Understanding disease, much less the ways to tackle it, is nearly impossible without the socioeconomic and political context. A pathogen is hardly a threat minus the structural vectors of poverty, hunger and discrimination based on caste, class, gender, ethnicity or religion. But rather than being an area of concerted scientific study, social epidemiology remains marginalised in mainstream public health and policymaking.
This context mandates a more nuanced reading of the results of Delhi’s recently publicised COVID-19 seroprevalence survey.
Delhi’s population in 2020 is estimated to be a little over 30 million. According to a WHO communique in March, 80%, 15% and 5% of all COVID-19 cases are expected to be mild or asymptomatic, severe and critical, respectively. The survey revealed a prevalence of antibodies against the novel coronavirus in 23.48% of Delhi’s people, so the total number of COVID-19 infections in Delhi would be 7.1 million. The number of people with severe and critical infections would be 1 million and 0.3 million, respectively.
However, the official count of cases in Delhi on 10 July (last day of sample collection) was 0.1 million – 1.09 lakh to be more precise. In other words, for every confirmed infection, 65 infections went undetected. The numbers of severe or critical infections, and deaths that may have been missed likewise, are thus frightening. Add to this the fact that various reports have shown that the proportion of mild or asymptomatic cases to be around 40% to 50% only.
These numbers could make one think the situation is too bad to be true. After all, wouldn’t the severity and criticality of infections have shown up in the form of packed hospital beds and a high death toll?
The implicit assumption here is that given the heightened concerns about the disease, if patients had troublesome symptoms, they would have shown up at the designated COVID-19 facilities for treatment. Since this was apparently not the case, most if not all ‘missed’ cases were mild or asymptomatic ones, which gives us reason to believe that a fourth of Delhi’s population has acquired immunity to the virus, howsoever inadvertently.
The desirability of such an outcome is hardly contestable, but what the reality is and why it is so can’t be a matter of conjecture. The estimates given above don’t go beyond stating that if the results of the survey are true, then this is the expected picture. Its denial or confirmation ought to be a matter of scientific investigation.
This said, the health-seeking behaviour of people is not always determined by biomedical rationality. Instead, the social, economic, cultural and political dimensions of peoples’ lives – as determined by the social vectors mentioned earlier – exercise an overbearing influence. The behaviour of health institutions is also an integral part of this vexed equation.
Unfortunately, the training our healthcare personnel receive doesn’t prepare them to grasp these real-world concerns. The Comprehensive Rural Health Services Project, in Ballabgarh district of Haryana, is the rural field practice area under the department of preventive and social medicine of AIIMS, New Delhi. As scholars of public health, we visited it in 2009. During the introductory briefing, a doctor of the department waxed eloquent on the above-average health outcomes in their area, backed by computerised data pertaining to every resident there on a variety of socioeconomic and health parameters.
Someone then asked if the health outcomes were segregated by caste and class. The reply was immediate: “We do not discriminate between our patients based on caste.” Eleven years since, the analysis remains wanting.
The self-righteousness of the doctor’s statement could be generalised – except society does discriminate between people on the basis of their identity and class, as borne out by outcomes of the national health surveys. Health institutions are societal institutions and reflect society’s biases and prejudices in their institutional behaviour.
So has the social blindness of our health institutions cost us the suffering of so many people going unregistered?
Half of Delhiites live in slums. Another 13% live in regularised unauthorised colonies. Poverty, undernutrition, hunger and unsanitary conditions render them most of them vulnerable to COVID-19. Judgements regarding their acquiring immunity need to take this into account. The poor can ill-afford any illness that deprives them of their daily bread. According to NSSO data, the poorest 20% of the population is about half as likely to report an illness, and about half as likely to seek hospitalised treatment, as the top 20% of the population does.
Does it then suffice to create 10,000-15,000 hospital beds or to cap the cost of medical care in private hospitals, and assume anyone with symptoms is welcome there? At a time of deepening insecurities, among even the better-cared-for, it’s not hard to conclude not many of the poor will readily seek care from institutions that appear increasingly like monuments to disease than institutions for rejuvenating life.
Instead, we need step into the shoes of the lonely migrant labourer, an ordinary Muslim worker, a hawker or a petty tradesperson, a domestic help banished from gated complexes, an elderly citizen and so many others who have faced the state’s apathy and antipathy during this pandemic. The thoughts of an intimidating hospital environment, the expenses to be incurred, the wages foregone, of who will look after their children at home and finally the stigma have weighed heavily even in the best of times.
We have been conveniently ignoring all of this, instead expecting that the resulting absence of evidence translates well enough into evidence of absence of a more worrisome picture of COVID-19’s onslaught. Rather than rest on the laurels of having created hospital beds, and putting illusionary price caps on corporate healthcare, the take-home message of the seroprevalence survey is that the government’s anti-COVID-19 policies should build in robust measures of reaching out to the indigent if alleviating people’s suffering is its objective.
This in turn entails a publicly funded healthcare system devoted to serving the people rather than wasting public resources to strengthen more exclusive facilities.
Vikas Bajpai is an assistant professor at the Centre for Social Medicine and Community Health, Jawaharlal Nehru University.