10 July 2020 05:15 AM

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SOUMITRA GHOSH | 25 MAY, 2020

Prolonged Hunger Will Destroy Lives and Minds of Millions

Lockown not the answer


In order to combat the deadly novel coronavirus, the Centre had yet again extended the nationwide lockdown. While imposing restrictions on various freedoms of citizens and economic agents, the central and state governments have taken refuge in the ‘evidence’ of rising cases of Covid-19 and coronavirus mortality. The statistics provided to justify these policy actions warrant critical scrutiny.

One way of determining the severity of a disease is by calculating its case fatality rate or CFR, which is the proportion of people who die out of all those who catch the disease. Calculating the CFR for Covid-19 poses significant challenges as it requires tracking the prevalence of the virus. In other words, we need to know exactly how many people are infected with Covid-19 in a given population.

But in India and elsewhere, the true burden of the infection is still unknown. In Maharashtra for example, as of May 15, no less than 51% of the 23,314 confirmed Covid cases were asymptomatic. Studies from China and the USA report that as many as 80% of Covid cases remain asymptomatic.

This has serious implications in terms of identifying the total number of infected people in a population, because testing is largely being limited to symptomatic individuals.

Although there is a close correspondence between the number of tests conducted (both diagnostic and antibody tests) and the counting of cases, it is very unlikely that any government will conduct universal testing to detect asymptomatic cases of Covid-19.

As a result, the case fatality rate is being estimated from the symptomatic or diagnosed cases, without making any adjustments for the undiagnosed or asymptomatic cases.

To make it worse, these numbers are displayed in real time on TV and other media to drive home the point that a pan-India lockdown is the only way out.

This focus deviates public attention from the social and economic implications of such measures, and the state’s failure to contain the infection or address the lockdown induced humanitarian crisis.

The way it is being calculated in the context of coronavirus, CFR is highly misleading. Consider a population of 1,000 people, 500 of whom have Covid-19 — 400 of them show no symptoms, and testing reveals 50 cases, five of whom die from the disease. In this case, the actual case fatality rate is 5÷500=1%, although the CFR from confirmed cases (through testing) is estimated as 5÷50=10%. Clearly, this amounts to overestimation of mortality by ten times!

Alternatively, we can estimate the mortality rate for Covid-19. The coronavirus crude mortality rate (CCMR) can be calculated by dividing the number of deaths by the total population at risk (and not just the diagnosed cases) during a specific time period.

CCMR estimates the true risk of dying from Covid-19, and is given in the table below.

 

Countries

CCMR

(per million)

India & States

CCMR

(per million)

USA

272.4

India

2.1

UK

508.0

Maharashtra

8.8

Italy

525.2

Gujarat

8.7

France

423.3

Madhya Pradesh

2.8

Spain

589.6

West Bengal

2.3

France

423.3

Delhi

6.4

China

3.2

Uttar Pradesh

0.4

World

40.2

Tamil Nadu

0.9


If we consider the first confirmed case on January 30 as the starting point of the pandemic in India (though many believe the virus reached India long before that) the CCMR for India is only 2.1 per million (or ten lakh) people during the last four months.

Nevertheless, the official fatality rate for Covid-19 is 3.23% in India, giving the impression that it is much more virulent than most viral diseases.

From the table above, India’s mortality rate appears very modest compared to other coronavirus hotspots. But caution is required when making this kind of cross-country comparison, because of confounding elements such as the under-reporting of Covid deaths.

In India, a lot of deaths never make their way into official statistics as they either occur at home, or do not get diagnosed or are misdiagnosed by doctors. Also, as seen with farmer suicides for instance, there is a tendency to misclassify the cause of death if there is political pressure to hide the extent of an outbreak.

An analysis of the coronavirus mortality data of 22 countries by the New York Times suggests an underestimation of official Covid-19 death counts by as much as 74,000 deaths in March and April.

When it comes to India, given that our mortality data are far more imperfect than others, let’s say we are reporting only one-fifth of Covid-19 deaths. Even after accounting for underreporting of this magnitude, the crude mortality rate would still be only 10.5 per million people, compared with a world average of 40.

The point to be noted is that the Covid-19 mortality rate is relatively low in India, and more importantly, it is not as high as the death rates of some of the killer diseases or non-natural causes like accidents in the country.

To put this in perspective, according to WHO estimates there were 2.69 million new TB cases in India in 2018. The TB mortality rate was 7.2 per million people and almost half the population is infected with TB.

Further, the country recorded 177,423 deaths (135 per million people) due to road traffic accidents in 2015, implying that the risk of dying from road traffic injuries is way higher than Covid-19.

Yet the state acting as the agent of polity, society and economy has decided to let people take the calculated risk of going out. This is based on the premise that letting people to go out would improve social welfare, as the benefits would outweigh the costs.

To illustrate, in 2004, the speed limit on the Mumbai-Pune Expressway was 80 kmph and it was raised to 120 kmph in 2014. This was done with prior knowledge that the decision would increase the fatality rates considerably (by 33% according to a study).

The government must have adopted the higher speed limit in the understanding that the economic value of the travel hours saved by increasing the speed limit amounted to more than the additional fatalities and injuries that people incurred.

Human lives are priceless; nevertheless the state seems to place value on human life (implicitly or explicitly) while deciding on various public policy matters.

In the context of the coronavirus pandemic, the Centre’s response reveals a very disturbing fact. While it has adopted a ‘business as usual’ attitude for diseases like TB (the poor man’s disease) or road traffic injuries, it decided to put a hasty brake on everything for Covid-19, with no major initiative to reduce the pains of those who live on the margins.

This reflects the government’s willingness to trade off the lives of the vulnerable for a change in the probability of death from coronavirus for others.

Till date 615 reported deaths have taken place as a result of the lockdown for reasons such as starvation, financial distress, exhaustion, denial of medical care, accidents during migration etc. This is just the tip of the iceberg as the majority of such deaths will never be reported in the media.

Moreover, death is an extreme health outcome. Prolonged hunger will take a toll on the bodies and minds of millions, leaving them very fragile, but the consequences of that may not show up in official statistics any time soon.

The government’s insistence on this lockdown also shows it has little faith in its own systems of medical care, which is not surprising. What is surprising is that health continues to be neglected in the government’s scheme of things. In the so-called package of 20 lakh crore, we have yet to hear anything about health.

The need for urgent investments in health cannot be overemphasised. As the visibility of coronavirus cases is making the public health system focus more on treating affected patients and protecting others from infection (it is already reaching capacity in hotspots like Mumbai), there are little resources left for attending to the medical needs of non-Covd-19 patients.

Before the situation escalates further, urgent efforts must be made to strengthen the public sector. To do so, as a first step, the resource envelope for health must be doubled at least as a share of GDP, up from its current level of 1.2%. With additional money the public sector will be in a position to address its massive health and medical workforce shortage by recruiting new people. This would also partly arrest the rising unemployment rate among the youth.

Our frontline health workers have been risking their own lives and their family members’ to contain the spread of the virus, and the least the government can do is to recognise their selfless contributions not by clanging pots and pans but by regularising Accredited Social Health Activists, contract workers and by taking good care of the health workforce.

The crisis provides an opportunity to get our priorities right. Being a middle-income country, our limited resources need to be used wisely. Prioritising people’s health and well being over, say, spending on arms and armaments, is a choice we can make. The choices we make today will determine the future of post-pandemic India for a long time to come.

Soumitra Ghosh is assistant professor at the Centre for Health Policy, Planning and Management at the Tata institute of Social Sciences
 

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