India presents a unique opportunity for a science-based approach for handling the Covid-19 pandemic in light of new scientific evidence. The availability of excellent serological evidence based on sample surveys of large populations provides crucial information for a rational path to managing the epidemic without undue fear or panic.
A serological survey measures the fraction of the population that has Covid-specific antibodies in their blood. This provides good evidence of prior infection. Recently, the ICMR has conducted a large-scale seroprevalence study in India, which estimated that tens of millions (crores) of Indians have already had the Covid-19 infection. This finding has been verified by a serological study conducted by Thyrocare and other private labs.
This may sound like bad news, but it’s actually good news. The vast number of these infected people experienced few symptoms from the infection and did not die. The vast majority are no longer infected and are not infectious.
Since there are so many previously infected people, the Covid-19 infection fatality rate (IFR) in India implied by ICMR’s previous study is around 0.1 per cent or lower — one death per thousand infections. This is much lower than the widely reported fatality rate estimate of 2.5 per cent, which ignores the large number of unreported and uncounted cases found by the serological studies. Unreported cases must then be also counted in the denominator to estimate the true danger from the Covid-19 infection.
Also read: One in four people in Delhi infected by Covid till first week of July, sero survey finds
Lockdowns are futile
Serological surveillance is a better and more reliable technique for assessing the progress of the disease rather than crude ‘increase in number of cases’ (or ‘doubling rate’) based on case counts. Increase in the number of cases is proportional to testing intensity in a population.
Likewise, reporting crude ‘recovery rate’ is unscientific, and adds to fear psychosis by falsely exaggerating the risk perception. Both of these statistics ignore the large number of unreported cases.
In a widespread disease with a proven infection fatality rate below 0.1 per cent, like Covid-19 in India, it is unscientific and futile to impose lockdowns in a bid to limit the increase in case counts.
Lockdown measures cannot permanently control the spread of the virus, as is evident from the widespread prevalence of the disease in India despite the lockdown. At best, lockdowns delay the onset of the disease to after the lockdown is lifted, rather than preventing disease altogether. Lockdowns themselves cause severe damage to both lives and livelihoods, as people delay required healthcare and lose their jobs.
Widespread pandemic is good news
As there is substantial global data and experience now available, the progress of the disease is known more clearly. It is clear that India has reached a stage where in many cities, the prevalence is in double digits (more than 10 per cent) while the countryside is relatively less exposed.
However, the best part is that the number of deaths in India due to Covid-19 infection is quite low relative to the experience of other countries. In the end, Covid-19 infections will have a relatively small effect on India’s annual death count of nearly ten million.
India’s daily burden of ischemic heart disease alone is approximately 4,000 deaths. If the lockdown is continued, it is possible that more people will die from neglected treatment of other diseases than from Covid-19 itself.
The lockdown encourages mismanagement of medical services by delaying or eliminating needed care for patients with other conditions that are not specifically Covid-19. It is a wrong and self-defeating policy to count deaths only due to Covid-19 on a day-to-day basis, while ignoring deaths and other malign outcomes from other diseases as a result of lockdowns. The daily death and health incidence data should be published for all causes and not just Covid-19, to put things into perspective.
Publicising only reported Covid-19 cases and deaths is a form of misinformation, inducing fear in the population, including in the medical community. The reported case counts present a false picture of the epidemic, greatly underestimating its true spread. In fact, the actual number of cases is tens of times higher if unreported cases are also counted.
Remember, a widespread epidemic is good news, since it implies a low infection fatality rate. So, it is better to recognise and publicise the vast number of cases that recover on their own, to rightly project the relative lethality of Covid-19 and address the disproportionate scare from the early days of the epidemic.
Also read: With rising cases, India far from flattening curve but low death rate a silver lining
The approach India should take
In view of the above evidence, a liberalised Swedish approach is the best course for India. This simply means emphasising public education, individual risk-taking and responsibility. The desirable, and, perhaps, unavoidable, outcome will be slow or natural exposure of the not-so-vulnerable segment of the population, while the capacity to handle severe cases is built up.
The more vulnerable (say persons of age 60-plus and with comorbid conditions) should receive special protection, including testing, close monitoring, and perhaps isolation.
The strategy of testing and tracing all asymptomatic or mild cases in order to isolate them will now be impossible, given the widespread nature of the epidemic. Waiting in lockdown for a vaccine is also risky, as the harms from the lockdown multiply. A heroic level of ‘trace, test and isolate’ will only further stigmatise the disease as it has already done, clog institutional capacity, and increase viral load all around, including on the medical personnel and on the asymptomatic or mild cases. This will make institutions hotbeds of avoidable nosocomial viral load (i.e. hospital-acquired infections) and result in more deaths.
By contrast, a decentralised approach involving all levels of primary, secondary and tertiary medical infrastructure, like any other communicable disease, will be more suited to manage the pandemic.
