Data must be applied to context and societal response must be proportionate

Vikram Patel
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The government must clearly communicate its plan to repair the lives of over a billion people devastated by a scale of disruption never seen before in any population as large and as desperately poor and unequal as ours.

A 25-year-old man ended his life on March 18 by jumping from the seventh floor of a government hospital in New Delhi, where he had come to be tested for COVID-19. He ended his life before the test result was available. A senior doctor in the hospital was quoted as saying that the man complained of “a headache, breathlessness, and was scared”. In my reckoning, he was probably experiencing a panic attack, often mistaken for an acute medical emergency by both the patient and health care providers. With all attention focused on the dreaded virus, no one bothered to care for this man’s mental health.

This tragedy was waiting to happen, as an increasingly febrile atmosphere about the threats posed by this new virus reaches suffocating levels, fuelled by hysterical predictions of the apocalyptic toll which will engulf India, sensationalist reportage ghoulishly documenting the death toll each day, and an avalanche of fake news spreading on social media. This has prompted terrified governments to impose an ever-growing range of restrictions on personal freedoms and public life, culminating in the nationwide lock-down on Tuesday.

We know from previous experience that these policies will have a profound effect on the well-being, social worlds and livelihoods of over a billion people; for instance, suicide rates in older Hong Kong residents showed a 31 per cent increase during the peak of the SARS epidemic, fuelled mostly by fear of contracting the disease and fears of disconnection.

This is not to deny that the virus threatens an existential humanitarian crisis. But the one lesson every infectious disease epidemic has taught us is that context matters. Simply put, bugs do not spread the same way everywhere. I vividly recall the hyped pandemic of HIV/AIDS which was predicted to overwhelm India in the late 1990s. These predictions were based on models which failed to recognise that sexual behaviour patterns in India were fundamentally different from those in southern Africa. One can argue that it was sensible to be prepared, but the fact remains that unless data are appropriately applied to the context, the risks are sensitively communicated and the societal response is proportionate, it can lead to a range of unintended bad effects. The HIV/AIDS predictions precipitated fear and panic, contributing to the diversion of scarce resources from building a stronger health system for all diseases, and to discrimination and stigma towards those affected. Context matters for this new virus too, as is evident from the vastly different trajectories in different countries and, indeed, within India itself.

One must wonder whether, given there was no evidence of widespread community transmission, we might have staved off the worst without a sledge-hammer approach, which no country at the stage of the epidemic we are in has imposed. Intensified case finding through testing and contact tracing, quarantining those who are infected, physical distancing by everyone, graded travel restrictions, preparing the health system to cater to those who may need intensive care and protect health care workers, and even locking-down limited populations with community transmission, could have stopped the epidemic in its tracks. That is what many of our Asian neighbours to the east successfully did; even China, the original epicentre of the epidemic, did not lock down the entire country.

It is not surprising that those proposing these policies — many of whom are members of my community of public health scientists — have salaried jobs which will not be threatened by such lock-downs. Their pay-checks will continue to be deposited in their bank accounts every month. They will emulate Europeans in using their Zoom accounts to maintain social connections and practise daily routines of yoga and exercise. They will send their maids to stand in line at the grocery store at 7 am.

But what do the hundreds of millions of Indians who face penury as a consequence of these lock-downs think about these policies? Is the risk of contracting a flu-like illness worth your family going hungry for weeks or longer? Why is it so much worse than other deadly infectious diseases, from TB to Japanese Encephalitis, which have been killing millions each year for decades? How do people who live jammed cheek to jowl in squalid slums with no water to drink and no money to buy food “socially distance”, “wash hands thoroughly with soap” and “use sanitisers frequently”? Why did the people who queued up with me on the street outside a half-shuttered grocery store, minutes after the PM’s speech, to stock up on essentials, get lathi-charged by imperious police? This, in Goa, where the COVID-19 case count is an impressive zero.

This epidemic is revealing to me one reason why government and scientists are distrusted by the poor. It is because we fail to recognise that all policies, even well-meaning ones, have impacts beyond what they were intended to achieve. We are already seeing the harmful consequences of policies which are spreading fear across the country.

The shaming and chasing down of those suspected of being infected is reminiscent of the vilification of sex workers and people with HIV. Racist discrimination against fellow Indians who “look Chinese” and European tourists, is being reported. The poorest have fled from their urban lives for their villages in states of panic, threatening to expose their rural communities, already gasping for health care, to this new infection.

The uncertainty of tomorrow, being disconnected from routine social interactions, loss of income, and realignment of health care services to focus on the predicted surge of COVID-19 cases, will have adverse impacts on a range of health outcomes. Ultimately, such heavy-handed policies may well lead to many more lives lost than the number they might have saved.

When governments act, they must do so in a proportionate and dynamic way that is appropriate for the context and takes into account the delicate balance between minimising the risk of predicted harm due to the infection with that of the possible harms due to the policies to contain it. But a nation-wide lock-down is now upon us, with no telling what its unintended consequences will be.

Hereon, public communication must focus on our collective responsibility towards the elderly and the health care system, and to one another, invoking our instincts of empathy, shifting the lens away from the fear of contracting a disease which, for the vast majority, will be negotiated with minimal distress.

Above all, the government must clearly communicate its plan to repair the lives of over a billion people devastated by a scale of disruption never seen before in any population as large and as desperately poor and unequal as ours.

The writer is the Pershing Square Professor of Global Health at Harvard Medical School. This article first appeared in the March 26 print edition under the title 'Let’s take a deep breath'.