Approximately 1,192 days since January 30, 2020, when COVID-19 was announced as a ‘public health emergency of international concern’, the World Health Organization, on May 5, 2023, declared that COVID-19 was no longer a public health emergency of international concern. In simpler terms, COVID-19 has acquired the status of other endemic diseases. India, arguably, reached the COVID-19 endemic stage a year ago.
Even so, there have been ‘knee-jerk’ and unscientific responses to spikes in COVID-19 cases in India, the most recent example being the response in March-April 2023, when there was an uptick in viral flu and SARS-CoV-2 cases, which led to the closure of schools in some Indian cities and States. In instances where schools were not closed, their managements made mask wearing a mandatory condition for children to attend classes. This, in some instances, happened without a formal government directive, indicating implicit endorsement.
Misinformation during the second wave
In April-May 2021, there was a COVID-19 misinformation blitzkrieg: that a ‘third wave in India would affect children’. Since then, there has been a tragic tale — of children being deprived of schooling and learning, and repeatedly being asked to mask-up. Two years later, in April 2023, school closure and making masks mandatory for schoolchildren had their origin in nearly identical challenges of actions not being supported by scientific evidence, misinformation, and social media influencers (not necessarily subject experts) shaping the public discourse, which was again not effectively addressed by governments.
In late April 2023, the not-for-profit Foundation for People-Centric Health Systems, which is based in Delhi, analysed the trends and stance of influencers and experts on social media platforms and in newspaper reports on the COVID-19 linked mask enforcement for schoolchildren.
Those based out of India were analysed into three sub-groups: trained or practising public health experts and epidemiologists (including those with a medical degree); other medical doctors (excluding those already in first group) and super-specialists such as hepatologists, cardiologists/cardiac surgeons and endocrinologists; and everyone else including media personalities, parents and those affiliated with schools. The fourth group was of those who had had an opinion about India but living abroad, irrespective of their education.
In the subgroup of trained public health experts and epidemiologists were concerned, there was near consensus that schools should not be closed, and, further, that there was no role in making mask wearing mandatory for children. Most clinicians and infectious diseases were a bit more supportive of masking, but very few supported universal masking for any age group. In the sub-group of super-specialists, there was greater endorsement of mask wearing for children and of school closure. Even though there was no pattern among mediapersons and parents, news stories and headlines often had a tangent of ‘playing to the gallery’ of the core readership of that platform. Interestingly, ‘experts’ and influencers living outside India were making more definitive and stronger arguments for school closure and mask wearing for children in India. As a matter of fact, the countries where they lived did not have, to a large extent, any restrictions. These disparate viewpoints existed despite cumulative epidemiological evidence that children are least at risk of moderate to severe COVID-19, so they should be the last group (if at all) to wear a mask, only when everyone else was universally wearing a mask. In fact, at the endemic stage, there is no role of universal and mandated masking for any age-group. Just because masks are beneficial and there is the virus around, it does not mean that everyone should be made to wear a mask, mandatorily.
Local context matters
Second, in outbreaks and epidemics, policy interventions and preventive advice need to factor in the local context. The context determines the epidemiological pattern, spread of disease and proposed interventions thereof. China faced a wave in December 2022 but no other country did. Switzerland, in April 2023, decided not to continue with any more COVID-19 vaccination. Many countries such as the United Kingdom and the United States have decided to drop nearly all pandemic-related restrictions. None of those moves was/is wrong but those countries had/have made decisions based on the local context. However, that does not mean every other country should do exactly the same thing. The sub-groups of super-specialists and those staying abroad failed to factor in the ‘local context’ while coming up with their opinions.
Third, an extremely worrying and unsettling trend has been the ‘ dogmatic stand’ that many ‘self-proclaimed experts’ and influencers have adopted, and who are continuing to selectively and conveniently use emerging evidence and published literature to support their stand. A few influencers have positioned themselves as ‘super-reviewers’ of scientific studies and use social media platforms to find limitations and criticise even the most robust studies, thereby misguiding gullible followers, as academic researchers do not get the opportunity to write rebuttals to such tweets that are often biased and serve as echo-chambers for the influencers. What these self-proclaimed experts and influencers (most often with no formal training to interpret such data) often fail to factor in is that no scientific study is ideal. The findings of a new scientific study should always be interpreted in the overall context of the cumulative body of evidence and not in isolation.
Fourth, if there were the ‘COVID deniers’ at the beginning of the pandemic posing a challenge, it is now the ‘COVID-foreverers’, i.e., a group of disparate individuals and social media groups that keep insisting on the enforcement of restrictions such as universal masking at ‘the drop of the hat’, often on frivolous grounds. Misinformation, irrespective of the origin, is likely to be an ongoing challenge even in the COVID-19 endemic period and there is a need for sustained efforts to tackle such misinformation.
With the WHO announcement, COVID-19 has ‘officially’ transitioned from a population-level challenge to more of an individual health concern. It is time for calm assessment, to shift the gears and also apply the lessons from the last three years. One, considering the immense interest in epidemiology, the government should offer formal training courses on the principles and practice of epidemiology to prepare India for more nuanced responses to outbreaks and epidemics and to curb misinformation. Two, the government needs to integrate the COVID-19 response to general health services. There is no role of universal measures against COVID-19 to be enforced. Three, India’s response to surges, outbreaks, and epidemics (of any infectious disease and not just COVID-19) should be guided by a nuanced understanding of epidemiology and not unduly derailed by ‘social media influencers’. Four, children were never at risk from moderate to severe COVID-19. Therefore, in future, schools should not be closed for a COVID-19 uptick. And wearing masks in order to attend school should never again be made mandatory. Most importantly, it is time to drop the COVID-19 fixation and move on to tackle other more pressing health challenges in the country.
Dr. Chandrakant Lahariya is a consultant physician and epidemiologist. He is the founder-director of the Foundation for People-Centric Health Systems, New Delhi