was the mandatory isolation of hospitalised patients from their
family. We read in horror, reports of the elderly in Italy dying absolutely
alone in claustrophobic plastic-encased hospital chambers (71). Once the
epidemic reached India, the families of the dead began to report of the neglect
and utter isolation of their relatives in the country’s designated Covid-19
hospitals. Families who had mobile phones tried to stay in touch with their
hospitalized relatives in that way. One family had to call the nursing station
for hours before their son was given a glass of water; he died alone a few days
later (72).
The idea of hospital isolation completely misses the fact that the family attendant is a key link in the chain of modern hospital care. In 21st century hospitals, the “medical gaze” is split between family attendant, machine, nurse and doctor. Like a cockroach’s vision, the complete picture is formed only by the coming together of the separate fragments recorded by each part of the composite eye. Take away any part, and the picture has a blind spot. The presence of the family attendant, therefore, is not merely a sentimental matter for patient and family.
The idea of hospital isolation completely misses the
fact that the family attendant is a key link in the chain of modern hospital
care. At the time of which Foucault wrote, the direct observation of the
patient was the centrepiece of the physician’s work. This was the starting
point for Foucault’s discussion of the so-called “medical gaze”. But in the
modern hospital, without a family attendant, the only “gaze” a patient is under
is that of his monitoring machines. Nurses look-in every so many hours, and
doctors do the rounds, not more frequently than once-a-day, stopping at each
patient for not more than a few minutes.
In 21st century hospitals, the “medical
gaze” is split between family attendant, machine, nurse and doctor. Like a
cockroach’s vision, the complete picture is formed only by the coming together
of the separate fragments recorded by each part of the composite eye. Take away
any part, and the picture has a blind spot. The presence of the family
attendant, therefore, is not merely a sentimental matter for patient and
family. For those immobilized by sickness, it is the family attendant who does
the nursing and acts as the patient’s eyes, ears and limbs for everything from
visiting the toilet, to discussing treatment with the doctors. Without this key
mediation, the patient is only incompletely attended and spoken for. This
places the patient, especially a critically ill one, at grave risk, even with
the best of efforts of the hospital, doctors and nurses.
We should have been aware of this, and accounted for
it in designing the scheme of treatment for hospitalized Covid-19 patients. No
doubt, there are practical difficulties with allowing family attendants into
Covid-19 wards. There is the question of limited PPE kits, and preventing
family attendants from spreading infection in the community. But their place in
the scheme of hospital care was not even recognized in the panicked and
mindless response to the Covid-19 pandemic.
Mike Ryan of the WHO showed himself to be a great fan of hospital isolation, infamously saying that since, with lockdown, transmission had been taken off the streets and pushed into families “now we need to go and look in families to find those people who may be sick and remove them and isolate them in a safe and dignified manner”. How can the WHO as health body be so insensitive to the impact of such statements and policies on people?
All these are things that the WHO, in its role as the
world’s overseer of medical practice, should have been aware of, and highlighted.
But Mike Ryan of the WHO showed himself to be a great fan of hospital
isolation, even going so far as to say that the reason the European outbreaks
were larger than the Chinese ones, was that in Wuhan, containment was not
confined to lockdown or physical distancing, and that along with lockdown the
Chinese authorities “continued to detect cases and isolate all cases including
mild cases away from the family”. Mike Ryan then made his now infamous
observation that since, with lockdown, transmission had been taken off the
streets and pushed into families “now we need to go and look in families to
find those people who may be sick and remove them and isolate them in a safe
and dignified manner”
Clearly, WHO officials, like epidemiologists, think
only of numbers and not of people. The question is: how can the WHO as health
body be so insensitive to the impact of such statements and policies on people?
How could it have endorsed the incarceration and endangerment of people by
forcibly concentrating them in hospital as was done by the Chinese government? Does
the WHO remember the last time that concentration was used as a state policy?
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A return to traditional medicine and natural therapies
One of the many useful perspectives that Foucault gives us about changes in medical science in The Birth of the Clinic is the way in which choices are made over time among competing perspectives of the body and disease. He gives the example of the emergence of tissue-analysis in diagnosing illness, as a change from the clinical method of observing the symptoms and inquiring about the history of the illness from the patient. This was a shift in attention to the tissues, i.e., to an inquiry of what lies below the surface of the body, from what can be seen on the surface of the body, i.e., the symptoms.
Foucault says that medical historians were wrong to attribute this shift in focus to the freeing of taboos on autopsies which then allowed the medical gaze to finally penetrate below the surface of the body. He says that autopsies were common before tissue-analysis became popular and that some practitioners had even published work that was based on autopsy-studies of the inner organs of the body.
Foucault says that this work remained in the background owing to pitched arguments taking place around the time of the French Revolution in the medical field regarding the abolition of hospitals. Hospitals had become so unpopular as a hub of disease where it was felt that the poor went only to die, that the cry that went up was “No more alms! No more hospitals!”. It was argued that if the Revolution were true to its principles of egalitarianism then there would be no disease, and hence no need for hospitals. There was also a demand to liberalise medical practice by doing away with licensing and allowing anyone who so wished to practice medicine. It was said that licensing was merely a way of preserving the privileges of the medical guilds.
Moves to abolish hospitals and licensing, however, led to a proliferation of quacks and masses of people being left with nowhere to go for treatment. As a compromise, the idea of the clinic was evolved, from which, incidentally, the book gets its title. It was said that in the clinic, doctors and medical students would be immersed in the actual observation and treatment of the sick, and be trained by the direct study of disease among the people and, not, as earlier, in the study of esoteric medical theory which had served merely to keep the privileges of medical practice to the few. In this way, it was argued, the clinic would be true to the principles of the Revolution.
So the return of the hospital was, according to Foucault, deeply caught up in being justified in terms of the observation of the sick, and in training the eye to observe knowingly. For this reason, Foucault argues, for a long time, medicine remained focused on the signs and symptoms of disease, i.e., on the surface of the body.
He says that it was a while before the practice of clinical observation led to thinking about what might be going on inside the body. Over time, clinics began to conduct autopsies to confirm their diagnosis when a patient died and this led to more and more study backwards from autopsied bodies about the origins and progress of disease. Interestingly, the medical gaze, having penetrated the body and fixed upon organs, and then the tissues for analysis, moved back to the surface of the body and beyond as the conversation moved on to whether lesions in tissues were the result of disease or the manifestation of it; and the observation of generalized symptoms such as fevers, which are not organ-specific, and brought doctors back to thinking in a less localized way about disease.
What this survey of the changing medical gaze tells us, is that the medical field witnesses the abandonment of forms of treatment; or categories of disease; or ways of understanding the body, not because they were wrong, but simply because another perspective of the body or disease comes to the fore. And this change of attention to new treatments or perspectives occurs for external reasons (political, cultural, even coincidental) that do not exist within the logic of medical science, without making them any less valid as science. This understanding of progress in medical science as not so much an inexorable advance onwards and upwards to wider and better levels of knowledge, but of a movement back and forth, and laterally, between different ways of looking at the body and disease, is something that is especially relevant today. Covid-19 has brought us to the limits of the current state of science and medical practice, and so we need to see if there are other systems of medicine that can come to our aid.
This understanding of progress in medical science as not so much an inexorable advance onwards and upwards to wider and better levels of knowledge, but of a movement back and forth, and laterally, between different ways of looking at the body and disease, is something that is especially relevant today. Covid-19 has brought us to the limits of the current state of science and medical practice, and so we need to see if there are other systems of medicine that can come to our aid.
Before allopathic medicine as we know it today, there were other systems of treatment, and other ways of categorizing the organs and functions of the body. In traditional medicine in South Asia and China, for instance, there is the idea of heat and cold. Some diseases create too much heat in the body, while others too much coolness. Treatments are given that will increase or decrease the heat, as needed. These treatments take the form of herbs, minerals, exposure to different airs, more or less sunlight and the prescription of special dietary regimens. Ancient systems like Ayurveda and Chinese traditional medicine are no less systematic than the nosologies of 18th century France, or any modern Encyclopaedia of Medicine. In the West, there was the idea of the “humours” of the body whose disturbed balanced had to be restored by treatment. A more modern non-allopathic system is homeopathy (only relatively speaking, as homeopathy is 200 years old). Though this developed in Germany, it is wildly popular in India, and I suspect in other parts of South Asia. I am among the millions of Indians who rushed to their homeopaths for Covid-19 preventive medicines, as soon as the first face masks began to be worn. Some state governments here have been prescribing it for Covid-19 prevention.
The medical profession almost universally scoffs at traditional remedies and mutters about clinical trials at their mention. But, as we have seen, the medical establishment is itself working with drugs that have not passed the gold standard of the clinical trial.
The medical profession almost universally scoffs at traditional remedies and mutters about clinical trials at their mention. But, as we have seen, the medical establishment is itself working with drugs that have not passed the gold standard of the clinical trial. We are at a moment where the medical establishment has to climb down from its high horse over traditional remedies and natural medicine. Clinical trial or not, natural remedies have been tried and tested over thousands of years, and found to be effective for a host of ailments. Surely, even for the most obstinately statistically-minded, 1000 years of unbroken and unforced use is at least something like a randomized placebo trial. For those who need the imprimatur of modern science, from time to time you see scientific research confirming the therapeutic qualities of products commonly used in traditional medicine, like turmeric. These are things that anyone in developing countries, rich or poor, educated or not, has known about and used for generations. Scientifically identifying the therapeutic qualities of traditional medicine merely confirms what has been seen and known for millennia. This is not an act of scientific discovery, but of trying to fit what is already well-known into the narrative of science.
Surely, even for the most obstinately statistically-minded, 1000 years of unbroken and unforced use is at least something like a randomized placebo trial.
Admittedly, there is nothing in natural medicine to beat the power of allopathic drugs. But for Covid-19 these drugs are yet to be found. It is also worth bearing in mind, that the subordination of traditional medicine to allopathic medicine has at least something to do with the fact that properly used, traditional medicine requires all manner of dietary and physical discipline, which people are glad to avoid if they can just pop a pill instead. So the decline of natural medicine is not entirely due to the surer and quicker results of allopathic medicines.
In Covid times, we have to remind ourselves of the link between natural and allopathic medicine. A link that has never been entirely broken.
Moreover, in Covid times when medicines have failed to do their usual magic, we have to remind ourselves of the link between natural and allopathic medicine. A link that has never been entirely broken. The therapeutic agent in many chemical drugs can be traced back to natural sources, and their discovery to their popular use in traditional medicine. One such example is quinine, used to treat malaria. It was developed from the bark of the cinchona tree that grows in South America and Western Africa, where European colonials found the natives using it as medicine. Everyone knows the story of how the gin-and-tonic was invented by British colonials in India who added gin to their daily dose of quinine tonic, to make it more palatable. Asprin was developed after studying the leaves of the willow tree, which had been used in Europe for thousands of years for fever and inflammation.
Quinine looms large over the medical landscape right down to the present Covid times. Chloroquine and hydroxychloroquine are synthetic forms of quinine. Another traditional herbal remedy is artemisia from plants found in the Far East and in Africa. Artemisinin is a synthetic form of artemisia, which is the current WHO-recommended malaria drug, that replaced quinine and chloroquine (149).
In their raw form, natural medicines can produce harsh side effects, so the work of science has been to find chemicals to mimic their therapeutic quality, while reducing the side effects. But the natural remedy is nevertheless the starting point for the search for the drug and remains at the core of the drug as treatment. This is not even in dispute in scientific research. There are volumes of scientific papers on the natural origins of drugs.
In this way we can see medicine as a system that emerges out of the general body of knowledge that we humans develop as a society. This is something that has been discussed for centuries in the medical field. Drawing from leading thinkers in the medical field in late 18th century France, Foucault sums up this proposition in The Birth of the Clinic in this way: “At the dawn of mankind, prior to …every system, medicine in its entirety consisted of an immediate relationship between sickness and that which alleviated it. This relationship was one of instinct and sensibility….multiplied by itself, transmitted from one to another, it becomes a general form of consciousness…. ‘Everyone, without distinction, practiced this medicine….each person’s experiences were communicated to others….and this knowledge passed from father to children’ ”.
Foucault is somewhat sceptical of the use of this argument to explain the clinical observation-based method as an egalitarian system that took medicine back to its true original form, but this need not concern us here. These strands of medical thought that point to the ancestry of medical thinking in traditional remedies need to be revisited in the present times when allopathic medicine is admittedly at a loss with Covid-19.
The Chinese were unabashed about using traditional Chinese medicine during their Covid-19 epidemic. But instead of encouraging countries to apply their knowledge of traditional medicine in the search for cures for Covid-19, the WHO discouraged the idea of traditional remedies.
The Chinese were unabashed about using traditional Chinese medicine during their Covid-19 epidemic. They reported the “widespread” use of Chinese Traditional Medicine among other treatments in the WHO-China Joint Mission Report. They opened hospital centres in Wuhan where people were treated with traditional herbal brews and the world famous traditional Chinese therapies of acupressure and acupuncture. But instead of encouraging countries to apply their knowledge of traditional medicine in the search for cures for Covid-19, the WHO discouraged the idea of traditional remedies (144). The WHO even issued a statement against the use of herbal remedies from the artemisia plant when the Madagascans claimed to have found a therapy based on it which they called “Covid Organics” (145).
The energetic Madagascan President, Andry Rajoelina, went on French radio to denounce the WHO for rejecting Covid Organics out of hand, saying that the West could not accept that a poor country like his might have found a treatment for Covid-19.
Regardless of WHO’s arrogant dismissal of Covid Organics, African countries queued up to purchase Covid Organics, and researchers from all over Europe initiated collaboration with the Madagascans to trials it (147). The energetic Madagascan President, Andry Rajoelina, went on French radio to denounce the WHO for rejecting Covid Organics out of hand, saying that the West could not accept that a poor country like his might have found a treatment for Covid-19 (148). With all this pressure, the WHO was forced to agree to co-operate with the Madagascans to start trialling Covid Organics (146).
The WHO has a history of resisting natural therapies, which is unfair and unhelpful in of itself. If its concern is poor countries, then natural remedies are a relatively inexpensive and widely accessible form of medicine. But the resistance to Covid Organics, which is based on naturally-found artemisia, is particularly surprising given that the WHO itself recommends artemisinin, the synthetic form of this same compound, for other treatments. Why could not the WHO have looked at the Madagascan claims about Covid Organics as a form of repurposing of drugs that is routine and permitted in the field of pharmacy? Why the dogmatic refusal to consider anything that does not come in the form of a synthetic drug? And is this merely dogma, or does the explanation for this resistance lie in competition from pharmaceutical companies who manufacture artemisinin?
The WHO fails and fails again as the world’s leading health authority to demonstrate the imagination and boldness required to, first, admit the defeat of medical practice in its current state against Covid 19, and, then, more importantly, to look for new ideas and lines of research that might lead us to therapies for this disease. All countries with a history of traditional medicine should look into its use for Covid-19.
The oppression, injustice and futility of disease containment
In India and Brazil, right from the start, it has been anticipated that people in slums and favelas would be the hardest hit by Covid-19. But that is not quite how things turned out.
Jair Bolsonaro, the President of Brazil, who has
resisted lockdown on principle, was widely criticized for not caring for the
favelas, which it was said, would surely see the worst of a Covid outbreak. But
what we need to understand about Brazil, is that contrary to the popular belief
that it had no lockdown, in fact state governors did impose lockdown. Bolsonaro was critical of these
measures, but as President he did not have the power to stop them. 25 of his 27
state governors went against his preferred course of less stringent measures,
and began imposing containment measures, including calls for people to
stay-at-home, restrictions on public gatherings and the closure of schools from
around March 17, a week before India’s lockdown. By March 24th, non-essential
businesses and quarantine were imposed in the cities of Rio de Janeiro and Sao
Paulo, among other places (73).
But despite two months of lockdown, cases in Brazil had
grown from around 2000 on March 23, to over 1 lakh by early May, with Sao Paulo
accounting for about 30 percent of the total cases, and Rio de Janeiro for about
11 percent. But hardly any of this came from the favelas. The city of Rio De Janeiro has 1000 favelas, in which about a
quarter of the city’s population is said to be living (74). But the
outbreak in Rio started in the richest and most exclusive parts of the city
By early June, although cases nationwide in Brazil had crossed 7 lakh, and reached over 36, 000 cases and 4500 deaths in Rio de Janeiro city, the Covid outbreak in Rio’s favela’s, even assuming significant underreporting, was relatively low (77). Voz da Comunidade, a well-known favela-advocacy group, which is tabulating Covid-19 data for favelas, reported a total of 1696 cases and 379 deaths from 15 of the city’s main favelas in early June (78). Of these, 284 cases and 60 deaths were reported in early June by this publication for Rocinha, which is said to be Brazil’s most populous favela. A month later, in early July, Voz da Comunidade the cases had grown by less than a thousand reported 2357 cases and 469 deaths from Covid-19 in these favelas, while the city’s case count had grown to over 1 lakh cases (7% of the national case count).
In early July when cases had doubled over the previous month in Brazil, news reports from Sao Paulo, now at over 3 lakh cases representing 20% of the national Covid case count, still said that favela residents had been spared any major outbreak so far (80).
The favela numbers may well explode in the future, but it is worth looking into why they have not yet done so, despite the congested living conditions.
The favela numbers may well explode in the future, but it is worth looking into why they have not yet done so, despite the congested living conditions, which, according to research, results in people spending 50% more time per day in contact with others than those living in richer areas (79).
A similar story is heard from slums in other parts of the world. Bangladesh’s Rajbari district, that houses the Daulatdia slum, which is also one of the world’s biggest brothels, had, by early July, only 457 cases as against national figures of over 1.5 lakh cases (App-E). Daulatdia was ordered to be shut down on March 20th, when Bangladesh had around 14 Covid-19 cases.
India is said to have 2613 towns and cities with slums and unauthorized colonies (congested ghettoes) housing over 6.5 crore people (2011 Census). But while Covid-19 cases began appearing steadily in India from the second half of March (and had been appearing sporadically since January), it was, till early June, still not a predominantly slum disease. By the end of May, Mumbai, which has been a major hotspot in India’s outbreak, had over 39,000 cases (85). But less than 2000 of these cases were in Dharavi, which is said to be Asia’s largest slum and to have anywhere between 8.75 lakh to 10 lakh residents, in an area of 2.5 square kilometres. And these Dharavi case numbers were based on the screening of nearly half the residents of Dharavi by the third week of May, (86).
The Indian newspapers talk up the extent of the outbreak in Dharavi but in fact, as in Rio and Sao Paulo, Covid-19 first came to the richer parts of Mumbai.
During April-May, the Indian newspapers tended to talk up the extent of the outbreak in Dharavi but in fact, as in Rio and Sao Paulo, Covid-19 first came to the richer parts of Mumbai. In late March, it was the well-off G South Ward of Mumbai that had the most cases. A resident of Malabar Hills, Mumbai’s most exclusive locality, who caught Covid-19 in London was among the first cases in Maharashtra. Another early case came from Scotland to Pune, another city in Maharashtra (81). In the second week of March, cases in Maharashtra were traced to the USA, Dubai, Russia, Japan, Singapore, the Philippines, France and the Netherlands. In Mumbai, most of the early cases were traced to the USA.
Cases rose dramatically in Mumbai in the month of June, more than doubling to over 80,000 cases by early July (177), but about 4200 of these were in Dharavi, Dadar and Mahim (178, 179). Of the over 4600 deaths from Covid-19 in Mumbai by early July, only 82 were from Dharavi (180). Incidentally, this is nearly a third of the Covid deaths and about a quarter of the cases in Norway, even though Norway has about the same to half the population of Dharavi (depending on how many migrant workers fled from Dharavi during the lockdown).
Even though, in the end, the number of cases in slums and chawls will be higher than in better off areas, owing to the much larger number of people there, the relative rates and size of spread is not in proportion to the relative disparity in population density or wealth.
By early July cases began to rise in the northern
wards of Mumbai and the lower-middle- to low-income areas in its southern wards
(181). The pattern that emerges is not so much of the disease being driven by poverty and congestion, but of its coming into the richer areas of the
city via international travel, spreading from there to the lower income areas,
and then coming back to the city’s better off areas often via domestic help and
drivers (182). So even though, in the end, the number of cases in slums
and chawls might well be higher than in the better off areas of Mumbai, owing to the much larger
number of people there, the relative rates and size of spread is not in
proportion to the relative disparity in population density or wealth. By
mid-June, it was reported that the rate of growth in Dharavi, at 1.5%, was half
that of Mumbai city overall, at 3%, and the rate in the newly emerging hotspots
of Mumbai’s northern wards was nearly double the city average at 5%
Data on Covid in Chennai, Delhi and Hyderabad, is not yet being released on a neighbourhood basis, so it is not possible at the moment to plot the picture of the disease here based on locality and income profile. But there is some indication of a much more complex dynamic, than the simple one of lessor wealth or infrastructure deciding the course of this disease. The district-wise data, in Delhi, for instance, shows a fairly broad distribution of cases between richer and poorer areas. Even assuming that the poorer pockets of these cities will eventually outpace its richer ones by wider margins, there is something to be understood in the relatively slow and small spread in these areas for all these months, even after the relaxation of lockdown, despite the congestion and poverty.
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Bad mathematics: containment measures disproportionately hurt the poor, while Covid-19 disproportionately hurts the rich
We seem to be missing something about the true nature of Covid-19 transmission, even though we so confidently set out to fight it by controlling transmission. Could it be that there is more robust immunity to infectious disease among people whose work involves hard labour, or who live in chronically unhygienic conditions? Favela activists are saying, that residents in their 70s, are recovering from Covid-like symptoms without medication or testing, and this is giving rise to a feeling that Covid might not be so serious a threat to favelas (87).
While it is laudable to be concerned that poorer parts of Mumbai, or any other place, should not be left behind in receiving care for Covid-19, there has been a blind spot about the disproportionate effect of containment measures on the poor.
While it is laudable to be concerned that poorer parts
of Mumbai, or any other place, should not be left behind in receiving care for
Covid-19, there has been a blind spot about the disproportionate effect of containment
measures on the poor. People living in big homes with access to gardens,
community parks and wide lanes are nowhere near as confined under lockdown as
a family of five in a one-room shanty. This is not merely a matter of
convenience, but also of health. A news report in the Indian Express from
Dharavi in late May says: “Almost everyone who has lived in Dharavi for a few
years agrees that it should have been obvious from the start that a ‘lockdown’
would worsen the epidemiological disaster that is a Mumbai slum colony. Already
living in unsanitary conditions, sharing toilets, the forced sequestering
imperilled people further” (26). Essential
supplies got disrupted; for example, in Chilla Village in East Delhi, the water
supply reduced to only once in four days (88). These are not problems in
well-serviced higher income localities.
The degree of surveillance and police presence to which slums in Delhi were subjected was much greater than for the rest of the city. Drones were deployed in Dharavi, I am not aware of them having been used in Malabar Hills. The official policy of the Mumbai municipal authorities was to seal entire slums and place police on guard when cases were found there. But in the city’s better-off areas, containment was limited to individual buildings, or even to single floors within a building and it was left to the building society to self-police for containment
In South Africa, which called out its army as well as
its police to implement containment measures, videos of brutal police action in
poor, black neighbourhoods surfaced on social media within days of lockdown (89,
28). People pointed out how the police would beat up lockdown violators
in black neighbourhoods, while negotiating with people in white ones (90).United Nations Human Rights officials
reported that the South African police used tear gas and water bombs to enforce
social distancing “especially in poor neighbourhoods”
'Residents in Hillbrow’s crowded apartment buildings watched this police brutality unfold from their buildings and would jeer whenever the policemen got out of their vehicles'
An early victim of disease policing in South Africa
was the poor and densely populated Johannesburg suburb of Hillbrow. The papers
reported that police with sjamboks (heavy whips made of hippopotamus or rhinoceros
hide or plastic) would leap out of their cars to whip and chase civilians found
out in the open. One report from South Africa’s Mail & Guardian tellingly
describes the feelings of the Hillbrow residents to these measures: “Residents in Hillbrow’s crowded
apartment buildings watched this police brutality unfold from their buildings
and would jeer whenever the policemen got out of their vehicles”; “Many
residents we spoke to felt they were on the receiving end of an excessive and
unfair response by the state to the threat of the Covid-19 pandemic”. One
resident is reported to have said, “if the cops find you standing, keep on
talking, doing anything, they give you the sjambok…I don’t think it’s okay for
the police to kick anyone, it’s not good”
As in India’s slums, stay-at-home orders in South
Africa were not just oppressive, but also unhealthy considering the living
conditions in its low-income localities. The Mail & Guardian report
describes how apartment buildings in Hillbrow were densely packed “with people
who would normally be at work at this time of day”. Tanya Zack, an urban planner
in Johannesburg who was interviewed for the report says, “It is impossibly difficult to
practice social distancing in circumstances where many people may share a
single room and where every room is occupied…..These are situations in which
people’s only access to space and fresh air may be outdoors….Denying access to
any public space at all may have the unintended consequence of confining
residents of Hillbrow to unbearable and extremely unsafe conditions”
Staying at home has very different implications for the rich and the poor.
Staying at home has very different implications for the rich and the poor. This was well expressed by a favela activist, Celso Athayde who said that while some can stay in the comfort of their homes with the fridge full, doing office-from-home, there are millions of Brazilians who are self-employed and with the “fridge empty”. Celso Athayde is the founder of favela-advocacy group, Central Unica das Favelas, in Rio de Janeiro. In late March when lockdown was being discussed in Brazil, a spot survey carried out by Data Favela Institute (of which Athayde is co-founder) showed that overwhelmingly people were concerned about the impact on their earnings of containment measures (94).
In Kenya, the familiar pattern was repeated of the poor being at the receiving end of mandatory containment measures, both from law enforcement and hunger. An Al Jazeera report from early April describes how informal workers like street hawkers and meat vendors disproportionately bore the brunt of Covid-19 curfew: “forcing people to be home by 7 pm significantly reduces working hours for those selling goods from roadside stands and outdoor markets, further exacerbating the economic hardship brought on by the coronavirus.
