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Saturday, May 28, 2022

Why selective testing and lockdown are more suitable for India than WHO’s ‘test, test, test’ doctrine

Given India’s resources, the current testing policy and lockdown to cut down transmission seems to be appropriate. On paper, it must flatten the curve, reduce the epidemic momentum and even almost stop it from becoming a generalised epidemic.

Written by G Pramod Kumar |
Updated: March 31, 2020 7:15:54 pm
A Government hospital at Bharatpur in Rajasthan. Express Photo by Gajendra Yadav.

In any epidemic, the multilateral agencies would keep saying things, and they keep changing them too, but it’s upto the countries to decide what to do. For instance, when antiretroviral (ARV) was available to treat HIV in early 2000s and when there was pressure from infected people, affected communities and countries for reduced prices, the World Bank was categorical that no country should push for ARV because it would bankrupt the latter.

I remember seeing them going around and telling countries as well as other multilateral agencies to only focus on prevention and not to advocate treatment. Those days, the annual bill for ARVs per person ran into a few thousand dollars and probably Big Pharma was behind that policy because all they wanted was to make money as quickly as possible and generics would have been detrimental to that.

But everything changed when Bill Clinton, Dr Paul Farmer and Cipla found a breakthrough and UN agencies such as the UNDP told the world that ARV treatment was indeed possible even in resource-poor settings with evidence from some poor countries. ARV generics soon became available – thanks to CIPLA and Clinton. Big Pharma fought it tooth and nail – against compulsory licensing and parallel import, but the counter policy succeeded because somebody militated against what they had been told. The same World Bank had a similar view on multi drug resistant TB, but that also changed because there was a counter view and there were people such as Dr Paul Farmer and Jim Yong Kim.

Interestingly, Kim went on to become the President of the World Bank.

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Now in the Corona pandemic, the WHO is asking everybody to test, test and test, and people are blindly following them with no sufficient evidence that it’s the only way to go. Just because South Korea tested so many people and the rich countries are also testing more people (as a proportion to their population), what extra advantage does it provide countries such as India that’s in a lockdown? The logic behind testing is to “test, isolate, treat”. WHO and others are not clear, how exactly would it work in a country of 1.3 billion population. Do they want us to test all people and isolate all those who test positive? Is it even remotely possible?

Instead, testing symptomatic people who had a possible risk-history, their contacts and isolating both symptomatic and asymptomatic people who had been at risk seems to be a more practical, affordable strategy. That’s what states such as Kerala and Tamil Nadu are doing.

Instead, how will indiscriminate testing of people work better? This strategy of testing at-risk people and lockdown is more logical than “test, test, test”. South Korea tested more because of the clustering of the infection and they had more capacity and resources. Getting all the clusters, if you have a choice of not locking them down, tested makes sense. However, the epidemic is not yet over there and is emerging in other clusters too. Even with just a 50 million population, is it going to test all and isolate and treat all those who will test positive? What if some of them get infected later and the cycle continues?

Given India’s resources, the current testing policy and lockdown to cut down transmission seems to be appropriate. On paper, it must flatten the curve, reduce the epidemic momentum and even almost stop it from becoming a generalised epidemic. Certainly, nobody is ever going to obliterate it completely. Just like HI1N1, we would remain endemic to Covid-19 too. How many of us know that we are now endemic to H1N1?

Testing is not as easy as many believe. PCR tests are not simple, even sample collection requires a certain skill without which tests can be misleading. Just entrusting to a network of private labs wouldn’t help either because there could be lapses in sample collection (how often have the technicians collected throat and nasal swabs earlier?), transportation etc. And the sheer time it would take (at one go, only 96 samples can be tested and some big machines apparently can take a max of four trays of 96 samples).

So, next time when somebody, whether it’s the WHO, some health specialist or a semi-informed journalist, says “test, test test, “ ask them, “test who”?

Also what’s the point if the test results take a few days to come because India’s scale would mean that samples will have to wait for a long time before they are tested. It’s not a simple serological test like a blood test.

The only possible scale up for testing (if at all one believes in the test, test, test doctrine) is serological screening (antibody tests developed by Singapore, China and South Korea, whose sensitivity and specificity are yet to be validated) or some simpler NAT tests if they are available, of all symptomatic and at risk people. However, its only gain will be to release people from isolation and quarantine, but what if there are a lot of false negatives? If some argue for testing on representative samples to assess the situation, it makes some sense though.

So don’t take what the WHO, World Bank or the multi-laterals say as gold standard. Our public health professionals who have been in the field in our resource poor settings have a better idea as to how to handle things. Did Cuba go by what these agencies say when the became the only country to cut down mother-to-child transmission of HIV? They were not even in the radar of the rest of the world. Denialism is certainly not an answer, neither is believing non-peer reviewed and non field-tested opinions just because they come from some “global experts”.

Post script: 2.5 per cent positive cases in a sample of at risk population sounds better in terms of disease-burden than a 20 or 10 per cent in a general sample. Testing more people per million population, at South Korea scale, doesn’t make testing at-risk population less logical or scientific. If we had the means to test all those who drive in like in South Korea, by all means yes, but unfortunately, we can’t. However, India can test on equal probability samples for an assessment of the real disease-load and we have enough experts with decades of field experience as to how to find the right samples. Ask the people in NSSO.

(The author was a Senior Advisor at the UNDP Regional HIV, Health and Development Programme in Asia Pacific for a decade and has worked with national and provincial governments, civil society organisations and vulnerable communities in several countries. He has also led largecale studies on the socio-economic impact of HIV at the household level in the region)

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