Covid Lectures Part 4: Exeunt Ventilators, Enter Foucault
Part 4: Exeunt Ventilators, Enter Foucault
Suranya Aiyar
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4.1 The Mistaken Focus on Ventilators
So the WHO’s incorrect and incomplete grasp of the facts, and its deep confusion about pandemics, cornonaviruses and their controllability, set us on the wrong path in responding to Covid-19. The other big mistake in our response to Covid-19 was the early and decisive formulation of the key medical intervention for this disease being ventilators. The “flatten the curve” strategy of reducing infections to match hospital resources assumed that saving lives was a matter of providing Covid-19 patients with ventilators and critical care. But ventilators left the picture in Europe and the USA almost as quickly as they had entered it in March. By early April, doctors there began to report that ventilators were not helping all Covid-19 patients, and might even be harming them
Very quickly, once they actually started seeing patients, doctors in Europe and the USA found that they had to think beyond ventilators for treating Covid-19
So very quickly, once they actually began seeing patients, doctors in Europe and the USA found that they had to think beyond ventilators for treating Covid-19. They began looking at delaying intubation and also at less invasive therapies for breathing support. The focus expanded from ventilator-care to other treatments, as doctors began to understand the way in which Sars-Cov-2 attacked the lungs and the body's immune response to it. The shift in attention from ventilators to the way the disease progressed in the body, opened up investigation into anti-virals to inhibit Sars-Cov-2 from multiplying in the body, and also to enzyme-inhibitors to block those aspects of the body’s natural immune response to it, that were exacerbating the damage caused by the pathogen itself. This is a living example for the world of what clinicians say – that medicine is a practice. It is not just about machines and equipment.
In China, Japan, India, Bangladesh and other countries in Asia and Africa, doctors immediately, as early as February and March when Covid-19 was first detected in their borders, began to use drugs like hydroxychloroquine, azithromycin, doxycycline and various anti-viral prescriptions like lopinavir, ritonavir, ivermectin and faviparivir for treatment and prevention of Covid-19 (40). By April-May, the Japanese had started trials with Avigan, an anti-viral preparation containing favipiravir that it had earlier approved for certain influenzas. The Bangladeshis announced excellent results with a combination of the antiviral ivermectin with the antibiotic doxycycline, and India’s Council of Scientific and Industrial Research began looking into the re-purposing of 25 drugs, including faviparivir, for Covid-19 treatment (43). These are only some examples from Asia and Africa of the immediate work that started with different therapies to help Covid-19 patients.
The Americans and Europeans were slower off the mark with anti-virals and other drugs than the Asians, Russians and Africans. This may be partly because doctors in Asia and Africa who regularly treat tuberculosis, meningitis, diarrhoeal diseases, dengue and malaria, among other infectious diseases, are more experienced with these drugs than Western doctors. We will go into this aspect in detail further down.
Eventually, even the US sent an anti-viral preparation called “remedisivir” for approvals, which was in the market by late June. At around the same time, UK scientists claimed to have improved results with a drug called dexamethasone with intubated patients. There does not appear to have been much innovation from Continental Europe or the Nordic States with drug therapies for Covid-19. Indeed, as we go through our survey of Covid-19, the decrepitude and dullness of these places contrasts sharply with the youthfulness and dynamism of Asia.
Some of the effects of severe Covid-19, such as blood clotting, noticed as new and atypical by Western doctors, are similar to those observed in patients in the final stages of any illness when they are headed to sepsis and septic shock (41). Some of the worse cases of Covid-19 sound similar to patients in the last stages of Ebola in West Africa, or dengue in India. Anti-coagulants like heparin for critically ill patients were included right at the start in India’s National Clinical Management Guidelines for Covid-19 (42). Chinese doctors cataloguing the clinical course of illness in hundreds of patients in Wuhan hospitals in January, emphasized the observation of thrombosis (blood clotting) in critical cases and noted that elevated levels of a substance called d-dimers correlated with cases that proceeded to become severe (21, 22).