The ‘trace, test and isolate’ doctrine raises significant human rights issues in terms of unequal treatment and freedom of the individual, as the tested asymptomatic or mild patients are forcibly exposed to additional viral loads on not only themselves but all around, leading to more deaths, while those untested (and hence not quarantined), develop natural immunity and live.
To sum up, disease projection models should be updated to account for the serological evidence of widespread disease prevalence and low infection fatality rates. Wherever the revised projection suggests that hospitals will not be overwhelmed, lockdowns must be lifted, boldly and confidently, but with special provisions to protect the vulnerable.
It is important to handle the epidemic as a public health issue and not a disaster or law and order issue. Police forces must be taken off completely, the Disaster Management Act should be lifted, and constitutional liberties fully restored. There must be a transparent disclosure of the widespread nature but very low true mortality of this disease, quite like many other diseases we live with in our day-to-day lives.
Dr Jay Bhattacharya is a professor of medicine at Stanford University, USA.
Sanjiv Agarwal is the founder of the Good Governance India Foundation, Mumbai. The GGIF is launching Rational Health Response to Covid-19, RHRC-19.com, for a collaborative response with medical practitioners in India.
This is an updated version of the letter written to PM Narendra Modi last month in response to his invitation for suggestions for Unlock 2.0.
Also read: Stopping traffic, discipline, ‘braking’ Covid spread — why states are bringing back lockdowns
Its articles like this that demonstrate the STUPIDITY of treating covid clinically as opposed to taking PREVENTATIVE MEASURES! Boy this didnt age well did it? While india now suffers finding enough wood to burn the bodies.. MORONS WRITING ARTICLES like this continue to be employed.
Great article! Kudos ??
I have been saying these same points for months and nobody even stops to think for a second.
For immunity compromised people, they are vulnerable to death/serious illnesses even by a common cold/fever. And deaths are actually the same rate/average as in previous years, if we compare. Just that many other deaths are classified as ‘covid'(icmr circular). And nobody is talking about the inefficiency of ‘testing kits’!
We can’t disinfect every inch of a place and backtrack every path. These are impractical.
Also virus can easily spread (already sprd) through essential supplies like milk, vegetables,etc.
If we are to impose a lockdown, then it should be 100% (absolute), which is impossible.
Also needy people who urgently require treatment are denied by many hospitals, over this ‘covid’; unnecessary panic.
Many may have died/lost livelihood directly/indirectly due to illogical lockdowns.
People are brainwashed and scared the crap out by Media and Govt.s( state and central). Such fear mongering by them should be stopped. The current hysteria/hype/panic is ridiculous!
Afterall this is the culmination of our lifestyle, habits,etc. What govt should have done is encouraging healthy lifestyle; banning Fastfood, packed foods(not all), pepsi-coke, alcohol, smoking,etc and why not mandating yoga or meditation!?..
Lets hope people realise and understand these.
Contact tracing may seem logical now but it isn’t, in long run. It leads to mass surveillance and tracking which will encroach into our privacy(leading to a totalitarian state, which isn’t far away!). You won’t realise this now. You would understand this if you read Edward Snowden’s books, articles. This thing is real!!
Covid 19 had proven all experts wrong – from those who were predicting peaks to those who were trying to find correlation with weather. Some humility among experts while writing such articles will do no harm.
I have read with interest the opinion article written by Bhattacharya and Aggarwal. Unfortunately, the article suffers from prescriptive hyperbole and fails to call attention to a number of weaknesses in their own weaknesses, and, strikingly for scientists, also suffers from a curious lack of attention to numbers.
First, what even if the current pandemic has a death rate of only 0.1% (a matter that has been contested, see below), considering that only a third of the population of India will be infected within a year or two, the total number of people to die of it is estimated to over 400,000 (that is over 4 crores).
Which natural disaster has killed nearly half a million Indians in living memory? The 2004 tsunami in Sumatra, the most recent natural disaster in living memory in India, killed a total of 228,000 people all over Indonesia and India together. That is about half of the number expected to be dead in India unless measures are taken.
Second, the number 0.1% as the death rate due to COVID-19 has been disputed. Part of this comes from the denominator, which Drs. Bhattacharya and Aggarwal claim to be 10x more than that which is generally accepted by epidemiologists. The authors’ lower estimate of the death rate of COVID-19 is based on a severely flawed study which has not yet mustered publication through peer reviews but has been criticized publicly on their (a) flawed sampling bias, (b) inadequate technical controls, (c) unacceptably high false positive rates that throws their entire study into question. The Indian serological studies which similarly used a lateral flow kit for detecting antibodies in the blood as did the authors, which, unless shown otherwise, is likely similarly flawed. The flawed results on which the authors base their high estimates of death rate have roundly criticized by scientists and epidemiologists, even by scientists of their own university (Stanford). I suggest caution in accepting the authors’ proclamations because in my opinion their studies and the parallel studies by ICMR are likely to equally flawed unless demonstrated otherwise. In fact, all other field studies suggest that their estimates of COVID-19 death rates are substantial underestimates.