“Street vendors and workers with long commutes – some of the poorest and most vulnerable groups in Nairobi – are the ones most at risk of being caught outside and punished by the police.”
A local meat vendor is reported to say, “If you defend against corona[virus] this way, many people will die of hunger” (109).
In Mumbai and Pune, when a shut-down of non-essential services was announced in March, their migrant worker population thronged train stations in the tens of thousands, desperate to get home. Most of them were daily wagers and the lockdown immediately cut them off from the means to eat and live. Construction labourers who would just camp out on building sites, now had nowhere to stay. “Asa hi maran aahe, tasa hi” a migrant worker in the crowd is reported to have said; “We will die this way, or that way” (95).
Similar scenes were reported from New Delhi’s Anand Vihar Bus Terminal, a week after its lockdown, where massive crowds of workers gathered to try and catch a bus home to their villages in Uttar Pradesh and Bihar. They said they had no money or food left (96). “What corona? My children are hungry, they have walked from Gurugram [a distance of 40 kilometres that Google Maps says takes over 8 hours by foot] with me, do you think corona is what I fear?” said a labourer in the crowd (97).
With their meagre possessions in gunny bags balanced on their heads, either barefoot or in thin chappals, holding their children by the hand, migrant workers streamed out of the cities in a passionate bid to somehow get to their villages and families, far away from the city that had suddenly lost its mind. This meant a walk of several days, with nothing but tea and a little rice with salt to sustain them, starting with hundreds of kilometres on the city highways, over open roads that were already steaming in the early summer heat. Highways are not meant for walking. They have no pavements, no shelter, not a tree in sight for miles. There is nothing to give even a moment’s relief from the blistering summer sun
It is difficult to express in words the extremes to
which migrant labourers were put by lockdown. With their meagre possessions in
gunny bags balanced on their heads, either barefoot or in thin chappals,
holding their children by the hand, migrant workers streamed out of the cities in
a passionate bid to somehow get to their villages and families, far away from
the city that had suddenly lost its mind. This meant a walk of several days,
with nothing but tea and a little rice with salt to sustain them, starting with
hundreds of kilometres on the city highways, over open roads that were already
steaming in the early summer heat. Highways are not meant for walking. They
have no pavements, no shelter, not a tree in sight for miles. There is nothing
to give even a moment’s relief from the blistering summer sun
Some of the walking labourers were mere boys of 14 and
15. Braving life in the city all by themselves they had quickly grown older
than their years. They had transformed from boys into men while shouldering the financial responsibility for their parents and siblings back home. But when
they were interviewed by television reporters who asked why they were leaving,
they suddenly became children again. One simply stood still and wept; he was
just a boy now, who wanted to get back to his mother.
As lockdown stretched on and on in India into May, and
more and more migrant labour families were forced to leave the cities, we
witnessed pregnant women among the thousands walking home. Cradling their
swollen bellies at seven- and eight- months pregnant, lockdown had forced these
women to take to the road on foot in temperatures now touching 40 degrees
Celsius. There were reports of women giving birth on the side of the highway on
saris and sheets spread out by their fellow travellers, and getting up hours
after delivering their babies, to continue the walk home.
Usually these labourers would go home laden with
clothes and presents for their families, but now they were putting all their
savings into hitching a ride on trucks and oil tankers to get home. Some of
these labourers had had to write home for the money to make the trip. A black
market opened where people were paying as much as the fare of a budget air
ticket to get back home crammed into these trucks. Some set off for home on
cycles bought at several times the market price (100). This was how loss-upon-loss
of every kind was piled on their heads by lockdown.
As it grew hotter, the walking labourers began to collapse
on the roadside from heatstroke (101). Others, including children, died of hunger and exhaustion on the way.
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It is completely wrong to see this suffering as a
straightforward matter of better managing the lockdown. While migrant labour
was jamming trains and bus stations to get a ride home, the editorial pages of
newspapers in India were jammed with expert opinion on how lockdown could have
been better managed. Certainly, India’s lockdown, announced with no prior
notice and no arrangement for the supply of essential goods and services, was
probably the most reckless and ill-planned in the world. Absolutely no one had
anticipated the migrant labour crisis. But it is flying in the face of reality to
assume that living for weeks and months on rice and dal in a government-sponsored
camp, even if these had been provided for, was a practical, realistic or humane option
for these migrant workers. “What am I here for, if I cannot earn” was the common
refrain. People hid in milk tankers to get away (102). Stopping work did not simply leave these people without means, it took away the
reason for their presence in the city, away from their beloved families and
native soil. Lockdown was more than an economic disruption for them, it
shattered the very reason for enduring the squalor and deprivation of their
lives in the city.
Stopping work did not simply leave these people without means, it took away the reason for their presence in the cities, away from their beloved families and native soil. Lockdown was more than an economic disruption for them, it shattered the very reason for enduring the squalor and deprivation of their lives in the city.
Even when the government made provisions, people were
not able to access them. Walking home from Delhi on the Noida-Agra Expressway daily wagers
said they had had to leave as their employers had told them that they would not
be paid until lockdown was over. They said they had no ration cards and so they would not have been able to avail of government rations if they had stayed on
in the city (98). In Brazil, favela activists also spoke about how residents
were unable to avail of government stipends, as they did not have the required identity
documents (103). There were slum dwellers from
all around India who reported that government rations never found their way to
them. This is not a problem of lockdown management, it is a problem of lockdown
in and of itself. Slums and favelas are made up of undocumented migrants living
below the radar of the city authorities. No one really knows exactly how many
of them there are. The lack of organization and paperwork is not an aberration
to be fixed, but is integral to the presence and survival of these people in
the city.
The lack of organization and paperwork is not an aberration to be fixed, but is integral to the presence and survival of these people in the city.
Measures are taken in the name of the poor without
engaging with them or understanding their attitude to disease. People in slums
and favelas tough it out everyday in poor and unhealthy conditions. In India, every
disease known to man festers in its slums. Afterall, they come up next to garbage dumps
and over canals fetid with the waste of the entire city. The poor are not
unscientific in their approach to the threat of disease, they have simply
learnt to live with it. When we, in India, began opening up from lockdown in May,
Covid-19 was not a fraction less lethal or contagious than it was before, we had
just arrived psychologically to a place where the poor have always been.
In mid-June, when the Covid cases exploded in India in numbers that were higher by the lakhs from the few hundred when we had locked down in March, we persisted in the project of “unlock”. Why? We had learnt the lesson of the futility of lockdown. A lesson learnt on the backs of the suffering of the poor. This disease is going to make its way through our population one way or the other. Had we remained unlocked, with a cluster containment strategy as we now have, we would at least have avoided the damage to from lockdown.
The poor are not unscientific in their approach to the threat of disease, they have simply learnt to live with it. When we began opening up from lockdown in May in India, Covid-19 was not a fraction less lethal or contagious than it was before, we had just arrived psychologically to a place where the poor have always been. In mid-June, when the Covid numbers exploded in India in numbers that were higher by the lakhs from the few hundred when we locked down in March, we persisted in the project of “unlock”. We had learnt the lesson of the futility of lockdown on the backs of the suffering of the poor. This disease is going to make its way through our population one way or the other. Had we remained unlocked, with a cluster containment strategy as we now have, we would at least have avoided the damage to from lockdown.
What makes the containment approach even more
questionable, is that despite all the hardship that it imposed, the cases
relentlessly grew and grew. As the cases grew, so did the damage caused by
lockdown. Favela-activist Rene Silva said that the population of
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Stamping on the people to stamp out the virus
In June, after two and a half months of social distancing, some young favela-dwellers in Rio seemed to have been keen to get back to life again. There were reports of so-called “funk dances” being held, and of establishments re-opening. Conscientious community activists like Rene Silva zealously went around telling people not to have their dances, warning that such events would be “bad for everyone”. You can’t help feeling sorry for the young favella-dwellers with itchy feet after weeks of lockdown that seems not to have stopped the rise of Covid-19 anyway (106). It seems a bit unfair for them to have to remain under an endless ban from socialising, considering that Covid-19 spread among the rich folk of Rio as they met in their exclusive clubs (75); and, as Rene Silva and others, like District Health Counsellor Maria Braga are reported to have said, even without balls, social distancing is difficult for people living in the small and crowded dwellings of the favelas (107).
There is something more than a little patronizing in saying that people who choose to go ahead with praying or partying “don’t know better”, and need to be guided by their betters in the community. Maybe they were wiser and better than those who followed the hollow gospel of lockdown.
Pakistan’s Prime Minister, Imran Khan, was severely criticized for
allowing people to attend prayers in the mosques during Ramzan. This was seen as irresponsible,
or somehow pandering to the religious orthodox in Pakistan. But he said, very
humanely, that he could not bring himself to arrest people for wanting to go to
the mosque to pray. Moreover, they went of their own volition and took precautions.
There is something more than a little patronizing in saying that people who
choose to go ahead with praying or partying “don’t know better”, and need to be
guided by their betters in the community. Maybe they were wiser and better than
those who followed the hollow gospel of lockdown.
As in the case of the funk dances of Brazil’s favelas, authorities in South Africa found it hard to stop people in the poor, and, significantly, black townships from socializing. Apparently there were many cases of “backyarding” where two or three men would get together for a beer in backyards of their own homes. Surely, this poses a minimal public health threat, especially to better off South Africans drinking beer in the privacy of their villas. But public health enforcement as party-pooper took its ugliest turn here with people actually being killed by the police for backyarding (110). South Africa’s Police Minister Bheki Cele had reportedly given orders not to “be nice” to people suspected of breaching lockdown (111). In Alexandra, soldiers stormed a man’s house after claiming to have spotted him having a beer with a friend in his backyard. They beat him up so brutally, that he died three hours later (112). In another poor, black locality called Vosloorus, a man was shot dead by police when chased into the veranda of his own home from a neighbour’s house, where the police claimed beer was being sold. Children of his household aged 5, 6 and 11 years were injured in the shootout.
In France, the enforcement of lockdown exacerbated tensions with the police in the low-income districts surrounding Paris. These districts have large numbers of residents of African origin. A few days into the lockdown, videos came out on social media of heavy-handed police arrests of people out in the open in these areas. People on social media commented that the same harsh approach would not have been taken in the better off areas of Paris. Things deteriorated to the point where there was rioting in many of these localities. The police claimed that encounters in these areas were owing to trouble with drug gangs whose activities were being interrupted by the lockdown. The French Interior Minister dug in saying the rioters would not deter the enforcement of the lockdown (113). It looked very much like a case of the authorities using lockdown to settle old scores. The situation got so bad that a petition was taken out by a number of human rights and Muslim community-advocacy groups, including Human Rights Watch, condemning these events (114).
In the USA, African-Americans were found to be faring much worse in the Covid-19 outbreak than White Americans. They were showing higher rates of mortality and in some cases also of infection. The state of Louisiana, which has a large black population that outnumbers whites in some cities, was an early Covid-19 hotspot in the USA. Many black activists and community voices were critical of the authorities for failing the black community in the Covid crisis. They said that owing to poverty and marginalization blacks in general had poorer health and lessor access to good medical services; and this was the reason Covid-19 disproportionately hurt their community.
Louisiana’s Covid-19 outbreak began in New Orleans,
weeks after their famous Mardi Gras festival. Many of their initial cases were
traced back to this festival, which was held in late February. The mayor of New
Orleans said that the state could not blamed for having gone ahead with Mardi Gras,
when the Federal Government itself was not taking Covid-19 seriously at the
time (169). It is a fact that US President Donald Trump was among the
world leaders who had scoffed at Covid-19 in February and early March.
It was said that many in the black community did not take social distancing, mask wearing and other containment measures seriously because the disease was perceived as not being a threat to them. If there was such a sense in black communities then there was some logic to it, as the rich international-jet-setters who brought Covid-19 to both the Americas, and, perhaps, also to the Mardi Gras which was attended by 1 million visitors from outside, were probably worlds apart from many of the black communities of Louisiana. There are reports of black doctors and activists being concerned about this from the start, and trying hard to persuade others in the community of the threat of Covid-19 (105).
But no one, of any race, was much concerned about Covid-19 at the time. Activists said that more should have been done to spread awareness of Covid-19 in black communities, and that government awareness campaigns should have included announcements that were specifically targeted at blacks. But officials said they were concerned that this would lead to stigmatisation (105). The initial approach of the authorities to not declare race-based data about Covid-19, was criticized for hiding the special vulnerability of the black community to the disease.
These concerns were correct. As soon as race-based
data was released, it was clear that blacks were disproportionately affected in Covid-19 outbreaks in many places in the US. But we have to pause here to see
the full implications of this line of argument, which essentially follows
WHO-led public health thinking behind lockdown, which is that the poor and
marginalised are especially vulnerable to disease as well as short on resources
for treatment, and so containment measures are necessary, above all, to protect
them (170). Imagine how it would have gone down if President Donald
Trump, of all people, had suggested shutting down Mardi Gras in February
because of some flu-like disease in far-off Wuhan.
It is foolish and dangerous to ask for already antagonised communities to take such severe and unprecedented self-inhibiting action at the word of authorities whom they do not trust, and who have let them down so often in the past. The explosion of the Black Lives Matters protests all across America in late May after the death of George Floyd while being arrested, shows the depths of racial tension in the USA. Versions of these tensions exist between different communities in all countries. The WHO and public health officials are demanding containment measures by assuming a trust and goodwill among the people, and between the people and the authorities that does not exist, and which has been betrayed over and over by majorities vis-Ã -vis minorities in society; not to mention the ever-present and universal phenomenon of government abuse and incompetence.
This is not to say that people would have been wrong
not have heeded him, but to point out that it is foolish and dangerous to ask
for already antagonised communities to take such severe and unprecedented
self-inhibiting action at the word of authorities whom they do not trust, and
who have let them down so often in the past. The explosion of the Black Lives
Matters protests all across America in late May after the death of George Floyd
while being arrested, shows the depths of racial tension in the USA. Versions
of these tensions exist between different communities in all countries. The WHO
and public health officials are demanding containment measures by assuming a trust
and goodwill among the people, and between the people and the authorities that
does not exist, and which has been betrayed over and over by majorities
vis-Ã -vis minorities in society; not to mention the ever-present and universal
phenomenon of government abuse and incompetence.
All this has to be weighed in the balance before choosing to take a containment strategy against disease in the name of saving the poor. The Indian Express report from the slums of Dharavi quoted earlier has the reporter accompanying social workers, known as “ASHA” workers, on a hunt for a family that had been snitched on by a neighbour for breaching quarantine. The public health administration is using ASHA workers who know the labyrinthine gulleys of Dharavi, to hunt the family down. All the slums and ghettoes of India are built around a maze of narrow gulleys. Ordinarily, they form an almost invulnerable shield over their residents, against even the most powerful of their counterparts in the city. “Anyone can hide for months without being found in our gulleys”, residents will tell you proudly. In normal times, they would be right. But Covid-19 has left the poor with nowhere to hide.
In Delhi, in late
June, when the Central Government tried to impose mandatory institutional
quarantine on everyone coming in contact with Covid positives, its decision was
overturned within 24 hours by the Supreme Court. Compare that with the fate of
the family in Dharavi, in the reporter’s own words (26): “the family
insists it’s mistaken identity — nobody is sick. Eventually, it emerges that
the neighbours had complained against the family for not completing quarantine
after a contact was found positive.
“Tempers run high briefly as the young man of the family emerges at the doorway and threatens to assault the neighbour who complained. ANM Vibha Kulkarni [female health worker] says this is common, and the team deals with the reluctant family with good humour and tact. “Put them all ‘inside’ for two weeks,” a neighbour shouts.”
The hapless family is then frogmarched to some no doubt miserable hovel for a spell in the grandiosely named “institutional quarantine”. Better off people are able to quarantine at home. The numbers speak for themselves. By the end of April about 1.7 lakh people had been quarantined in Mumbai, 10,000 of them in institutional quarantine, of which by the third week of May over 7000 were from Dharavi. Officials were reported to say that “More people from slums will be kept in institutional quarantine facilities” (86).
In Africa, as in India, quarantine and other mandatory
measures fell harder on the poor. United Nations Human Rights officials noted
that “those who cannot pay bribes, poor people, are taken to mandatory
quarantine centres” (91). In South Africa, the homeless were rounded up
and taken to quarantine shelters that were in such poor conditions that they would run
away. There was also the fear of contagion from being concentrated in these
shelters
--------------------
The toxic culture of lockdown
Officials in Louisiana were right to believe that
racially targeted awareness campaigns for Covid-19 would have been
stigmatizing. Asking people to essentially look upon others as contamination
risks and pandering to people’s instincts of self-preservation gave free reign
to their pettiest and most blatantly divisive tendencies; from rampaging
through stores to hoard essential goods, to vigilantes beating up people for
“spreading Covid”.
The intervention of a good, civil society ought to have been, to anticipate and moderate these reactions, but civil society advocates were at the forefront of demanding a complete lockdown, in the name of protecting the poor and marginalised. In many countries that have right wing majoritarian governments, such as India, Brazil, the UK and USA, it was liberals, left wing activists and opposition party mayors and governors, who were the earliest, loudest and most insistent voices, for social distancing, the banning of public gatherings, stay-at home orders and other restrictive and intrusive state measures, against Covid-19.
Indian progressives, saw no irony in advocating social distancing, after having spent generations, fighting caste-based personal pollution norms, and touch taboos. No one in civil society in India, raised a question, about the stigmatization that is embedded, in notions of keeping inter-personal distance. We were now one people, facing one germ and with one, united purpose – to flatten the curve. Anyone who objected, that this was actually flattening the people was unscientific, irresponsible, and callous about the poor.
As the intrusion and repression of disease containment-measures were couched in the language of public policy and social work, which is sacred to liberals everywhere, they fell into a familiar pattern, of going in the teeth of all liberal values, to become the greatest friends and advocates of state power. They did not see, the ways in which non-pharmaceutical interventions for disease control, are directly and immediately stigmatizing, divisive and generally toxic. They did not see that they were demanding what was, in effect, a total and indefinite suspension, of the very civil liberties, and constitutional freedoms, on which liberal society is founded, and on which, the poor and marginalised depend, to extract some pickings of justice and fairness from society. They rushed to show, what good global citizens they were, and how caring they were for the poor, by espousing the creed of disease-containment.
Discipline & Punish
In India, the cultivation of fear and suspicion in the name of disease-containment had an almost instant fallout on its beleaguered Muslim minority. First, sensing that they would be blamed for any Covid-19 outbreak in India, they voluntarily broke up a nationwide sit-in, the Shaheen Bagh Protests, that had been going on for three months against a discriminatory citizenship law passed by the Hindu-majoritarian government at the Centre. Then, four days into the lockdown, and despite all their efforts to prove themselves as “good citizens” by dispersing their hard-fought movement, Muslims found themselves being blamed nevertheless for Covid-19, based on some cases that were traced to a gathering of an obscure orthodox Muslim group called the Tablighi Jamaat. For India, this was a small gathering of some 1500 people. Big Hindu temples were attracting many more people all over the country, more by the tens of thousands, at the same time as the Tablighi Jamaat gathering.
But for four weeks, Covid-19 was treated as though it were an entirely Muslim problem, to a stream of abuse and taunts from the anti-Muslim sections of the Indian media and public. Even the liberal media started with a tut-tutting tone about the Jamaat. They had been zealously participating in the social distancing and community hygiene drive against Covid-19, seeing themselves as they do, as enlightened, public-health-conscious, globally aware liberals. They had followed people on camera on their morning walks and while buying vegetables from street hawkers, berating them for violating social distancing. So, running as they were full tilt on the momentum of hysteria over Covid-19, it took a few days of Muslim-bashing from the right-wing media before the liberal media realised on whose side it had landed in supporting social distancing. Then they changed tack, but it was too late. A vicious atmosphere had been created. Pretty soon we had reports from all over the country of Muslim men being set upon and thrashed by Corona vigilantes, of posters going up in colonies telling Muslim to keep out and all the ugliness of communal hatred in India that is always waiting in the corner to show itself (118).
Even the liberal media started with a tut-tutting tone about the Jamaat. They had been zealously participating in the social distancing and community hygiene drive against Covid-19, seeing themselves as they do, as enlightened, public-health-conscious, globally aware liberals. They had followed people on camera on their morning walks and while buying vegetables from street hawkers, berating them for violating social distancing. So, running as they were full tilt on the momentum of hysteria over Covid-19, it took a few days of Muslim-bashing from the right-wing media before the liberal media realised on whose side they had landed in supporting social distancing.
Members of the Tablighi Jamaat had been staying in a six-story building called ‘Markaz’ in New Delhi’s Nizamuddin Basti. The Nizamuddin Markaz functions as an institutional centre and board-and-lodge facility for Jamaat members visiting from outside Delhi. They come from India and all over the world. The Markaz accommodates several thousand people for night-stay on any given day. The ultra-orthodox Tablighi Jamaat is a fringe group. Their strict rules of conduct keep their members wrapped up in prayer and a generally monastic life. As a result, members keep to themselves, and very few cases spread out into Delhi from the Markaz, even in the cramped ghetto of Nizamuddin Basti, where the lanes are so narrow that you cannot even stretch your arms out fully from side-to-side as you walk through them.
After the Tablighi Jamaat cases were detected, Nizamuddin
Basti was sealed off for 70 days, thousands of people were quarantined and
tested, but, to the best of my knowledge, no cases were found there apart from
those in the Markaz.
The Tablighi Jamaat story very clearly demonstrates the ways in which containment strategies of sealing off areas, contact tracing and quarantining can be used by governments to target and victimise people.
The Tablighi Jamaat story very clearly demonstrates
the ways in which containment strategies of sealing off areas, contact tracing
and quarantining can be used by governments to target and victimise people. The
government had actually begun routine contact tracing of Tablighi Jamaat
members in mid-March, before the lockdown. What appears to have happened was that one person who had visited the Nizamuddin
Markaz from outside Delhi, early in March, had fallen ill and succumbed to Covid-19 on
returning home. In the third week of March, on the eve of India's lockdown, the Central Government had written to state governments to contact trace Tablighi Jamaat members (115). All this
was going on quietly in the background while the Indian public was rivetted by
the migrant labour crisis, which had hit the news with a bang within days of
the lockdown. For forty-eight hours the television and papers went
cover-to-cover excoriating the government for having overlooked the devastating
effect on India’s poor of the imposition of its shock lockdown. The Government had
clearly been utterly unheeding of Indian realities in making its shock
announcement of lockdown seeking, as it seems, only the approval of the WHO
which, even while Covid-19 was showing itself to be the disease of the richest
cities of Europe and the USA (Paris! Milan! London! New York!), was issuing
press briefings all through late March invoking the world’s “poor” and “densely
populated” countries as determining the course of this disease (36).
Now the Indian government, after getting a star and smiley face from the WHO for locking down, suddenly found itself being stood in the corner by the Indian public that it had forgotten about. This is when the Tablighi Jamaat story which had begun before the lockdown, suddenly entered the news (115). A slick move, indeed, as overnight the main news story changed from the migrant labour crisis to Muslim “super-spreaders”. While Donald Trump was tweeting about the “Wuhan-virus”, hashtags like “CoronaJihad” were trending in India.
The Tablighi Jamaat were shown on live television being taken under police escort from the Markaz where they had been quarantining themselves, to another place where they would be quarantined by their caring Government, and given a “medical check-up” of whose intimidating and humiliating nature no one was in any doubt. One Jamaati was so scared that he attempted suicide (37).
It was an absolutely perfect opportunity for a certain quarter in India to give free reign to all its malice against Muslims. Jamaatis were accused of “spitting”, a high crime under the reign of Covid-19. In reality, spitting is a common Indian habit, especially among the poor who are great fans of the betel nut, which is enjoyed by tucking it into a corner of the mouth, where it generates copious amount of saliva, which is then spat out expertly in bright-red jets. The corners of government offices and law courts in North India are often stained red from expectorated betel juice. But this commonplace indulgence gave great scope for those with a grudge against Muslims to accuse them of deliberately spreading Covid-19. Riled up residents of the neighbourhoods to which they were bused for quarantine, claimed the Jamaatis spat on the road, “deliberately” (116)! It would have been better to have left the Jamaatis to quarantine in the Markaz where they were found, but riling people up is just what was wanted.
Delhi’s Chief Minister, who is a great fan of the Northern European welfare state model, and, along with other public health enthusiasts, sees Covid-19 primarily as a challenge to keep numbers down, lashed out at the Jamaatis. The previous week he had issued an order restricting the size of public gatherings which no one, not just the Jamaatis, had heeded. He dug up the order at a press conference to show how he was being a good boy about Covid-19 when the Jamaatis did their “harkat” or “mischief”, and spoilt everything (117). No one asked him about the millions who had been circulating all around Delhi at the same time on crowded public transport and other places. No one asked him about the festival of Holi that had just been played by many Hindus in Delhi, including this writer, with throwing coloured water on each other and generally engaging in Covid-enhancing behaviour.
The Tablighi Jamaat affair was only one of many
examples of discrimination from around the world against minorities in the toxic
social distancing atmosphere that was encouraged in response to Covid-19. In South
Korea, an early Covid-19 outbreak was traced to a small Christian sect called
Shincheonji. Even though South Korea made not locking down a matter of pride in
their Covid-19 response, the Church’s members were blamed for gathering despite
the Covid-19 threat, and, as is typical in all religious targeting for the
epidemic, portrayed as holding themselves above the risk of infection, because
of their blind faith in God.