A lot of the issues raised by Italian and American doctors in March and April, when they were first hit by Covid-19, about being careful of lung damage from intubation, keeping patients “dry”, i.e., being conservative on fluid replacement as this can cause further lung damage, and on the timing of intubation for patients showing severe respiratory distress, are covered as a routine matter in the Indian National Clinical Management Guidelines for Covid-19. This may well be the case for other Asian and African countries, as well. By mid-April there was a recognition even in the West that the blood-clotting, and other “atypical” reactions they were observing in Covid-19 patients, might be part of the general deterioration into sepsis is as seen with other severe viral diseases, and, eventually, Western doctors also began to talk about adding anti-coagulants like heparin to the treatment (47).
So what you have is a very different picture of treatment than the one envisaged in the “flatten the curve” model, where everything hinged on ICUs and ventilators.
By mid-May, ICU facilities that had been “surged” by rich Western countries, as frantically recommended by epidemiologists, were being shut down, many without seeing any patients.
By mid-May, ICU facilities that had been “surged” by rich Western countries, as frantically recommended by their epidemiologists, were being shut down, many without having seen any patients. In England, the NHS had taken over convention halls in five cities, converting them into open-plan ICUs, with thousands of beds, complete with ventilators and other critical care equipment. These were called “NHS Nightingale Hospitals”. The one in London was opened with great fanfare by Prince Charles himself (48). By mid-May, three of the NHS Nightingale facilities were closed without having seen a single patient. The London facility, which had a capacity of 4000 beds, was closed after having seen only 54 patients.
The same story was repeated in the USA. The Engineering Corps of the US Army had been seconded to set up thousands of hospital beds in convention centres and other big venues around the country. However, many of them did not see a single patient, including in New York, which was the worst affected city, not just in the US, but perhaps in the world at the time. By early May, all of these facilities were being scaled down (49).
A British Medical Journal report from the time quotes some British doctors as being extremely critical of all this. Richard Sullivan, the director of the Institute of Cancer Policy, King’s College, London is quoted as saying, “The trouble is that Neil Ferguson’s modelling was wildly exaggerated. You cannot rely on a model to predict what happens with a pandemic. There are too many variables.
“You need good local intelligence to work out what transmissions rates really are; this did not appear to have happened.”
Another doctor, who tellingly for the repressive atmosphere of the times, wanted to remain anonymous, questioned the disproportionate focus on intensive care capacity, given the massive spread of Covid-19 in prisons, old age homes and dementia wards, which was not anticipated, and went unnoticed for weeks, with tragic consequences in the UK (50).
Interestingly, ventilators were not front and centre in the Chinese response to their Covid-19 outbreak. The WHO-China Joint Mission Report gives ventilators and ECMOs (Extra Corporeal Membrane Oxygenation machines) only a passing reference, “in critically ill patients can improve survival”, along with a range of treatments used for Covid-19 including chloroquine, phosphate, antivirals and traditional Chinese medicine (13).Ventilation and ECMO were given to only a quarter of the “severe” and “critically” ill patients. According to this report, 18.8% of patients were severe, and 6.1% were critical, so 25% of these patients amounts to 4.4% of the total Covid-19 patients being ventilated, as opposed to the figure of 30% taken by the Covid Experts Group. The report says that oxygen supplementation was given to the rest of the severe and critically ill patients.
Oxygen supplementation also requires equipment, but of a much simpler variety than ventilators and ECMO machines. Some of them can be used at home, and are available for hire. They don’t even require oxygen cylinders, as they operate by concentrating the oxygen from the air. All of this is much less costly than hospital intensive care. A fraction of unlucky patients who might become critically ill may require full ICU intervention, but there were many more options for the rest that the epidemiologists clearly had no idea about. What this tells us, is that epidemiologists really need to spend some time with actual doctors and patients. It is absurd for them to go about making predictions by models alone, without knowing anything about the actual practice of medicine.
The emphasis by epidemiologists on ventilators was dubious from the start. Anyone who has seen a relative being moved to intensive care knows that ventilation is not a cure.
