Covid Lectures Part 3: What is a pandemic?
Yesterday, we did a detailed review of the most influential epidemiological work, the Imperial College Report, that sent the world into lockdown. We saw how they kept changing their key parameters, their case number estimates, their Reproduction Number (R), and their doubling rate every few days; we saw how they switched, from looking at case data to death data, after belatedly acknowledging that case data was unreliable, but without accounting for the fact, that death data was also unreliable and, at the time many countries had not even started putting out their nursing home death counts which later turned out to be the biggest single contributor of deaths from Covid in many places; we saw how key parameters, like the percentage of hospitalised patients that would need ventilators, were decided, simply by calling up some random doctor, and asking him what he thought. We saw how unconvincing the attempts of the Imperial College epidemiologists were, at proving that suppression measures were driving down the Reproduction Number. And finally, we saw how their claims about herd immunity completely contradicted their theory about R. First they said that we had to drive the R value to below 1 with suppression, and then, they said that this was preventing herd immunity, and so we had to stay in indefinite lockdown until a vaccine or drugs were found.
So, as I said yesterday, 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, according to the epidemiologists, 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.
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.
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. 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.
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3.2 Pandemic Containment vs. Mitigation
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 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 (10).
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 (12).
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.
3.3 The WHO's Deep Confusion Over Covid Transmission
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).
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.
But the WHO kept digging its heels in with its theory of containment, and when social distancing and hand hygiene was seen not to contain the virus, they blamed it on insufficient testing, famously saying, “Test, test, test” (18A). But it is a waste of money and manpower to do generalised testing and contact tracing in the belief that this will contain the virus. In a pandemic situation, your testing is always going to be several steps behind the virus. Just one infection needs hundreds and thousands of contacts to be traced. This takes days. In the meantime, the virus is travelling everywhere. So, contrary to what the WHO was saying, in a pandemic, testing and contact tracing cannot be used to stop the spread of infection. They can at best be used to help to break chains of transmission here and there, or identify places or activities that are particularly exposed to infection, and so on. But you have to be acutely conscious of the fact that even while you are contact tracing and testing, the virus is spreading in places of which you are not yet aware.
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 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.
The WHO's confusion over hospital- and asymptomatic- transmission
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).
3.4 Why Pandemic Containment Cannot Work
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, thinking the cases were being imported from Italy owing to some early chains of transmission having been connected to travel there, early contact tracing in Sweden focussed on people with a travel history to this country. This was able to quickly contain the cases originating from Italy, but Swedish officials have since discovered that while they were focussed on Italy, cases were coming into Sweden from a number of other countries around the world, including Austria. This is a very clear example of how contact tracing and other containment measures fail to grasp the basic characteristic of pandemic viruses, which is that they come from many countries at once. It also demonstrates how these 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, 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.
....To be continued
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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NOTES AND REFERENCES
a. 1 lakh = 100,000; 1 crore = 10 million
(1) Report 1: Estimating the potential total number of novel Coronavirus (2019 n-CoV) cases in Wuhan City, China, COVID -19 Response Team, 17 January 2020. Link: https://www.imperial.ac.uk/mrc-global-infectious-disease-analysis/covid-19/report-1-case-estimates-of-covid-19/