This was the story. But a White Paper on this episode
by a number of European human rights groups, including a body called Human
Rights Without Frontiers and some international groups speaking for Christian
minorities worldwide, painted a very different picture (119). The Shincheonji
sect was deeply unpopular in South Korea and had a history of discrimination
there. The woman from this Church who was said to have infected others, had been
hospitalized in February after being involved in a minor car accident. She had
been diagnosed with a cold and sent home. Thereafter, she went about her normal
life, including attending the Shincheonji gatherings. She was diagnosed with Covid-19
only several days later, when her condition worsened and she had had to go to
hospital again. The woman said that she had not refused to be tested for Covid-19
and that doctors were making these claims to cover their own mistake in missing
her infection previously.
The White Paper conceded that some people had tried to
hide their association with Shincheonji when the contact tracing exercise was
undertaken, but this was because the Church was so unpopular that they feared repercussions, including losing their jobs if their association with it was disclosed.
So once again, you have the same pattern of stigma,
finger-pointing and fear generated by containment measures. The White Paper on
the Shincheonji episode also gives some interesting information on how religious
minorities have historically been targeted during epidemics. Even during Covid
times the Wall Street Journal ran a story luridly titled “Coronavirus is
spreading at religious gatherings, ricocheting across nations” (120). Actually,
what is abundantly clear is that it was international travel and trade by the
sort of reader who takes the Wall Street Journal that was making Covid -19 “ricochet
across nations”.
If you follow countries as they trace back their
outbreaks you will see that Covid-19 spread in diverse settings and from
diverse vectors of transmission all at once – travel, sports events (like a big
football match in Italy against a Spanish team), festive family reunions (in
China over their annual Spring festival), social events at exclusive clubs (in
Rio de Janeiro) and bars (in Japan and South Korea), big street celebrations
(like Mardi Gras in Louisiana and beer festivals in Germany), choir groups (in
Washington State), from doctors, in hospitals, in communal settings like old age
homes and even International Women’s Day parades held in early March in Paris
and Madrid.
The myth of the "Super-Spreader"
At the start of an outbreak, no one knows where a
disease is going to come from. It takes weeks of painstaking contact-tracing to
build up a picture of the transmission-routes of a disease. But religious
gatherings are easy to spot; and an easy target for blame. Take, for instance,
what happened when the first cases were detected in Free State in South Africa.
Among the first cases, five were traced to a church gathering. It looks as
though the church gathering was responsible, but the people coming there had
caught the infection from many different parts of the world - the USA, France and
Israel. So foreign travel played as much of a role here as attending church (121). On the same day as these cases were
found, South Africa’s “Patient Zero”, who had imported the infection from Italy,
was reported to have recovered. But despite this vigilance with early tracing
and quarantining of cases, South Africa went on to have a substantial Covid-19
outbreak. So even the identification of Patient Zero and of public gatherings
with infected patients, has limited value in actually containing a disease that
is coming into a country from everywhere
Identification of “super-spreaders” has to be understood with a little less of the “gotcha” attitude.
This is why the identification of “super-spreaders”
has to be understood with a little less of the “gotcha” attitude. You can have
no super-spreaders, no patient zero and still have a massive outbreak, as in
Paris or New York. Or, as in New Delhi, you can find and isolate super-spreaders
like the Tablighi Jamaat, and still have a massive outbreak months later. In
late June, the super-rich New Delhi colony of Jor Bagh was sealed after a
sudden outbreak of Covid-19. There is no question of any Jamaati ever having
met a single person from there.
There are no clear figures on how many cases were
eventually traced back to the Tablighi Jamaat. The Health Ministry claimed in
mid-April that over 4000 cases were linked to the event, but while the
controversy was raging, the Central Government insisted on taking over
publication of Covid data from the autonomous Indian Council of Medical
Research (ICMR). There are no details as to how cases were attributed
to the Tablighi Jamaat, whether they were linked to any Jamaat event in the
Nizamuddin Markaz, or merely people who had stayed or passed through the
building, whether the figure quoted refers to contacts, i.e., suspects or
confirmed cases, and so on. Even
assuming the Government’s figures attributed to the Tablighi Jamaat are fair
and correct, today, just three months on, with India at over 10 lakh cases and more
than 26,000 deaths, the Jamaat event is so small as to be invisible in the full
picture of its Covid-19 outbreak.
Super-spreaders are not those who drive disease outbreak, they are simply those who are most easily identified as spreaders by contact tracers.
Super-spreaders are not those who drive disease
outbreak, they are simply those who are most easily identified as spreaders by
contact tracers. We should stop using this stigmatising expression. This has
already been recommended by UNAIDS which, based on its experience with AIDS,
published a paper early in the Covid-19 pandemic warning that expressions like super-spreader should not be used should not be
used (123).
--------------------
South Korea attracted widespread praise for keeping
its Covid-19 numbers low using vigorous testing and contact tracing. But we
also need to take note of the discrimination and blaming of those who fell sick,
that ran in parallel with these containment efforts. After several weeks free
of Covid-19 cases, there was a second outbreak in South Korea which was traced
to an area said to have a number of gay night clubs. Hostile remarks targeting
gays were made on videos of the night clubs and, as in the case of the
Shincheonji Church, people were driven underground to avoid testing and quarantine.
There were also stories from South Korea of establishments putting up posters barring
Chinese or all foreigners from entry.
Chinese people abroad, and people with racial features similar to theirs, were targeted all over the world, from India to the USA. At the same, time there were reports of racism in China against Africans who were being thrown out of their rented accommodations and denied entry into restaurants owing to fear of “imported cases” of Covid-19. This attracted sharp rebuke from the African Union (124). The list of xenophobia, racism and discrimination sparked by Covid-19 goes on and on. It got so bad, that Wikipedia has taken out a separate page dedicated to such incidents under the title “List of Incidents of Xenophobia and Racism related to the Covid-19 pandemic” (125).
Policing to death for disease containment
Some countries like Bangladesh, and many in Africa, went to the extremes of deploying their armies to enforce disease containment measures (126). In Bangladesh, the Army Chief claimed that his troops patrolling the streets made the populace “mentally relieved” and had “highly energized” them! Human Rights Watch claimed that civilians, including academics and Opposition party workers, had been arrested for posting social media messages on Covid-19 that the Bangladesh Government called “rumours” and “propaganda” (127).
In Nigeria, by the middle of April, eighteen people had been killed by armed forces and police in the enforcement of lockdown. More than the total number of people dead of Covid-19 in Nigeria by that time (128). In Kenya, a 13-year old boy was killed by a bullet fired in the air by the police to impose Covid-19 curfew (109).
I have already described the killing of people in the poor, black neighbourhoods of South Africa by the Army and police while enforcing lockdown. There were 3 deaths in South Africa in the first 3 days of lockdown. The number grew to 8 in the following week (28). By this time, the lockdown mentality had taken such firm hold that even the BBC, which has positioned itself as the voice of social justice around the world, published laudatory reports praising “South Africa’s ruthlessly efficient fight against coronavirus” and President Cyril Ramaphosas’s “formidable leadership”. While young men were being shot to death in front of their children for drinking beer by the South African Army, which had been unleased on the country to enforce lockdown by Ramaphosa, the BBC described him as “composed” and “compassionate”. The shooting of civilians was brushed off as the mistakes and thuggery of the police alone (129). Ramaphosa even claimed that the WHO had commended South Africa for “acting swiftly and for following scientific advice to delay the spread of the virus” (130).
People of the developing world, especially coloured people, should take note of how quickly the West forgot about human rights and civil liberties, the things they keep lecturing us about and claim to have gifted to us.
People of the developing world, especially coloured
people, should take note of how quickly the West forgot about human rights and
civil liberties, the things they keep lecturing us about and claim to have gifted
to us. The
biggest irony of all, is the way in which the Western press began in January and February
with criticism of China for its harsh measures against Covid-19, and then
proceeded to vigorously advocate them itself.
--------------------
The false choice between the economy and saving lives; and the utter hypocrisy of the WHO
The trail of death-by-lockdown was not limited to shootings by security forces in Africa. In India, the government responded to the news of migrant workers streaming out on the highways by putting the police there to stop them, and send them back to the cities. After a good beating, of course. So the migrant workers began to take off-highway routes out of the cities. The trains had been stopped for lockdown, but the tracks provided a clear open route back home. With the authorities focused on the highways, there was a good chance of making it home without being caught. It worked, no one knew this was going on until one early morning, in the first week of May, when a group of migrant workers who had camped along the tracks for the night were run over by a goods train. Sixteen of the group were cut to shreds by the train (131). Since passenger trains had been stopped by lockdown, some goods trains were being run, at double the usual speed, on passenger routes. But the public hadn’t known about this.
By the time of writing, road accidents, heat stroke, exhaustion and hunger had taken hundreds of lives among the migrant workers, and their children and babies on the journey home (132). Hundreds, that is, were identified. We will never really know the full extent of the numbers who fell victim to this perilous and unnecessary, but for lockdown, journey. These were informal, undocumented workers, making an informal, undocumented journey; forced to run from hunger, while hiding from the authorities who were flattening the curve and being responsible public health administrators according to the expert advice of the WHO, and such eminences as Richard Horton, editor of The Lancet. Horton wanted a 10-week lockdown for India (133).
The adoption of containment measures is phrased by epidemiologists like the Covid Experts Group as a false choice between saving lives and saving the economy. In their report of March 26th, the Covid Experts Group says, “We do not consider the wider social and economic cost of suppression, which will be high….Our analysis highlights the challenging decisions faced by all governments in the coming weeks and months, but demonstrates the extent to which rapid, decisive and collective action now could save millions of lives” (7).
But while epidemiologists talk of a choice between the
economy and saving lives, in its Guidance for Managing Ethical Issues in
Infectious Disease Outbreaks of 2016, the WHO itself shows that it was, at least
at that time, alive to the fact that the two are not separate: “Even short term
restrictions on freedom of movement can have significant – and possibly
devastating – financial and social consequences for individuals, their
families, and their communities.”
Governments have finally woken up to what was obvious all along, which is that the economy and health are inextricably tied up with each other. So even though the Covid Experts Group and other epidemiologists wanted indefinite lockdown till drugs or vaccines were found, governments everywhere are scaling back their containment measures. This is not a “choice” between health and the economy. Lockdown was affecting health too. And killing people.
For the WHO to have advocated a strategy that imperilled the lives of so many, and put so many more through hunger and deprivation, is all the more outrageous when you consider that death from accidents (“unintentional injuries”) and malnourishment are actually declared as heads of disease in its Global Burden of Disease profile. By the WHO’s own logic, therefore, no excuses are allowed for anything, not even fate, when assessing the health of a people. This is the only logic for the WHO to have included things like death by “unintentional injuries” are included in the WHO Global Burden of Disease listings. By including malnourishment in its Global Burden of Disease profile, it is the WHO that tells us that there is no choice between the economy and lives. So how could the WHO have advocated and supported disease containment measures when they put people in the way of the very deprivations and accidental deaths that the WHO itself says have to be eliminated from life? What has the WHO gained, other than its own aggrandizement, by making a global project of these universalist and totalizing claims about health, disease and death?
For the WHO to have advocated a strategy that imperilled
the lives of so many, and put so many more through hunger and deprivation, is
all the more outrageous when you consider that death from accidents (“unintentional
injuries”) and malnourishment are actually declared as heads of disease in its
Global Burden of Disease profile. By the WHO’s own logic, therefore, no excuses are allowed
for anything, not even fate, when assessing the health of a people. This is the
only logic for the WHO to include that things like death by “unintentional injuries” are included in its Global Burden of Disease listings. By including malnourishment in its Global
Burden of Disease profile, it is the WHO that tells us that there is no choice
between the economy and lives. So how could the WHO have advocated and
supported disease containment measures when they put people in the way of the
very deprivations and accidental deaths that the WHO itself says have to be
eliminated from life? What has the WHO gained, other than its own aggrandizement,
by making a global project of these universalist and totalizing claims about
health, disease and death?
To really place the Covid-19 saga in context, we have
to get a full understanding of how the WHO and public health thinking in
general have cultivated a global culture of health extremism, without, as it
turns out, actually believing in it themselves.
This was how it went: dealing with sickness and death
was not enough to contain the big bleeding hearts of the WHO and the public
health field. So they made longevity into an index of national health. Now
societies were declared to be callous and irresponsible if they did not manage
to make their people survive till past 80. Because endless lonely
years in an old age home is, obviously, the end that everyone desires and
deserves. There are no marks here for poorer countries having, as the Covid
Experts Group noted, much wider social contact and integration of the elderly,
than in richer countries.
Even this was not enough to satisfy the
all-encompassing and infinite concern of the public health policy field. They
evolved the concept of DALY – Disability-Adjusted Life Years. Life was to be
measured not in years, but in time lived without disease or pain of any kind. In
this way, health became no mere matter of disease and injury but a bizarre
ideal where there would be no sickness or accident, and, it seems even death
would be indefinitely postponed, if not eliminated altogether. I alternate
between finding this comical and deeply unsettling. Who are these weirdos at
the WHO to whom we have outsourced thinking about so important and personal a matter
as our health, and that of our children?
--------------------
The misery and failure of disease containment for Ebola
Even though the WHO led with a containment approach for
Covid-19, there was already a lot of evidence that this was not working very
well, from the Ebola epidemics of West Africa. Contact tracing made people feel
victimized for falling ill, and resentful of health officials.
Foreign funds given to hygiene “sensitizing” campaigns came to be seen as nothing more than a money-making racket (29). West African governments have been accused of using Ebola, and now Covid-19, outbreaks as an excuse to postpone elections and target opposition strongholds (134). Contact tracing, identifying “super-spreaders”, attributing the spread of infection to age-old food habits or burial rituals, which epidemiologists and the WHO see as benign processes to help contain epidemics, all make people feel targeted and alienated (135). Mandatory quarantine in government centres without basic facilities and the insistence on bringing victims for treatment in designated hospitals, where they are completely isolated from their loved ones, is traumatizing for both patient and family (30).
A 1995 report from the Ebola outbreak in the Democratic Republic of Congo (then known as Zaire) describes people running away from quarantine with help from the community, and of villagers resisting Red Cross trucks that came to take the sick away for treatment (31). 25 years and four outbreaks later, the same scenes are described by Human Rights Watch in the 2020 Ebola-gripped Democratic Republic of Congo. Resentment has spilled into hatred, with cases of health workers being murdered by local militias (134).
The freezing of borders in West Africa and designating
so-called “containment zones” cuts off villages and towns, leaving people short
of medicine, food and other supplies. There is economic damage from weeks and
months of lockdown. The closure of international borders between Ebola-affected
West African nations in the 2014-16 outbreak is said to have grossly interfered
with the dense historical social, filial and economic links between these
nations, making the breaches by the public of border restrictions inevitable,
and even necessary (29).
All measures of disease containment, which the WHO believe are routine and beneficial, cause immense suffering to the people. They also appear to have little effect. There have been five Ebola outbreaks in West Africa since 1976; each outbreak reads like a repeat of the previous one, with the disease inexorably raging through small clusters in villages and cities, and then abruptly stopping, regardless of containment measures.
In this way, all the measures of disease containment,
which the WHO believe are routine and beneficial, cause immense suffering to
the people. They also appear to have little effect. There have been five Ebola
outbreaks in West Africa since 1976; each outbreak reads like a repeat of the
previous one, with the disease inexorably raging through small clusters in
villages and cities, and then abruptly stopping, regardless of quarantine
measures, contact tracing, locking the borders, PPE kit
supplies and so on.
Hospitals have been the origin of Ebola outbreaks on
successive occasions despite all the forewarning and preparedness about this. What
more proof do we need that containment does not work for a sufficiently
contagious virus?
Each Ebola outbreak has been bigger and lasted longer than the last, and yet the WHO has applied the same containment approach each time, without questioning whether it may be ineffective, or worse, contributing to the successive rise in epidemic size.Instead of introspecting, the WHO makes a big song-and-dance about “communicating” the importance of measures to the people. Maybe the WHO should start communicating by listening to the people it is supposed to be saving.
Each Ebola outbreak has been bigger and lasted longer
than the last, and yet the WHO has applied the same containment approach each
time, without questioning whether it may be ineffective, or worse, contributing
to the successive rise in epidemic size.
The Army is routinely called out in West Africa to
enforce containment. In 2014, Sierra Leone passed a law making it a crime,
punishable with 2 years’ imprisonment, to shelter Ebola patients (134).In this manner, since the 1970s, when the
WHO first instituted containment measures as an Ebola response, more and more
force has had to be used in West Africa to make people adhere to them. This is
at least an indication that they are not working. But no one asks why people
resist containment measures if it is so clear that they are working for them.
Instead of introspecting, the WHO makes a big song-and-dance about
“communicating” the importance of measures to the people. Maybe the WHO should
start communicating by listening to the people whom it is supposed to be
saving.
Every time there has been an Ebola outbreak in West
Africa since the 1990s, scholarly articles have been written on the need to
build trust in the community, to engage the public in agreeing to changes to
their burial rituals, on the need for general improvement in West African
health infrastructure, on whether the blame lies with the colonial legacy or global
disparities, whether it is right to blame the consumption of bushmeat for the
spread of the disease, and whether, even if this is responsible, it is
the result of ecological damage, and so on (29, 32).While all of this is well-meant and correct in its way, it completely
ignores a more prosaic and, perhaps for Western commentators, less exotic
reason, for the resistance from the general public to non-pharmaceutical
interventions. This being that they are oppressive, ineffective and do harm
beyond the disease itself. As Ignace Gata Mavita, the Mayor of Kikwit, the
epicentre of the 1995 Ebola outbreak in Zaire said to an American reporter
“It’s good to issue a quarantine, but they have to find another solution or we
will have dire economic circumstances….If the quarantine continues much longer
the world may have its solution, but we will starve. When people don’t eat
well, their health suffers, and they will create another crisis. Here in Kikwit
we know the link between hunger and disease”
Similar frustration is expressed by people in the
poultry business in India, Vietnam and other Asian countries where the WHO
insists on their changing age-old informal home-based poultry rearing based on
scanty scientific evidence, and demands widespread culling of poultry after a
few cases of illness. Again, instead of reconsidering its kill-and-contain
policy, the WHO accuses the locals of being ignorant, irresponsible and so on (136).
--------------------
The WHO’s single-minded focus on disease as a public health strategy misses the fact that disease sits
inside people. Its war on disease becomes a war on the people. The blindness of the WHO and public health field in
general to the obvious failures of non-pharmaceutical measures in West Africa
speaks to the extent to which the dogma of disease containment has taken hold
of them. The way in which the WHO and public health policy have extended their
reach into the depths of people’s lives by using stretched and abstract concepts
of health, disease and death, while winking at the real ill-health,
disease and death caused by their proposed containment measures, should be a
standing lesson to the world of the insensitivity and arrogance of public
health thinking.
The way in which the WHO and public health policy have extended their reach into the depths of people’s lives by using stretched and abstract concepts of health, disease and death, while winking at the real ill-health, disease and death caused by their proposed containment measures, should be a standing lesson to the world of the insensitivity and arrogance of public health thinking.
While migrant workers in India were dying, their young
wives becoming widows, their children orphaned, their ageing parents losing
their only support in life, this is what Mike Ryan of the WHO had to say about
India’s lockdown in late March: “society-wide measures are difficult, they are
not easy and they are hurting people. But the alternative is even worse……But
unfortunately in some situations right now they’re the only measures that
governments can actually take to slow down this virus and that’s unfortunate
but that is the reality and we need to continually explain the reasons for this
to our communities” (19).That’s right,
“explanation” is what was needed by the women giving birth in India on the
sides of highways on the long escape from lockdown.
While migrant workers in India were dying, their young wives becoming widows, their children orphaned, their ageing parents losing their only support in life, this is what Mike Ryan of the WHO had to say about India’s lockdown in late March: “society-wide measures are difficult, they are not easy and they are hurting people. But the alternative is even worse……But unfortunately in some situations right now they’re the only measures that governments can actually take to slow down this virus and that’s unfortunate but that is the reality and we need to continually explain the reasons for this to our communities”.
When insisting on a containment approach to Covid-19 on March 9th at an international press briefing, Mike Ryan sanctimoniously lectured the world about how while in epidemiology “we talk about the n, the size of the population we’re dealing with….Well, for me, as a medical professional, n equals one. Every person matters” (17). What happened to these lofty sentiments when Mike Ryan endorsed India’s lockdown three weeks later, despite what it was doing to its people? What fraction of n=1 were the dead migrant labourers, their women giving birth on the highway, their babies starving to death on the way home, and their orphaned children?
The reality of the WHO's "All-of-Society and All-of-Government" approach to disease containment
Two months later, in May, when stories of the plight
of the poor in India under lockdown must have finally registered with the WHO,
they tried to backtrack from it. They trotted out their Chief Scientist, Soumya
Swaminathan, who luckily for them, happened to be an Indian. In a
television interview in early May, Soumya Swaminathan said, cool as a cucumber,
that the WHO had never recommended lockdown (39). Given the things that the WHO was saying in March about India, which I have quoted above, this is stretching the truth as far as any smooth-tongued WHO bureaucrat can make it go..
From the start the WHO has insisted on a containment
strategy for Covid-19, insisting that even mitigation will not do. Mitigation
being measures to contain the virus within cluster outbreaks,
instead of what Mike Ryan calls “society-wide” measures. The Director General
of the WHO, Tedros Adhanom, repeatedly insisted that there must be an
“all-of-society” and “all-of-government” approach “built around a comprehensive
strategy to prevent infections” (18, 17). He said that he wanted to have an approach that mobilized “the whole society” and
made “the response everybody’s responsibility” (18). Maria Van Kerkhove, the WHO’s Covid-19 Technical Lead, said that what was
required was “repurposing your government to tackle this one virus” (18).
The WHO got what it asked for. I first came across this phrase “all-government, all-of-society response” in the WHO-China Joint Mission Report on Covid-19. At the time I rolled my eyes at this as something the Chinese must surely have put in. Then I read Tedros Adhanom repeatedly use this ominously Great Dictator-like expression at his Covid-19 press briefings, where it was faithfully echoed by his officials, Mike Ryan and Maria Van Kerkhove.
Let us pause a moment and ask ourselves what does an “all-of-government, all-of-society response” mean? All the people who bore the brunt of Covid-19 discrimination, racism, stigma and bigotry around the world could tell us a lot about this.
Let us pause a moment and ask ourselves what does an
“all-of-government, all-of-society response” mean? All the people who bore the
brunt of Covid-19 discrimination, racism, stigma and
bigotry around the world could tell us a lot about this. Tedros Adhanom should
ask the Tablighi Jamaat members and their families how they felt about all-of-Indian-society
hunting them down them with all-of-the-Indian-government for Covid containment.
Maria Van Kerkhove should ask Indian migrant workers how they feel about the entire
government “repurposing to tackle this one virus”. When the dead workers’
orphans grow up Mike Ryan should ask them how they feel about their parents who
were flattened by trucks and trains as they were forced to walk home from
lockdown-induced famine in the cities where everyone was following his global directives
to “flatten the curve”.
In a way, Soumya Swaminathan was correct, the WHO did
not specifically recommend lockdown. Even the Chinese do not mention this word
anywhere in the WHO-China Joint Mission Report. Going by this Report, even social
distancing appears to have been marginal to the Chinese strategy on Covid-19. The
main intervention of the Chinese for disease containment was to effectively imprison
all Covid-19 suspects in hospital. By hunting the sick down in their homes,
going door-to-door through their Communist Party cadres and by sniffing out Covid
suspects using GPS-tracking, and dragging them all to compulsory hospital
confinement. This is what was the “all of society, all of government approach”
that Tedros Adhanom so fulsomely praised in his January briefings was all
about. This is not what we can or should have.
Where, in any open and democratic society, is the uniformity, obedience and single-mindedness that is implied in the phrase “all-of-society, all-of-government”? In truth it does not exist anywhere, except where it is rammed down the throats of the people by totalitarian and abusive regimes. Seen in this light, it is trust and conformity with authority that are dysfunctional, and not mistrust or a wait-and-watch attitude.
Mistrust of authorities is our shield against
government intrusion and incompetence. Where, in any open and democratic
society, is the uniformity, obedience and single-mindedness that is implied in
the phrase “all-of-society, all-of-government”? In truth it does not exist
anywhere, except where it is rammed down the throats of the people by
totalitarian and abusive regimes.
As an African, Adhanom should feel ashamed for what he
has brought upon his compatriots with Covid-19 containment. He should have
known that some African governments would be trigger- happy with calling out
their armies to enforce containment, and that in places like South Africa, poor
blacks would be at risk of being shot at. As an Indian, Soumya Swaminathan
should likewise be ashamed of what the WHO has brought upon India. She should
have anticipated the communal forces that would be unleashed, the stigma that
would have followed all the social distancing propaganda and the hunger and
deprivation that would follow lockdown. If public health officials don’t know
their people, then what good are they? Why do we have a concept of public
health if it does not consider the people, their culture, their weaknesses and
strengths? If the WHO feels that taking these factors into consideration is
“political”, then it should stay its hands and not recommend any measures at
all. Because it is always political.
--------------------
Human Rights and Public Ethics Groups have repeatedly shown their discomfort with disease containment as a strategy
In a paper published on March 20th called “Rights in the time of COVID-19”, UNAIDS sets out step-by-step the inherent danger, injustice and futility of this approach, predicting with devastating accuracy the wrongs of each type, petty and profound, that came to pass under the reign of WHO-prescribed Covid-19 containment measures.
Even while the public was being hustled into accepting
lockdown and containment measures, some experts, like UNAIDS, tried to warn the
world of exactly these things. In a paper published on March 20th called
“Rights in the time of COVID-19”, UNAIDS starts by picking up on Adhanom’s
repeated exhortation for countries to respond to the Covid-19 pandemic with
“containment as the central pillar”. UNAIDS says: “Countries are being requested
to take a comprehensive approach…with containment as the central pillar.
