Of the many sero-prevalence surveys conducted in India, the first official results have finally been published. This was done by the National Centre for Disease Control, an agency of the Government of India. More than 20,000 random blood samples were taken in the period June 27 to July 10, from the city of Delhi and tested for antibodies to the COVID-19 virus. Close to 23 per cent were found to have experienced corona in some form, good enough to have become immune to it for at least the next few months if not years. The actual number of the people immune may be even larger, given that a serological test does not count immunity due to suitable T-cells which may be present in our blood.
This is a remarkable finding and should provide a turning point in the management of the epidemic. Of the 198 lakh people of Delhi, 23 per cent, that is, close to 45 lakh have been infected. Of these 45 lakh, the number of officially confirmed cases is a mere 1.23 lakh, of which roughly 3,700 people have died. This gives us an infection fatality ratio (IFR) of about 0.9 per 1,000. This is, of course, much less than that in the US, Germany and other countries and more in line with other tropical countries such as Thailand.
The second fact is the timing. It was about July 10 that the intensity of the epidemic started to diminish in Delhi. Hospital beds became available and the number of cases started to fall. The survey seems to indicate that since a large number of people are already immune, the virus is indeed finding fewer and fewer new people to infect. Moreover, the informal workers of Delhi who stay in dense pockets were the first to face the epidemic and are most likely to have developed this immunity. Since they form the matrix for a majority of the social and economic transactions in the city, their immunity should be an important factor in slowing the epidemic. That such heterogeneity in the population, in terms of number of daily contacts, may hasten the onset of herd immunity was recently noted in the reputed journal, Science, in their June issue. And this is what seems to be playing out in Delhi. A similar scenario is unfolding in Mumbai, Ahmedabad and other cities of India. Thus, if we continue to take care, we will now see a slow burn and the extinguishing of the virus within our major cities.
The second conclusion that we must draw is that the virus is indeed intensely infectious. It has jumped over roadblocks, slipped through containment zones, evaded quarantine and contact tracing and managed to infect 43 lakh anonymous people, whose names have not appeared in any official record or contact lists. Most of them had mild or no symptoms. Those who had more severe symptoms and visited a clinic, entered into the official corona rosters. Whatever be the claims of our top bureaucrats, scientists and ministers, this transmission has happened right under their very noses.
Worldwide, the management of the disease has revolved around three key operations. The first is to control transmission, the second is to provide access to those who are ill, and finally, the third is to evolve the science of treatment. The worst excesses in India have been in the name of controlling transmission. In fact, common people, traders and industrialists, workers and farmers, are vexed by the current patchwork of local and regional lockdowns and a range of regulations which are purported to “break the chain of transmission”. We now know that this is futile. What is needed is a rapid response to symptomatic patients and a statistical approach to transmission, of simple rules of masks, ventilation and distance. Of better designed public spaces and markets, auto rickshaws and bus schedules, and new ways to manufacture new products. And, of course, to avoid super-spreading events.
The third part, that is, the science of treatment has also evolved. We now know that the treatment for the 97 per cent is simple and may even be given at home. Early diagnosis and care can reduce mortality substantially.
It is really the middle part, of ensuring that the ill have rapid access to hospitals, which is proving to be our weakest link. It is this we should be afraid of and not so much the virus. Even with such a small infection fatality ratio, the high infectivity and the large number of cases pose huge logistical problems. Simple calculations now show that we need to provide one additional hospital bed per 1,000 population, along with nurses and doctors. Most districts in Maharashtra have struggled to arrange 0.3 beds per 1,000 through public infrastructure. These will not suffice. The experience of Aurangabad, Thane and Jalgaon shows that private hospitals already play a significant role. This comes with the usual malpractices and exorbitant hospital bills, especially for those who have little access to good information or advice.
The key, then, is to get the maximum out of our public health systems. In Maharashtra, this means home treatment of mild patients, identification of moderate and serious patients by local health workers and their quick transfer to the hospital. This requires guidance, equipment and support from the state administration to gram panchayats, towns and cities, to ASHA workers and the newly formed cadre of Community Health Officers. It also means better utilisation of hospital beds and better hospital management. This requires a planning approach and a measurement framework. For example, we still don’t know the average time a corona patient stays in the hospital, or the fraction of patients who need oxygen treatment. Such frameworks should have come from our central scientific agencies. But the less said about them, the better. It is time for the states to do their science themselves.
In summary, the results of the survey offer us hope, and perhaps mark a beginning of the end. The initial lock-downs did provide us some time to understand the virus, if not to prepare for it. And it did provide our poor, the first patients, the first crack at our public systems. But the next phase requires a widespread understanding of the disease, of less fear and better governance. And a schedule of relaxations and tightening of rules which aim to meet infrastructure constraints and not merely to promote virtue. It needs a more studied approach and a partnership between bureaucrats and the communities that they serve. This will save both, lives and livelihoods.
This article first appeared in the print edition on July 24, 2020 under the title ‘Time to be less afraid’. The writer is with Centre for Technology Alternatives for Rural Areas, IIT Bombay. He is currently on deputation to IIT Goa.