(2) Report 2: Estimating the potential total number of novel Coronavirus cases in Wuhan City, China, COVD -19 Response Team, 22 January 2020. Link: https://www.imperial.ac.uk/mrc-global-infectious-disease-analysis/covid-19/report-2-update-case-estimates-covid-19/
(3) Report 3: Transmissibility of 2019-nCoV, COVID -19 Response Team, 25 January 2020. Link: https://www.imperial.ac.uk/mrc-global-infectious-disease-analysis/covid-19/report-3-transmissibility-of-covid-19/
(3A) Report 5: Phylogenetic analysis of Sars-CoV-2, COVID -19 Response Team, 15 February 2020. Link: https://www.imperial.ac.uk/mrc-global-infectious-disease-analysis/covid-19/report-5-phylogenetics-of-sars-cov-2/
(4) Report 7: Estimating infection prevalence in Wuhan City from repatriation flights, COVID -19 Response Team, 9 March 2020. Link: https://www.imperial.ac.uk/mrc-global-infectious-disease-analysis/covid-19/report-7-repatriation-flights-covid-19/
(5) Report 9: Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand, COVID -19 Response Team, 16 March 2020. Link: https://www.imperial.ac.uk/mr-global-infectious-disease-analysis/covid-19/report-9-impact-of-npis-on-covid-19/
(6) Report 11: Evidence of initial success for China exiting COVID-19 social distancing policy after achieving containment, COVID -19 Response Team, 24 March 2020. Link: https://www.imperial.ac.uk/mrc-global-infectious-disease-analysis/covid-19/report-11-china-exiting-social-distancing/
(7) Report 12: The Global Impact of COVID-19 and Strategies for Mitigation and Suppression, COVID -19 Response Team, 26 March 2020. Link: https://www.imperial.ac.uk/mrc-global-infectious-disease-analysis/covid-19/report-12-global-impact-covid-19/
(8) Report 13: Estimating the number of infections and the impact of non-pharmaceutical interventions on COVID-19 in 11 European countries, COVID -19 Response Team, 30 March 2020. Link: https://www.imperial.ac.uk/mrc-global-infectious-disease-analysis/covid-19/report-13-europe-npi-impact/
(9) Estimates of the severity of coronavirus disease 2019: a model-based analysis, Verity et al., Lancet Infect. Dis. 2020, published online on 30 March 2020, pre-review published 9 March 2020 on www.medrxiv.org). Link: https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30243-7/fulltext
(10) Factors that make an infectious disease outbreak controllable, Frazer et al., PNAS, Vol. 101, No. 16, pp. 6146-51, 20 April 2004. Link: https://www.pnas.org/content/101/16/6146
(11) Strategies for mitigating an influenza pandemic, Ferguson et al., Nature, Vol 442, pg. 448, 27 July 2006. Link: https://www.nature.com/articles/nature04795
(12) Modeling targeted layered containment of an influenza pandemic in the United States, Halloran et al., PNAS, Vol 105, No. 12, pg. 4639, 25 March 2008. Link: https://www.pnas.org/content/105/12/4639.short
(13) Report of the WHO-China Joint Mission on Coronavirus Disease 2019 published on 28 February 2020. Link: https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf
(14) International Health Regulations Emergency Committee on novel coronavirus on China, WHO Press Briefing, 23 January 2020. Link: https://www.who.int/docs/default-source/coronaviruse/transcripts/ihr-emergency-committee-for-pneumonia-due-to-the-novel-coronavirus-2019-ncov-press-briefing-transcript-23012020.pdf?sfvrsn=c1fd337e_2
(15) Novel coronavirus press conference at United Nations of Geneva, WHO Press Briefing, 29 January 2020. Link: https://www.who.int/docs/default-source/coronaviruse/transcripts/who-audio-script-ncov-rresser-unog-29jan2020.pdf?sfvrsn=a7158807_4
(16) WHO Emergencies Coronavirus Emergency Committee Second Meeting, WHO Press Briefing, 30 January 2020. Link: https://www.who.int/docs/default-source/coronaviruse/transcripts/ihr-emergency-committee-for-pneumonia-due-to-the-novel-coronavirus-2019-ncov-press-briefing-transcript-30012020.pdf?sfvrsn=c9463ac1_2
(17) WHO Emergencies Coronavirus Press Conference, 9 March 2020. Link: https://www.who.int/docs/default-source/coronaviruse/transcripts/who-audio-emergencies-coronavirus-press-conference-full-09mar2020-(1).pdf?sfvrsn=d2684d61_2
(18) Virtual press conference on COVID-19, WHO, 11 March 2020. Link: https://www.who.int/docs/default-source/coronaviruse/transcripts/who-audio-emergencies-coronavirus-press-conference-full-and-final-11mar2020.pdf?sfvrsn=cb432bb3_2
(18A) WHO Press Conference 16 March 2020. Link: https://www.who.int/docs/default-source/coronaviruse/transcripts/who-audio-emergencies-coronavirus-press-conference-full-16mar2020.pdf?sfvrsn=7c0c37bf_2
(19) COVID-19 - virtual press conference, WHO, 30 March 2020. Link: https://www.who.int/docs/default-source/coronaviruse/transcripts/who-audio-emergencies-coronavirus-press-conference-full-30mar2020.pdf?sfvrsn=6b68bc4a_2
(20) Nonpharmaceutical Interventions for Pandemic Influenza, International Measures, World Health Organisation Writing Group, Centres for Disease Control and Prevention Vol 12 Number 1, January 2006. Link: https://wwwnc.cdc.gov/eid/article/12/1/05-1370_article.
