The novel coronavirus infection is extremely contagious and spreads fast through respiratory droplets and contaminated surfaces. Although a very high proportion of infected individuals (around 85%) have mild symptoms, the sheer number of people infected means that large numbers become seriously ill. Social distancing and frequent handwashing were advised to slow the spread. Countries with well-established social security systems used lockdowns as a desperate measure.
Unplanned step
In India, the lockdown was sudden and not accompanied by effective social security measures. Migrant workers, in their millions, crowded into any available means of transport to return to their homes. No social distancing was possible. Many lakhs walked long distances to return home with little food and water. The morbidity and mortality that this has caused can only be guessed. It is likely that the virus has been carried to the hinterland which was largely protected since the virus was brought into India by air travellers. The concept that the social situation forms an integral part of disease, most commonly attributed to the German pathologist Rudolf Virchow, came into prominence once again after the Second World War. Response to a pandemic has some worldwide elements, but it also has elements particular to countries. An effective response in India must consider not only the behaviour of the pathogen but also the socioeconomic and cultural characteristics of the country. Geoffrey Rose, a pioneer in preventive medicine wrote; “The primary determinants of disease are mainly economic and social, and therefore its remedies must also be economic and social. Medicine and politics cannot and should not be kept apart.”
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The pathogen in the present epidemic was identified very quickly. Only supportive treatment is available for the seriously ill. A vaccine will be ready only after the present crisis is over. India does not have the capacity to manage a large number of very sick patients simultaneously and cannot ramp up resources significantly in the short time available. Besides infrastructure, critical-care medicine requires a large number of highly skilled health-care workers. We simply do not have the numbers.
The Indian Council of Medical Research performed surveillance of Severe Acute Respiratory Illness at 41 sentinel sites between February 15 and March 19. Diagnostic kits and laboratories equipped to perform the Reverse Transcriptase-Polymerase Chain Reaction test were few. This limitation has hampered efforts to get a good estimate of numbers infected in India. The extent of testing required for better estimates may never be done considering the resources required. One of the principles of screening laid down by Wilson and Jungner over 50 years ago is that the cost of case-finding (including diagnosis and treatment of patients diagnosed) should be economically balanced in relation to possible expenditure on medical care as a whole.
India’s poor are vulnerable
Imposing a lockdown as a means of enforcing social distancing ignores the reality that the poor have no option but to live in densely packed slums and tenements. Personal hygiene in the form of frequent handwashing is impossible in their present circumstances.
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The World Bank estimates that there are over 650 million poor people in India (living on less than $3.20). The current policy of geographical containment may protect the rich and the middle-class, but it ensures rapid spread of the infection among the poor because they have no chance of maintaining the recommended six feet distance.
Learning from success
South Korea, Singapore, Taiwan and Japan have been successful in containing the disease. South Korea relied on active, free and massive screening, closing schools and recommending remote working. Nearly 20,000 tests are done every day. There is widespread use of masks and sanitisers. No lockdown was imposed. In Hong Kong, Singapore and Japan, surveillance systems identified potential cases and their contacts. Diagnostic tests were developed early, and laboratory testing capacity was increased. In all these countries, costs are covered by the government. Countries which imposed lockdowns have very strong social security systems. In India, the lockdown has caused severe suffering among the poor, especially migrant workers, and has been unsuccessful in the primary objective of enforcing social distancing. The reports that over an estimated two lakh migrants returned to Uttar Pradesh after the lockdown is only the most extreme facet of the problem. Without massive support from the government, chiefly in providing adequate shelter and food to all those who need it, social distancing is impossible. At present, the burdens of quarantine, lockdown and social distancing have been left to individuals. Worse still, in many rural areas and towns, governments have shut down small private clinics. All government health staff are now concentrated on COVID-19. Important primary health-care services including maternal and child health, immunisations, deliveries and tuberculosis care are on hold. It amounts to abandoning the poor to their fates.
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The lockdown has imposed tremendous economic hardship on the poor, without any important benefit as they cannot practise social distancing or proper personal hygiene. If the Central government is serious about the containment strategy proposed by the Ministry of Health and saving lives irrespective of social class, it must provide economic and social resources on a massive scale. It has revealed no such plan. States and individuals cannot handle this crisis on their own. Exhortations to help oneself sound cruel when people have no means to do so.
Dr. George Thomas is an orthopaedic surgeon at St. Isabel’s Hospital, Chennai