However, as in all acute epidemics, especially where causal person-to-person
transmission occurs, there is a need to ensure that the response is grounded
firmly in human rights.” Drawing from its own, and incidentally also the
WHO’s experience, of years fighting AIDS, UNAIDS then sets out step-by-step
the inherent danger, injustice and futility of this approach, predicting with
devastating accuracy the wrongs of each type, petty and profound, that came to
pass under the reign of WHO-prescribed Covid-19 containment measures:
“Forty years of responding to the HIV epidemic has
generated significant experience and lessons learnt on the importance of a
human-rights based approach to ensuring effective and proportionate responses
to epidemics…..swift action must not be rendered ineffective by existing
inequalities…..and barriers related to cost, stigma, privacy and concerns
around employment and livelihoods….
“In times of fear and panic, some countries may resort
to politically driven, restrictive, stigmatizing and punitive measures. These
may include compulsory blanket travel restrictions, quarantining large groups
of people, combining people who have and people who do not have the virus,
publishing the names and details of people who have the virus, using
stigmatizing language such as “super-spreaders” or criminalizing people who may
have breached restrictions or transmitted the virus to others.
“From the HIV epidemic we have learned that
restrictive, stigmatizing and punitive measures can lead to significant human
rights abuses, with disproportionate effects on already vulnerable communities…..
“Governments need to work to prevent the creation of
stigmatizing view or attitudes…UNAIDS’ experience is that such stigma only
serves to send people and communities underground and ultimately threatens the
success of any response.
“Words matter The way governments, communities
and the media speak about an epidemic, its modes of transmission and people who
have the virus can all shape the way people and communities are perceived and
treated. Avoiding phrases such as “super-spreader”…can make a difference as to
whether people feel empowered and willing to be tested and self-isolate, or to
provide help to others in need…
“Criminalisation is not the answer and can do more
harm than good: ….Use of criminal laws in a public health emergency is often
broad-sweeping and vague and they run the risk of being deployed in an arbitrary
or discriminatory manner. People caught up in a criminal or punitive approach
are also often the more vulnerable members of society.”
It was not just UNAIDS who had the knowledge and the
experience that showed containment measures to be, in practice, unjust,
discriminatory and stigmatising. The issues raised by UNAIDS are anticipated a
document prepared in 2007 by the WHO called “Ethical considerations in
developing a public health response to pandemic influenza”. About public health
measures such as isolation, quarantine, social distancing and border control,
this document says:
“Many critical ethical questions arise in pandemic
influenza planning, preparedness and response. These include…….How can surveillance,
isolation, quarantine and social-distancing measures be undertaken in a way
that respects ethical norms? …The purpose of this document is to assist social
and political leaders at all levels who influence policy decisions about the
incorporation of ethical considerations into national influenza pandemic preparedness
plans…
“While all of these measures can legitimately be
attempted in order to delay the spread or mitigate the impact of an influenza
pandemic, the burden they place on individual liberties requires that their use
be carefully circumscribed and limited to circumstances where they can be
reasonably expected to provide an important public health benefit…..policy
makers should pay specific attention to groups that are the most vulnerable to
discrimination, stigmatization or isolation, including racial and ethnic
minorities, elderly people, prisoners, disabled persons, migrants and the
homeless…..Plans related to isolation of symptomatic individuals and quarantine
of their contacts should be voluntary to the greatest extent possible….ensure
safe, habitable, and humane conditions of confinement….”.
Another WHO publication from 2016, “Guidance for
Managing Ethical Issues in Infectious Disease Outbreaks” reiterates the immediate
risk of discrimination and heightening of prejudices in an infectious disease
outbreak:
“Members of socially disadvantaged groups often face
considerable stigma and discrimination, which can be exacerbated in public
health emergencies characterized by fear and distrust. Those responsible for
infectious disease outbreak response should ensure that all individuals are
treated fairly and equitably regardless of their social status or perceived
“worth” to society. They should also take measures to prevent stigmatization
and social violence…
“even when public health measures are designed with
the best of intentions, they can inadvertently place a disproportionate burden
on particular populations. For example, quarantine orders that require
individuals to stay in their homes can have devastating consequences for
persons who need to leave their homes to obtain basic necessities such as clean
water or food….
“Infectious disease outbreaks can exacerbate social
unrest…and induce violent behaviour, especially against vulnerable groups such
as minority populations……
“Officials involved in outbreak planning and response
efforts should be prepared for the possibility that specific populations may be
targeted as being the cause of the outbreak or provoking transmission;
strategies should be proactively designed to protect such groups from a
heightened risk of violence.”
If all this work, some of it by the WHO itself, had been given its due, lockdown and containment would not have been so severe, brutal or overemphasised as it was. There might even have been a chance that we would have decided not to go for lockdown, and do what we are now doing, which is to keep the economy and social life going, while doing cluster containment where cases break out, but in a humane way, recognising the invasion of rights, the possibilities of government overreach, and giving people recourse against this. We have to recognise that containment measures are inherently unjust. Rather than demanding adherence to them as a matter of social responsibility, we should see them for the imposition that they are, applying them in as limited a manner as possible, and with procedures that give full scope for individuals to challenge them.
The public health field needs to engage in far more sophisticated, imaginative and empathetic thinking on health matters
The WHO and public health thinking in general works
with fixed ideas of wealth and hospital resources in evaluating health issues. But
what is health and what are resources? Covid-19 reduced to nothing the
resources of the world’s richest and most technologically advanced countries.
We have to ask ourselves what was the worth of all these resources when looking
at the ravages of Covid-19 in countries like the UK and Italy. These are
countries that have made public health services into a defining socio-political
project since middle of the last century.
How much of the Western response to Covid-19 was a scientific and public-spirited response to a new disease, and how much of it was the disorientation of being shocked out of its complacency and a scramble to cover-up the fallibility of its vaunted health services?
Covid-19 reduced to nothing the resources of the world’s richest and most technologically advanced countries. How much of the Western response to Covid-19 was a scientific and public-spirited response to a new disease, and how much of it was the disorientation from being shocked out of its complacency and a scramble to cover-up the fallibility of its vaunted health services?
Professor Knight’s observations when the NHS Nightingale facility in London was wound down are revealing of the true psychology of the Western response to Covid-19. As mentioned earlier, he is a senior doctor in the NHS and was appointed CEO of the London Nightingale Hospital, which was one of the surged many surged facilities built in the UK to accommodate the anticipated flood of Covid patients requiring ventilators reported. It was built with 4000 beds and closed after seeing only 54 patients and basically remaining empty for weeks. Professor Knight is reported to have said about this that, “It’s much easier to build a new hospital, than to staff it. I think the honest answer is that it would have been really very, very, very difficult to staff all those thousands of beds.
“But we were faced with a situation where people were going to die because of a lack of a ventilator so we had to do something … because the alternative was unthinkable” (57).
But patients will die if they are put on ventilators
without the staff to operate them properly. What was the “unthinkable”
alternative – patients dying or allowing yourselves to admit that your medical
services had been reduced to nothing before this novel disease?
Covid-19 put rich and poor nations on the same plane. What also comes through starkly is the lack of experience in the developed world of dealing with infectious disease.
Recall the Italian doctors I quoted earlier who called Covid-19 the “Ebola of the rich”. Covid-19 put rich and poor nations on the same plane. What also comes through starkly is the lack of experience in the developed world of dealing with infectious disease – a condition itself brought about by wealth. Most of us are familiar with the idea of demographic transition. A study of the disease profile of countries reveals that in parallel to demographic transition there is also a kind of epidemiological transition. In low income countries, the disease burden, i.e., the deaths from disease in the population, is preponderantly from infectious disease. In the Democratic Republic of Congo, for instance, the infectious disease burden is 60%, while the non-infectious disease burden is 20% of the total disease burden. In high income countries like Italy, Germany, the USA, France and the UK, the disease burden is reversed, ranging from about 3 to 8 percent under the head of infectious disease and around 90 % under the head of non-infectious disease. Developing countries like India, Pakistan and Bangladesh show a state of epidemiological transition to a higher burden from infectious to non-infectious disease, in the proportion of about 30% infectious to 50% non-infectious (140).
Some countries, like Iceland, have no infectious
disease burden at all, apart from about 100 respiratory infection deaths a
year! Yearly infectious disease deaths in Norway and Sweden number in the mere thousands.
This is toytown compared with larger, and more diverse and complex countries
elsewhere in the world, whose infectious disease burden is in the tens of thousands,
if not the millions.
Owing to their small size and relative isolation,
Nordic countries were able to keep their Covid-19 incidence relatively low. But
you cannot look upon these countries as models for others to follow. They are
saved from disease by their smallness, lack of diversity, climate and distance
from the rest from the world. These places have no lessons for us, especially
not in Covid times.
When the full story of Covid-19 is finally told, a chapter will surely be devoted to the lack of experience of Western doctors with malaria, dengue and fevers uncertain provenance.
Not only do rich
countries have a lower incidence of infectious disease, owing
to climate and geography, many infectious diseases simply do not exist there,
further limiting their experience in dealing with this type of disease. When
the full story of Covid-19 is finally told, a chapter will surely be devoted to
the lack of experience of Western doctors with malaria, dengue and fevers
uncertain provenance which made them hesitate and hesitate again over the use
of medications like hydroxychloroquine, broad spectrum antibiotics like
azithromycin and doxycycline, and mild viral inhibitors like ivermectin.
These are drugs used in malaria, dengue, de-worming
and other infections, and with whose therapeutic effects doctors from Asia and
Africa are well familiar. Even relatively less developed countries, like
Bangladesh, quickly turned to these drugs for treatment and prophylaxis of Covid-19,
which may go some way in explaining why this disease spread slower and had a
lower mortality in developing countries than in richer ones.
While the WHO made the case for disease-containment by invoking grim portents for what it called the “poor and dense populations” of developing countries, it was these countries who led the charge for finding therapies for Covid-19.
While the WHO made the case for disease-containment by
invoking grim portents for what it called the “poor and dense populations” of
developing countries, it was these countries that led the charge for finding therapies
for Covid-19. In Bangladesh, the enterprising Dr Tarek Alam was the first
doctor who designed the ivermectin and doxycycline protocol for patients, which
he said gave excellent results, and after that countries around the world
started trying these medicines. He has been asked by several Western countries, including the USA, to join clinical trials for ivermectin. I have
already described the immediate issuance in India of advisories for the off-label
use of hydroxychloroquine and azithromycin, the work started for the repurposing
of drugs and the development of an indigenous version of faviparivir. Once the
USA cleared remedisivir, contracts for its manufacture were given to Indian and
Pakistani pharmaceutical companies. Nepal and Pakistan were able to rely on
their firm ally, China, for medical supplies and other assistance. India turned
to Russia for help with data on faviparivir trials. The WHO has to stop
thinking of Asia and Africa as merely charity cases. We are not entirely without resources
against epidemic disease. Our doctors and pharmaceutical companies have shown
an agility and resourcefulness in Covid times that matches and even surpasses
that of the most advanced countries in the world (137).
The WHO has to stop thinking of Asia and Africa as charity cases. We are not entirely without resources against epidemic disease. Our doctors and pharmaceutical companies have shown an agility and resourcefulness in Covid times that matches and even surpasses that of the most advanced countries in the world.
There are many ways in which we need to start thinking differently about health issues, especially when we compare countries. An interesting example is the death rate of countries. Even though we think of richer countries as being healthier than poorer ones, the annual death rates of countries are surprisingly similar, despite the massive disparities in wealth. Going by figures given out by the WHO, the death rate for most countries of the world is close to 1 percent, with a few countries at the lower end at about .5%, and even fewer countries at the higher end at 1.5% (139A). The picture that emerges is by no means one of a conquest of death or disease as countries get richer. People in richer countries tend to die from different causes – cancers and heart disease - as compared with those from poorer ones, but there is no escaping death and sickness. They merely come in different forms. People in rich countries may have greater average longevity, but the picture of old age that has been revealed from the ravages of Covid-19 in developed countries is hardly one to be envied. It looks more like a Faustian deal with disease, than a release from it. Personally, I would rather die of malaria in the arms of my grandchildren at 50 in the African bush, than slowly watch myself suffocating to death all alone in a care home in some rich Western country.
The WHO, and public health sector in general, will
look at the numbers of physicians or hospital beds per thousand of population, as a determinant of the state of affairs of the health of a population. As a very
generalized point, this is correct – the more doctors and hospitals you have,
the more people you can treat. The richer you are, the more doctors and
hospitals you can have. But what should be taken as a tentative, opening-volley
sort of understanding of the health landscape of a society is interpreted too
literally and given axiomatic status. Cuba probably has the most
medical resources per capita, its physician-per-1000-of-population ratio is the
world’s highest at eight, the second highest is Sweden’s whose figure is only
half that of Cuba’s, at four (138).
Even the hospital beds to population ratio of rich countries is nowhere near in proportion to their relative wealth. Going by the World Bank’s system of national income classification, the relative wealth of Lower Income Countries to the least
wealthy Higher Income Countries is 1:12, but their beds-per-1000-of-population
ratio is 1:3.88 (139). This ratio is even higher when it comes to a comparison of High Income Countries with Lower Middle- and Upper Middle- Income Countries. To the 4.82 beds per thousand of High Income Countries, Upper Middle Income Countries have a figure of 3.41 and Lower Middle Income Countries, 2.8. The difference in the percentage of ICU beds between these groups of countries is even lower, with High Income Countries and Upper Middle Income Countries having
about the same percentage of ICU beds within their hospital beds, Low Income Countries having 1.63% to High Income Countries' 3.57%, and Lower Middle Income Countries having 2.38% (7).
If you compare the incidence of tuberculosis as a percentage of the number of tuberculosis deaths given by the WHO, you get a figure of about 8.5% for India, which is about the same as the figure for Italy and Germany (about 8.5% and 8.3%, respectively), and lower than for France at 10.6%; and only double that for the USA, 4.6%, and UK, 4.3%. The figure for Kenya and South Africa, 4.3% and 4%, respectively, is as good or better than that for the USA and the UK. The figure for Mexico is about 11%, which is close to that for France. The figure for Sweden is exceptionally high at nearly 17%. Norway has shown zero tuberculosis deaths in recent years, but the number of tuberculosis patients has remained unchanged at about 300 for several years. This might be indicative of some difficulty in Norway's ability to cure tuberculosis, even while keeping its victims alive. 2002 was a terrible year for tuberculosis in Norway, with 100 tuberculosis deaths estimated in that year against an estimated incidence of 280 cases, giving a crude mortality of over 35% (140A, 140B).
Readers should note that the calculation of tuberculosis death rates above are not from the WHO, they are my calculations based on the WHO mortality estimates and case incidence for this disease (140A, 140B). The WHO and public health officials will say that you cannot compare the country-wise data, or even the year-wise data. But if that is the case, then why are they doing exactly this when it comes to Covid-19? What do the numbers mean, if you can’t compare either year-on-year figures for a country, or country-to-country figures? All the WHO disease data seems to be nothing other than modelled estimates from the Institute for Health Metrics and Evaluation (IHME) which is headquartered in the remote State of Washington in the USA, and for all we know they have never even been to countries like India for which they have done these estimations.
The physician-per-1000-of-population ratio for
developing countries is about 0.6 to 1 in South Asian countries, .1 to .2 in
poorer African countries, like Kenya, and 2.6 to 4 in high income countries
like the USA, UK and European countries. Considering this disparity, South
Asian and African countries are doing quite well to have comparable
tuberculosis death rates to the USA, UK and Europe. The four-times higher
doctor-to-patient ratio of Sweden to India’s did not stop it from having more
Covid-19 deaths than India till as late as mid-May.
Even accounting for cases missed in South Asia and Africa, this says something about how well doctors are coping with the cases that do come to them, despite the relative lack of resources and larger number of cases. Even a country like the Democratic Republic of Congo, with a physician-per-1000-of-population ratio of .1, is managing extraordinarily well if you look, for instance, at their yearly malaria figures: 1.5 crore reported cases to about 62,000 deaths. So is Kenya, with over 27 lakh reported malaria cases to 9800 deaths, yearly (140C).
So
there is no straight line between a country’s wealth and its hospital resources; physician density; or its ability to combat infectious disease; or to manage a high
volume of patients. But this is how superficially, mechanically and crudely the
WHO and public policy experts have been thinking of health issues for a long
time.
There is no straight line between a country’s wealth and its hospital resources; physician density; or its ability to combat infectious disease; or to manage a high volume of patients. But this is how superficially, mechanically and crudely the WHO and public policy experts have been thinking of health issues for a long time.
We should pause here a moment to explore more deeply the rather curious
phenomenon of countries like Norway and Sweden appearing to do so badly by
tuberculosis patients despite their wealth and high physician per thousand ratios of 2.9 and
4.0, respectively.
If you look at the WHO’s Burden of Disease data, there is an indication that countries
in North America and Europe seem to have had a persistent problem with treating
respiratory infections, including influenzas that flare up into severe
respiratory illnesses. This is something that the WHO has been recording in the data periodically without seeming to have noticed it, or understood its import. The Global Burden of Disease
data for these countries, has a smattering of tuberculosis,
meningitis and diarrhoeal disease deaths every year, but the bulk of their
infectious disease burden comes in the category of “Respiratory Infections”.
This is an intriguing WHO category, as it is not clear why it is taken into a
separate head from other infectious diseases. Technically, under the WHO
International Statistical Classification of Diseases and Related Health
Problems (“ICD”), “Respiratory Infections” includes influenzas and pneumonias,
but the Burden of Disease profile does not record deaths under these disease
sub-headings, simply sub-dividing Respiratory Infections into “upper
respiratory”, “lower respiratory” and “otitis (ear)”-related infections.
In Italy, doctors writing about the Covid-19 epidemic noted there has been, in general, a “heavy seasonality” of deaths, with 25% more deaths in
the winter as compared with other seasons, and many of these yearly excess
deaths are related to respiratory infections from influenza (23). Perhaps these respiratory infections have
been neglected in rich countries because in terms of absolute numbers, the non-communicable
disease burden totally eclipses the communicable one. So with Covid-19, not
only were richer countries caught by surprise with an infectious disease, which
is a category of disease with which they already have relatively low experience,
but also with a respiratory infectious disease, which is a category of
infectious disease with which they were already not doing very well.
With Covid-19, not only were richer countries caught by surprise with an infectious disease, which is a category of disease with which they already have relatively low experience, but also with a respiratory infectious disease, which is a category of infectious disease with which they were already not doing very well.
By early July, deaths by Covid-19 were double (or more
than double) the annual respiratory infectious disease deaths for the USA,
Italy and France; nearly three times the annual respiratory infectious disease
deaths for Spain; nearly double those for Sweden and well over those for the UK
(140). So even though Covid-19 deaths might turn out to be a blip in the
overall mortality in Western countries, this will be because their mortality
profile is dominated by their non-communicable disease burden. But there is no
denying that as an infectious disease, the Covid-19 mortality in these
countries is unprecedented, massive and represents a real crisis in their
system. At the same time, their disease profile also raises the question of how
long Covid-19 can be privileged as it has been when so many, many more of their
people are affected by non-communicable disease. By early July, the typical annual
number of deaths in the USA from non-communicable diseases still exceeded Covid-19
deaths by 19 times (this was exceeded by 24 times in May), and in the UK and
Spain by 12 times and in Italy and France by 16 times (140). What these
countries need to do is not to narrow the focus to Covid-19, but to expand
the focus to include more attention to infectious disease, than they have been
used to doing in the last 80-odd years. And I think that the public there are right to question the excessive, almost exclusive focus on Covid-19, given the disease profile of these countries. I think that we may actually be in the middle of a much worse and silent health crisis over there in non-communicable diseases for this reason.
The situation for developing countries is different,
as infectious disease already occupies a large part of medical attention here.
Although, this might be a good reminder to countries like India not to lose
sight of infectious disease as it goes up the income ladder. With the
proliferation of private hospitals, some of our infectious disease burden may
also be going unnoticed as it is less lucrative for these hospitals than cancer
and heart treatment.
There is no denying that as an infectious disease, the Covid-19 mortality in developed countries is unprecedented, massive and represents a real crisis in their system. At the same time, their disease profile also raises the question of how long Covid-19 can be privileged as it has been when so many, many more of their people are affected by non-communicable disease. What these countries need to do is not to narrow the focus to Covid-19, but to expand the focus to include more attention to infectious disease, than they have been used to doing in the last 80-odd years. The situation for developing countries is different, as infectious disease already occupies a large part of medical attention here, although this might be a good reminder to countries like India not to lose sight of infectious disease as it goes up the income ladder.
In Covid times, it is also important to recognise the value of the experience of developing countries with large numbers of people and patients. In a given year, developing countries in South Asia and Africa see an infectious disease incidence numbering in the lakhs and crores, while developed countries like the UK, Germany, Italy or Spain see mere tens of thousands of cases. In absolute numbers, even the incidence of non-communicable disease in developing countries is much greater than that of developed ones.
At India’s 2400-bed All India Institute of Medical
Services (AIIMS), a huge Government hospital in New Delhi (and this is only one of thousands of large public hospitals around the country), the average daily
footfall is 15,000. This means that it sees as many patients in two or three days as some of the biggest US hospital see in a year. I take US hospitals as an example because of its large population compared with other developed countries. In 2018-19, AIIMS reported that it saw about 38
lakh outpatients, 2.5 lakh in-patients and conducted 2 lakh surgeries (141).
Compare this with the USA’s biggest hospitals: according to a site called
Becker’s Hospital Review, the New York Presbyterian Hospital/Weil Cornell
Medical Centre which has about 2200 beds, sees 48,000 emergency room patients and
conducts about 77,900 surgeries annually; the Florida Hospital in Orlando sees
32,000 in-patents and 53,000 out-patients annually; the Methodist Hospital in
Indianapolis sees 97,000 patients a year (142). This is not to say that
poorer countries have some kind of magic formula by virtue of seeing more cases.
But a better understanding of the kinds of numbers developing countries face as
a routine, would have helped both them and richer countries respond more
sensibly and moderately to the Covid-19 crisis.
We need to pivot for answers from looking at the richest countries in the world, to looking at the poorest ones. They are the ones with the relevant experience, whereas the richer ones have virtually none.
We are not seeing the relevance of the differences in hospitals and medical practice that grow out of the wide differences discussed above in the disease profile of countries at different stages of their development. Led by the world’s leading authority on disease, the WHO, we think of the differences only in terms of rich and poor; and resource-constraint or resource-abundance. We fail to see that the nature of medicine, hospital management and disease control practiced in developing countries with a large burden of infectious disease and an endemic lack of resources might actually have lessons for all of us in Covid times. We need to pivot for answers from looking at the richest countries in the world, to looking at the poorest ones. They are the ones with the relevant experience, whereas the richer ones have virtually none. We should have been speaking to doctors who function with less and not more resources, because Covid-19 dwarfs even the world’s best resources.
Talking to doctors who have cut their teeth in Indian hospitals is in of itself a fascinating experience. I am sure this is the case for doctors in any part of the Third World. In the normal round they see a breath-taking range of diseases among patients of every class and colour, and in every stage of illness. They function in conditions of perpetual resource shortage. Indian doctors familiar with big government hospitals like the AIIMS in New Delhi, will describe how patients are lined up on mattresses in the corridors at a pinch. The other day a dentist friend had me spellbound describing his early training at King George’s Medical College in Lucknow where there would be four patients lined up in a row on dental chairs in the corridor. He would treat them simultaneously, injecting one with local anaesthetic; leaving the anaesthetic to kick in while checking a cavity in the next; and so on.
In the pre-Covid era all this would have Westerners shaking their heads in horror. But this is life in a crowded and under-resourced situation. Many of the scenes from India described here would now be familiar in Covid-hit hospital in the West. A few weeks into their Covid outbreaks were reports from Europe of patients being treated in corridors.
Public policy experts who are trained in the paradigm of public health thinking that was developed in the West are particularly closed to the idea that they may actually have something to learn from Third World countries. What we really needed was public health experts who had the measure of the contrasting disease profiles and capabilities of countries. We needed experts who could have drawn upon these diverse experiences with disease and medical resources to suggest new ways of thinking in the Covid crisis. This is where the WHO as a supposedly international health authority could have shown real leadership by bringing the attention of nations to the medical experience with disease beyond their borders, in other settings, even in places far away on the other side of the globe, to spark off the novel thinking that this novel disease so clearly requires. But the WHO seems to have no sense of the richness or meaning of the information about the state of disease and medical practice at its disposal (and collected by it!) from all over the world. All the attention is on de-contextualized and disease-agnostic (and endemically inaccurate) mathematical modelling.
We should have been speaking to doctors who function with less and not more resources, because Covid-19 dwarfs even the world’s best resources.
We should also pause here to note the advantage of numbers and of having a relatively large young working population that countries like India and China have. China tops the world with 28 lakh physicians, going by its physician density of 2-per-1000. India’s, physician density of .9 per 1000, gives a total of about 11.8 lakh physicians. So even though the USA has a much higher physician density than both these countries, at 2.6, it has fewer physicians in total – about 8.5 lakhs. Italy and Sweden have among the highest physician densities of developed countries, at 4 per 1000; the UK and Norway have physician densities of 2.8 and 2.9 per 1000, respectively. These densities work out to about 1.9 lakh physicians in the UK, 2.4 lakh in Italy, 36,000 in Sweden and 15,500 in Norway. These are very small pools to draw upon compared with many developing countries. Cuba, with over 90,000 physicians is able not only to cater to its own population, but to also send doctors around the world for its famous medical diplomacy, much to the discomfiture of Western countries who, instead of being grateful for this, have been berating Cuba for trying to “spread influence” by offering its doctors to the world (143).
Almost always, when the sceptre of exponential growth is raised, it is the bigger, faster growing and coloured populations of the developing world that experts have in mind.
The idea that larger populations are nothing but a burden on countries is far too simplistic an evaluation of the dynamics of a large population, especially a young one. Having a large population to draw upon in times of emergency had its own advantages. We also have to interrogate the notion of exponential growth when applied to populations. Almost always, when the sceptre of exponential growth has been raised, it has been the bigger, faster growing and coloured populations of the developing world that experts have had in mind.