(21) Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study, Zhou et al., The Lancet, Vol 395, 1054, 28 March 2020, first published on 9 March 2020. Link: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30566-3/fulltext.
(22) Clinical Characteristics of 138 Hospitalized Patients with 2019 Novel Coronavirus-infected Pneumonia in Wuhan, China, Wang et al., JAMA 2020; 323 (11): 1061-1069, 7 February 2020. Link: https://jamanetwork.com/journals/jama/fullarticle/2761044.
(23) At the Epicentre of the Covid-19 Pandemic and Humanitarian Crises in Italy: Changing Perspectives on Preparation and Mitigation, Nacoti et al., NEJM Catalyst, 21 March 2020. Link: https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0080.
(24) Hospitals as health factories and the coronavirus epidemic, Giorgina Barbara Piccoli, Journal of Nephrology (2020) 33: 189-191, 21 March 2020. Link: https://paperity.org/p/237906528/hospitals-as-health-factories-and-the-coronavirus-epidemic
(25) What Other Countries can learn from Italy during the COVID-19 Pandemic, Boccia et al., JAMA Intern. Med., 7 April 2020. Link: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2764369
(26) In fight against Covid, Dharavi grapples with sanitation, health, poverty, Kavitha Iyer, Indian Express, 31 May 2020. Link: https://indianexpress.com/article/cities/mumbai/dharavi-slum-coronavirus-covid-19-cases-6434996/
(27) Police use sjamboks and rubber bullets to enforce Hillbrow lockdown, Micah Reddy & Simon Allison, Mail & Guardian, 31 March 2020. Link: https://mg.co.za/article/2020-03-31-police-use-sjamboks-and-rubber-bullets-to-enforce-hillbrow-lockdown/
(28) Police kill three people in three days of lockdown. This is normal for South Africa, GroundUp, 1 April 2020. Link: https://www.groundup.org.za/article/police-kill-three-people-three-days-lockdown-normal-south-africa-data-reveals/
(29) Ebola – Myths, Realities and Structural Violence, Annie Wilkinson and Melissa Leach, African Affairs, pp.1-13, 4 December 2014. Link: http://www.ebola-anthropology.net/wp-content/uploads/2014/12/Briefing-Ebola-Myths-Realites-and-Structural-Violence.pdf
(30) Barriers to supportive care during the Ebola virus disease outbreak in West Africa: Results of a qualitative study, Loignon et al., PLOS ONE, 5 September 2018. Link: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0201091
(31) Plague Warriors: The Deadly Ebola Outbreak in Zaire, Laurie Garret, Vanity Fair 1 August 1995. Link: https://archive.vanityfair.com/article/1995/8/plague-warriors.