The emphasis by epidemiologists on ventilators was dubious from the start. Anyone who has seen a relative being moved to intensive care knows that ventilation is not a cure. It is a measure of last resort, taken when all other treatments fail. Most of us who have been through the hospital grind with older family members see ventilators not as a life-saving therapy, but as a death knell. Spouses tell each other that when the time comes, they would rather not be put on a ventilator, but end their lives peacefully at home. There is a popular belief that once people go on a ventilator, you may never see them again, and research for this paper revealed the scientific truth behind that popular belief – 30 to 50% of ventilated patients don’t make it.
A lot of patients may have been lost in Europe and the USA because of the over-use of ventilators at the beginning of their Covid-19 outbreaks. Not having enough pulmonologists and ventilator-trained nurses to take care of the sudden surge in ventilated patients, doctors from other fields, and untrained medical students and nurses, were deployed in places like New York (51). This is in contrast to the Chinese approach, where they designated separate hospitals for severe patients, to which they deputed teams of pulmonary specialists (13).
High-tech ventilators are complicated to use. Intubation, being a highly invasive procedure in which a tube is sent deep into the patient’s body, requires a high degree of training and experience. The machines have different settings for air pressure flow and need to be carefully calibrated to the capacity of the individual patient’s lungs to withstand the pressure of the air being pumped in. Even basic things like turning over an intubated patient (which has to be done every two hours) and feeding them through a tube requires skill and experience to avoid internal damage. It was probably a mistake to use untrained personnel for ventilated patients in New York and other places.
In Italy and the USA, ventilator protocols that were initially used for Covid patients, were the ones that had been developed for acute respiratory distress syndrome (ARDS). Based on the ARDS protocols, patients were being sedated and put on ventilators depending on their oxygen levels. But doctors reported that this was often causing a further deterioration in the patient (52).Some doctors disagreed with patients being actively sedated and intubated according to ARDS protocols when their breathing was relaxed, their heart rate was not high, and they were able to speak in coherent sentences.
Dr Kyle-Sidell, an emergency and critical care specialist in Brooklyn, New York, started off a discussion at the end of March over the need to change ventilator protocols with an impassioned YouTube broadcast. He said that Covid-19 patients were not behaving like typical patients suffering from lung collapse, and there was a need to change the way in which they were being looked at – what he called the treatment “paradigm” - which was based on ARDS at the time (53, 54). We discussed earlier the way in which the experience with SARS clouded judgment on the part of China and the WHO as to the most suitable response to Covid-19. The ventilator protocol for ARDS is another example of how assumptions from prior experience were not working for Covid-19.
Doctors in Italy, led by a world-renowned critical care specialist, Dr Luciano Gattinoni, reported that the pressure at which air was pumped into patients with lung collapse from ARDS was too high for Covid-19 patients, some of whom showed good lung function despite lower oxygen saturation levels. They said that although such patients should be watched for future intubation in case their breathing became laboured, many patients did not progress to that stage and should be given other breathing support. Intubating such patients was also exacerbating the problems from vascular damage caused around the lungs by Covid-19. A paper by Dr Gattinoni and colleagues warned that even when patients were intubated, attention should be paid to treating fluid collection and inflammation around the lungs caused by Covid-19. This gives us a hint that perhaps these aspects of Covid-19 disease had been missed with the early excessive reliance on ventilation
The decision about what treatment to use involves a much more subtle calculation than the epidemiologists’ one of matching the numbers of patients to the numbers of ventilators. Where you do not have the staff to man complex equipment, it is better to start looking for other forms of treatment, and this is what doctors began to do.
What emerges is that critical care is not, as envisaged by the epidemiologists, a simple matter of ventilators and oxygen-supply. Such a simplistic understanding of critical care, even endangers patients as it fails to account for the importance of training and experience in their use. The decision about what treatment to use involves a much more subtle calculation than the one that the epidemiologists were making, of matching the numbers of patients to the numbers of ventilators. Where you do not have the staff to man complex equipment, it is better to start looking for other forms of treatment, and this is what doctors began to do.
4.2 Doctors had to battle existing protocols as much as the disease itself
An interesting comment from Dr Kyle-Sidell at this time, which throws light on how a novel disease situation demands novel thinking, beyond the established rules and divisions of medical practice, is his description of how as an emergency care specialist he was able to see Covid-19 patients in different stages and degrees of illness – from the emergency room, to the hospital floors, to the ICU - and how this gave him a wider picture of the progress of the disease, unlike the ICU doctors who were only receiving patients “on breathing tubes” (56).