The last time that exponential growth was made into an
enterprise by the West, was in the era when the coloured nations had just begun to
emerge from colonialism. There was a feeling in the West, that these countries
would now flood them with immigrants. From the late 1940s to the early ‘80s,
Malthusianism was preached to coloured nations everywhere, and they were
encouraged to take drastic measures of population control. It was this that led
China to implement its notorious one-child policy, and India to unleash its
infamous sterilization drive. Much of this was advocated and funded by Europeans
and Americans intent on improving the lives of the poor. Many of them were great believers in eugenics and other horrible ideas as well. We have to always remember that among the ancestors of ideas of hygiene are the genocidal ideas of racial hygiene and population hygiene.
Once the atrocities of Chinese and Indian population
control became known, exponential population growth was debunked as a theory. As in the case of modelling for Covid-19, nowhere did populations double at the predicted exponential rates. Instead, the
phenomenon of demographic transition was observed which, though it gave big
populations, also showed the “demographic dividend”, the benefits of a
thriving, young population.
Now exponential growth has reared its ugly head again through the discourse of Western epidemiologists. We should not be naïve about the very real fears that the ageing and diminishing populations of the developed world have about us in the developing world. And we need to be vigilant about how agencies like the WHO and UN organisations can be used by these forces to keep developing nations in check. We should always have our eyes peeled for the tendency these developed nations display from time to time of developing exponential rates of paranoia about us, whether it is expressed in the form of concerns about population growth, pollution or pandemics.
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We need more focus on anti-viral medicines
The epidemiologists told us that if Covid-19 was allowed to spread unchecked, then billions would be infected, and millions would die. The World Health Organisation and public health experts told us that, therefore, we had to have a disease-containment strategy that would stop the virus from spreading. On this basis, the epidemiologists and public health fraternity told us to “flatten the curve!” The idea, they said, was to bring the number of infections to within manageable levels.
But Covid-19 proved to be unmanageable whether you had one case or a billion. For reasons that we do not, as yet, understand, Covid can be mild and clear up in a few days, or have you choking to death in 9 days flat. No amount of flattening the curve can solve this problem. And it is a problem of some significance if you or a loved one are on the curve, however flat it may be. But this is a problem not of containment, but of treatment.
Why, when anti-virals, were known to be effective in reducing the severity of viral infections, was the WHO and public health field in general so focused on “non-pharmaceutical” interventions? Because we do have medicines for viral diseases. This is how AIDS was brought under control. With anti-viral drugs you can be HIV-positive for years, for decades even, without falling ill.
Anti-virals and medicines like hydroxychloroquine do not “cure” viral disease, in the sense of eliminating them from the body, but they are well-known to reduce the severity of infection, which can also be life-saving.
In epidemiological work on pandemic influenza, the assumption is that anti-virals can be given for viral infections, both as a preventive and as treatment. For instance, writing in the journal Nature in the year 2006, Neil Ferguson and colleagues say that: “prompt treatment with antivirals reduces clinical severity and infectiousness” (11). Even the WHO has acknowledged the efficacy of anti-viral drugs and medicines like hydroxychloroquine in retarding the progress of viral infections (19).
So we need to turn away from those hypnotising exponential graphs of the epidemiologists, and look into why disease containment rather than treatment has become the guiding principle of public health interventions for epidemics, despite the availability of medicines. The formal name for disease containment is “Non-Pharmaceutical Measures”. This gives us some hint of what might be going on. The negation implied in this expression is of Pharmaceutical Measures, i.e., medicines. So the question that arises is this: Did the idea of disease containment arise as an alternative to, or perhaps even in opposition to, pharmaceutical measures?
Writing in 2006 about non-pharmaceutical interventions
for pandemic influenza, the WHO Writing Group rejects pharmaceutical interventions
saying that the availability of antiviral agents is “insufficient” and that while
pandemic preparedness “ideally would include pharmaceutical countermeasures
(vaccine and antiviral drugs), but for the foreseeable future, such measures
will not be available for the global population [of more than] 6 billion”
But this was clearly a huge underestimation of the capacity of countries to deploy anti-virals. We saw earlier that it was the poorer countries in Asia and Africa that were the first to use anti-virals, viral inhibitors and other therapies like hydroxychloroquine, ivermectin, plasma therapy and faviparivir for Covid-19 treatment. It was Bangladesh that led the way with the ivermectin and doxycycline treatment protocol. If anything, it was rich countries with their, in the case of Continental and Nordic Europe, total lack of innovation in pharmaceuticals, and, in the case of the USA, cumbersome clinical trials, that fell behind in the race for pharmaceutical interventions for Covid-19.While it may be impossible to produce drugs for all the 7 or 8 billion people in the world in a short time, this is not the way any disease progresses. You will not have all these people falling ill at once; and given the vast numbers of mild cases for Covid-19, not even all those who do fall ill will need pharmaceutical intervention.
If you think about it, this was surely something that the WHO knew very well already. Could the truth lie in the fact that no one wanted to encourage the idea of drugs when this might have meant footing the bill (or giving up patents) for drugs for infectious diseases which, until Covid-19, were really only a problem for low-income countries in Africa? As we discussed in yesterday’s lecture, high income countries have a tiny disease burden from infectious disease compared with non-infectious disease, and middle income countries show epidemiological transition, with a reducing burden of infectious disease, and an increasing one under the head of non-infectious disease.
The curious case of ZMapp
For many years there has been something dysfunctional
in the entire approach of rich countries to drugs. A particularly sordid
episode occurred during the Ebola outbreak of 2014-16 in West Africa. Some European
and American health workers who caught Ebola there, were flown back home for
treatment. Most of them were cured after being given a cutting-edge medication
called ‘ZMapp’. There was outrage in West Africa where people had been told for
decades that Ebola had no cure.
The extent of the betrayal of the West African people
by this is underscored by the role played by Europeans in the two previous
Ebola outbreaks. In the 1976 outbreak, it was Belgian nuns acting as nurses who
spread the disease with contaminated needles used on pregnant women who had
been encouraged to come in for iron shots. In the 1995 outbreak, a badly
botched operation at a Missionary-run hospital set off a chain of transmission
involving Italian nuns who were evacuated for special treatment to a bigger
hospital in another area, unlike the locals who did not have these special
privileges (31, 151).
Initially it was claimed in America that only 7 doses
of ZMapp were available, which had all been used up, and so nothing remained to
be sent to West Africa. But there was widespread speculation that ZMapp was still
being sent to Spain and other places for repatriated European health workers. The
governments of Nigeria and Liberia immediately requested the medicine to be
sent to them, even while Western commentators were delivering sermons on the
indispensability of clinical trials. The WHO stepped in to say that given the
emergency situation, the experimental use of the drug should be allowed in West
Africa
This led to an outcry from academics sitting in the UK and Australia against the use of medicines for Ebola. Writing in The Lancet and the BMJ Journal of Medical Ethics these experts made the argument that looking merely at medicines to cure a few patients was “individualistic” or that this somehow betrayed what they saw as being wider community good of disease-containment measures (152, 153). This is where we get some hints of where the thrust for disease-containment is coming from among public health experts. They see disease-containment as a form of socialist, communally-minded medicine, and a moral victory over free market principles. There are certainly obvious dangers with allowing an unregulated free market circus in the medical sector. But prioritising medieval disease containment measures over medication for novel diseases is taking things a bit too far. Even with the best containment, those who fall ill want to be cured. Containment is not a cure, but medicines are. It is outrageous for public health experts to be opposing pharmaceutical interventions in poor countries as they write their papers from the richest countries of the world, with every medical facility at hand.
Luckily, common sense prevailed over these academic
fulminations, and ZMapp was sent to Liberia and Nigeria. So much for the claim
that “only 7” doses were available (154). Old
hands at the Ebola game in West Africa, Peter Piot and David Heymann, stepped
in to say that given the severity of Ebola, they themselves would have been
happy to try experimental drugs for it, had they contracted the disease.
They also said, pointedly, that if Ebola had broken out in the West then it was
“highly likely” that the authorities would have speeded up the testing of
experimental drugs for it (150). This turned
out to be prescient going by the promptness with which remedisivir was put to
trial in the USA after it was hit by Covid-19.
The West owes a debt to Ebola and West Africa. It was
only after West Africans insisted on access to experimental drugs that
attention was finally given to working on Ebola drugs, and it is in the course
of this work that remedisivir was developed (154, 155). If the
Lancet and other journals who had opposed experimental drugs for Ebola had
prevailed, there would be no remedisivir today.
The curious case of hydroxychloroquine
There have been similar controversies over pharmaceutical interventions
in Covid times. We are all familiar with the controversy over
hydroxychloroquine which also seems to be at least as political as it is
scientific. As discussed above,
hydroxychloroquine is an anti-malaria drug widely used in many developing
countries. It was deployed, “off label”, meaning without clinical trials, in places
like India as a prophylactic and treatment for Covid-19 as it was considered by
experienced clinicians to have some therapeutic use with viral infections. This
was considered routine in developing countries, but the endorsement of the drug
by polarizing leaders like Donald Trump and Jair Bolsonaro led to a lot of
controversy around it (156). Media outlets
such as CNN and the BBC led a sustained media campaign against
hydroxychloroquine, which reached its zenith when Donald Trump announced in
late May that he had actually taken the drug. Days later, on May 22nd,
The Lancet published a paper claiming that data showed hydroxychloroquine to be ineffective, and even harmful. Three days later, on May 25th, the WHO suspended its
Solidarity trial on hydroxychloroquine, citing this paper. Doctors all over the
world, including Dr Mande, the head of India’s Centre for Scientific and
Industrial Research were extremely critical of this move (157). 140 scientists issued a letter refuting
the claims of The Lancet article. Dr Mande described it as a “knee jerk”
response by the WHO.
Curioser and curioser
Two weeks later, The Lancet paper was discredited; basic weaknesses in the data used by it were revealed. There was also some doubt as to the credentials of those who had written the paper. The Lancet was forced to retract the paper, and similar work was retracted by the New England Journal of Medicine, and the WHO resumed trial of hydroxychloroquine.
There are two things here. One is the unreliability of stalwarts in the medical field such as The Lancet and New England Journal of Medicine, showing us once again that Covid-19 challenges all the established authorities in the medical field and that the need of the hour is new thinking, questioning and not blind conformity with what the supposed experts are saying. But what should concern the lay public even more, is how politicised science and medicine have become in the tensions that have arisen around Covid-19 (156). This is the nub of the issue for us as the lay public – we need to facilitate a cooling down of the atmosphere. If we are poised and patient ourselves, then perhaps it will open the way to a fair and open scientific investigation of all things related to Covid-19. Otherwise we will just keep sinking into the vortex of confusion that has been created by the experts who are, quite frankly, running around like chickens with their heads cut off.
Scientific discovery in happier times
The public also needs to better understand the role
played by mistakes and sheer chance in scientific discoveries. Penicillin was
discovered when some bacteria cultures were accidentally left exposed near an
open window by Alexander Fleming, when he went abroad for his annual vacation.
Mould formed on the open bacteria cultures. When Fleming returned, he noticed
that the mould seemed to have inhibited the growth of the bacteria, and thereby
hangs the tale of the discovery of penicillin.
In today’s culture of hyper-concern about safety
standards, Fleming would probably never have gotten the chance to check out his
mouldy petri-dishes. He would have been hauled off from his vacation to a
committee of investigation for being careless about his laboratory, never to be seen again.
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The exclusive focus on severe cases
Another mistake that is being made in the response to Covid-19 is the exclusive focus on severe cases for treatment. The drugs that we have are better suited for early onset of the infection. As we just discussed what hydroxychloroquine and anti-virals do, is to inhibit viral replication in the body. It is, therefore, important to intervene early with patients. There are studies to show that each day’s delay after the onset of symptoms reduces the effectiveness of antiviral drugs. As these drugs are only able to inhibit virus-replication, they are of less use when the virus has already exploded in the body.
This is recognized even by the WHO. Mike Ryan, WHO's Executive Director of Health Emergencies, when questioned about hydroxychloroquine, said: “no one here is actually talking about cure…..Some drugs may actually prevent the virus replicating early in the disease and therefore shorten the length of the illness and reduce the progression to severe disease.
“Once the disease is very well-established and in the later stage of the disease a lot of the damage that’s being caused by the virus is not necessarily being caused by the virus itself but all of the secondary effects; the inflammation, the organ failure and other things that happen. So a lot of antiviral therapies are focused on getting a person with the disease treated at an earlier stage of the disease and if you look at a lot of the anti-flu medications like Tamiflu and others, the main benefit that has been found for those again has been shortening the course of illness” (19).
But treatment, and even many clinical trials for
Covid-19, are overly focused on severe cases. In India, the medical advisory
for hydroxychloroquine and azithromycin is confined to the severely ill. But we
should be using these and other drugs early on patients to reduce severity and
help avoiding the stage where the secondary effects of the disease overtake the
damage caused by the virus. We should not be waiting till people need to be
hospitalized, by which point we can offer them little more than supportive
treatment. While testing may be useful for contact tracing, if we are not
treating patients as soon as they test positive, then tests are of scant
comfort to the patients themselves.
Despite all the information available on antivirals
and hydroxychloroquine, the attitude of many doctors in Delhi is to say they do
not know anything about that. The only advice is to report to a Covid-designated
hospital in case the patient tests positive. But there are waiting lines for
testing and several days can be lost, especially if you fall ill over the weekend,
just waiting for the test results to come in. This is not an optimal way of
combatting a galloping disease like Covid-19 that can get critical in merely
nine days. This is also very different to how doctors typically function in
India, where they pride themselves in their ability to diagnose clinically without
asking for a battery of expensive tests. Doctors who keep sending patients for
tests are considered to be incompetent at clinical diagnosis and in cahoots
with testing laboratories making money off people. We need to reinstate some of
this approach in India for Covid-19. The Indian Council of Medical Research should look into issuing a
treatment protocol for early stages of Covid-19, instead of leaving early onset
Covid-19 patients with nothing but paracetamol and luck until they turn severe.
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Let's not be shy of asking the basic questions: Is there such a thing as viral burn-out?
The focus on containment has also led to attention being trained away from the virus itself. It is a mystery that cries out for investigation how each time there has been an Ebola outbreak in West Africa, it has died out even though there has been (till recently) no medicine or vaccination for it. The same phenomenon of viral diseases dying out inexplicably has been observed in the case of other infections, such as SARS (38). There has been speculation that the Ebola virus weakens dramatically and peters out after four rounds of transmission (31). Similar claims that the Covid-19 virus has lost its potency, or that it may peter out on its own, have surfaced from experts in Italy and the United Kingdom.WHO’s
Mike Ryan lost no time to intervene to rebuff any such speculation. In a press briefing he
said sarcastically that it could not be that the virus “all of a sudden of, its
own volition, has decided to become less pathogenic” (158). But
the gentleman doth protest too much. This is hardly a fair representation of
what the Italian doctors were saying, which was that the viral load observed in
patients was much smaller than earlier in the epidemic, and that, clinically, Covid-19
appears to no longer be the same disease. The British doctor who suggested the
possibility of the virus petering out over time is himself a former WHO Director.
Viral burn-out is at least as scientific a possibility as that of finding a vaccine for Covid-19, which Mike Ryan has been insisting is the only solution, the “one great hope”, for this disease (159). But there has not been much success with finding a vaccine for coronaviruses so far. Vaccination has been elusive even for other viruses. None was found for AIDS despite vast sums of money being pumped into AIDS research.
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More basic questions: Did China and Italy lockdown after they had peaked?
There are indications that we might be wrong on some very basic things about Covid-19. One puzzling set of facts needs us to go back to where we began with the outbreak in China. The Chinese asserted, and the WHO unquestioningly agreed, that it was restrictive measures that drove down the Covid-19 epidemic in China. But the facts as narrated by the Chinese themselves cast doubt on this understanding. The Chinese are on record in the WHO-China Joint Mission Report saying that their “cases peaked and plateaued between 23 January and 27 January, and have been steadily declining since then, apart from a spike that was reported on February 1” (13).
In
this report, the Chinese were able to tabulate
the daily number of cases both by date of onset of illness and date of
laboratory test results (Figures in the WHO-China Joint Mission Report
reproduced at App-A and B below). As would be
expected, there is a time lag between the date of symptom onset and the date of
laboratory test results. The figures for China show that while laboratory
reports began to come in around January 20th and peaked between
February 4th and 10th, the peak of onset of symptoms,
i.e. the highest numbers of people falling ill per day, was on January 23rd,
after which it plateaued for about 5 days and then went into a steady downward
trend, (save for a spike on February 1st which appears to be the
result of a reporting anomaly that was discovered sometime around February 12th
).
The reason why this puts into question the idea that containment measures brought down cases in China, is that lockdown was implemented in Wuhan/Hubei Province only on January 23rd and measures were triggered in other provinces of China only later in January (160). There are reports of fairs, public feasts and a local Communist Party cadre meeting attended by tens of thousands of Wuhanese in the days of January just before the lockdown, as this period coincided with the festival time of the Chinese New Year and Spring Week celebrations (161). With an incubation period of 14 days, it is highly unlikely that lockdown would affect the growth of Covid-19 cases the very day that it was implemented, especially considering all the activity I have just described that occurred in Wuhan in the weeks immediately preceding lockdown.
Also, there was very high traffic in all of China in the weeks before the lockdown, owing to the approaching Chinese New Year. This is popularly called the period of “Chunyun” where millions of Chinese travel from back home to their native towns and cities in the lead-up to the Chinese New Year, which fell this year on January 25th, followed by the annual Spring Festival holiday week. This was also a period when University students were going home for the holidays. Every year, over 3 billion trips are estimated to be made during Chunyun (literally translated as “Spring Travel”) with immigrant labour laying out on the corridors in trains in the rush to get home. Who knew then the scenes that were going to be played out in India two months later with its own immigrant-labour walking to their native villages on foot for thousands of kilometres, fleeing the hunger and penury of the cities caused, by the Chinese-inspired lockdown.
The traffic rush of Chunyun took place in the early weeks of January; and press reports from the time show photographs of massive crowds in Chinese trains and transport stations at this time (162). Wuhan is a transport hub for Hubei, which employs many industrial workers. The Chinese estimated that 50 lakh people travelled out of Wuhan to other provinces of China in this period. So travel was high in the run up to the lockdown, albeit with many wearing facemasks, and screening at bus- and train-stations for fever. Fever-screening was used in China for SARS, but unlike that disease we now know that people with Covid-19 can be infectious even if they are asymptomatic or before they develop fever (10). Clinical research papers by Chinese doctors that trace the history of cases in January show that people travelled thousands of kilometres across provinces to reunite with their families, and that people were meeting socially right until the time of lockdown (163). A German study of transmission of Covid-19 by asymptomatic persons in late January shows business travel out of China days before the lockdown (164).
Given these facts, it is an open question which must receive more scientific attention as to why Covid-19 cases in China plateaued from January 23rd onwards, and trended downwards from the end of that month.
A similar pattern can be seen in Italy, which has also
been publishing data on the date of onset of Covid cases (App-C). Like
in China, there is a lag between the date of case onset and the date of diagnosis.
Even WHO officials accept that we have to work backwards from the date of cases
as reported, to get a correct picture of how the disease is spreading. Mike
Ryan said at a WHO press briefing in late March that, “the cases we see today
really reflect exposures two weeks ago….The cases you see today are almost historical
in the same way as we’re told when we’re looking at galaxies through a
telescope that we’re seeing light from a billion years ago, we’re seeing a
reality that existed before. When you count your cases on a daily basis in an
epidemic it reflects a reality of transmission and risk two weeks ago” (19).
In Italy, the lockdown was imposed in its Northern
provinces on March 8th, and extended to the rest of Italy on March
10th. According to the date
of onset data, daily case onset peaked on March 10th, remained high
at between 4000 to 6000 cases for the next ten days, though trending downwards
from March 14th, apart from a spike on March 20th, after
which cases trend more consistently downwards (App-C).
Again, these downward trends are too near to the
lockdown for any easy assumption to be made about their having been impacted by
it. These are questions that we should be asking about, and investigating. This is what I meant when I said at the start, about the pandemic being
partly the fantasy of epidemiologists. It is not that there is no Covid-19, but
we are only seeing it in the way the epidemiologists made it up. We need to start looking
at it for what it is.
The date of onset data from China shows that in January, when the Covid Experts Group was estimating case numbers in China at 4000, these estimates did not come anywhere near the cases that had onset by then which, extracting roughly from Appendix A and B below, show that cases went from over 12,000 on January 23rd to nearly 40,000 by the end of January. So the Covid Experts Group’s estimation of cases in Wuhan in January was wildly off the mark, and they also did not know that at the time when they were making their estimates, the cases were actually peaking in China. During the same period when, on January 23rd, Tedros Adhanom was saying that it was too early to call a PHEIC as there were only 575 cases in China, this was based only on the laboratory results that had come in by then. Similarly, on January 30th, when the WHO finally declared Covid-19 to be a PHEIC, Tedros Adhanom only had partial figures when he said there were 7736 cases in China. The case onset data published in February in the WHO-China Joint Mission report, showed over 40,0000 cases by then (App-A and B). So the scale of the outbreak was much bigger than the WHO or even perhaps the Chinese had realized in January.
If the WHO had realized the full extent of the
outbreak in China, they might not have been so confident of its controllability and the
conversation over what measures were feasible and optimal might have taken a
different route. These are questions that we should be asking the WHO. We
should also ask the WHO to explain why it did not bring attention to the
difference in case estimations between what they said in January and what they
said in the February WHO-China Joint Mission report.
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Do we really know all about how Covid-19 transmits?
There are other anomalies in the Covid-19 data that
are crying out for inquiry. Although early outbreaks in many places were
attributed to large public events called “super-spreader events”, there is no
consistency between the occurrence of public gatherings or crowded mass
movement of people, and the appearance of a Covid-19 cluster. For instance, we
already noted how 50 lakh people travelled out of Wuhan to places all over
China in the weeks leading up to the lockdown there on January 23rd. Contact
tracing began outside of Hubei only late in January. But you did not see
anything like the outbreak in the rest of China as you saw in Hubei, which saw about
three fourths of the cases overall (13, 165). This cannot be explained simply
by the closure of the Hubei border or measures introduced outside Hubei by the
Chinese government, as the time lag between people arriving from Wuhan in other
places in China and the start of contact tracing and hospital isolation more
than accounts for the 14-day incubation period for Covid-19. Not only
were there disproportionately fewer cases outside of Wuhan, a published study
of all cases until February 11th, showed that the lethality of the
disease also changed as you moved away from Wuhan; the case fatality rate of
patients in Hubei was said to be more than seven times as high as that of patients
in other provinces
The huge mingling of people from different provinces during the Chunyun travel should itself have made certain travel routes into hotspots or “hot-routes” for the disease. But there are no such reports from China, even though millions travelled in close contact, for 12 hours and more, on long journeys in over-crowded trains. There are no reports from any country or city of overcrowded bus, train or metro routes being especially associated with any Covid-19 outbreak.
With mass gatherings there are other
puzzles. Even though some big outbreaks were traced to large gatherings, not
all gatherings in the same period sparked outbreaks. For example, although
malls have huge footfalls, not a single outbreak in any country has been linked
to gatherings here. This indicates that the sharing of public spaces as such is
not in of itself resulting in significant transmission, and a more intense,
intimate and prolonged interaction is required for transmission to occur. If this is true, then the whole idea of stopping public movement to
contain Covid transmission is questionable.
There were mass gatherings around the world in March and April that did not lead to a mass outbreaks. For example, there were two gatherings in Bangladesh, one in Lakshmipur District of a prayer meeting with an estimated 10 to 25,000 in mid-March, and a second, in mid-April, when 1 lakh people defied lockdown to attend the funeral of a popular political figure in Brahmanbaria District (166). However, even by early June, there were less than 200 cases in both these places (App-D). A month later, in early July, Brahmanbaria reported 733 cases and Lakshmipur district reported 929 cases, showing that the rise in cases here, which follows a general rise of cases in South Asia, was driven by other factors than the gatherings in March and April (App-E). In France, a large Church gathering in Mulhouse in Haut Rhin is thought by some to have resulted in 2000 infections, among the 2500 attendees (167). A nurse who attended the gathering from nearby Strasburg is said to have spread the virus to 250 colleagues in the hospital where she worked. But a pastor from Burkina Faso who also attended the gathering and is said to have been the first case, along with his wife, of Covid-19 in that country, spread the disease to only five other people. This is despite the fact that a pastor’s work involves contact with many people, and it was a good fortnight before he was diagnosed and placed in quarantine. A pastor from Guyana who also attended the Mulhouse gathering, was among those who unknowingly contracted the disease. But it is reported that he and his four travel companions did not pass it on to the over 80 people with whom they came into contact before discovering the infection, save for one child who had a mild illness (167). One of the most popular events of Louisiana’s Mardi Gras festival, the Zulu Ball, was held on February 21st with 20,000 people (169). One million people are said to have attended the Mardi Gras from around the world. But while Louisiana was an early Covid-19 hotspot in the USA, no hotspots in other countries have been identified, at least so far, linked to visitors at the festival.
Even when large gatherings resulted in outbreaks, chains of transmission did not radiate as widely as you would expect for a virus that does not burn out, but simply, as the epidemiologists presumed, endlessly propagates from person-to-person in the same line of contact, until you intervene to break the chain of contact. An example of this is the Tablighi Jamaat outbreak in New Delhi, which remained confined to people in the Markaz, and did not spread into the surrounding Basti.
