Are we not Missing an Elephant? Epidemiology may be more Reliable and our
Covid Data Gross Underestimates
Had modern medicine not been introduced in
India, about a century ago, we would have relied on our own traditional medicine
to cope with the Covid pandemic. India had survived worse
calamities of pandemics and famines. The 1918 Spanish flu pandemic killed several
millions but we survived and flourished. So we shall overcome the Covid pandemic also.
Those days virology and epidemiology were not available
in India or other low income countries.
With modern medicine we learnt virology and
epidemiology. We knew through epidemiology that a new respiratory, person to person
transmitted epidemic, left to itself, will spread until herd immunity threshold
(HIT) is reached and then become entrenched at low ebb as endemic. The HIT of Covid is 60-70%. When half that level is reached the epidemic
curve would be at peak, thereafter declining steadily until becoming endemic. Spread
over one year, the curve would be not quite bell-shaped but like a mountain with
roughly symmetrical shoulders.
From other countries we learnt that the vast
majority of the population would survive the infection. Risk of death was mostly
in those above 65 years (in India 80 million) and in the younger population mostly
those with co-morbidities (130 million). So our mortality would be incomparably
lower than in Western countries with far greater proportions of both. At 5% case-fatality
we would have 10 million deaths. India’s annual toll of death is already about 10
million, an additional ten can be taken in our stride. It will not show up in our
next decadal census when we expect 150 million additions; 140 could be attributed
to lower births. We can never know the truth.
Worldometers publishes daily pandemic statistics. India’s
epidemic curve peaked by September 16, six months after start. It should reach valley
in another six months, by March 2021. It is reasonable to assume that at the peak,
half HIT (30-35% or 414-483 million) was reached. At that time only 5 million lab
confirmed infections had been recorded.
In end December we reached halfway mark of
the second six months – for 207-242 million more infections – total, 621-725 million
already infected. Our lab confirmed infections
are below 11 million with 1,50,000 deaths. Are we not missing
an elephant? Is epidemiology more reliable and our data gross underestimates? The
Indian Council of Medical Research conducted two population-based antibody surveys
that corroborate the epidemiological numbers, showing the counted numbers are gross
underestimates. The mountain-shaped epidemic curve, with its base spread over one
year, is qualitatively representative of reality, while quantitatively quite unreliable.
Countries with public health infrastructure
and expertise took early need-based actions that flattened the curve and shortened
the epidemic to a few months – to such an extent that the majority of population
remained uninfected, among whom larger second waves developed. We will not have
that problem as we allowed the virus to run the epidemic to half HIT in six months
and another half will be infected in the next six months.
Health management in general and epidemic control
in particular require public health infrastructure. What could not be prevented
by public health has to be treated under healthcare. Research is essential for both,
to raise their bars constantly. Disease surveillance and real-time counting of all
important communicable diseases, as well as deaths with cause certified, is one
of the essential functions of public health that cannot be obtained through what
we have, namely healthcare. The greater function of public health is disease-prevention
and health-protection. We take pride in our healthcare performance. The lack of
a public health wing in the government is camouflaged by misleadingly redefining
public health as public sector healthcare.
India does not have reliable data on any communicable
disease, be it rabies, cholera, tuberculosis or Covid.
The only disease with reliable data is polio, for which we have a special one-disease
surveillance and virological validation of every suspect
case. The Covid statistics derived through healthcare,
cannot be complete.
The government took a lot of drastic administrative
actions in the genuine belief that they would flatten the epidemic curve and slow
down the epidemic, while waiting for private sector companies coming up with vaccines.
Their collateral damage is well known. Looking back we must ask if the malady or
its remedy was worse.