As they worked through their Covid-19 epidemics, critical care in rich Western countries saw both a quantitative as well as a qualitative change. The protocol for Intensive Care Units in First World countries is one-nurse-per-patient. This is quite different to intensive care units in India, where a nurse would serve more than one patient. In India, intensive care units are built on an open plan with beds arranged on a perimeter around the nurses’ station, so they can have a 360-degree view of the patients at all times. But things changed dramatically in rich countries once Covid-19 reached their shores. For instance, in the UK, NHS Nightingale ICU facilities were opened with thousands of beds, but just a few dozen staff. So much for the one-nurse-per-patient rule.
Professor Charles Knight, a senior doctor and functionary in the British National Health Service (NHS) system, who was seconded to the London NHS Nightingale as CEO, spoke of the importance of cutting bureaucracy and expanding NHS hospitals’ in-house intensive care units in a manner that used fewer resources
If you follow the discussion in developed countries among doctors around Covid-19 treatment, what comes through is that the issue they had to contend with was not so much ventilator-availability, as the inflexibility of top-down treatment protocols devised by hospital administration. The entire thrust of hospital organization is for adherence to consistently applied protocols. But this might be making them less agile than is required in a novel disease outbreak. The reality of big hospitals, with worries about litigation claims and maintaining insurance cover, is that what should be a purely technical matter for doctors, i.e., what treatment protocol to use, is not in reality so......a big hospital becomes a place for churning out medical services as a sort of assembly-line of treatment. It is not a place for thinking. Consider how futile, and even dangerous, this makes the hospital in a time when we are confronted with a novel disease that defies the rules. How can a new treatment be found without innovation, receptibility, openness, and giving some space for trial-and-error?
If you follow the discussion in developed countries among doctors around Covid-19 treatment, what comes through is that the issue they had to contend with was not so much ventilator-availability, as the inflexibility of top-down
Listening to Dr Kyle-Sidell in interviews where he talks about the need to reconsider ventilator-protocols, one gets the impression that while some colleagues may have supported him, changing hospital protocols is no easy matter. In the end, Dr Kyle-Sidell was moved out of the ICU because he said that he could not, in good conscience, follow protocols that he believed were harmful, and the hospital was unable to change them.
The reality of big hospitals, with worries about litigation claims and maintaining insurance cover, is that what should be a purely technical matter for doctors, i.e., what treatment protocol to use, is not in reality so. To steer clear of litigation and insurance trouble, a big hospital has to diligently follow set procedures. In this way, a big hospital becomes a place for churning out medical services as a sort of assembly-line of treatment. It is not a place for thinking.
Consider how futile, and even dangerous, this makes the hospital in a time when we are confronted with a novel disease that defies the rules. How can a new treatment be found without innovation, receptibility, openness, and giving some space for trial-and-error, something that has become an anathema in advanced countries with their risk-averse, insurance driven, litigious culture? Will the media and lay public give doctors and public health authorities the space to experiment, or will every death, every failure be blamed on them, to a chorus of condemnation from news broadcasters all around the world? In this atmosphere of hyper-vigilance, why would doctors be encouraged to think and try new things? They would be safer to follow the protocols.
Dr Kyle-Sidell was forced to come on social media as he was unable to persuade his hospital administration to allow him calibrate ventilator-use to what he saw in his patients. Hopefully, his honesty will not prove be career-destroying. His and Dr Gattinoni’s interventions sparked off an energetic debate on ventilator protocols, and protocols in general, among doctors in New York who were at the frontlines of the Covid-19 outbreak. While some doctors took a more conservative approach, expressing their dissatisfaction with working on anecdotal evidence without widespread clinical trials, many doctors reported that within weeks of these events, hospitals had pulled back on their initial response of rushing Covid-19 patients to intubation based on ARDS protocols (58).