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We need to pay more attention to the clustered nature of Covid-19 spread
Another aspect of Covid-19 transmission that deserves
closer attention is its clustered nature. Writing in 2006 on influenza pandemics,
Neil Ferguson and colleagues argue they would spread homogenously in a place
like Great Britain because of “its relatively small size and frequent long
range travel”, and in the US, early spread would be “focal around seed
infections (typically in urban areas) imported from overseas, but rapidly
becomes almost homogenously distributed across the whole population”
But this is not at all how Covid-19 spread in the UK
where, even as late from the start of their outbreak as the first week of July,
85% of the cases and 90% of the deaths have been in England. Within England,
the outbreak has not been homogenous. Going by rates of hospitalisation,
London, followed by the Midlands, is showing the highest cases compared with other
regions; and the South and East of England are lesser affected than other
regions (185).
In the USA, from the end of March to early May, save
for a few weeks at the very beginning when there were more cases in Washington
and Louisiana, the greatest number of cases per million and in absolute terms were
in New York. New Jersey had the second highest cases in the same period, again
both in cases per million and absolute terms, but the total count has been a
quarter to a third of those in New York. Other US states with significant
Covid-19 outbreaks such as California, Michigan, Illinois and Pennsylvania accounted
for about 3 to 5% of the total US cases till early May. The picture began to
change only in June, over two months from the start of the outbreak, with
California overtaking New Jersey and Texas reaching New Jersey levels, in
absolute cases but not deaths or cases per million. Three months from the start
of the US outbreak, in early July, cases per million vary from about 21- to 20,
000 in New York and New Jersey, to just under 16,000 in Massachusetts and Rhode
Island, to under 15,000 in the District of Columbia, about 13,000 in
Connecticut and Louisiana and 9 to 11,0000 (about half that of New York) in
Illinois, Arizona, Maryland, Delaware, Nebraska and Mississippi. So what you
have here is different states growing at different rates and in significantly
smaller measures than the big epicentre of New York for over a three month
period. This is not homogenous growth.
The pattern of cluster transmission can be seen all
over the world. In Italy, between April and July, Lombardy accounted for about
40 to 50% of the cases and just under half the deaths, the second highest cases
and deaths were in Emilia-Romagna and Piedmont, each at a third of the cases
and a fourth of the deaths compared with Lombardy. Throughout the Italian
outbreak, the Northern provinces of Lombardy, Emilia-Romagna, Piedmont and
Veneto accounted for 70% of the cases and about 80% of the deaths.
In Japan, from late March to early July, the same
three prefectures had the highest number of cases: Kanto, Kansai and Chibu; and
within these prefectures, the highest number of cases were consistently found
in the cities of Tokyo, Osaka, Hyogo and Aichi. By early July, Fukuoka in
Kyushu Prefecture had more cases than Aichi and Hyogo, but otherwise, this
relative distribution of cases has held consistently. Overall, Kanto has
consistently accounted for over half the cases and deaths, with Tokyo having
the biggest share of the cases in this region. Overall, Tokyo has, till early
July, had the most cases in Japan, double those in the entire prefecture of
Kansai, and several times more than any other city.
In Spain, from the end of March to the end of April, the
bulk of cases were in the Commune of Madrid, followed by Catalonia. In Pakistan,
from April to early July, the bulk of the cases have been in the provinces of
Sindh and Punjab; with the cities of Karachi and Lahore having the most cases
within these provinces, respectively.
In India, from March to early July, this has been
almost entirely a big-city disease, with first Mumbai and Ahmedabad, and then
Delhi and Chennai showing the most cases. Each of these cities is in a separate
state in an entirely different part of the country – Delhi being in the North,
Chennai in Tamil Nadu in the South and Mumbai and Ahmedabad in Maharashtra and
Gujarat in the West. As of the date of
this paper, Chennai has over 60% of the cases in Tamil Nadu and Mumbai has over
40% of the cases in Maharashtra. Out of 29 states in India, Delhi, Maharashtra
and Tamil Nadu together account for 60% of the outbreak and Maharashtra has
double the number of cases of Delhi and Tamil Nadu. Gujarat has a third of the
cases than Tamil Nadu and Delhi, and less than 20% of the cases in Maharashtra.
Rajasthan, Telangana and West Bengal have just under 20,000 cases each, being
two-thirds the count in Gujarat. In Telangana, the city of Hyderabad accounts for
77% of the cases. So, again, we have a scenario where different states are
getting cases at different rates, and within each state, cases are clustered
around particular cities in a pattern that has held consistently for several
months. Also, the early epicentre, of Maharashtra, as in many other countries,
has a case and death count that is several times higher than that in states
coming in second place.
There is no place here to go into all the examples, but the pattern of clustering is to be observed in many other countries as well. So while the cases grow and spread to different cities, they remain concentrated for a long time in a few places and cities. Even within cities, spread is clustered, moving from neighbourhood to neighbourhood and, in general, holding to early trends in terms of where the most cases appear. Some of the clustering, and consistency in trends can be accounted for by lockdown, but given the difference in the timing and quality of lockdown from place to place, there is a strong indication that, unlike the epidemiologist’s predictions of homogenous growth, Covid transmits in a series of clusters, with, in most cases, each new cluster being smaller in size and density than the previous ones.
The clustered nature of Covid transmission has implications for deciding on the best ways to tackle it. For example, given the clustered progress of the disease, there should be more attention to sharing medical resources and giving other assistance at the inter-state and inter-district level, and even between neighbourhoods. This has not happened to any great degree in most countries. The Chinese were able to send large teams of doctors from other provinces into their Covid-19 epicentre of Hubei. This ability to call on doctors from other provinces was a great strength of the Chinese response to Covid-19. Unfortunately, it did not occur to the same measure in other countries.
In India, there is no drive to co-ordinate doctors and other health workers between states. The New Delhi state government, revealing its focus on numbers over people, tried to issue a rule barring people from outside the city from coming here for treatment. This was struck down by the Central Government, but its motivation was more political than humane - to show up the Delhi Government which is run by an Opposition Party. This kind of political one-upmanship between national or federal governments, on the one hand, and provincial or state and city-level governors and mayors, on the other, were played in countries all over the world from Japan to the US to Brazil. By making Covid-19 into a game of numbers, we are not giving the right incentives to our politicians to care equally about each life everywhere. We are encouraging them to take heartless action like locking borders or refusing treatment to outsiders or hoarding medical resources, just to show that their numbers are lower than their rivals in other jurisdictions. We need to start thinking nationally rather than locally when it comes to treatment and assistance for Covid-19.
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Let's clear up the confusion about case data and mortality rates
The confusion in the minds of the supposed experts about Covid-19 was compounded by wide public misunderstanding, generated by a clueless media, about key epidemiological terms like the Infection Fatality Rate (IFR) and Case Fatality Rate (CFR). The IFR of a disease is the ratio of the number of deaths from that disease to the number of infections in the entire population. This is to be distinguished from the CFR, which is calculated by diving deaths to cases at any point in time. The CFR does not give a population-wide picture of the fatality resulting from the disease for a number of reasons. For instance, owing to the delay from infection to symptom onset, you may miss the true number of cases at a given point in time, which would lead to an overestimation of the overall death rate. On the other hand, the CFR would not include cases that have not yet had an outcome, which could result in an underestimation of the overall mortality rate, depending on what the outcomes eventually are. So the CFR is not a measure of the overall mortality rate of a disease.
Also, depending on where and when you are looking, the CFR
may change. So, for instance, China reported a CFR of 17.3 to 0.1 as its
epidemic progressed (13). For this reason,
the initial CFR rates calculated while an outbreak is ongoing are also called
“crude” CFRs. So the popular media was wrong to quote CFRs as if they were a
population-wide estimate of the expected mortality from Covid-19. One such
figure was what was called the “WHO’s” CFR of 3.8% for China which sent
shockwaves through the reading public as the mortality rate from the ‘flu and
other similar illnesses is a fraction of that. But this is because the IFR, which is based
on a population-wide range of cases, is usually a fraction of the CFR which is
based on a subset of the cases in a population.
About the IFR, we also have to understand that there is no direct counting of the number of infections in a population. So epidemiologists need to estimate this. Estimates again! For their estimation, epidemiologists use the data from “serological surveys”, which is sampling for antibodies in the blood. The Imperial College epidemiologists estimated the IFR from the CFR (9, 5). This is quite a questionable way of going about the IFR estimation as it basically collapses the difference between the IFR and CFR, but no one noticed.
Even serological surveys are not completely reliable. In serological surveys blood serum from a
sample of the population is tested for the presence of antibodies related to
the particular disease. So we have a double estimation - one in the selection of the sample for serological analysis, and the second in the calculation of the IFR.
Serological surveys are useful to the medical
community as they alert them to the pathogen strains found in the population and
their reactivity to different drugs. So, for instance, the Indian medical
authorities periodically put out reports based on serological surveys for
different strains of bacteria and viruses found in laboratory samples, with
reports on which drugs are effective against them and which pathogens seem to
be developing drug resistance. This is why it is called serological
“surveillance”. This is a method of surveillance for what pathogens are
circulating in the population.
So the prime use of serological surveys is not to estimate disease prevalence (or how many people are infected by a disease) or infection fatality rates, even though epidemiologists and the WHO use them to estimate these things. There are two things to understand here. One, that any IFR, then, is subject to all the uncertainties and possibilities of being mistaken as we discussed at the start about epidemiological modelling. The more important lesson is that in the normal course we do not follow disease in real time, counting cases and deaths as they emerge, and estimating severity from there. This is important because all the numbers that went flying around, and are still being bandied about, on Covid-19, really only make sense if there is something to compare them with.
This is a problem because a number by itself gives very limited information, and numbers that are very small or very large can be misleading if taken simply by themselves. For example, if I tell you that Iceland has only 100 deaths from infectious disease a year, that tells you one thing. If I tell you that Iceland overall has only 2000 or so deaths a year, that tells you another. If I tell you that India has 12 lakh Covid cases, that tells you one thing. If I tell you that India has over 31 lakh tuberculosis cases a year, that tells you another thing. If I tell you that India has 26,000 Covid deaths, that tells you one thing. If I tell you that India has 2.7 to 4.0 lakh tuberculosis deaths, 10 lakh diarrhoeal disease deaths and 6 lakh respiratory disease deaths, a year, that tells you several other things. If I tell you that the USA has 30 lakh Covid cases, while its annual tuberculosis and HIV cases are 10 lakh each, that tells you something. When I tell you that the US typically has 60 thousand deaths a year from respiratory infections and the death toll from Covid is 1.4 lakh and counting, that tells you something else. If I tell you that the US has 22 to 24 lakh deaths a year from non-infectious diseases, that tells you yet a third thing.
So, in order for us to really speak intelligibly about the Covid numbers, we have to know something about what the numbers are for other diseases. But here we run into the difficulty that in the normal course, we do not have outbreak curves for any other disease because these are never plotted in real time as they were done for Covid-19. So we never had an outbreak curve from another disease with which we could compare the Covid ones.
We also have no actual counting of cases for other diseases. In order to determine the case incidence or mortality rate for any disease epidemiologists need to do estimation. Yes, estimation again! So anything you hear about the number of cases say for tuberculosis, AIDS or malaria in any country are not actual counts, or even rough aggregations or averages of cases. They are modelled estimates, which are, therefore, subject to all the uncertainties and inaccuracies that we discussed at the start of this lecture series about epidemiological modelling.
This means that we are all punching in the dark when we are trying to figure out exactly what the Covid numbers mean. It is a quagmire of estimates.
Even WHO mortality data needs to be placed in context in the same way. If you study the notes to the WHO world mortality data, you will discover that there are varying degrees of certainty as to the accuracy of deaths reported under different heads of disease (140F). For a given year there may be no data at all, and the figure reported is…you guessed it….”estimated” again!
The WHO makes these estimates even for countries with no death registration data for the year under study, or with no information on the cause of death. The estimation is made from various things like projections based on available mortality data for a previous period, or estimating deaths by looking at the demographic profile of a country. Even the disease to which the deaths are attributed is done by estimation for the year under study, or with no information on the cause of death, or with no data for a particular disease. Even the disease to which the deaths are attributed can be done by estimation! The estimation is made from various things like projections based on available mortality data for a previous period, or estimating deaths by looking at the demographic profile of a country, “interpolation/extrapolation of number of deaths of missing country-years”, “scaling of total deaths by age and sex to previously estimated WHO all-cause envelopes”, estimating adult mortality from child mortality and a key called the “WHO modified logit life table system”, and so on.
The WHO does not even carry out its own estimations every year. Mortality estimates are carried with gaps of about two or three years, and take several years to be finalised. The 2008 estimates, for example, were updated in 2011, after taking comments from all counties. For later years, for the moment, all that the WHO seems to have are modelled estimates by the American epidemiological institute called the Institute for Health Metrics and Evaluation (IHME). The WHO estimates from after the year 2008 do not say whether they have been circulated to countries for comments, and there is nothing to indicate that anyone from IHME, which is headquartered in the remote State of Washington in the USA, has ever been to countries like India for which they have done these estimations.
Let's clear up the confusion over testing
There is no escaping the uncertainties of disease estimation, even with large-scale testing. Led by WHO’s exhortation to “Test, test, test”, people everywhere have insisted on more and more testing as a way of containing Covid-19. But even though some countries tried to do real-time testing to assess disease-prevalence, no country had the resources to test everyone. By the middle of May, Iceland had conducted the highest numbers of Covid-19 tests per million in world, but this amounted to only about 16% of their population. Being a small and remote country, it was able to keep its Covid numbers down with a combination of testing and case isolation. But this is not a feasible response for big countries.
By early June, the USA had conducted the most tests in
the world - over 3.7 crore - but this covered only about 11% of its population.
Monaco was able to test the maximum percentage of its population, 41%, but this
amounted to only 16,200 tests. The richer Arab countries like the United Arab
Emirates and Bahrain were able to test 35% of their population. They, and some
of the other small and well-off countries like Luxemburg, Denmark and Singapore
were able to use testing to significantly contain the virus. But, in absolute
numbers, their tests were a fraction of the tests conducted by countries like
the UK (over 1 core), Russia (over 2 crores) and the USA (140G).
Even population-wide testing can only give you a
snapshot of the infections at the moment. To keep tabs on disease prevalence
via universal testing over a period of time, the entire population would have
to be tested periodically. Testing and contact tracing might be a worthwhile
expenditure of resources while there is still hope of disease containment. But
today, months on, it is clear that this is not possible anymore, if it ever was,
and we should be thinking seriously about saving resources for treatment.
For bigger nations in the middle of their outbreaks,
besides the cost of population-wide testing, there is also a question of the
massive infrastructure and manpower needed for this. In South Korea, to find a
few hundred Covid-infected, when their second outbreak was traced to some night
clubs, tens of thousands had to be contact-traced. A few weeks later, a case
occurred involving a woman who went to a park, and there was a scramble to
locate every single person who had visited there.
The South Koreans may have found that this approach
made sense to them, but it is not an obvious model for other countries. Before
prescribing it to ourselves in India, we also have to understand the full
nature of the South Korean response, which heavily relied on information
technology, and went to the extent of providing lower income families with
Samsung tablets to continue their children’s education, and so on (46).
The cell phone network they used for this was already in place as an emergency
response system. In all likelihood it came up in context of their historical situation
with North Korea. So, the lesson from South Korea is not so much the use of testing
and contact tracing, but to do as they did in terms of intelligently
identifying and then leveraging what you have locally in conceiving a
practical, sensible and effective response to the disease.
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Conclusion
I now proceed to my conclusion. I have shown you the
many ways in which the epidemiologists, the WHO and public health experts
proceeded on a wrong scientific understanding of the pandemic. From the start
we underestimated the speed and global spread of this disease. This led us to take
up a containment strategy that was doomed to fail. Being fixated on
society-wide containment measures and saving hospital resources, we failed to
notice, for too long, the discrete places where disease clusters actually took
root, and the channels through which they mainly transmitted.
What is much more useful and reliable is what we can see, not through the crystal ball of epidemiological modelling, but what we see and have seen from the start with our own eyes, which is that many people were falling ill and dying fast from Covid-19, and that it was not amenable to conventional treatments. That is really all the information we needed to start thinking and responding intelligently to this disease. Instead of being fixated by how big the outbreak would be and trying to pre-empt that with an untested hypothesis about pandemic control, which in the end failed, we should have focussed on following the outbreak as it happened, trying to keep it within clusters, where possible, dispersing it instead of locking down where we found it to have concentrated, as in the case of old age homes.
We should have been a lot more focussed, not on social distancing, but on international travel, which was the first and most effective driver of this disease. The community awareness efforts for Covid-19 should have been on encouraging people who had had a history of international travel since January to practice quarantine, special hygiene and social distancing and, for business travellers to conduct their meetings online where possible. The logic for these measures should not have been containment, but for individuals that did not have pressing business travel needs to gain some time while doctors came to grips with this novel disease.
We should have immediately starting working with the tourism industry to find ways of mitigating and dispersing travel-related Covid transmission, in a respectful and voluntary way, by offering medical services and warning people to watch out for symptoms of cold or fever. We should also have thought about giving high quality masks and face visors to the travel guides, drivers and hotel staff, who are most at risk of contracting infection from foreign clients.
In countries like India, instead of locking down slums and basically imprisoning poor people, we should have taken measures considering the basic fact of Covid transmission that emerged very early on, which was that households with family members having a history of foreign travel were the main theatre of transmission to slums typically via domestic help. This is essentially what seems to have happened in places like Mumbai. Instead of shutting down construction work, street hawkers, and all the other activity that keeps slum-dwellers and migrant workers in employment, we should simply have requested people coming in from abroad to give their non-live-in domestic staff a few days' holiday while they quarantined.
Regarding foreign travel, as I explained in detail earlier in this paper, we should not have been solely focussed on Wuhan and China. We should have kept in mind the key message of pandemic research before Covid-19, which was that pandemics come from many countries at once. We should have remembered that in a globalised world, by the time you see an outbreak in one place, you have to assume that it is in many other places already. On being alerted to the mushrooming outbreak in Wuhan, we should have focussed on shoring up our medical resources so as to be able to do our best by whoever fell ill, that is all. We should not have set out on the foolhardy and unscientific mission of pre-empting the virus with containment measures.
We wanted to conquer Sars-CoV-2 and went to war against it. A war that we have lost. But there is another path to conquest, and that is with love. Let me take you away from the thoughts of death that have haunted you all these months, to thoughts of love. When we fall in love with someone, we are acutely aware of their every word and gesture. We are fascinated by every line of their face, every nuance of expression, every inflection of voice. We have to do something like this with Sars-CoV-2, the reigning Queen of Viruses today; as we all know, 'corona' means crown.
Instead of thinking of the coronavirus as this dreadful adversary; as this demon of death that we can hardly bear to look upon, we should make this virus an object of fascination for ourselves: what is this, what makes it so strong, how does it find us, what does it want from us, can I feed it in a different way than with my death, can I calm it down, can I distract it.
Maybe, instead of engaging in war with Sars-CoV-2, we can engage it in play, in some form of give-and-take, like the passing of a ball between players in a tennis match, maybe we can find some kind of exchange, if you like, with Sars-CoV-2 that will allow us both to live in harmony.
War is not the only possibility. And anyway, let’s face it, the war has been won by Sars-CoV-2, hasn’t it? We went into an unprecedented lockdown and took other extreme measures. In places like India we did this at a few hundred cases and now we have over 12 lakh cases. Containment has been a success only if you take the epidemiologists’ claims of billions and billions as the standard. The war on Covid-19 has been lost, let us find other ways of dealing with it, beginning with trying to really understand this disease.
Not only did the containment strategy fail, it caused damage and destruction of many more kinds, including death and sickness, and to many more people than would ever have been caused by Covid-19 alone. The hysterical fear that has been created around this disease will inhibit a return to normalcy in many areas of life for years, if not decades, to come. Every sphere of life that functions around the gathering of people, especially the arts and festivals, will be especially repressed, and for the longest time. We have, quite literally, taken the colour and music out of our lives.
Other than the death, hunger, suffering, loss of
livelihood, forced displacement and economic and social disruption from containment
measures, we failed to understand that such measures are inherently unjust,
stigmatising, divisive, and fall hardest on the poor and marginalised among us.
All these wrongs must be accounted for. WHO Director-General, Tedros Adhanom and Health Emergencies Director, Mike Ryan must resign. There has to be an independent and public inquiry into the manner in which the WHO has conducted itself throughout, not just during the Covid saga, but also in other epidemics, such as Ebola and bird flu.
The Imperial College of London must suspend its
epidemiology department and face an ethics enquiry - not just of Neil Ferguson and his team, but of the entire management of that University. In fact, all the big
Universities around the world need to show that they have understood and taken
seriously this crisis of weak thinking and woeful ethics in the sciences and public
policy field. All of you professors and researchers in your comfy positions in your Universities, you
Public health experts must introspect over the devastation
that has been caused by their over-simplistic and numerical approach to health
issues. They need to throw away all their lists of health indicators and
epidemiological modelling. They have to find a way of weaving the humanity back
into public health thinking, and never letting it go, ever again.
A good way of keeping their feet on the ground, is to
abandon utopian thinking on health issues. The idea of eradicating disease and
injury altogether from our lives is bizarre and self-defeating. It is this which has
led to the soul-destroying use of the precautionary principle in social welfare
thinking. We must stop second guessing life. We should go back to basic ideas
of giving assistance when the need for it appears. Chance is part of life. You,
public health experts, you cannot subtract chance from life. That is not how
the mathematics of life works. All you end up doing is cutting off life
in order to stop it from running into chance. As a member of the lay public, as
an ordinary citizen of the world, as a mother, I say to your grand schemes of
global control over disease, death and luck, enough! Give me back my
life, and I will take my chances.
Whenever we humans make blindingly obvious mistakes, and allow blatant injustices and foolishness to pass, as we have done with Covid-19, then we have to also look at the three fingers that point back at us, when we point to the persons who led us in these mistakes and injustices. All this folly took place within the framework of a certain wrong way of thinking in science and social welfare that we have all come to accept, and even to celebrate.
Science has left its roots in theory too far behind, and now seems to spend all its time playing games with mathematical modelling and super computers. This is not the way to produce good science. All this epidemiology and these super-computers are taking us away from science, and not towards it. If we are relying more on super-computers than on our brains to do science, then we should assume that there is something wrong with our science. The brain must lead the machine. Numbers are an adjunct to thinking, not a substitute for it. That’s when you have science. Anything else is just a rarefied form of accountancy.
Public policy and social development also have to end their romance with modelling and numbers. You are killing common sense and humanity with your indicators and projections-based approach. Like public health experts, you are forgetting the people behind the numbers. You are also not conscious enough, when you design interventions for the betterment of society, of the danger of using the state as your ally in so doing. In recent years, there has been a general tendency in welfare thinking, to ignore the adversarial aspect of the relationship between state and citizen. The state is seen as the engine for delivering welfare, for helping those left behind, and, therefore, to be accepted and trusted by all good-hearted and responsible citizens. Anyone standing in the way is seen to be violating their responsibility both to society, and to themselves. But we are seriously undermining the very freedoms and liberties on which we rely to keep our society just and fair by giving in too completely to this way of thinking.
The assumption when using the state to intervene on
welfare grounds must be that things could go wrong in unpredictable ways, and
also in the predictable ways of state overreach, corruption and incompetence.
Instead of digging their heels in on one or other side of various social
development models, or blaming the government for not acting strongly enough, or
blindly asking for more money to be pumped into welfare schemes that go toxic,
social development professionals should be vigilant about interventions that go
bad. They should be at the forefront of moves to stop or change course. Right
now, there is too much of a superior attitude in the social welfare field about
these things. Social development professionals, NGOs, activists and
philanthropists are so caught up in the nobility of their mission to save the
world, that they are not willing to accept that they themselves might be
creating and perpetuating the inequalities and injustices that they set out to
conquer.
As I came to the end of writing this paper, I found a
fascinating debate between Noam Chomsky and Michel Foucault from the 1970s,
that reflects upon these issues (172). Chomsky, the progressive, argues
that we must intervene to constantly improve society, to make it just and fair,
and that such an approach is in turn founded upon an idea of the ideal man in
all his goodness, creativity, and other potential. Foucault, the post-modernist,
says that structures of power will inevitably influence how you articulate the principles
of a just and fair society, and how you conceive of the ideal man; and so any
intervention carries the possibility of perpetuating the very imbalance of
power that produced the injustice or other social-ill that you set out to
correct (191).
Foucault here is not really arguing against social
action. Foucault
was pointing towards what the right philosophic approach to social action must
be. He was saying, what we saw him say in The Birth of the Clinic, about
the role of social and economic dynamics, and even of chance, in forming
systems of thought or practice.
If you have social action that is not reflective about
this, that will not concede this, that questions the motives of people who try
to point this out, that is when it becomes oppressive, and just another form of
the unjust exercise of authority and control over others. And that is where we
are today with social welfare interventions of all kinds, of which lockdown has
only been the most dramatic and widespread.
My own interest in this matter comes from the field of
child protection, where I have for years been witnessing the brutal snatching
of children by the state from loving families for no good reason, and with an
absolute refusal on the part of the child rights field to do something about
it. I first witnessed this system in the Nordic countries of Norway and Sweden,
and was struck by the widespread support in these societies of their child
services. Everything I saw in the way child protection functions in these
countries - the intrusiveness, the punitive approach, the
lack of transparency, decisions being taken by executive power, the lack of due
process - all this contradicted the openness
and freedoms for which these societies are so famous.
It was in struggling to understand this contradiction,
that I had at first approached simply as lawyer concerned about basic
principles of due process and administrative accountability, that I saw the
full extent of the pact which binds people to the state in the Nordic welfare
model. I saw that when you rely on the state to take care of you, it really does
take care of you, in the sense that you are subject to its interference to a
much greater degree in the areas of life where it intervenes, than in those
where it leaves you to your own devices.
In the United Kingdom, I saw the same aggressive interventionism in the fields of child services, elder care, the provision and withholding of certain types of medical services, and the sectioning of the mentally ill. Though the British have in general retained their sense of irony, and the distance that implies, towards the state in all areas other than these, in Sweden and Norway I have found a degree of respect, obedience and solidarity with the state-as-government, not as nation, that would be more in place in authoritarian regimes. Scandinavians are highly conformist and amenable to authority when it is expressed in terms of their welfare. This is the true context for understanding the so-called “no lockdown” policy of Sweden. They did not need it, because Swedes could be depended upon to follow government advice on social distancing.