(32) Ebola and Learning Lessons from Moral Failures: Who cares about Ethics? Maxwell J. Smith and Ross E.G. Upshur, Public Health Ethics, Vol 8, No. 3, 305, 17 October 2015. Link: https://academic.oup.com/phe/article/8/3/305/2362913
(33) Doctor’s death from coronavirus sparks a digital uprising, rattling China’s leaders, Washington Post, 7 February 2020. Link: https://www.washingtonpost.com/world/asia_pacific/doctors-death-from-coronavirus-sparks-a-digital-uprising-rattling-chinas-leaders/2020/02/07/a4cb3492-4998-11ea-8a1f-de1597be6cbc_story.html; Reasons for healthcare workers becoming infected with novel coronavirus disease 2019 (COVID-19), Wang et al., Journal of Hospital Infection, March 2020. Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7134479/
(34) 80% of New York’s coronavirus patients who are put on ventilators ultimately die, and some doctors are trying to stop using them, Business Insider, Sinead Baker, 9 April 2020. Link: https://www.businessinsider.in/science/news/80-of-new-yorks-coronavirus-patients-who-are-put-on-ventilators-ultimately-die-and-some-doctors-are-trying-to-stop-using-them/articleshow/75065623.cms
(35) Italian mayor claims the true death toll from Covid-19 likely to be much higher, euronews.com, 21 March 2020. Link: https://www.euronews.com/2020/03/21/italian-mayor-claims-the-true-death-toll-from-covid-19-likely-to-be-much-higher
(36) ‘India has tremendous capacity to combat Covid-19’: WHO Executive Director, 24 March 2020. Link: https://www.youtube.com/watch?v=bydILYTQUsA
(37) Covid 19: Tablighi Jamaat attendee attempts suicide from 6th floor of Delhi Hospital, PTI, Deccan Herald, 2 April 2020. Link: https://www.deccanherald.com/national/covid-19-tablighi-jamaat-attendee-attempts-suicide-from-6th-floor-of-delhi-hospital-820254.html
(38) Problems in identifying the origins of an outbreak, Tom Jefferson & Carl Heneghan, 3 April 2020, https://www.cebm.net/covid-19/problems-in-identifying-the-origins-of-an-outbreak/; Global experts go head-to-head over claims the coronavirus ‘no longer exists clinically’, CNBC Report, 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; 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
(39) Kya WHO ne lockdown ka sujhav diya hai? Prime Time with Ravish Kumar, 1 May 2020 (in Hindi). Link: https://www.youtube.com/watch?v=FNzlq1whlq4
(40) 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
(41) Unexpected cause of death in younger Covid-19 patients is related to blood clotting, BioSpace, 28 April 2020. Link: https://www.biospace.com/article/covid-19-increases-risk-of-heart-attacks-and-stroke/?fbclid=IwAR3wum5CgAyBrlCQ2eBwQCy_sU2Evq4iuyV4dqhT7ZP5efdSOVb_KWPkUnw
(42) Revised Guidelines on Clinical Management of Covid-19, Government of India, Ministry of Health & Family Welfare, 31 March 2020. Link: https://www.mohfw.gov.in/pdf/RevisedNationalClinicalManagementGuidelineforCOVID1931032020.pdf
(43) Avigan trials will continue in Japan with drug efficacy unclear, Nikkei Asian Review, 21 May 2020. Link: https://asia.nikkei.com/Business/Pharmaceuticals/Avigan-trials-will-continue-in-Japan-with-drug-efficacy-unclear ;Wanted Covid-19 patients in Japan…..for clinical trials, The Japan Times, 24 June 2020. Link: https://www.japantimes.co.jp/news/2020/06/24/national/science-health/japan-coronavirus-patients-vaccine-trials/;Bangladesh Medical College Hospital Physician see ‘astounding results’ with drug combination targeting Covid-19, Trial Sites News, 18 May 2020. Link: https://www.trialsitenews.com/bangladesh-medical-college-hospital-physician-see-astounding-results-with-drug-combination-targeting-covid-19/; CSIR identifies top 25 drugs/drug candidates for repurposing, Ministry of Science & Technology, 30 April 2020. Link: https://pib.gov.in/PressReleasePage.aspx?PRID=1619671.