4.3 The Clinical Trial: A Gold or Gilt standard?
Rigid protocols might also have played a role in retarding the search for drugs for Covid-19 treatment in the West. While Western experts continue to debate the use of hydroxychloroquine, and the WHO has been plodding along for months with its “Solidarity” trial for this and other drugs, the Indian medical authorities advised this drug as treatment and preventive for doctors and high risk contacts of patients.
The Indian advisory for Hydroxychloroquine as Prophylaxis states the position clearly and simply: “Hydroxy-chloroquine is found to be effective against coronavirus in laboratory studies and in-vivo studies. Its use in prophylaxis [prevention] is derived from available evidence of treatment as supported by pre-clinical data. The following recommendation for the use of hydroxy-chloroquine as a prophylactic agent against SARS-CoV-2 infection is based on these considerations, as well as risk-benefit consideration, under exceptional circumstances that call for the protection of high-risk individuals”
For the treatment of severe Covid patients, India’s National Clinical Management Guidelines for Covid-19 say: “No specific antivirals have been proven to be effective as per currently available data. However, based on the available information, (uncontrolled clinical trials) [Hydroxychloroquine combined with Azithromycin] may be considered as an off-label [meaning without clinical trials] indication in patients with severe disease and requiring ICU management” (42). So the guidelines they take a practical view, given the limited options and severity of Covid-19 disease.
Certainly, the use of hydroxychloroquine carries a certain risk; in India, in the early days of our Covid-19 epidemic, two doctors who were said to have been self-prescribing hydroxychloroquine died from suspected side effects. But its use among doctors here is now fairly wide, and there has been no explosion of bad reactions. Its use may even explain the relatively low incidence of hospital outbreaks of Covid-19 in India, compared with hospitals in Italy and the USA. Doctors have even been giving hydroxychloroquine in India as a preventive to patients with heart disease, under careful supervision, of course.
The risk profile of drugs like hydroxychloroquine may need to be re-calibrated by taking into account their potential for prophylaxis and treatment, given the limited options available in the current state of science for Covid-19. Even the idea of the clinical trial, which keeps rejecting therapies that doctors at the bedside find are working on patients, might need an overhaul.
There can be no neat answers; ignoring protocols also has risks. Some clinicians will object, quite reasonably, that intervening in this way will “complicate the clinical picture”, i.e., the true progress of the disease in the body, and the search for effective interventions. These are all valid considerations. Perhaps, instead of looking for neat, universal solutions, we just have to have an open-ended, incremental approach, being very conscious when we take a conservative line, of the risk of missing out on innovation in treatment, and equally being conscious of the risk of abuse, when we take an unconventional approach. This is a state of mind that comes naturally to many in the developing world – a kind of dialectical approach to life. The WHO has only added to the confusion by conducting its own ‘Solidarity” clinical trials. Instead, the WHO could have shown real leadership by spotting these oppositions and encouraging countries to evolve a way of negotiating them, in finding solutions for the Covid crisis.
Private enterprise is doing better with encouraging new thinking. Online physicians’ platforms, like Sermo, began to publish data on the use of hydroxychloroquine and anti-viral drugs by physicians around the world. On Sermo, you can already see the emergence of a new language and a groping for new standards for drugs-testing to deal with the new realities of Covid-19. In their “About” section they use the term “Observational Study” which is described in these words:
“They are called observational studies because the investigator relies on the physician’s self-reported or observational reports of treating patients without manipulation or intervention. This is in contrast to randomized controlled clinical trials, which are designed experiments where investigators intervene and look at the effects of the intervention on an outcome.
“While randomized, placebo-controlled clinical trials are still the ‘gold standard’ for assessing the safety and effectiveness of therapy, observational studies are a fundamental part of epidemiological research” (44).
Sermo’s focus on physicians’ experience, even its disclaimer to the media listed under the title “How Sermo studies compare to the scientific standard of polling”, show the first the glimmers of a paradigm shift in standards and the emergence of a new scientific language to deal with the new challenges of Covid-19.
Lines are being crossed in other ways too. For all the blame-game between China and the West over Covid-19, doctors from these countries immediately got into a conversation with each other over treatments for Covid-19. Doctors across the US spoke of the need to consult with Chinese and Italian doctors to learn from their experience with this disease. Established journals like the New England Journal of Medicine, the Lancet and the British Medical Journal published Covid-19 case studies and findings by Chinese doctors and national research institutions; and Chinese medical journals also published Covid-related research, meticulously translated into English. In fact, readers would be interested to know that the exchange of views and research through medical journals has been going on for years between China and the West.