Let us look at the facts on the ground in Sweden. By mid-April about half of Sweden’s workforce was reported to be working from home (187), from mid-March onwards there was a 50% drop in the use of public transport in some counties (188) and a 30% drop in Stockholm in the use of cars (189). Inter-state travel over Easter was down by 80-90% (190). Therefore, movement was substantially reduced, more than in many countries with mandatory lockdowns. So whatever else the Swedish response to Covid-19 was about, it was not about people having more freedom in Swedish society. If anything, it was symptomatic of the degree to which certain freedoms have been ceded to the state by Swedes a long time ago.
And it gets more and more interesting as you keep thinking deeper about the Swedish response to Covid-19. Note how the Swedes
did not attempt to justify their strategy by pointing out that they did have
a voluntary near-lockdown in place. Clearly, they are not willing to disclose
just how compliant their people are to the merest suggestions of the
authorities.
But what is even more noteworthy is how the de facto lockdown of Sweden did not satisfy pro-lockdown advocates elsewhere in Europe and the USA. This really shows the twisted psychology of the pro-lockdowners. They were not so much concerned about whether there had been an effective suspension of social and economic activity in Sweden for the sacred “flattening of the curve”. What was really getting the lockdowners’ goat was that Swedes were being permitted even the theoretical right to decide not to stay-at-home. This is where public welfare thinking really reveals itself for the nakedly repressive and dogmatic thing that it has become. These people want nothing less than our blind obedience. We need to tell them to get lost!
The philosopher Slavoj Zizek wrote recently about Covid-19 that governments, I presume he meant Western governments, because no one in our part of the world spoke of this, when speaking of herd immunity were like the cat in the cartoon that walks off the precipice, and keeps walking so long as he does not look down, but when he does, he falls (171)! In fact, these Western governments were not so innocent as that cat. They suggested herd immunity to cover up their inability to save their people from Covid-19, and when the people objected, they punished them with lockdown.
I will end with Zizek’s metaphor of the cat.
Are we not all like that cat? We are even more pathetic than it, because we
never have even a second’s doubt of the abyss that yawns right before us. Each
day, is not even a wager against death, because we know that death is certain. We
simply shrug it off, and carry on. We laugh in the face of death. We have snatched meaning and joy from
the unrelenting silence and randomness of the Universe around us. This is our genius. Let us forget
about Covid -19. Let us get back to life.
6 July 2020, New Delhi
Suranya Aiyar is trained in mathematics at
St. Stephen’s College, India and law at Oxford University, UK and New York University,
USA. She lives in New Delhi, India, with her husband and two children.
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was published in a number of formal papers subsequently and can be accessed
here: Covid-19 pneumonia: different respiratory treatments for different
phenotypes? Gattinoni et al., Intensive Care Medicine, 46, pg. 1099, 14
April 2020. https://link.springer.com/article/10.1007/s00134-020-06033-2?tk=eo_8ec810cc-57e5-4bc1-bb85-e22b9e068904_JOUOgWdVMbWC4XIzzfHwSizVS09ocy3MoJOK
and Management of Covid-19 respiratory distress, John J Marini and Luciano
Gattinoni, JAMA Insights, Clinical Update, 24 April 2020. Link: https://jamanetwork.com/journals/jama/fullarticle/2765302
(59) Advisory on the use of hydroxy-chloroquine as
prophylaxis for SARS-CoV-2 infection, Indian Council of Medical Research, 22
March 2020. Link: https://www.mohfw.gov.in/pdf/AdvisoryontheuseofHydroxychloroquinasprophylaxisforSARSCoV2infection.pdf
(60) https://www.history.com/news/black-holes-albert-einstein-theory-relativity-space-time
(61) https://hsm.stackexchange.com/questions/5937/why-did-einstein-oppose-quantum-uncertainity
(62) Announcement of New Coronavirus Infectious
Disease Control Experts Meeting dated 24 February 2020 (in Japanese): https://www.mhlw.go.jp/stf/seisakunitsuite/newpage_00006.html ; Prevention Measures against Coronavirus Disease,
Japan, 25 February 2020 (in Japanese): https://www.mhlw.go.jp/content/10900000/000607629.pdf
(63) Early state of a Japan outbreak: The policies
needed to support coronavirus patients, Saito Katsuhisa, Nippon.com, 19
February 2020. Link: https://www.nippon.com/en/news/l00267/early-stage-of-a-japan-outbreak-the-policies-needed-to-support-coronavirus-patients.html
(64) China coronavirus: Wuhan medical staff being
infected at much faster pace than reported as national death toll hits 26,
South China Morning Post, 24 January 2020. Link: https://www.scmp.com/news/china/society/article/3047441/wuhan-medical-staff-being-infected-virus-much-faster-pace
(65) Coronavirus: shocking footage shows Chinese
family being forced into quarantine by police, Evening Standard, 8 February
2020. Link to video: https://www.youtube.com/watch?v=nNeTWX7WgwA
(66) Ebola community health workers trained for the
future, 10 March 2020. Link: https://www.afro.who.int/news/ebola-community-health-workers-trained-future?fbclid=IwAR2zmg7cus3tbD8LCJZCzCsjFXM_BuQ9o9dhYxNx7z6u7X_cUR0DPwMNkVQ
(67) Sweden’s relaxed approach to the coronavirus
could already be backfiring, Time, 9 April 2020. Link: https://time.com/5817412/sweden-coronavirus/
(68) Spanish soldiers find elderly patients
‘abandoned’ in retirement home, France 24, 24 March 2020. Link: https://www.france24.com/en/20200324-spanish-soldiers-find-elderly-patients-abandoned-in-retirement-homes
; ‘Just sedate old people, pray they live’: with nearly 12k deaths in Spain,
Covid-19 suffocates hospitals, News19=8.com, 5 April 2020. Link: https://www.news18.com/news/world/they-just-sedate-old-people-pray-they-live-with-nearly-12k-deaths-in-spain-covid-19-suffocates-hospitals-2564945.html;
Pensioner, 84, on lockdown due to coronavirus….Daily Mail, 8 April 2020. Link: https://www.dailymail.co.uk/news/article-8201815/Pensioner-84-lockdown-coronavirus-forced-eat-old-food-BIN.html;
Burials on New York island are not new but are increasing during pandemic,
npr.org, 10 April 2020. Link: https://www.npr.org/sections/coronavirus-live-updates/2020/04/10/831875297/burials-on-new-york-island-are-not-new-but-are-increasing-during-pandemic
; Mass graves for coronavirus victims shouldn’t come as a shock, The
Conversation https://theconversation.com/mass-graves-for-coronavirus-victims-shouldnt-come-as-a-shock-its-how-the-poor-have-been-buried-for-centuries-136655;
‘This whole corridor is dead’: Europe’s coronavirus care home disaster, The
Irish Times, 19 May 2020. Link: https://www.irishtimes.com/news/world/europe/this-whole-corridor-is-dead-europe-s-coronavirus-care-home-disaster-1.4256568
; Coronavirus: Europe’s care homes struggle as deaths rise, BBC, 3 April 2020.
Link: https://www.bbc.com/news/world-europe-52147861
; A deluged system leaves some elderly to die, rocking Spain’s self-image, New
York Times, 25 March 2020. Link: https://www.nytimes.com/2020/03/25/world/europe/Spain-coronavirus-nursing-homes.html
(69) New York Governor Andrew Cuomo criticised over
highest nursing home death toll, The New Indian Express, 10 May 2020.
Link: https://www.newindianexpress.com/world/2020/may/10/new-york-governor-andrew-cuomo-criticised-over-highest-nursing-home-death-toll-2141550.html
(70) Nation-wise data from the International Long Term
Care Policy Network, “Mortality associated with COVID among people who use long
term care”, updates of 21 May 2020 and 26 June 2020. Link to 26 June 20202
update here: https://ltccovid.org/wp-content/uploads/2020/06/Mortality-associated-with-COVID-among-people-who-use-long-term-care-26-June-1.pdf;
State-wise data for the USA from Covid-19 brutal on NY long-term care
facilities, The Buffalo Post quoting Kaiser Family Foundation data, 26
May 2020. Link: https://buffalonews.com/business/local/covid-19-brutal-on-ny-long-term-care-facilities-nationwide-its-worse/article_739b408b-5d34-5b8d-be83-124047368d2b.html
(71) A deluge of death in Northern Italy, 25 March
2020. Link: https://graphics.reuters.com/HEALTH-CORONAVIRUS-LOMBARDY/0100B5LT46P/index.html;
‘We take the dead from morning till night’, The New York Times, 27 March 2020.
Link: https://www.nytimes.com/interactive/2020/03/27/world/europe/coronavirus-italy-bergamo.html?auth=login-email&login=email
(72) Mumbai: 25-year-old with no conditions dies after
3 days in hospital, Time of India, 21 April 2020. Link: https://timesofindia.indiatimes.com/city/mumbai/mumbai-25-year-old-with-no-conditions-dies-after-3-days-in-hospital/articleshow/75262442.cms
(73) Coronavirus: with SP and RJ from this Tuesday,
all capitals stop trade to reduce the risk of contagion, globo.com, 24 March
2020 (in Brazilian Portuguese). Link: https://g1.globo.com/economia/noticia/2020/03/24/cidades-fecham-comercio.ghtml;
Bolsonaro says he ‘wouldn’t feel anything if infected with Covid-19 and attacks
state lockdowns, The Guardian, 25 March 2020. Link: https://www.theguardian.com/world/2020/mar/25/bolsonaro-brazil-wouldnt-feel-anything-covid-19-attack-state-lockdowns;
Bolsonaro and governors on a collision course, The Brazilian Repot, 26 March
2020. Link: https://brazilian.report/newsletters/brazil-daily/2020/03/26/governors-in-brazil-on-a-collision-course-with-president-bolsonaro/;
Rio and 5 other municipalities in the state declare an emergency to contain the
coronavirus, g1.globo.com, 18 March 2020 (in Brazilian Portuguese). Link: https://g1.globo.com/rj/rio-de-janeiro/noticia/2020/03/18/prefeitura-do-rio-declara-situacao-de-emergencia.ghtml;
https://g1.globo.com/rj/rio-de-janeiro/noticia/2020/03/17/governo-do-rj-determina-reducao-de-50percent-da-capacidade-de-lotacao-dos-transportes-publicos.ghtml
(74) Data from catcomm.org/favela-facts.
(75) Brazil’s super-rich and the exclusive club at the
heart of a coronavirus hotspot, The Guardian, 4 April 2020. Link: https://www.theguardian.com/world/2020/apr/04/brazils-super-rich-and-the-exclusive-club-at-the-heart-of-a-coronavirus-hotspot
(76) Rio’s favela’s count the cost as deadly spread of
Covid-19 hits the city’s poor, The Guardian, 25 April 2020. Link: https://www.theguardian.com/world/2020/apr/25/rio-favelas-coronavirus-brazil
(77) Brazil Covid-19 data from https://disasterresponse.maps.arcgis.com/apps/dashboards/b16474584d1b43948955ca1462b9e998
(78) Data from https://painel.vozdascomunidades.com.br/
(79) How one of Brazil’s largest favelas confronts
coronavirus, Bloomberg, 3 May 2020. Link:
https://www.bloomberg.com/news/features/2020-05-03/how-one-of-brazil-s-largest-favelas-confronts-coronavirus?fbclid=IwAR2L1GWPMDyUgtXBdQGbcEYPbcOQ9jTccTaZiCJHH4GsmHgvshvVUAXS3fg
(80) Brazil’s favelas forced to fight coronavirus
alone, DW, 2 July 2020. Link: https://www.dw.com/en/brazils-favelas-forced-to-fight-coronavirus-alone/a-54031886;
Data on favelas from https://painel.vozdascomunidades.com.br/
and state-wise Brazil data from https://www.statista.com/statistics/1103791/brazil-coronavirus-cases-state/
(81) Malabar Hill resident among 5 new cases, Mumbai
Mirror, 21 March 2020. Link: https://mumbaimirror.indiatimes.com/coronavirus/news/malabar-hill-resident-among-5-new-cases/articleshow/74740898.cms
(82) Asia’s largest slum Dharavi reports first
Covid-19 case, Economic Times 2 April 2020. Link: https://economictimes.indiatimes.com/news/politics-and-nation/asias-largest-slum-dharavi-reports-first-case-of-coronavirus/articleshow/74937159.cms ; Number of coronavirus
cases in Maharashtra rises to 335, LiveMint, 1 April 2020. Link: https://www.livemint.com/news/india/number-of-coronavirus-cases-in-maharashtra-rises-to-335-11585749948541.html
(83) Mumbai becomes epicentre of Covid-19 positive
cases and death reports, The New Indian Express, 5 April 2020. Link: https://www.newindianexpress.com/cities/mumbai/2020/apr/05/mumbai-becomes-epicentre-of-covid-19-positive-cases-and-death-reports-2126173.html
(84) Maharashtra nears 10,000 mark.., NDTV, 29 April
2020. Link: https://www.ndtv.com/india-news/maharashtra-nears-10-000-mark-mumbai-has-6-644-coronavirus-cases-2220609
(85) Mumbai Covid19 Tracker: 12 BMC wards report over
1500 positive cases, Mumbai Mirror, 31 May 2020. Link: https://mumbaimirror.indiatimes.com/coronavirus/news/mumbai-covid-19-tracker-12-bmc-wards-report-over-1500-positive-cases-dharavi-dadar-and-mahim-among-citys-worst-hit/articleshow/76120988.cms
(86) Mumbai: In Dharavi 75% infected are frontline
workers, Indian Express, 23 May 2020. Link: https://indianexpress.com/article/cities/mumbai/in-dharavi-75-infected-are-frontline-workers-6423111/
(87) In the week funk dances returned to communities,
favelas recorded more than 100 deaths from Covid-19, OGlobo, 8 June 2020 (in
Brazilian Portuguese). Link: https://oglobo.globo.com/rio/na-semana-em-que-bailes-funks-voltaram-comunidades-favelas-registram-mais-de-cem-mortes-por-covid-19-1-24468827
(88) In Delhi slums people queue for drinking water
ignoring social distancing norms, Business Insider, 18 April 2020. Link: https://www.businessinsider.in/india/news/in-delhi-slums-people-queue-for-drinking-water-ignoring-social-distancing-norms/articleshow/75218038.cms
(89) Ramaphosa announces 21day coronavirus lockdown
for South Africa, BusinessTech, 23 March 2020. Link: https://businesstech.co.za/news/government/383927/ramaphosa-announces-21-day-coronavirus-lockdown-for-south-africa/
(90) Mzansi reacts to police & army ‘brutality’
during lockdown, TimesLive, South Africa, 31 March 2020. Link: https://www.timeslive.co.za/news/south-africa/2020-03-31-mzansi-reacts-to-police-army-brutality-during-lockdown-they-must-respect-the-law/
(91) UN Raises alarm about police brutality in
Covid-19 lockdowns, Al Jazeera, 28 April 2020. Link: https://www.aljazeera.com/news/2020/04/raises-alarm-police-brutality-covid-19-lockdowns-200428070216771.html?fbclid=IwAR0luxsHfBtWv1GuDp46YitHRZi5ER3xjfplukqDrK7Hjb5KY5bxSOiUWAE
(92) Maharashtra government seals all hotspots
including Dharavi, LiveMint, 9 April 2020. Link: https://www.livemint.com/news/india/mumbai-seals-parts-of-dharavi-11586437129347.html
(93) Coronavirus fallout: From Maharashtra an exodus
of migrant workers with no work, The Wire: Science, 22 March 2020. Link: https://science.thewire.in/health/coronavirus-maharashtra-migrant-workers/
(94) Quarantine puts at risk the income of Brazilian
slum dwellers, says research, globo.com, 24 March 2020 (in Brazilian
Portuguese). Link: https://g1.globo.com/bemestar/coronavirus/noticia/2020/03/24/quarentena-poe-em-risco-a-renda-de-moradores-de-favelas-brasileiras-diz-pesquisa.ghtml
(95) Coronavirus fallout: From Maharashtra an exodus
of migrant workers with no work, The Wire: Science, 22 March 2020. Link: https://science.thewire.in/health/coronavirus-maharashtra-migrant-workers/
(96) Ground Report: Chaos at Anand Vihar as buses
prepare to take migrant workers home, The Wire, 28 March 2020. Link: https://www.youtube.com/watch?v=gW61drhb8FE;
India lockdown: Migrant workers in very large numbers at Delhi’s Anand Vihar
bus terminal, The Economic Times, 28 March 2020. Link: https://economictimes.indiatimes.com/news/politics-and-nation/india-lockdown-migrant-workers-in-very-large-numbers-at-delhis-anand-vihar-bus-terminal/videoshow/74865929.cms?from=mdr;
Watch: Thousands of migrant workers crowd Anand Vihar Bus Terminal amid lockdown,
Times of India, 28 March 2020. Link: https://timesofindia.indiatimes.com/videos/city/delhi/watch-thousands-of-migrant-workers-crowd-anand-vihar-bus-terminal-amid-lockdown/videoshow/74865108.cms;
Covid 19 Lockdown: Hungry Helpless Migrant Workers Flee Cities, 29 March 2020,
India Today (Video). Link: https://www.youtube.com/watch?v=lUVGVBNWDZ0;
Stranded Migrant workers walk for days to reach home amidst lockdown, CNN
News18, 27 March 2020. Link: https://www.youtube.com/watch?v=PgIbqEzdPyg
(97) My kids are hungry, you think Covid-19 is what I
fear? News18.com, 29 March 2020. Link: https://www.news18.com/news/india/my-kids-are-hungry-you-think-covid-19-is-what-i-fear-thousands-of-migrant-workers-flee-amid-lockdown-2555453.html
(98) Covid 19 lockdown triggers massive exodus of
migrant workers Noida-Agra Highway, CNN News18, 28 March 2020. Video link: https://www.youtube.com/watch?v=tt8e8owMTGY;
Migrant Workers Walking their ways back home say hunger will get them before
the virus, CNN News18, 27 March 2020. Video link: https://www.youtube.com/watch?v=-PBD4yBJlJQ;
Stranded Migrant workers walk for days to reach home, CNN-New18, 26 Mach 2020.
Video link: https://www.youtube.com/watch?v=PgIbqEzdPyg
(99) Des ki baat Ravish Kumar ke saath: Mazdooron ki
Majboori, NDTV India, 6 May 2020 (in Hindi), https://www.youtube.com/watch?v=lfdmcaOeWmY; Des ki baat Ravish Kumar ke saath: Mazdooron
ki Ghar Waapsi ki Jaddojehad, NDTV India, 11 May 2020 (in Hindi). Link: https://www.youtube.com/watch?v=ovbpvCLaYL8
(100) Des ki baat Ravish Kumar ke saath: Mazdooron ki
Ghar Waapsi ki Jaddojehad, NDTV India, 11 May 2020 (in Hindi). Link: https://www.youtube.com/watch?v=ovbpvCLaYL8
(101) Des ki baat Ravish Kumar ke saath: Mazdooron ki
Majboori, NDTV India, 6 May 2020, (in Hindi) https://www.youtube.com/watch?v=lfdmcaOeWmY
(102) Uddhav Thackrey appeals to migrant workers to
stay put, The Hindu Business Line, 28 March 2020. Link: https://www.thehindubusinessline.com/news/uddhav-thackeray-appeals-to-migrant-workers-in-maharashtra-to-stay-put/article31189724.ece
(103) How the coronavirus is impacting favelas in Rio
de Janeiro, Forbes, 29 April 2020. Link:
https://www.forbes.com/sites/joshualaw/2020/04/29/how-the-coronavirus-is-impacting-favelas-in-rio-de-janeiro/#3023c783ee39
(104) Daulatdia brothel: as clients disappear hunger
sets in, The Business Standard, Bangladesh, 8 April 2020. Link: https://tbsnews.net/panorama/daulatdia-brothel-clients-disappear-hunger-sets-66586
(105) ‘This is what happens to us’, The Washington
Post, 3 June 2020. Link: https://www.washingtonpost.com/graphics/2020/politics/coronavirus-race-african-americans/
(106) The social inequalities that the Covid-19
pandemic shows us, Brasil de Fato, 4 April 2020 (in Brazilian Portuguese).
Link: https://www.brasildefato.com.br/2020/04/04/artigo-as-desigualdades-sociais-que-a-pandemia-da-covid-19-nos-mostra
(107) To contain coronavirus, residents negotiate end
of funk balls in Rocinha, midiamax, 9 June 2020 (in Brazilian Portuguese).
Link: https://www.midiamax.com.br/brasil/2020/para-conter-coronavirus-associacao-de-moradores-negociou-fim-dos-bailes-funk-na-rocinha
(108) 1 million Bangladeshi garments workers lose jobs
amid Covid-19 economic fallout, mpr.org, 3 April 2020. Link: https://www.npr.org/sections/coronavirus-live-updates/2020/04/03/826617334/1-million-bangladeshi-garment-workers-lose-jobs-amid-covid-19-economic-fallout
(109)
Fury in Kenya over police brutality amid coronavirus curfew, Al Jazeera, 2
April 2020. Link: https://www.aljazeera.com/news/2020/04/fury-kenya-police-brutality-coronavirus-curfew-200402125719150.html?utm_source=website&utm_medium=article_page&utm_campaign=read_more_links
(110) Lockdown: cops, metro cop face 3 counts of
murder and other serious charges, news24.com, 31 March 2020. Link: https://www.news24.com/news24/southafrica/news/cops-face-3-counts-of-murder-and-other-serious-charges-amid-lockdown-20200331;
Police brutality on the rise during lockdown, IOL, South Africa, 5 April 2020.
Link: https://www.iol.co.za/news/south-africa/police-brutality-on-the-rise-during-lockdown-46250431;
SANDF issues stern warning after soldiers accused of beating Alexandra man to death,
IOL, 12 April 2020. Link: https://www.iol.co.za/news/south-africa/gauteng/sandf-issues-stern-warning-after-soldiers-accused-of-beating-alexandra-man-to-death-46625061?fbclid=IwAR3j00XAzYI5j6rOLwEe5k_VoWiRQYeh4reKfCNLINELcc4JHVRSVt5S8tQ.
Also see (28).
(111) Covid-19: Security forces in Africa brutalizing
civilians under lockdown, DW, 20 April 2020. Link: https://www.dw.com/en/covid-19-security-forces-in-africa-brutalizing-civilians-under-lockdown/a-53192163?fbclid=IwAR1zWI6PygaOesr1Ntw32ShrUyRS2pgbYD7G_E1OCe44d1dnlK0
(112) Court orders suspension of South African
soldiers over death of man in lockdown, Reuters, 15 May 2020. Link: https://www.reuters.com/article/us-health-coronavirus-safrica-military/court-orders-suspension-of-south-african-soldiers-over-death-of-man-in-lockdown-idUSKBN22R24O
(113) We’ll keep enforcing lockdown, says French
Minister amid unrest, Reuters, 22 April 2020. Link: https://www.reuters.com/article/us-health-coronavirus-france-security/french-motorcyclist-whose-crash-fuelled-riots-urges-calm-amid-more-unrest-idUSKCN2240DC
(114) Containment Measures: Police checks must not be
abusive, violent or discriminatory, Human Rights League and Others, France, 27
March 2020 (in French). Link: https://www.ldh-france.org/mesures-de-confinement-les-controles-de-police-ne-doivent-etre-ni-abusifs-ni-violents-ni-discriminatoires/
(115) The Religious Retreat that sparked India’s Major
Coronavirus Manhunt, Reuters, 2 April 2020. Link: https://www.reuters.com/article/us-health-coronavirus-india-islam-insigh/the-religious-retreat-that-sparked-indias-major-coronavirus-manhunt-idUSKBN21K3KF
(116) Tabligh members undergoing treatment…The
Economic Times, 3 April 2020. Link: https://economictimes.indiatimes.com/news/politics-and-nation/tabligh-members-undergoing-treatment-not-cooperating-doctors-to-delhi-govt/articleshow/74969727.cms?from=mdr
(117) Tablighi Jamaat par bole CM Arvind Kejriwal,
Navbharat Times, 31 March 2020 (in Hindi). Link: https://www.youtube.com/watch?v=yNA_OKk4IKE
(118) Coronavirus conspiracy theories targeting
Muslims spread in India, The Guardian, 13 April 2020. Link: https://www.theguardian.com/world/2020/apr/13/coronavirus-conspiracy-theories-targeting-muslims-spread-in-india ; ‘Muslim traders not
allowed’, reads poster in Indore village, Scroll.in, 3 May 2020. Link: https://scroll.in/latest/960924/muslims-not-allowed-reads-poster-in-indore-village-police-file-case;
Gurugram: Youths assault neighbour, 6 of them arrested, Times of India, 7 April
2020. Link: https://timesofindia.indiatimes.com/city/gurgaon/youths-assault-neighbour-6-of-them-arrested/articleshow/75018533.cms
(119) Press Release: International Institute for
Religious Freedom and Human Rights Without Frontiers. Link: https://www.iirf.eu/news/other-news/cesnur-and-human-rights-without-frontiers-release-white-paper-on-shincheonji-and-coronavirus/ ; Shincheonji &
Coronavirus in South Korea: Sorting Fact from Fiction, Human Rights Without
Frontiers et al.. Link: https://drive.google.com/file/d/1DRcWhbQ1xoJRs-tkAFp38IWi-3QB8qJX/view
(120) Coronavirus is spreading at religious
gatherings, ricocheting across nations, The Wall Street Journal, 18 March 2020.
