People wearing protective face masks travel in a passenger bus amidst the spread of COVID-19 in Kolkata, September 2, 2020. Photo: Reuters/Rupak De Chowdhuri.
On August 25, the Indian Public Health Association, the Indian Association of Preventive and Social Medicine and the Indian Association of Epidemiologists jointly issued a statement on the ongoing COVID-19 crisis that generated some eye-catching headlines. According to most media reports, the experts’ key recommendation was that “the government’s focus should be to prevent deaths from COVID-19 and no longer on containing the infection.”
If we read “containing” to mean “limiting the spread”, then this is rather strange advice since the one sure way of preventing COVID-19 deaths is, of course, to limit the spread of infection. So what exactly were the experts trying to say?
A closer look reveals that the statement is more complex than media reports suggest. It includes some important and often neglected observations about the collateral effects of strategies to control COVID-19. But it also has misleading claims and some glaring omissions.
Let’s focus on the positives first, beginning with a welcome call for empathy:
“The ongoing pandemic is a public health problem that is fast worsening existing health inequities. It is not a law and order problem and should be dealt with empathy and meaningful community engagement.”
The authors are concerned with the negative impacts of responses to COVID-19 on marginalised groups, education and access to health care. Their broad messages include the following.
– Heavy handed measures like lockdown cause lots of damage. More focussed approaches which respond to local circumstances are needed.
– We need to think about health beyond COVID-19, and education too.
– It is essential to tackle the stigma, fear and discrimination associated with COVID-19.
– Testing alone cannot bring the epidemic under control.
– Healthcare expenditure needs to increase. Healthcare workers need to be protected and paid properly.
It is hard to disagree with any of these – so what are the problems with their statement?
Containment, testing and lockdown
There are sweeping dismissals of attempts to control COVID-19. Here is one:
“In Large cities (Y class) where already there has been substantial spread … there is NO advantage of creating containment zones and aggressive testing.”
No data is given to substantiate such a strong claim. Seroprevalence surveys in cities like Chennai and Indore have revealed widely varying levels of infection in different localities. This could well be a consequence of containment zones restricting spread of the disease and protecting residents of some areas. Even where such measures fail to halt geographical spread, slowing the spread can be worthwhile.
One may also ask if any area has indeed seen “aggressive” testing. A general negativity about testing runs through the document. The authors advocate “discontinuing universal testing” and later write that “increased testing does not prevent the deaths from COVID-19”.
Indeed, no one argues that testing directly prevents deaths. But coupled with quarantining, contact tracing and isolation, it can form the basis for reducing the spread of disease and preventing deaths. Even in cities like Mumbai, with high levels of infection, there are likely to be areas where the majority is still susceptible, and testing must surely help in identifying and limiting new clusters.
The authors also assert that “lockdown as a strategy for control should be discontinued”. It is true that the lockdown has been a blunt instrument leading to all sorts of suffering. But a proper analysis should note that ‘lockdown’ in and of itself is a vague term, and encompasses various measures to reduce the movement of people and to slow transmission. It would be more constructive to consider which aspects of the lockdown slowed or limited spread and whether the same effects could have been achieved in less destructive ways.
When it comes to badly hit cities, the experts tell us bluntly that the “focus should be to prevent deaths from COVID-19 and not on containing the infection”. Leaving aside for the moment the false dichotomy in this proposal, it ignores the complexity of COVID-19 in Indian cities. Seroprevalence surveys in Delhi, Mumbai, Chennai, Pune, Ahmedabad and Indore indicate very different COVID-19 stories. Indore, for example, reported very low seroprevalence compared to Mumbai, even though both saw a rapid early rise in cases and deaths.
It is clear that disease containment has not failed uniformly. Instead, it has had patchy success, and interacted with factors such as housing poverty. For example, Mumbai’s and Pune’s seroprevalence surveys found very different levels of spread in slum and non-slum areas. The unevenness means that despite high prevalence there are no doubt still areas of both cities with relatively large numbers of vulnerable people. So to suggest that containment is futile is, effectively, to abandon these people.
A herd-immunity ‘strategy’?
There are worrying undertones in the call to abandon containment in the face of high spread. The authors are hinting at the inevitability of herd immunity developing via widespread infection. When they recommend that “health care services … should resume as early as feasible, at least those areas that are progressing towards higher levels of immunity”, this is clearly a reference to immunity acquired via infection rather than via vaccination. In fact, the statement emphasises that we should not hope for an effective vaccine to sort out our COVID-19 troubles any time soon.
Now, herd immunity through widespread infection may occur locally whether anyone likes it or not. But dangerous arguments for allowing this to occur, often founded on speculation and misunderstandings, are increasingly being made by some commentators internationally and in India. These either ignore or accept a potentially huge toll in deaths and long-term health effects of infection. The experts have not endorsed any such views explicitly – but their call to abandon containment can easily be interpreted in this way.
Finally, let’s return to the phrase, “focus should be to prevent deaths from COVID-19 and not on containing the infection”. How do we reduce deaths other than by controlling the level of infection? The only concrete suggestion seems to be to monitor symptomatic patients and ensure early hospitalisation if necessary. While obviously sensible advice, no evidence is given that this would significantly cut COVID-19 deaths.
If reducing mortality is not an empty slogan, then surely we need more specific recommendations on how to do this, alongside careful monitoring of COVID-19 deaths. But astonishingly, the experts simply fail to mention death surveillance. What of the many state and city administrations which are known to be underreporting their COVID-19 deaths, sometimes quite unashamedly? And how many localities are releasing real-time local excess death data which could confirm whether a strategy of reducing mortality is working?
The statement by three public health bodies on COVID-19 includes some valuable commentary on the ongoing crisis. But it is also deeply flawed. It criticises mitigation efforts in sweeping terms without suggesting alternatives. These criticisms do not seem to be based on evidence, and ignore the complexity and unevenness of COVID-19 spread. The statement includes dangerous calls to abandon containment in some circumstances. And it sets up a false opposition between containment and reducing mortality while – crucially – failing to explain how mortality is to be monitored or reduced.
Murad Banaji is a mathematician with an interest in disease modelling.