Health

Lockdown, Shutdown, Breakdown: India's COVID Policy Must Be Driven By Data, Not Fear

If you can't solve the problem, you are not employing evidence. And India's reaction to the coronavirus is a classic illustration of this truth.

A lockdown cannot be imposed on a whim or gut feeling. Crucially, it should never be imposed to garner approval ratings. There has to be a science behind it; the decision must be evidence based, not a reflection of a house constructed from sand. The lockdown in India, now all set to enter its fourth stage, is laughable. It was imposed from March 25. As per the WHO, there had been a total of 434 cases till that day, with a cumulative 9 deaths. Italy had 63,927 cases with 6077 deaths, and the US had 42,164 cases and 571 deaths.

It is now May 17 and India has seen the total number of cases rise to above 90,000 with 2872 deaths. Around 120 patients died yesterday. The lockdown has obviously not worked one bit. Its timing was too premature, draconian measures were imposed much before cases had begun to mount. No attempt was made by the government or the media to assure the public that all data on COVID-19 pointed to more than 80% people developing mild or no symptoms. The majority of infective people would simply shrug off the virus with absolutely no harm to themselves, especially if they were young (as most Indians are) or had no underlying disease.

Source: UK Column

The number of cases keeps rising every day for the simple reason that more people are being tested now than before. Mercifully, the number of daily deaths are still around 100 and not much more. To put this mortality in perspective, more than 20,000 Indians die every day because of a variety of reasons. This is not the time to discuss those but to stay focussed on what is happening right under our noses.

Millions of people have been displaced, lakhs of businesses are shuttered, all schools closed, restaurants and hotels shut, and millions are without jobs or any means of sustenance. The poor have been hit like never before and the middle class too will soon begin to crumble. Crores of children are corralled with unimaginable psychological adverse effects, domestic and child abuse that largely go unreported must be substantially elevated. These matters are well known.

Most public health doctors worth their salt will endorse the fact that a lockdown if needed must coincide with the peak incidence of cases; it should never be imposed too early or too late. It must be put in place at the time of peak infection. The graph below clearly shows that despite the lockdown, cases in India have shown no decline. There has been a steady increase in the number of active cases since mid-March; what could be the reason for this? The reason is simple, faulty timing of the lockdown.

SARS-Cov-2 is basically a respiratory virus, evolved from nature. Even if man-made, as some conspiracy theorists imply, it is near identical to SARS-Cov-1 and other corona viruses. It is also similar to other viruses that affect the respiratory system, including the flu virus. Every respiratory virus, particularly the flu virus, has a pattern – it emerges in winter, and after infecting people for 6-8 weeks, makes a retreat. In the process, the flu virus manages to kill 30,000 to 60,000 people in the US alone, and many thousands more worldwide, without much hue and cry.

COVID-19 has played havoc in Spain and Italy but as expected, the number of new cases there is declining. This pattern will be the same for almost all countries: a rapid increase in new cases and then a fall in numbers over 4-6 weeks. This has been the natural history of flu as can be seen in the graph from Germany below.

But the moment a lockdown is imposed, you interfere with the natural progression of the disease. The curve is simply flattened at most, meaning that cases/deaths will take place but will be spaced out or delayed. The logic behind flattening the curve was to buy time to improve logistics in hospitals, get more beds and ventilators. And also to ramp up the ability to test for the virus and check for past infection (antibody tests). The percentage of positive cases has remained steady despite a lockdown since mid March; in Europe, they have realised the futility of the strict lockdown and are preparing to loosen it now.

However, the situation was completely different in India – the cases have been remarkably few and deaths fewer. There are two main reasons for this: a younger population cohort and much higher temperatures than Wuhan, Europe and the US. Let the so-called experts say whatever they want, a 35C plus temperature will paralyse this virus. The small number of cases is ample evidence. Some may argue that the lockdown has been our great saviour. Not true. New cases keep coming each day despite the most draconian lockdown on the planet, yet they are few. Most hospitals are lying empty with health workers twiddling their thumbs. The corporates have already announced a significant reduction in salaries of doctors.