(44) Sermo website: https://www.sermo.com/methodology/
(45) Protecting health-care workers from subclinical coronavirus infection, Chang et al., The Lancet, Correspondence, Vol. 8, March 2020, published online 13 February 2020. Link: https://www.thelancet.com/pdfs/journals/lanres/PIIS2213-2600(20)30066-7.pdf; Fewer deaths in Veneto offer clues for fight against virus, Financial Times, April 5, 2020. Link: https://www.ft.com/content/9c75d47f-49ee-4613-add1-a692b97d95d3; Offline: COVID-19 and the NHS – “a national scandal”, Richard Horton, Comment, The Lancet, Vol. 395, 28 March 2020. Link: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30727-3/fulltext; Italian doctors warned hospitals are coronavirus vectors. One Russian region proves their point, The Moscow Times, 9 April 2020. Link: https://www.themoscowtimes.com/2020/04/09/italian-doctors-warned-hospitals-are-coronavirus-vectors-one-russian-region-proves-their-point-a69924
Woman is first UK victim to die of coronavirus caught in hospital, The Guardian, 24 March 2020. Link: https://www.theguardian.com/world/2020/mar/24/woman-first-uk-victim-die-coronavirus-caught-hospital-marita-edwards, We’ve become the ‘super-spreaders’: NHS doctor pleads for more protective equipment, Yahoo News, UK, 18 March 2020. https://sports.yahoo.com/dr-nishant-joshi-coronavirus-protective-masks-equioment-130525108.html?guccounter=1&guce_referrer=aHR0cHM6Ly93d3cuZ29vZ2xlLmNvbS8&guce_referrer_sig=AQAAAEPC0bVREj6Nbb_kjlYlxY4XDEKlAUxdxO1HO__5G858semg6WxHnPlD7Q4diQV6TpI82OS_uTKs5wS1I61YuMVQ_ksQuyYW7DZr-_6ZVIDiX81iyLXNxxFPdub8AyM-safropIQ1qHKVzeWiyGrQWh0LGZScW0Yy5nd2tFUdvtE ; When our hospitals are the pandemic superspreaders, The American Conservative, 20 April 2020. Link: https://www.theamericanconservative.com/articles/when-our-hospitals-are-the-pandemic-superspreaders/
(46) “Flattening the curve on COVID-19: How Korea responded to a pandemic using ICT”, publication of the Government of the Republic of Korea dated 11 May 2020.
(47) Blood clots in severe Covid-19 patients leave their clinicians with clues about the illness – but no proven treatments, statnews.com, 16 April 2020. Link: https://www.statnews.com/2020/04/16/blood-clots-coronavirus-tpa/; Doctors are discovering coronavirus causes blood clots harming organs from brains to toes, The Print, 5 May 2020. Link: https://theprint.in/health/doctors-are-discovering-coronavirus-causes-blood-clots-harming-organs-from-brain-to-toes/414479/
(48) Prince Charles to open NHS Nightingale to treat Covid-19 patients, The Guardian, 3 April 2020. Link: https://www.theguardian.com/world/2020/apr/03/prince-charles-to-open-nhs-nightingale-to-treat-covid-19-patients
(49) US Field Hospitals stand down, most without treating any Covid-19 patients, npr.org, 7 May 2020. Link: https://www.npr.org/2020/05/07/851712311/u-s-field-hospitals-stand-down-most-without-treating-any-covid-19-patients; London NHS Nightingale hospital will shut next week, The Guardian, 4 May 2020. Link: https://www.theguardian.com/world/2020/may/04/london-nhs-nightingale-hospital-placed-on-standby
(50) Covid-19: Nightingale hospitals set to shutdown after seeing few patients, BMJ 2020; 369, 7 May 2020. Link: https://www.bmj.com/content/369/bmj.m1860
(51) Improvisation and retraining may be key to saving patients in New York’s ICUs, npr.org, 8 April 2020. Link: https://www.npr.org/sections/health-shots/2020/04/08/830153837/improvisation-and-retraining-may-be-key-to-saving-patients-in-new-yorks-icus
(52) Why ventilators may not be working as well for Covid-19 patients as doctors hoped, Time, 16 April 2020. Link: https://time.com/5820556/ventilators-covid-19/
(53) From NYC ICU, Cameron Kyle-Sidell, 31 March 2020. Link: https://www.youtube.com/watch?v=k9GYTc53r2o
(54) Webinar on avoiding intubation and initial ventilation in Covid-19, EMCrit, 4 April 2020. Link: https://www.youtube.com/watch?v=mZqNiQxJLSU
(55) 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
(56) Do Covid-19 vent protocols need a second look? https://www.webmd.com/coronavirus-in-context/video/coronavirus-in-context-cameron-kyle-sidell
(57) NHS Nightingale chief says NHS must ‘never go back’ to old bureaucratic ways, The Independent, 28 April 2020. Link:
(58) Doctors face troubling question: are they treating coronavirus correctly? The New York Times, 14 April 2020. Link: https://www.youtube.com/watch?v=bp5RMutCNoI. Note that the doctors’ research referred to as an “editorial” in this report 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
(173) Noam Chomsky on Moral Relativism and Michel Foucault https://www.youtube.com/watch?v=i63_kAw3WmE
(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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