The true rate of death due to COVID-19 evidently varies substantially by age groups, which is a factor that the authors failed to study and do not mention in this prescriptive opinion piece. The true death rate due to COVID-19 in the US for the 65 years old and above likely is between 2 and 10% at the minimum, and for India, although no data are yet publicly available, one might guess that the rate would be even higher due to the lack of adequate medical facility accessible by most Indian residents. This is even more serious in crowded cities, where the pandemic would have the highest mortality among the elderly age groups. With a conservative death rate of 3% among the elderly (6.8% of the Indian population is above 65 years) and again assuming a 30% infection rate, one can estimate that over 800,000 (8 crores) of the elderly would die in 2 years. That means in nearly every city block in an Indian city, typically with some 400 families per block, there would be at least one death. Is that not a disaster?
The authors are concerned about the economy, but the economy is for the people only if they survive. As a nation, one must decide what is the acceptable level of loss of life so as to trade against economic loss. Ultimately it is a moral question. By losing 8 crores of the elderly, India stands to lose a generation–that generation which has a historical memory. No nation since the great plagues of the 13th century Europe has lost such a large proportion of its historical memory and managed to survive…perhaps the only nation where such a human disaster occurred was in Cambodia during the Khmer Rouge regime, and its effects are still reverberating through that nation.
Don’t worry about losing a generation and therefore historical memory. The Sanghis are interested in fabricating a new narrative, and for that an erasure of memory is needed. They were the freedom fighters and makers of modern India.
You seem to confuse lakhs with crores in several places, so you are irrationally and disproportionately scared ten times, to say the least. There are many diseases among us that kill more people than the number you yourself estimate for Covid 19.
I fully agreed, lock down is not the permanent tool for combating the pandemic. Lock down is an interim measure to stop spread till the necessary arrangements are put in place to prevent outbreak. It will be appropriate to establish dedicated hospitals for patients having flue and covid like symptoms and test them, if turned positive treat them in hospital. If we keep the asymptomatic patients in hospitals and go for contract tracing continuously it will affect the whole health care system and the death rate will increase which will create fear psychosis among the people and patients may not prefer to go hospitals as they cannot get proper treatment in the hospitals due to lack of care which they were getting earlier and such home deaths will increase. The best way is to create adequate covid related health infrastructure, treat symptomatic confirmed patients in hospitals, stop contract tracing, advice the symptomatic patients for home quarantine and keep them under surveilance , if symptoms reported to any one, shift the patient to hospitals. Wide publicity be given through local media channels and social networking sites about the details of asymptomatic patients so that people living in the vicinity will be aware about such persons and take precautions till they turn negative. Further. Govt should keep the comorbidity patients under surveilance. Instead of wasting huge amount in spraying it will be appropriate to give masks/ sanitizors to the people free of cost through PDS per head /per family.
I knew you media people are uplifting this covid19. Which was already there in our environment but invented later for some business and environmental purposes and everyone are going to have this virus and can heal too with previous version of corana vaccine or pneumonia vaccine or common flu medication . only pveople who are already sick with lungs are always in dangerous condition when any seasonal flu starts. why such big hunhgama spreaded all because of media. Earlier Ebola, H1N1, swine flu, and many came but never spreaded the news as a disaster.
The procedures adopted by the government is acceptable because they have implemented on recommendations of the experts in medicine in India & abroad.
So don’t blame on what has been done,now think what best we can adopt to eliminate or control covid cases other than what has been done .
Arguments are not for solution so think positive by the experts in management of pandemic.
Let’s hope for the best.
The authorities have no control over lockdown.Peoples are not obliged.
Let us lift the lockdown with stringent penalty for violation of rules.
Aged people may be isolated from coming outside their residence except for medical treatment.Before lifting lockdown , guidance or helping hand may be given by the authorities to improve the individual’s immunity.
I agree with you at some point.
My father is covid positive , he has very mild infection in his body. Right now he is currently with the authorities among people who are more exposed to the infection than him, it is very risky for him.
May be by self treatment it would have been easier for him recover.
We all are quarantine also and right now indirectly we are also being exposed to infevtion even though we are okay.
Yeah toh samaj mai aata tha ki The print wale leftist hai…Par gadhe aur unpadh hai aaj pata chala…Thoda tata namak kha ke article likha karo…
From the very beginning our approach towards covid 19 pandemic has been disastrous and faulty. Surprisingly the pandemic has been highly commercialized for no known reasons. The interest and reason needs to be investigated thoroughly. Symptomatic approach as has been in practice for treatment of other ailments are not being availed for covid treatment. Instead conclusions are drawn on the ingress of the pandemic. In fact the entire medical/research fraternity is frightened and is wandering in the darkness. General public are being psychologically drained and made to hide in fear psychosis. The entire socio-economic environment is put to a standstill putting the entire human race into a steam-sterilised bottle with little option for free breathing not to mention walking or talking. How much can we survive and how long?