The ministry of health, predictably, has been found wanting on every front. The mandarins and their advisors seem to come from another planet or are just confused. A neighbouring country announces the arrival of a new respiratory virus on January 10, and we do not still have a validated antibody test with us on May 17. So much for our preparedness or reflexes. This is a cruel joke that a nation which attempts an unmanned landing on the moon does not have the scientific intellect to set up an antibody test over five long months. Worse, no one seems to care. Even the medical fraternity, which should have been screaming for serological testing for themselves has drowned itself in deafening silence.

True death rate of COVID-19

It is imperative that we know the incidence of infection. For example, they tested 3300 people in Santa Clara, California and found that 2.5-4% people had a past infection or COVID-19 antibodies. The study was conducted by Stanford University. The simple math is that around 50,000 to 85,000 people in Santa Clara county have been infected, but only 1000 people had tested positive for COVID-19 by PCR. The conclusion, and a correct conclusion, is that the true prevalence of COVID-19 is 50 to 85 times more than the PCR estimate. Using the data in India, 85,000 cases and 2752 deaths gives us a crude mortality rate of 3.2%. But if we extrapolate from the Santa Clara findings, COVID-19 mortality is less than 0.04%.

New York state too tested 3,000 people for antibodies to find that 14% had been infected; in fact 21% of New York City inhabitants were infected. The implication, again, was that almost 2.7 million people had got infected. The good news was that armed with this knowledge, governor Andrew Cuomo could publicly declare an infection fatality rate of 0.5%. The numbers should be tempered with the knowledge that numerous patients got treated by ventilators that proved detrimental.

Instead of telling people the true death ratio, the media keeps banging non-stop on the dangers of this virus. So relentless has the propaganda been that I’m sure if people were asked for their opinion on the loosening of the lockdown, a significant number would insist it be kept on for 6-8 weeks more. People have become paralysed by fear, they are scared out of their minds. It will take a miracle to mitigate their apprehension or rather terror.

Most doctors are so scared that they prefer staying not six but 12 feet away from a patient. These are remarkable times. The politician and his babu in the blink of an eye are prepared to seal a hospital if a couple of cases are discovered there. Sealing a hospital on finding a COVID-19 case, which kills less than 0.05% affected people, is more than absurd, it is scary. Albert Camus wrote of bad and good people in The Plague, but he could never have imagined that the nation of the Mahatma would go around sealing hospitals if a case was spotted within the premises. Where else would you expect to find this virus if not in hospitals? People go to hospitals for treatment but now you scare the hell out of them by sealing hospitals. No wonder thousands of patients are petrified of visiting a hospital even as they suffer chest pains or paralysis.

Mark my words, there will be far more deaths due to heart attacks, cancers and strokes in the next two to four years, than COVID-19. A bizarre and impossible situation has been created in this country. How many know that Gandhiji actually treated patients of pneumonic plague in Johannesburg. Pneumonic plague has always been a killer, but Gandhiji had the guts in 1904 to actually try to treat the patients. India’s leadership today is limited to delivering messages on TV and Twitter. I do not know which leader has mingled with the people (albeit from the prescribed distance) or visited a single hospital. Instead it has been the usual vacuous soundbites with minuscule substance, and even lesser (if possible) reassurance. This virus has no respect for caste, creed, religion or political affiliation. It demands that we shed our intellectual laziness and get to know the truth in order to tackle it. But if we do not, it certainly will not mind.