4.4 A Foucauldian Moment for the Medical World
What you have in all these developments is the breakdown of established systems of hospital organization, medical practice and pharmaceutical standards. While this may throw up new questions, the process of questioning the fundamental principles of hospital and medical practice is of long standing in the medical field. The study of these questions is part of the regular curriculum for medical students, many of whom would be familiar with the philosopher Michael Foucault’s seminal work, The Birth of the Clinic. In this book, Foucault chronicles changes in the field of medicine just before and after the French Revolution, using these changes both as a metaphor and an example in philosophizing about how systems of thought, institutions and modes of practice come into being and change.
There are important lessons for the present time in Foucault’s exploration of the different ways and objectives with which hospitals and clinics were organized at different times; emerging, as he argues, out of the play of ideas between medical expertise, social, political and economic concerns about medical practices and institutions, and the lay sentiment towards hospitals and doctors.
There are important lessons for the present time in Foucault’s exploration of the different ways and objectives with which hospitals and clinics were organized at different times; emerging, as he argues, out of the play of ideas between medical expertise; social, political and economic concerns about medical practices and institutions; and the lay sentiment towards hospitals and doctors. Foucault engages in this interrogation of changes and new developments in the medical field without, in any manner, denying or diminishing the validity of medical science as science: “I should like to make it plain once and for all that this book has not been written in favour of any one kind of medicine as against another kind of medicine, or against medicine and in favour of an absence of medicine. It is a structural study that sets out to disentangle the conditions of its history from the density of discourse, as do others of my works.” This is precisely what makes Foucault’s work on medical science all the more compelling for present times in which are always being told (especially by non-scientists) to “follow the science”. You can follow the science and still question its institutions, and currently favoured trends of thought.
At a very simple level, Foucault tells us that we don’t have to be tied to established categories and systems of organization. If the current best practices for hospital protocols or clinical trials are not working to help Covid-19 patients, then we can break them down, mix them up, abandon or invert them. If established divisions between areas of medical specialization are obscuring a full understanding of the disease, then let those divisions be dissolved. Covid-19 has changed the game, and this is the time for questioning, not compliance. Only through the recognition that the old truths no longer hold, can we have the free and honest scientific enquiry that this moment demands.
Italian doctors were quick to intuit the misalignment of their current medical practice, with the exigencies of a highly contagious disease like Covid-19: “Coronavirus is the Ebola of the rich…..The more medicalized and centralized the society, the more widespread the virus…” (23); “the Coronavirus epidemics should indeed lead to a number of reflections on the organization of healthcare and the way contemporary medicine has lost sight of some diseases, such as infectious ones, that were, probably prematurely, seen as diseases of the past…..many hospitals, including ours are reorganising and “industrializing” out-patient care, building large open spaces where multiple specialists will furnish hundreds, or perhaps even thousands of consultations per day….We are now slowly realising that this “super-efficient” factory-like program is incompatible with the periodic occurrence of epidemics, a scenario many experts consider likely, whose consequences will probably be more severe because of globalisation. While economies of scale seem to favour “hospital factories”, events like Covid-19 infection, risk compromising their ability to function….We have definitely not won the fight against infectious diseases, but we have probably forgotten about them too soon. In a high-technology setting, it is all too easy to forget the overwhelming, often dark power of nature” (24).
We do not know what new ways of medical thinking might run up against which commercial interests in the pharmaceutical, research or medical insurance field. Even non-commercial actors in the health sector, like developmental or philanthropic organisations, such as the WHO and the Bill and Melinda Gates Foundation, may push back against new ways of doing things as a result of institutional inertia, the fear of losing prestige or the fear of other, earlier interventions being questioned. A radical re-think is discomfiting for all established players in the field.
