At the start of the national coronavirus lockdown put in motion by Prime Minister Narendra Modi, it is useful to take a few deep breaths and recapitulate what the challenge is, where India stands, and what is the most plausible way forward.
First, the challenge
Like the rest of the world, India is faced with a new virus with sizeable ill effect that requires hospital-based care in a fraction of the cases – 10 per cent or more – and sizeable mortality rate, which is higher among older people with pre-existing health conditions.
If everyone in India was exposed to the novel coronavirus over the next year, our calculations indicate that it would kill 50-100 per cent of the number of people who would die during that period from other causes. And hospitals would be unable to cope. So clearly, we should not get to that point or even a point where, say, 60 per cent of the population has been exposed and it has resulted in ‘herd immunity’ – which means a lot of people are now immune and the virus no longer spreads en masse. That reduces the problem, but the numbers are still too big.
The other chief fact to know is that 20-50 per cent of infected people do not exhibit clear symptoms and that is what makes life difficult. Were it not for those cases, simply isolating people with symptoms by standard measures that India’s health officials are very good at would do the trick and the country could relax.
Where India stands
India has reported 16 recent deaths. Assuming that each comes from a group of 100 cases two-weeks prior, we can conclude that there might be as many as 30,000 infections in the country. This is a tiny fraction of the population – slightly more than 2 cases per 100,000 people. We are in the very early stages of a potential epidemic. Of course, these cases are mostly concentrated in a few places and the fractions are higher there, but even then not higher than 1 case per 10,000. This is not the regime of the frightening curves with millions dead from standard epidemiological models, even as a matter of theory, and instead is absolutely a controllable situation.
Before we turn to what can be done, it is important to understand that we are looking, with the rest of the planet, at about a two-year problem. Until such time as a vaccine is widely available, there could be periodic outbreaks as the virus makes its way to places where it is not present and because we are never truly able to stamp it out. It continues to spread at very low rates and hide among other health challenges. A vaccine may come sooner, or, the virus may mutate enough to make a perfect vaccine impossible. Or medicines may become available that cure almost all cases with care at home. But thinking of two years is a good frame of mind.
What needs to be done
If everyone who gets the virus showed symptoms immediately, we would not need to worry. Such people would be isolated and the epidemic would never take off. But instead, we are faced with people who are infected and do not exhibit symptoms yet – they are in the ‘omega’ period – or will never show noticeable symptoms. We need to find these people and get them off the streets, as it were.
If absolutely everyone could be tested for the presence of the virus today, this would again be a solved problem. But that is not possible and might not be possible for a while in a country such as India – although, given the intense global effort on the problem, we should not rule it out in a year or more from now.
So, we need a solution that requires testing resources used in a stratified and well-thought-out manner. The solution that enables this exists and is called ‘contact tracing’. Indeed this is what health officials around the world do anyway – they go looking for people who crossed paths with an infected person and test/isolate/treat them. As of today, we don’t really know if Indian health authorities have managed to find all contacts of known cases. If they have, we are in good shape. Internally, their logic is self-consistent – the rate of positive tests is low, suggesting that they are covering enough people. If the higher estimates of likely coronavirus cases are correct, they have not and there are people walking around carrying the virus far from the contact trails known to Indian health officials. Making sure that such missing cases are identified is the challenge today.
Roughly 40 per cent of Indians own a smartphone, and roughly another 40 per cent own a less talented mobile phone. It is entirely feasible to give each simple mobile phone owner – who already have some training in using this class of device — a cheap or free smartphone in the next few months. It could either be a used phone whose numbers in India and elsewhere are surely sizeable or a subsidised one. We should aim at a basic device for everyone who needs it to take part in the following.
What we need are phones that can run apps, Bluetooth and GPS. The data usage can be subsidised and even made free to users for the specific applications below. Now, what we need is for this army of smartphone users to do two things with their phones. First, to self-report any troubling Covid-19 symptoms – fever, shortness of breath, dry cough and so on – that can be used for a purely digital and automated estimate of the likelihood that they have contracted the virus. This would expand the reach of disease surveillance enormously and allow the ‘missing’ cases to show up. The same app could be used to direct them to medical care and to provide ‘telemedicine’ via the app itself. Second, they should run a ‘contact tracing’ app on their phones, which would keep track of other people they had close physical contact with over the past few weeks.
If everyone does this, the moment one person is identified as having contracted the disease, it will be possible to find everyone who could have potentially been infected by this particular individual. These people can then be isolated/tested/treated. As the ‘omega’ period is shorter than the ‘latent’ period, we can find those exposed to the virus before they can infect others. Equally, one can go back and find the person from whom this person got the virus – who might have no symptoms and thus might not have been found were it not for such tracing. With this combination of digital and physical testing, no epidemic will be possible.
Privacy and universality
In order for this to work, ideally everyone with a smartphone should carry it and think of it as a new, portable, healthcare device. And everyone needs to use self-reporting and buy into the contract tracing system. For both parts of the enterprise, Indians need to feel secure that this will not be followed by government or commercial abuse of data. There are known technical and organisational solutions for this – all governments must make it clear to citizens that no system of mass surveillance is in the offing and to realise themselves that the public health imperative requires a step back for them.
With that agreed, the best solutions can be picked – such as arm’s length supervision of such systems with control vested in a panel of eminent citizens, distributed data processing as suggested by MIT’s Ramesh Raskar and colleagues, separation of the self-report and contact tracing functions, and so on.
The second part of the enterprise – contact tracing – needs a single data system. If everyone is on it, then everyone can be notified if exposed. A truly national system would be best, but short of that, at least regional uniformity is urgently needed. For those with feature phones, simpler versions of tracing can be readied, and indeed query-based systems by community workers could also address those without phones.
Setting the goal of constructing this digital system rapidly is key and doable. India has a great deal of strength in exactly this area. Once this is done, a major epidemic will no longer be possible. That will allow healthcare and testing capacity to expand over the next full year.
With any luck, medical advances that benefit a large number of cases (say younger than 60 years of age and lacking co-morbid conditions) will become available in a few months and will reduce the challenge even further. Meanwhile, there will be other things to continue: social distancing in everyday life (the World Health Organization now prefers to call it ‘physical distancing’), creating a culture of wearing of masks in public places to reduce transmission, antibody testing to ‘certify’ immunity, and measures to protect the vulnerable.
These could take the form of setting aside time slots for the elderly in public places and yet more imaginative solutions to the problem of protecting them ‘in place’ – at home with their families. Doing this inexpensively is a major challenge that should exercise talented technical people worldwide. For those Indians who need to travel internationally, measures will have to be worked out cooperatively with other nations. And if this set of tools fails periodically and there is an outbreak in a particular location, lockdowns are always possible. But they will not be needed nationally. This should be the last one.
Crisis as opportunity
A digital system of the kind discussed here could bring much more reliable healthcare information to all Indians, bring telemedicine and improve their health outcomes. It will make the management of any future epidemic vastly simpler. It will also push India into the digital age. Prime Minister Modi has been bold in flagging the coronavirus pandemic as a crisis.
He should now be equally bold in seizing the opportunity and announce the principles enunciated here and task an extremely high-level group of officials to make it happen. It should include the participation of governments at all levels, the private sector and India’s citizens.
The author is Professor of Physics at Princeton University and is working on India’s coronavirus challenges with a group of students, postdocs and faculty. Views are personal.