Link: https://www.wsj.com/articles/coronavirus-is-spreading-at-religious-gatherings-ricocheting-across-nations-11584548174
(121) 202 confirmed coronavirus cases in South Africa,
BusinessTech, South Africa, 20 March 2020. Link: https://businesstech.co.za/news/lifestyle/383455/202-confirmed-coronavirus-cases-in-south-africa/
(122) Coronavirus: SA’s patient zero and one other are
home and all clear, IOL, South Africa, 20 March 2020. Link: https://www.iol.co.za/news/south-africa/kwazulu-natal/coronavirus-sas-patient-zero-and-one-other-are-home-and-all-clear-45296869
(123) Rights in the time of Covid-19, UNAIDS, 20 March
2020. Link: https://www.unaids.org/en/resources/documents/2020/human-rights-and-covid-19
(124) African countries respond to Guangzhou’s ‘Anti
Epidemic Measures’, The Diplomat, 27 April 2020. Link: https://thediplomat.com/2020/04/african-countries-respond-to-guangzhous-anti-epidemic-measures/
(125) List of incidents of xenophobia and racism
related to the Covid-19 pandemic, Wikipedia.
https://en.wikipedia.org/wiki/List_of_incidents_of_xenophobia_and_racism_related_to_the_COVID-19_pandemic
(126) Covid-19: Bangladesh Army says troops will be on
streets until govt recalls, PTI, The Hindu, 29 March 2020. Link: https://www.thehindu.com/news/international/covid-19-bangladesh-army-says-troops-will-be-on-streets-until-govt-recalls/article31197469.ece
(127) Bangladesh: End wave of Covid-19 ‘rumour’
arrests, Human Rights Watch, 31 March 2020. Link: https://www.hrw.org/news/2020/03/31/bangladesh-end-wave-covid-19-rumor-arrests?fbclid=IwAR0ZW3igg-DHw24SfVWvAdgC-bckCRRaANzt7YQf4fpcSSkdIhFW5G7IOnU
(128) Nigerian security forces kill 18 during curfew
enforcement, AL Jazeera, 16 April 2020. Link: https://www.aljazeera.com/news/2020/04/nigerian-security-forces-kill-18-curfew-enforcement-200416142503603.html?utm_source=website&utm_medium=article_page&utm_campaign=read_more_links
(129) South Africa’s ruthlessly efficient fight
against coronavirus, BBC, 3 April 2020. Link: https://www.bbc.com/news/world-africa-52125713?fbclid=IwAR3z4vjmq_PPI2_GB3divYSX3_UKODdSMa6DARgbsLFhHkRm0B8LtjJIyFs
(130) Statement by President Cyril Ramaphosa, 23 April
2020. Link: https://sacoronavirus.co.za/2020/04/23/statement-by-president-cyril-ramaphosa-on-south-africas-response-to-the-coronavirus-pandemic-union-buildings-tshwane/
(131) Des Ki Baat Ravish Kumar ke Saath, Patri par
zindagi lautti hai, yahan majdooron ko mili maut, NDTV India, May 8, 2020, ;
Des ki Baat Ravish Kumar ke Saath: Rail ki patriyon par chalta desh, NDTV
India, 8 May 2020. Link: https://www.youtube.com/watch?v=K2W2Fq2-BTs&list=PLpSN4vP31-KuS06SnZK5As7hprxvALTQ8&index=59&t=0s;
Des ki Baat Ravish Kumar ke Saath Media ko majdooron ki bebassi dikhane se prashasan
ki taraf se roka gaya, NDTV India, 8 May 2020. Link: https://www.youtube.com/watch?v=og-wP1VqRQY&list=PLpSN4vP31-KuS06SnZK5As7hprxvALTQ8&index=57;
Migrant workers: Maharashtra accident victims were battling hunger; The Hindu,
8 May 2020. Link: https://www.thehindu.com/news/national/other-states/maharashtra-train-accident-victims-were-battling-hunger/article31538217.ece
(132) Mapping accidents that killed over 100 migrant
workers on the way home during lockdown, New18.com, 20 May 2020. Link: https://www.news18.com/news/india/mapping-accidents-that-killed-over-100-migrant-workers-on-their-way-to-home-during-nationwide-lockdown-2627947.html;
UP migrant walking home dies allegedly of hunger, The Hindu, 17 May 2020. Link:
https://www.thehindu.com/news/national/other-states/up-migrant-walking-home-dies-allegedly-of-hunger/article31609993.ece;
Coronavirus lockdown: The Indian migrants dying to get home, BBC, 20 May 2020.
Link: https://www.bbc.com/news/world-asia-india-52672764;
22 migrant workers, kin have died trying to return home since the lockdown
started, The Wire, 30 March 2020. Link: https://thewire.in/rights/coronavirus-national-lockdown-migrant-workers-dead;
198 migrant workers killed in road accidents during lockdown: Report, Hindustan
Times, 2 June 2020. Link: https://www.hindustantimes.com/india-news/198-migrant-workers-killed-in-road-accidents-during-lockdown-report/story-hTWzAWMYn0kyycKw1dyKqL.html;
Walking home, migrant worker dies of sunstroke in Andhra Pradesh, The New
Indian Express, 22 May 2020. Link: https://www.newindianexpress.com/cities/vijayawada/2020/may/22/walking-home-migrant-worker-dies-of-sunstroke-in-andhra-pradesh-2146527.html;
378 die on the way home according to this report11 May Des ki Baat Mazdooron ki
ghar wapsi ki jaddojehad. Coronavirus lockdown: Deaths in Shramik trains not
due to lack of food, water, says government, The Hindu, 5 June 2020. Link: https://www.thehindu.com/news/national/coronavirus-lockdown-deaths-in-shramik-trains-not-due-to-lack-of-food-water-says-government/article31759464.ece
(133) India should aim for 10-week total
lockdown…India Today, 22 April 2020. Link: https://www.indiatoday.in/india/story/india-should-aim-for-10-week-total-lockdown-not-rush-exit-top-health-journal-editor-1669917-2020-04-22
(134) Congo’s Ebola fight has lessons for Covid-19,
Human Rights Watch, 26 March 2020. Link:
https://www.hrw.org/news/2020/03/26/congos-ebola-fight-has-lessons-covid-19;
Was DR Congo’s Ebola virus outbreak used as a political tool? The Lancet,
Editorial, Vol. 393, 12 January 2019. Link: https://www.thelancet.com/action/showPdf?pii=S0140-6736%2819%2930002-9
;191 Biosocial approaches to the 2013-2016 Ebola Pandemic, Richardson et al.,
Health and Human Rights Journal, June 2016, 18(1): 115-128. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5070685/.
(135) Ebola and the narrative of mistrust, Richardson et
al., BMJ Glob Health 2019 4(6) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6936462/
(136) Bulletin of the World Health Organisation, Jane
Parry, 12 December 2005. Link: https://www.who.int/bulletin/volumes/83/12/news21205/en/;
Risky Zoographies: The limits of place in Avian Flu management, Natalie Porter,
Environmental Humanities (2012) 1 (1): 103-121. Link https://read.dukeupress.edu/environmental-humanities/article/1/1/103/8073/Risky-Zoographies-The-Limits-of-Place-in-Avian-Flu
(137) China sends medical aid to Pakistan via PoK…HT,
28 March 2020. Link: https://www.hindustantimes.com/world-news/china-sends-medical-aid-to-pakistan-via-pok-dispatches-team-of-experts-to-help/story-K5tpx8meEnXNQ8Q9ITNxGL.html;
Doxycycline and Ivermectin combo may be new effective Covid-19 treatment,
Medical Dialogues, 18 May 2020. Link: https://medicaldialogues.in/medicine/news/doxycycline-and-ivermectin-combo-may-be-new-effective-covid-19-treatment-65868;
215 Pakistan to start manufacturing Covid-19 treatment drug, Gulf Today, 15 May
2020. Link: https://www.gulftoday.ae/en/news/2020/05/15/pakistan-to-start-manufacturing-covid19-treatment-drug;
Bangladesh Medical College Hospital physician see ‘astounding results’ with
drug combination targeting Covid-19, TrialSite News, 18 May 2020. Link: https://www.trialsitenews.com/bangladesh-medical-college-hospital-physician-see-astounding-results-with-drug-combination-targeting-covid-19/
(138) Physicians to population ratios reference: https://data.worldbank.org/indicator/SH.MED.PHYS.ZS
(139) For 2019 World Bank thresholds for income
classification see https://blogs.worldbank.org/opendata/new-country-classifications-income-level-2019-2020);
Data for beds-per-1000-of-population and percentage of ICU beds taken from the
Covid Expert Group’s Report No. 12, dated 26 March 2020 (at (7)). According
this report, Lower Income Countries have 1.24 beds per 1000 population on
average and High Income Countries have 4.82 beds per 1000 population on
average.
(139A) Source: https://www.who.int/healthinfo/global_burden_disease/estimates_country_2004_2008/en/
.
In general, I have preferred using WHO data from this year, which was updated
in 2011, as this appears to be the last year for which the WHO has received and
incorporated comments from other countries.
(140) These calculations are based on WHO mortality
estimates for 2008 at https://www.who.int/healthinfo/global_burden_disease/estimates_country_2004_2008/en/
.
(140A) These percentages are NOT from the WHO, they are
my calculations are based on WHO estimates for 2008 of tuberculosis incidence
here: https://apps.who.int/gho/data/view.main.57040ALL?lang=en
and number of tuberculosis deaths) here (see under “by sex”): https://www.who.int/healthinfo/global_burden_disease/estimates_country_2004_2008/en/. The underlying data used
by me is in the table below:
|
Country |
Tuberculosis Incidence |
Tuberculosis Deaths |
|
India |
31,40,000 |
2.7 lakh (approx.) |
|
Italy |
4700 |
400 |
|
Germany |
4800 |
400 |
|
France |
6600 |
700 |
|
USA |
15,000 |
700 |
|
UK |
9300 |
400 |
|
Kenya |
2.25 lakh (approx.) |
9700 |
|
South Africa |
4.86 lakh (approx..) |
19,500 |
|
Mexico |
24,000 |
2700 |
|
Sweden |
590 |
100 |
(140B) For tuberculosis incidence in Norway see https://apps.who.int/gho/data/view.main.57040ALL?lang=en
. 2002 was a terrible year for tuberculosis in Norway with 100 deaths estimated
in that year to this disease against an incidence estimate of 280 cases, giving
a crude fatality rate of over 35%. Again this percentage is NOT from the WHO,
it is my calculation based on WHO estimates for tuberculosis incidence here: https://apps.who.int/gho/data/view.main.57040ALL?lang=en and
for mortality here: https://www.who.int/healthinfo/global_burden_disease/estimates_2000_2002/en/.
(140C) Source: WHO malaria figures for 2016 from here: https://apps.who.int/gho/data/node.main.A1364?lang=en (incidence) and here: https://www.who.int/healthinfo/global_burden_disease/estimates/en/
(mortality) click under ‘By Country WHO Member States, 2016.
(140D) Source: https://apps.who.int/gho/data/node.main.620?lang=en. HIV positive and AIDS
cases for US for the year 2010 (later year case incidence is not available) and
for other countries for the years 2018.
(140E) Ebola figures from
https://www.who.int/news-room/fact-sheets/detail/ebola-virus-disease
(140F) “Mortality and Burden of Disease Estimates for
WHO Member States” issued by WHO’s Department of Measurement and Health
Information and “WHO Methods and data Sources for Country-Level Causes of Death
2000-2016” dated 2018.
(140G) Testing data from Worldometer.
(141) AIIMS data from https://www.aiims.edu/images/pdf/annual_reports/annual%20report19-e-20-1-20.pdf
(142) Becker’s Hospital Review data https://www.aiims.edu/images/pdf/annual_reports/annual%20report19-e-20-1-20.pdf
(143) ‘Doctor diplomacy’: Cuba seeks to make its mark
in Europe amid Covid-19 crisis, The Guardian, 6 May 2020. Link: https://www.theguardian.com/world/2020/may/06/doctor-diplomacy-cuba-seeks-to-make-its-mark-in-europe-amid-covid-19-crisis
(144) WHO says Madagascar’s herbal tonic against
Covid-19 is not a cure, AL Jazeera, 4 May 2020. Link: https://www.aljazeera.com/news/2020/05/madagascars-herbal-tonic-covid-19-cure-200504081212753.html?xif=
; Coronavirus: What is Madagascar’s ‘herbal remedy’ Covid-Organics? Al Jazeera,
6 May 2020. Link: https://www.aljazeera.com/news/2020/05/coronavirus-madagascar-herbal-remedy-covid-organics-200505131055598.html
(145) The use of non-pharmaceutical forms of
Artemisia, WHO, 10 October 2019. Link: https://www.who.int/publications/i/item/the-use-of-non-pharmaceutical-forms-of-artemisia
(146) ‘WHO commends Madagascar’s fight against
Covid-19’, AA.com, Africa, 21 May 2020. Link:
https://www.aa.com.tr/en/africa/who-commends-madagascars-fight-against-covid-19/1848550
(147) Covid-19: Tests for miracle cure’ herb Artemisia
begin, DW, 15 May 2020. Link: https://www.dw.com/en/covid-19-tests-for-miracle-cure-herb-artemisia-begin/a-53442366
(148) Madagascar slams WHO for not endorsing its herbal
cure, AA.com, Africa, 11 May 2020. Link: https://www.aa.com.tr/en/africa/madagascar-slams-who-for-not-endorsing-its-herbal-cure/1836905
(149) Overview of malaria treatment, WHO, 18 January
2018. Link: www.who.int/malaria/areas/treatment/overview/en/
(150) Africans, three Ebola experts call for access to
trial drug, Los Angeles Times, 6 August 2014. Link: https://www.latimes.com/world/africa/la-fg-three-ebola-experts-release-drugs-20140806-story.html
(151) Discovery and description Zaire Virus in 1976…,
Breman et al., The Journal of Infectious Disease, October 2016, 15; 214
(Suppl 3): S93-S101. Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5050466/#JIW207C1;
Ebola haemorrhagic fever in Zaire, 1976, Report of an International Commission.
Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2395567/pdf/bullwho00439-0113.pdf
(152) Ethical considerations of experimental
interventions in the Ebola outbreak, Annette Rid and Ezekiel J Emanuel, The
Lancet, Vol. 384, 22 November 2014. Link: https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(14)61315-5.pdf
(153) Ebola: What it tells us about medical ethics,
Angus J. Dawson, The Journal of Medical Ethics 2015; 41: 107-110; Link: https://jme.bmj.com/content/41/1/107;
Ebola and ethics: autopsy of a failure, Christian A Gericke, BMJ 2015; 350.
Link: https://www.bmj.com/content/350/bmj.h2105
(154) Trial of Ebola drug ZMapp launches in Liberia,
US, Centre for Disease Research & Policy, 27 February 2015. Link: https://www.cidrap.umn.edu/news-perspective/2015/02/trial-ebola-drug-zmapp-launches-liberia-us
(155) Ebola is now curable…wired.com, 8 December 2019.
Link: https://www.wired.com/story/ebola-is-now-curable-heres-how-the-new-treatments-work/
(156) Politics around Hydroxychloroquine hamper
science, npr.org, 21 May 2020. Link: https://www.npr.org/sections/health-shots/2020/05/21/859851682/politics-around-hydroxychloroquine-hamper-science?fbclid=IwAR3f9iSiYsnpSkaN7T-wauT0I0D3kWlyB-7_s5QkQhWIFdqhs0EW9xwqxDY)
(157) CSIR chief flays Hydroxychloroquine trial
suspension, The Hindu, 30 May 2020. Link:
https://www.thehindu.com/sci-tech/health/coronavirus-csir-chief-flays-hcq-trial-suspension/article31712065.ece
(158) Global experts go head-to-head over claims the
coronavirus ‘no longer exists clinically’, CNBC, 2 June 2020. Link: https://www.cnbc.com/2020/06/02/claim-coronavirus-no-longer-exists-provokes-controversy.html?__source=iosappshare%7Ccom.apple.UIKit.activity.CopyToPasteboard&fbclid=IwAR2vY80wwIBIiCGbFawFU-75UoYf_junth2xy4ogfbQ8ZKaJqmfX1-YM0Lc
(159) Coronavirus could ‘burn out’ on its own before
we have a working vaccine: Former WHO chief, Firstpost, 20 May 2020. Link: https://www.firstpost.com/health/coronavirus-could-burn-out-on-its-own-before-we-have-a-working-vaccine-former-who-chief-8387911.html
(160) Indians in Wuhan say strict lockdown….The
Economic Times, 9 April 2020. Link: https://economictimes.indiatimes.com/news/politics-and-nation/indians-in-wuhan-say-strict-lockdown-social-distancing-only-ways-to-contain-covid-19/articleshow/75064547.cms?from;
China ends Wuhan lockdown…The New York Times, 7 April 2020. Link: https://www.nytimes.com/2020/04/07/world/asia/wuhan-coronavirus.html
(161) Early missteps and state secrecy in China likely
allowed coronavirus to spread farther and faster, The Washington Post, 1
February 2020. Link: https://www.washingtonpost.com/world/2020/02/01/early-missteps-state-secrecy-china-likely-allowed-coronavirus-spread-farther-faster/
(162) People in China will make 3 billion trips in the
next 40 days….Business Insider, 14 January 2020. Link: https://www.businessinsider.in/business/news/people-in-china-will-make-3-billion-trips-in-the-next-40-days-to-celebrate-lunar-new-year-the-worlds-largest-annual-human-migration/articleshow/73236413.cms#aoh=15910888889118&referrer=https%3A%2F%2Fwww.google.com&_tf=From%20%251%24s
(163) SARS-CoV-2 Viral Load in Upper Respiratory
Specimens of Infected Patients, Zou et al., The New England Journal of
Medicine 382: 12, 19 March 2020, first published on February 19, 2020. Link: https://www.nejm.org/doi/full/10.1056/NEJMc2001737
(164) Transmission of 2019-nCoV Infection from an
Asymptomatic Contact in Germany, Rothe et al., The New England Journal
of Medicine 382; 10 March 5, 2020, first published on January 30, 2020). Link: https://www.nejm.org/doi/full/10.1056/NEJMc2001468
(165) The Novel Coronavirus Pneumonia Emergency
Response Epidemiology Team, The Epidemiological Characteristics of an Outbreak
of 2019 Novel Coronavirus Disease (COVID-19) – China 2002, China CDC Weekly
Vol. 2 No. x, pg 1. Link: http://weekly.chinacdc.cn/en/article/id/e53946e2-c6c4-41e9-9a9b-fea8db1a8f51
(166) Bangladesh virus prayer gathering sparks outcry,
Taipei Times, 20 March 2020. Link: https://www.taipeitimes.com/News/world/archives/2020/03/20/2003733062;
Brahmanbaria funeral crowd: Probe body starts investigation, Dhaka Tribune, 20
April 2020. Link: https://www.dhakatribune.com/bangladesh/nation/2020/04/20/probe-body-starts-working-over-brahmanbaria-funeral-crowd
(167) FranceInfo Survey: “The majority of people were
infected”: from Corsica to overseas….franceinfo.com, 30 March 2020. Link: https://www.francetvinfo.fr/sante/maladie/coronavirus/video-coronavirus-le-nombre-de-contaminations-lors-du-rassemblement-evangelique-de-mulhouse-a-ete-largement-sous-evalue_3889133.html
(168) Back to the Future for Influenza Preimmunity –
Looking Back at Influenza Virus History to Infer the Outcome of Future
Infections, Francis et al., Viruses, 30 January 2019. Link: https://www.mdpi.com/1999-4915/11/2/122
(169) ‘A terrible price’: The deadly racial
disparities of Covid-19 in America, The New York Times, 29 April 2020. Link: https://www.nytimes.com/2020/04/29/magazine/racial-disparities-covid-19.html
(170) Racial disparities in Louisiana’s Covid-19 death
rate reflect systemic problems, 4WWL, 7 April 2020. Link: https://www.wwltv.com/article/news/health/coronavirus/racial-disparities-in-louisianas-covid-19-death-rate-reflect-systemic-problems/289-bd36c4b1-1bdf-4d07-baad-6c3d207172f2
(171) We have an appointment with death, Slavoj Zizek,
Kultur, 1 April 2020. https://www.welt.de/kultur/article207219549/Slavoj-Zizek-The-epidemic-as-a-date-with-death.html
(172) Debate Noam Chomsky & Michel Foucault, On Human
Nature https://www.youtube.com/watch?v=3wfNl2L0Gf8
(174) Coronavirus: What’s going wrong in Sweden’s care homes, BBC, 19 May 2020. Link: https://www.bbc.com/news/world-europe-52704836
(175) Mumbai high rises report spike in
Covid-19…..Firstpost, 22 June 2020. Link: https://www.firstpost.com/health/mumbai-high-rises-report-spike-in-covid-19-cases-but-implementation-of-sealing-norms-patchy-bmc-puts-onus-on-housing-societies-8509391.html
and High rise in number of positive cases in Mulund, Mumbai Mirror, 13 June
2020. Link: https://mumbaimirror.indiatimes.com/mumbai/cover-story/high-rise-in-number-of-of-ve-cases-in-mulund/articleshow/76349782.cms
(176) More than 28,000 stranded Indians have landed in
Mumbai since May, MumbaiLive.com, 4 July 2020. Link: https://www.mumbailive.com/en/transport/more-than-28000-stranded-indians-have-landed-in-mumbai-since-may-52292
(177) Updated list of containment zones or red zones
in Mumbai as of July 2, Mumbai Live, 3 July 2020. Link: https://www.mumbailive.com/en/civic/containment-zones-list-mumbai-list-coronavirus-lockdown-52242
(178) Source: Mumbai Live Covid Updates
(179) Mumbai: Dharavi sees a drop in new Covid-19
cases and deaths, Mumbai Mirror, 30 June 2020. Link: https://mumbaimirror.indiatimes.com/coronavirus/news/mumbai-dharavi-sees-a-drop-in-new-covid-19-cases-and-deaths/articleshow/76713018.cms
(180) BMC begins to withdraw after 90-day Covid-19 war
in Dharavi, Mumbai Mirror, 3 July 2020. Link: https://mumbaimirror.indiatimes.com/coronavirus/news/bmc-begins-to-withdraw-after-90-day-covid-19-war-in-dharavi/articleshow/76769595.cms
(181) Cases as on July 2 https://www.freepressjournal.in/mumbai/coronavirus-in-mumbai-ward-wise-breakdown-of-covid-19-cases-issued-by-bmc-as-of-july-2
(182) Coronavirus: 21 cases found, building on Nepean
Sea road sealed, Mumbai Live, 23 June 2020. Link: https://www.mumbailive.com/en/civic/the-bmc-sealed-an-entire-building-nestled-on-the-nepean-sea-road-after-21-cases-of-coronavirus-were-reported-from-the-society.-51737
(183) How Covid hotspot Dharavi, Asia’s largest slum,
fought against all odds to flatten the curve, The Print, 14 June 2020
Link: https://theprint.in/india/how-covid-hotspot-dharavi-asias-largest-slum-fought-against-all-odds-to-flatten-the-curve/441036/
(184) BMC has sealed 1,000 buildings in a week, Mumbai
Live, 25 June 2020. Link: https://www.mumbailive.com/en/civic/the-surge-in-the-number-of-coronavirus-cases-in-the-suburbs-of-mumbai-has-led-to-the-sealing-of-1000-buildings-in-the-past-eight-days-51856
(185) Coronavirus UK map….BBC, 6 July 2020. Link: https://www.bbc.com/news/uk-51768274
(186) Tegnell: Italian travellers are not the main
source of infection, Sweden, SVT Nyheter, 2 May 2020 (in Swedish). https://www.svt.se/nyheter/inrikes/tegnell-italienresenarerna-inte-storsta-kallan-till-smitta
; ‘Coronavirus came to Sweden from countries that were under our radar’: Public
Health Agency chief, The Local, 11 June 2020. Link: https://www.thelocal.se/20200611/public-health-agency-head-coronavirus-came-to-sweden-from-countries-that-were-under-our-radar
(187) Critics question Swedish approach as coronavirus
death toll reaches 1,000, The Guardian, 15 April 2020. Link https://www.theguardian.com/world/2020/apr/15/sweden-coronavirus-death-toll-reaches-1000
(188) Large reduction in travel by public transport in
the county, Sweden, KalmarPosten, 15 April 2020 (in Swedish). Link: https://www.kalmarposten.se/article/stor-minskning-av-resande-med-kollektivtrafik-i-lanet/
; Travel halved at Skanetrafiken, Sweden, Aftonbladet, 25 March 2020 (in
Swedish). Link: https://www.aftonbladet.se/nyheter/a/Op7rjq/resandet-halverat-hos-skanetrafiken ; West traffic takes the corona crisis very
seriously, GT, expressen.se, Sweden, 8 April 2020 (in Swedish). Link: https://www.expressen.se/gt/debatt-gt/vasttrafik-tar-coronakrisen-pa-allra-storsta-allvar/
(189) Close to every third car away from Stockholm’s
streets, Omni, Sweden (in Swedish). Link: https://omni.se/nara-var-tredje-bil-borta-fran-stockholms-gator/a/awQ7jL
(190) Stockholmers stay home at Easter,, SVT Nyheter,
Sweden, 9 April 2020 (in Swedish). Link: https://www.svt.se/nyheter/snabbkollen/stockholmare-stannar-hemma-i-pask
; Travel from Stockholm during Passover, Telia.se, 9 April 2020 (in Swedish).
Link: http://press.telia.se/pressreleases/svenskarna-stannar-hemma-under-paasklovet-2990179
(191) I call Foucault a “post-modernist” here with
apologies to him. He famously disliked being called this. Certainly, his
message was more profound and more delicate than the term allowed. In fact,
Foucault was at his most Foucauldian when rejecting this label. Categorisation
subtracts from the whole of what is being said. This is precisely the attitude
we, especially scientists and doctors, need to adopt in the present crisis.
(192) Appendix-A & B; Appendix-C; Appendix-D; Appendix-E
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