Epidemics have both, a clinical and scientific side as well as a governance and public health management side.
The Corona COVID-19 crisis, given its world-wide scope, has seen a variety of national strategies. These match national capabilities and reflect their concerns for the costs and expected benefits for different segments of their society. A popular international paradigm is of containment and elimination.
Our Hon. Prime Minister too has made a forceful case for elimination of COVID-19, with behaviour change and containment as the way ahead. We are also to continue with lockdowns and an aggressive approach to “hot-spots”, that is, dense clusters of infections, which includes contact tracing and total perimeter control. The objective is to stamp out the disease in all locations. Let us all pray that Plan A works, while the numbers are still relatively small.
Elimination, Containment and Plan B.
The international argument for containment rests on two facts which hold for many countries. The first is that they are comparatively better governed and for them, elimination of a disease is an option. They have the technical heft and institutional experience. Secondly, the potential number of patients and the number of hospital beds are in the same range. Whence, lockdown spreads out the infection ensuring hospital care for all patients, thereby socializing risks. This for them, paves the way for containment and elimination. However, evidence is mounting that asymptomatic carriers far outnumber symptomatic ones. This has confounded the very basis of containment, and countries are now formulating more heterodox post-containment strategies.
For us, containment and the lockdowns which go with it, continue to have massive economic and welfare costs without this attendant benefit. The costs, in terms of dignity, livelihoods lost, economic shock, and the trauma for migrants are all well reported. It is not clear that our strategy of aggressive containment is based on a cost benefit analysis. If containment has failed, then the reasons to continue such methods are largely administrative and not clinical. Yet, as of today, we do not seem to have an empirical system in place to answer this or other basic questions about the infection, its geography and its dynamics. Either our elite scientific institutions have not asked for such data, or our bureaucrats have not provided it. In the absence of such analysis or guidance, each state is now charting out its own contain-and-eliminate plan. Given their different trajectories, this is likely to disconnect and disrupt the national economy at all levels, and for a longer time.
However, we must consider situation B, that containment has failed. One indication is that new clusters keep emerging. Or that the disease has already become widespread with asymptomatic carriers. In either case, it is likely that a sizable fraction of us, across villages, towns and cities, will eventually be infected. Managing this transition and the long battle ahead, needs a plan. Unfortunately, there is little that we know in concrete terms of the preparations for this eventuality. As a thought-experiment, let us try and formulate a possible Plan B. The first task is to ensure that food is available and essential services are provided. This is already in Plan A. The next task is to evolve a schedule and geography of restrictions so that health risks are managed. The final task is to minimize the effects of the disruptions on the economy and the welfare of the people, especially the vulnerable. This may mean ensuring that some parts of the economy run and wages are earned. Thankfully, this appears to be on the cards, at least for the rural economy.
The Logistics of Health and Welfare
Let us just look at health and welfare. The key parameters of the infection are not very bleak. By various reports , between 8% and 30% of India’s total population is likely to be infected and this may happen in cycles spread over several months. The fraction depends on the broad person-to-person contact rate of the underlying society. Rural communities have a distinct advantage over dense urban clusters. Lockdowns, i.e., temporary reductions in contact rates, merely postpone the infection and do not change the overall numbers. In some situations, the peaks become flatter and broader. Most infections are mild, and the number who need hospitalization is estimated to be about 10-15% of those infected. Thus, about 2% of our population may need to visit the hospital. The overall mortality is estimated to be smaller at about 5 per 1000 population. Just for comparison, according to WHO , we added 20 lakh TB patients in 2018, i.e., about 1.3 per 1000 population, and 4 lakhs died due to it.
COVID-19 is perhaps the first time that the top 20% of India faces a morbidity which is routine for the bottom 80%. Moreover, the intertwining of the lives of the two classes and the conflicting interests, are not yet fully appreciated. Firstly, it has resulted in a sudden interest in conditions of the people in the slums and their welfare, and exhortations for collective action. Next, containment and elimination is the chosen strategy for the top 20%. It follows global thinking, it is technological and it matches the kind of medical resources they can access. On the other hand, the management of the disease through public health systems and basic welfare are the primary concerns of the bottom 80%. Unfortunately, that and preparedness, have not received as much attention as the science of the disease, conjectures on R0, and the gadgetry of testing.
Assuming that we flatten the peaks, we still get a peak hospital occupancy of 1-2 beds per 1000 population due to COVID-19. Let us assume that existing morbidities make an additional 1 per 1000 to give us a total of 2-3 beds per 1000 population. That is about 1000 beds for a typical ward of Mumbai, 500 beds for the tribal taluka of Karjat, Raigad, 4000 beds for the state of Goa and about 30 lakh beds for India as a whole. It is estimated by World Bank , that nation-wide, we have between 0.7 to 1.0 beds per 1000, i.e., between 9 and 13 lakh beds, with different levels of care. On paper, we have about 10 lakh doctors and 17 lakh nurses. But the spread is uneven across the states, and largely urban. Thus, access and transport will be critical. The treatment itself, except the use of the ventilator, is simple enough. Making ventilators is now a topic of intense innovation, and yet, ironically, poor people in India have died of pneumonia for decades.