Sweden is not under lockdown. It never went under lockdown. Schools and restaurants are open. People have been advised to maintain distance amongst themselves and apply common sense. They anticipate herd immunity by the next fortnight. Moreover, their death rate is substantially lower than other European countries. It is more than their neighbours who are under lockdown but expect the figures to level off by the time the season is over. There is grudging admiration for the Sweden model, despite orchestrated critiques thrown in influential media sources. Mercifully the Swedes did not buy the famed Ferguson model from Imperial College that two million would die in the US and 500,000 in the UK if a lockdown were not imposed. Remarkably, Ferguson did not publish a peer reviewed paper anywhere nor does Imperial College. They just have a document that forced the British to make a U-turn. The same Ferguson then gave testimony before parliament that deaths would be around 20,000 and two-thirds of these would be deaths in the normal course of events. It must be kept in mind that almost 50% of deaths in Europe including Sweden have been in old age homes. Ironically the people for whose protection the lockdown was imposed in the first place turned out sadly to be the ones that got most neglected. Sweden has conceded to this sad state of affairs and is making amends.

Stopping doctors, sealing hospitals 

So terrified are we of the virus the authorities went to the extent of sealing Delhi from both NOIDA and Haryana.

I was compelled to do two angioplasties the other day. Both patients were hanging by a thread. The procedure by any standards was life saving in both of them. Both patients had successful procedures and wished to be discharged as soon as possible. A patient expects the doctor who has done a major procedure on him to examine him before discharge. So it was with these two. But alas, it could not be done. To my utter horror, I was stopped at the border on my way to hospital. The hospital falls in Dwarka, Delhi whilst I currently reside technically in Haryana. So that’s it folks; I did not bother to reason with the policeman, I knew it was a waste of time. The man had orders from above. The situation is  hilarious. A pandemic has gripped the planet. An epidemic is unfolding in this country but the high command is not prepared to permit doctors to treat patients. George Orwell would have never thought of this one.

In India, we have faltered at every stage of this epidemic. We never got PCR testing done on time, even today we do not have a validated serology test, we have absolutely no randomised data on any intervention attempted during this pandemic, an ill-timed lockdown was inflicted without any scientific evidence, we have no idea when was the peak of new cases, even today we do not know the virus genome, and crucially we have absolutely no clue of the infection rate. We all wait with bated breath for a vaccine to materialise in the next 6 to 18 months, in the meantime we are the classic deer in the headlights. It is imperative that we read up on this virus, attain some clarity while shedding our trepidation. It is not enough to watch TV all day, especially not the health ministry sermons. It is time to realise that sealing hospitals, sealing borders and extending this lockdown indiscriminately will not prevent infections in the slightest way.

Sealing borders and hospitals is the trend today.  You declare a pandemic, create coloured zones, constantly go on that the virus lurks in front , behind and around you, continuously remind the average man that he is a sitting duck if he gets infected, but then at the same time  prevent a doctor from going to hospital. Incredible India. Enforcing a lockdown without a shred of evidence is easy, but what parameters will you apply to lift it?

As of now, there has been no impact on the curve, as was expected. Each new day brings more cases. If the lockdown is lifted, the virus will come roaring back because most people would not have developed immunity against it, while confined in their homes. The elderly will continue to be vulnerable. The misery that has been inflicted on crores of people is compounded by the fact that a staggering amount of time, money and lives has been wasted. Amidst an officially declared national medical emergency, preventing a doctor from crossing the Delhi Gurugram/NOIDA border is not only bizarre but plain idiocy. The obsequious babu in his zest for lockdowns is totally oblivious of the fact that there are hundreds of other serious ailments apart from COVID-19 demanding both attention and treatment. Hospitals will shy away from doing what they are trained to do because if you spot a case you will close it down. Please remember that getting infected by this virus is not at all a death warrant; most people (80-90%) get mild to moderate symptoms. The more cases the cases pick up, the greater the immunity the community is developing.

This is a classic Catch 22; you do not fly if you have lost your marbles; but if you know that you have lost your marbles you actually have not, so you jolly well fly into enemy territory, John Yossarian.  Transplant it to today’s India; you as a doctor have to treat COVID-19 and other diseases. But if you or a patient in the hospital is found positive, your hospital (including you ) are to be locked up. Remarkable stuff. I wonder how many hospitals have been sealed in New York City, London, Madrid, Paris, Manchester, or Berlin? Lots of them would have, if the Indian babus had their way.