Unlock 2

Sanjiv Agarwal
Founder,
Good Governance India Foundation Mumbai, India
sanjiv@ggif.in

Hon’ble Prime Minister,

Jay Bhattacharya, MD, PhD Professor of Medicine Stanford University Stanford, California USA jay@stanford.edu

 

Thank you for inviting suggestions regarding Unlock 2.0 in your recent speech. In response to your invitation we are writing our suggestions in the form of this open letter.

India presents a unique opportunity to disseminate a science-based approach for handling the pandemic for the entire world. In particular, the availability of excellent serological evidence based on sample surveys of large populations provides crucial information for a rational path forward to managing the epidemic without spreading undue fear or panic.

India can make a great contribution by avoiding the simple arithmetic blunders inherent in the conventional discourse. This can be done by publicizing the prevalence of COVID-19 in about 10 million (1 crore) persons, as per serological data disclosed by ICMR (2:00 to 8:00). While this may sound like bad news, in fact it is good news. The vast number of these infected people, detected by the antibody studies did not die from the infection and most of them are no longer infected.

Since there are so many previously infected people, the COVID-19 infection fatality rate (IFR) in India is just 0.08%, which is much lower than the widely reported fatality rate estimate of 3%, as would appear on the basis of the counts of reported cases only. Unreported cases must then be also counted in the denominator to estimate the true danger from COVID-19 infection.

If one were to add India’s reported Cases, Recoveries and Deaths (at the time of writing) as 410,000, 228,000 and 13,000 respectively (based on clinical case counts), to those on the basis of serological studies – approximately 10 million, 9.9 million and 10,000 (@ 0.1% IFR) respectively, the worst case of Infections, Recoveries and Deaths and hence an IFR would be approximately 10.41 million, 10.12 million, 23,000 and hence a 0.22% IFR, which is in line with other studies referred to above, adjusting for the younger demographic profile of India. Given that the serological survey was conducted in more affected districts and case counts are evidence based, the worst case IFR cannot be estimated at higher than 0.22%.

The infection fatality rate (IFR) in India is lower than the IFR in the USA, which the US Centers for Disease Control (CDC) estimates to be 0.26%. Several other serological studies confirm the low IFR around the world. Once this serological data is taken into account, the recovery rate from COVID-19 infection in India is in excess of 99% (and not 52% as is widely being publicized in the media) since the vast number of unreported cases must be recognized. If 52% is a good rate to reopen, 99% is even better.

This pandemic should saturate in India at approximately 300,000 to 900,000 deaths, assuming the Infection Fatality Rate (IFR) is closer to 0.1% (as the ICMR data suggests) and a saturation point of

    

Sanjiv Agarwal
Founder,
Good Governance India Foundation Mumbai, India
sanjiv@ggif.in

Jay Bhattacharya, MD, PhD Professor of Medicine Stanford University Stanford, California USA jay@stanford.edu

 

most likely 20% to the worst case of 60%. That will be less than two to six weeks of natural deaths. In the end, COVID-19 infections will have a relatively small effect on the annual death count of nearly ten million in India.

Given India’s daily burden of Ischemic heart disease alone is approximately 4,000 deaths, if the lockdown is continued, it is possible that more people will die from neglected treatment of other diseases due to the closure than from COVID-19 itself. The lockdown encourages mismanagement of medical services by delaying or eliminating needed care for patients with other conditions that are not specifically COVID-19. It is a wrong and self-defeating policy to count deaths only due to COVID- 19 on a day to day basis, while ignoring counting deaths and other bad outcomes from other diseases as a result of lockdowns. The daily death and health incidence data should be published for all causes and not just COVID-19, to put things into perspective.

Publicizing only the reported COVID-19 cases and deaths is form of misinformation, inducing fear in the population, including in the medical community. The reported case counts present a false picture of the epidemic, greatly underestimating its true spread. In fact, the actual number of cases is tens of times higher if unreported cases are also counted. Remember a widespread epidemic is good news since it implies a low infection fatality rate. So, it is better to recognize and publicize the vast number of cases that recover on their own, to rightly project the relative lethality of COVID-19 and address the disproportionate scare from the early days of the epidemic.

In view of the above evidence, a liberalized Swedish approach is the best suited and the only feasible course for India. This simply means emphasizing public education, individual risk-taking and responsibility. The desirable and perhaps unavoidable outcome will be slow or natural exposure of the not-so vulnerable segment of the population, while the capacity to handle severe cases is built up. The more vulnerable (say persons of age 60+ and with comorbid conditions) should receive special protection, including testing, close monitoring, and perhaps isolation.

The present strategy of testing and tracing all asymptomatic or mild cases in certain clusters and quarantining them with highly symptomatic/severe cases could in fact be counter productive. It will clog the institutional capacity and increase viral load on all around, including on the medical personnel and the asymptomatic/mildly symptomatic patients themselves. This will make institutions hotbeds of avoidable nosocomial viral load and result in more deaths, as seems to be happening in Mumbai. Indeed, Mumbai’s stress on testing and institutional quarantining of asymptomatic and mild cases is leading to more severe and complicated infections, shortage of critical care and avoidable deaths. Delhi may follow the same course if its policy of allowing segregation in homes is reversed.

    

Sanjiv Agarwal
Founder,
Good Governance India Foundation Mumbai, India
sanjiv@ggif.in

Jay Bhattacharya, MD, PhD Professor of Medicine Stanford University Stanford, California USA jay@stanford.edu

 

The Trace, Test and Quarantine doctrine raises significant human rights issues in terms of unequal treatment and freedom of the individual, as the tested asymptomatic/mild patients are exposed to additional viral loads on not only themselves but all around, leading to more deaths, while those untested (and hence not quarantined) may live naturally.

To sum up, disease projection models should be updated to account for the serological evidence of widespread disease prevalence and low infection fatality rates. Wherever the revised projection suggest that hospitals will not be overwhelmed, lockdowns must be lifted, boldly and confidently, but with special provisions to protect the vulnerable. There must be a transparent disclosure of the widespread nature but very low true mortality of this disease, quite like many other diseases we live with, in our day to day life, without fear but with individual precautions taken especially by the elderly and vulnerable.

It is important to handle it only as a health issue and not a disaster or law and order issue. Police forces must be taken off completely, the DMA should be lifted and the Constitutional liberties must be fully restored.

Sincerely,

Sanjiv Agarwal
Founder, Good Governance India Foundation Mumbai, India
sanjiv@ggif.in

Jay Bhattacharya, MD, PhD Professor of Medicine Stanford University
USA

  

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