In summary, it is likely that 80% of the cases will be treated at home or within the village or the locality, until they need help, but hopefully before they get very ill. Thus, to inform, guide and support the household is an important project with several steps. First, is the preparation of a region-specific COVID-19 pack of medicines and supplies (such as a thermometer and masks) and instructions on taking care. This should include critical points and actions, including moving the patient to the nearest hospital. Perhaps, some of these households may send data for the benefit of the scientific community. We must next decide on the support that village and ward level health workers can provide. Suitable kit and training, such as oxygen measurement and provisioning, may then be arranged. Included in this should be guidelines on quarantine and sharing of community resources in times of infection. An independent assessment should be done of the preparedness of district and sub-district hospitals, in terms of equipment, facilities and supplies. Finally, live updates should be provided on availability of beds and facilities. Many deaths have been reported of critical patients unable to find a suitable hospital in time. This information at the local level or a general analysis of preparedness is still not available in the public domain. There is no analysis, for example, of the high mortality in Maharashtra vis a vis the low rates seen in Kerala or Punjab, and the connected health management practices.
In all of this, oversight by elected representatives is important. That, and structured support and engagement by local scientific and social agencies and institutions will be very helpful. The crisis needs coordination, professional skills and empathy over a long period, and it is only they who have the wherewithal. Such mobilization has proved useful in many countries. In India, sadly, the role of local agencies has been eclipsed by a dysfunctional expertocracy and political theories to support it.
Coming to urban clusters, their management is a governance nightmare and blanket lockdowns may not yield the expected health outcomes. It may well be that some residents are better off in the districts than in urban chawls, provided they do not take the infection with them. Whence, easing transport restrictions to allow for controlled migration must be considered. Public transport should resume in a controlled manner and on a new schedule to cater to new demands. Instructions should be given to the city, taluka and village on testing and quarantine rotation of returning migrants so that vigilante pressure is reduced.
At the local level, there will be many without food, work, money or proper papers. PDS and other welfare schemes must deliver, perhaps under modified operating procedures. Summer is approaching and drinking water scarcity will begin. Smooth functioning of such basic amenities is essential for keeping transmission in check. In short, the boring stuff must work, and this is especially crucial for affected households. For this, state government staff at all levels, may be deployed across departments, if required, and delegation protocols must be in place. They have had the most secure lives in recent years, and they must do an exemplary job.
Situating Plan B.
Thus, for the bottom 80%, good governance, predictability and preparedness are crucial for health and welfare. These are as amenable to detailed measurement and analysis as parameters of the disease. Lockdowns serve a limited purpose, only if they translate into improved preparedness. Otherwise, they disrupt wages, livelihoods and disconnect the economy. More important is a well-informed long-term reduction in contact rates in all social and economic activities – in the factory, offices and institutions, at the bus depot, in the markets, at restaurants and hotels and at gatherings. Thankfully, such guidelines are now emerging. All this together constitutes Plan B. Without that, the impact on the precarious lives of many of our people will be dreadful.
Individuals must learn social distancing, adopt behaviour change and communities must adapt and speak a new jargon. The disease demands that. But it also demands a transition to a consistently higher level of governance. The performance of our senior bureaucrats and scientists and their teamwork will be the decisive factor in achieving and sustaining this new normal. The success of Plan B depends on this social comprehension and the ability of our leaders to convey the key ideas and uphold trust in the system. Some state leaders are in fact, very good communicators.
In summary, Plan B is a careful calibration of behaviour change at the individual and community level with state preparedness. It is also an admission that the costs, benefits and vulnerabilities differ for different strategies and that demographics of the disease and governance must be taken into account. Moreover, the dynamics of the disease actually allows several trajectories or schedules, of balancing between health objectives, social and economic disruptions and overall welfare. Each country must prepare its strategy based on its capabilities and priorities, and so must we. And this must adapt to facts on the ground, for otherwise much of the misery may be in vain. While South Korea or Singapore are oft cited examples, perhaps closer to our situation are Indonesia or Thailand or the balanced approach of Germany.
Science and the Anthropocene.
But there is more to learn here. What is now clear is the fragility of the anthropocene, i.e., the global society, its dependence on Big Science, and the sheer inequality in the access to it. And it may get worse. The global economic leadership is now proposing a “passport” system to manage the risk created by the virus. The first step is for nations to create a hierarchy of “safe” and “unsafe” parts within their economy, whereby workers who are “safe to return” will work in safe environments. This will pave the way for the construction of a new and safe global economy. The entry into the “safe” economy may be based on electronic contact tracing, advanced testing technologies and more high-tech gadgetry. This has substantial inefficiencies and it is unclear if the new global economy can bear these costs. But it will certainly limit the economic options for the working class. Politically too, for many countries including India, it is one step closer to a paternalistic surveillance state.
The Indian elite are likely to join this system and also enroll us into it, since, proverbially, “there is no alternative”. This will require India to adopt its mechanisms and reproduce this hierarchy within the national economy. Our workers, formal and informal, may have to prove likely through private means, that they are “safe” to be employed. This is the very opposite of socialization of risk. The Indian informal economy is of course, a construction of our higher education system, of what we choose to study formally and what we ignore. Now, our public health policies are likely to lead to further informalization and fragmentation at the lower end of the economy.
For us in the Indian scientific establishment, the COVID-19 crisis is yet another wake-up call.
It is a reminder that the practice of science is also served by looking at the problems of the vicinity, and the systems of delivery of basic services. These are indeed the sites of innovation, of new technologies, new ways of organizing our society and serving our interests. But this needs a radical change in the way we do science. For decades, we have been free-riding on new vaccines and new cars, without ever understanding the discipline, creativity and social comprehension that is needed to produce either. We have lived longer on borrowed science, let us now prepare to face a borrowed illness, one household at a time.
 The Global Impact of COVID-19 and Strategies for Mitigation and Suppression, https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-Global-Impact-26-03-2020.pdf (accessed on 14th April, 2020)
https://www.who.int/tb/publications/global_report/en/ (accessed on 14th April, 2020)
https://data.worldbank.org/indicator/sh.med.beds.zs (accessed on 14th April, 2020)