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A medical check-up being conducted at a slum in Mumbai on 23 August. 57% slumdwellers, part of a seroprevalence survey in Mumbai, tested positive for antibodies. (Getty Images)
A medical check-up being conducted at a slum in Mumbai on 23 August. 57% slumdwellers, part of a seroprevalence survey in Mumbai, tested positive for antibodies. (Getty Images)

Opinion | Covid-19: Dark clouds and silver linings

Doctors have got a handle on the disease but the government needs to get a handle on the economy

In a column published on 16 May, I wrote that India had lost the battle to contain the novel coronavirus. At the time, the daily count of infections was a little over 4,000. It is now 25 times higher, closing in on 100,000, and likely to cross that figure by the time this article is printed. In another column the same month, I questioned the efficacy of the government’s contact-tracing app, Aarogya Setu. It appears my doubts were well founded, for the greatly hyped app has proven next to worthless. On 2 July, when detected cases in India had just topped 500,000, I wrote that low per capita figures meant little because the virus had an unimpeded path to five million cases and beyond. We have passed the five million watershed, and the current pace suggests we will soon overtake the US as the nation with the most cases.

Although I was correct in these pessimistic predictions, I drew the wrong conclusion from them. I assumed that India’s healthcare system would break down if we had the kind of daily case load we are now seeing. Instead, though dreadfully overburdened, general hospitals continue to function, and there are empty beds in covid-19 wards in many cities. Who could have imagined six months ago, when European fatalities were skyrocketing despite a low level of total cases, that a nation might cope with a hundred thousand new covid-19 infections each day, that too with only a minimal augmentation of existing treatment facilities?

What changed in these six months was the ability of doctors to treat the disease thanks to an improved understanding of how covid-19 works. There is no silver bullet, and there may never be one, but the tamping down of the death rate is an incredible achievement for modern medicine, and one deserving of greater acknowledgement. Doctors now understand who needs hospitalization and who is better treated at home, and prescribe cocktails of easily available anti-inflammatory corticosteroids and antivirals that pre-empt a trip to the ICU for most patients.

There are other reasons for the drop in death rates that are unconnected with better treatment. Testing capacity has grown tremendously, detecting cases that would otherwise have gone unnoticed. Since these are mild infections, they lower the total case fatality rate. Conversely, in a number of nations deaths are being underreported. In India, for instance, many covid-19 deaths are being attributed to co-morbidities, and some patients who die of covid-19 symptoms are never tested. As the disease moves into rural areas with poor facilities, more citizens will die undiagnosed.

However, the gap between the enormous increase in cases and the much lower growth rate in deaths cannot be explained by these factors alone.

The figures are startling. France is in the grip of a second wave of infections, with daily cases of over 10,000. Though that is twice the previous peak in April, fatalities are down by over 90% from the earlier period. Other European nations are also experiencing surges, and Israel just announced a second lockdown, but the story regarding fatalities is encouraging everywhere.

On the negative side, the disease constantly reveals new facets of perniciousness. We know that many severe infections lead to long periods of debilitation. Union home minister Amit Shah’s hospital visits after recovering from covid-19 are the most visible sign in India of this phenomenon. Covid-19 can cause neurological complications, it can damage a variety of organs, and a recent study in the US found significant cardiovascular problems in young athletes recovering from the virus. It is untrue that whatever does not kill us makes us stronger.

The best news in the past months has come from two seroprevalence surveys, one conducted in Mumbai by the city’s municipal corporation in association with a group of public and private organizations, and the other across 70 districts in 21 states by the Indian Council of Medical Research (ICMR). These surveys tested for the presence of antibodies indicating an individual had been exposed to SARS-CoV-2. Both sero-surveys found that the number of infections in India was massively understated. Extrapolating from its data, the ICMR suggested India had over six million cases in early May, a figure only now being approached in the official count.

The Mumbai survey found that in slums that were part of the study, 57% of those tested were positive for antibodies. That is a mind-bogglingly high number and if it accurately estimates covid-19 infections, it means the virus has torn through the city’s shanty towns largely undetected, causing incredibly few serious illnesses and deaths. If the fatality rate is actually so low in India, it would suggest we ought to remove almost all aspects of the lockdown and start up train services in cities like Mumbai to allow office-goers and labourers to get to their places of work. We need to shift entirely from closures to behavioural modification as our primary response to the virus.

Mumbai’s municipal corporation has just launched a “My family, my responsibility" campaign, having concluded it is “now necessary to adopt some changes in our personal, familial and public lives" beyond physical distancing and the use of masks and sanitizers, but I wonder what took it so long. Given the gravity of the pandemic, the public outreach and education effort by the Central government and states thus far has been shockingly lax. Mask mandates, where they exist at all, have not been stringently enforced. The Delhi Metro appears to be doing a reasonable job since reopening but that is often the case with a newly implemented system. It remains to be seen whether commuters will adhere to the rules a few weeks down the line.

In the early days of the global outbreak, thousands of deaths were precipitated by a condition called silent hypoxia. A number of covid-19 patients suffering from pneumonia could breathe without effort, and were therefore not diagnosed in time. The lack of protests in India over the past months, the acceptance of hardship by the population, has created a feeling that things are under control, though we might be perilously short of oxygen. If the economy is, indeed, suffering from silent hypoxia, I hope it will be recognized before we require the ICU.

Girish Shahane writes on politics, history and art.

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