The medical world can take this as its Foucauldian moment and ask for radical changes in confronting Covid-19. Those who do, should expect resistance, as happened with Dr Kyle-Sidell. Each way of organizing systems comes with its own hierarchies and privileges, which will resist change. We do not know what new ways of medical thinking might run up against which commercial interests in the pharmaceutical, research or medical insurance field. Even non-commercial actors in the health sector, like developmental or philanthropic organisations, such as the WHO, Medecins Sans Frontieres, and the Bill and Melinda Gates Foundation, may push back against new ways of doing things as a result of institutional inertia, the fear of losing prestige or the fear of other, earlier interventions being questioned.
A radical re-think is discomfiting for all established players in the field. Established players include the news media. Without rejecting the mainstream media out of hand, the public needs to be conscious of the alignments and camaraderie that have built up between the media and those in the health establishment over decades of collaboration and exchange on health issues. This gets in the way of a proper scrutiny of the current situation by the media, apart from the generally low levels of science and maths knowledge.
The politicisation of the Covid crisis has also worked against a sober and fair scientific assessment of the situation. Only through open scientific debate will better ways of treating Covid-19 emerge. Some doctors and academics were quick to see this. They have already begun to chip away at the established protocols and treatment paradigms. Prestigious universities and affiliated hospitals have set up online forums, like the Oxford Covid-19 Evidence Service, run by Oxford University and Nuffield Hospital. This portal puts out research pointing out gaps in the scientific understanding of Covid-19, as well as contradictions and uncertainties in the data and epidemiological analyses of the pandemic. Many medical journals, assisted by publishers like Elsevier and researchgate.com, made papers on Covid-19 available free to the public on their online portals. Some papers were put out while they were still in review to facilitate quick and open discussion of Covid-19 research, even at the cost of the peer review controls of normal times.
4.5 Questioning "the" Science
These were not exactly dispassionate exercises, entered upon purely for an objective discussion of the science. The outrage of some scientists at the mainstream view, the preference for this or that approach, a greater or lesser emphasis on certain aspects of the many issues that arise, are all fairly evident in the work that has been put out. Not all the work that has come out will stand the test of time, and positions will be softened as tempers cool down. But what is important for us as the lay public to understand, is precisely the contested, contingent and tentative nature of the science of Covid-19. It is from the churn of ideas that a better understanding of the disease will emerge, but this needs patience and restraint from the watching public.
The idea that the science somehow “settles” itself, is something only non-scientists believe. In reality, science is peppered with paradoxes, unsolved equations and unproven assumptions.
Above all we have to be open to questioning everything. Query whether there can be any science without questioning? The idea that the science somehow “settles” itself, is something that only non-scientists believe. In reality, science is peppered with paradoxes, unsolved equations and unproven assumptions. They are even given names, like Quantum Uncertainty, the Reimann Hypothesis and Fermat’s equation, which was only solved a few years ago, after over three centuries. Scientific research is pervaded with debates that have no “settled” answer. Albert Einstein did not believe in the existence of black holes, even though the idea of black holes is posited on his own theory of relativity (60). Interestingly, the idea of black holes came from a form of mathematical modelling. In general, Einstein seems not to have been greatly impressed with modelling as a method of reasoning. He even said of quantum physics that “God does not play dice with the Universe.” (61). This is the elevated level to which have to return in the sciences. From Galileo to Isaac Newton to Einstein, none of the paradigmatic shifts or fundamental breakthroughs in science have come from the bean-counting exercises of modelling and number-crunching. Many great mathematicians like Ramanujan, and physicists like Stephen Hawking, saw the answer first, and then spent their careers trying to demonstrate it in mathematical terms. So the idea or the understanding or intuitive insight is, in a way, greater than the science. In a sense, the science only follows the understanding, in its raw and instinctive form. No supercomputer can ever do what Isaac Newton did, when observing an apple falling from a tree.
Also, contrary to the picture portrayed by the lay media, scientific, and indeed any field of academic enquiry, does not progress from one certainty to another. It is more a process of ongoing argumentation, testing and revision. It is a conversation. At its best, it is an erudite and measured conversation, in which the questions add to our understanding as much as the answers. But it is a conversation nonetheless, quite different in tone and intent to the oracular quality that scientific assessments are given in the lay media these days.
....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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