We continue on the same yellow brick road to development, paying homage to the same model, which makes humanity much poorer and pushes our planet further away from reasonable and fulfilling living. Poverty, as defined by economists, has certainly fallen and fantastic things happen as a result of the great creative talent of human beings. The imbalance, however is far too great. The existential threats are enormous.
When the World Health Organization determined that the Covid-19 outbreak was a pandemic (March 11th, 2020), globalization was in full swing, racism persisted, migrants were everywhere on the high seas, climate change was warming up the planet, declarations were crumbling and elections were on the agenda.
How the world thinks and will think about the lockdown and whether and how it controls a pandemic is a subject that should, and will, receive continual scrutiny. A proper and deeper understanding of pandemic containment policies and practical measures applied is important to third and fourth waves as well as for all future pandemics. With respect to Covid, there are many knowns and far more unknowns. In my mind, for some time and again recently, I can’t shake the thought that the common cold is an asymptomatic case of influenza.
My focus herein is on India, in its agony, as it suffocates and buckles at the knees under the worst wave of coronavirus the world has seen. Its people are gasping for breath on stretchers shuttled by despairing loved ones from hospital to hospital where there are no beds, others hunting for oxygen. We are witness to inhuman suffering with horrible demise even as temples offer oxygen cylinders to share.
My brief perspective on Covid today and Covid’s to come, Covid-19 did not create a new reality but greatly aggravated what already existed. Symptoms and effects of a world going mad were there before Covid took off from China to contribute to growing social dementia or global madness that we see and are living through, a world poised between global impoverishment and inspirational innovation. Economic systems rejuvenate better than people systems after a crisis and public health constitutes one fundamental element and practical ingredient for mankind’s hope for the future. Education should come first supported by classical philosophy. Autonomous institutions with a highly trained staff, well supported and governed are the bastions of culture and science. Beware, for the media presents shifting public attitudes as science and government can destroy its own cultural institutions.
Human behavior and systems integrity matter in response to the crisis and in determining the impact of any disaster. With insufficient public health and a lack of understanding of its value system, the weakness of political leadership may be secondary but important. One comment I read is that the response strategy of India is that it is one not to apply: too oppressive policy measures with communications that undermine public health interventions. In parallel Indian and foreign journalists are straining at the bit with the current tragedy in a hurry to place blame as Modi-made. There is little doubt that large election-related gatherings helped precipitate runaway Covid diffusion. They can super spread and with only one asymptomatic in the crowd. To think never again Covid is short-sighted. Sweden’s approach was one of limited disruption, although citizens did isolate and stayed at home and death rates are similar to other countries.
Five decades ago, Surjit Singh Bhalla was a Beatles fan at Princeton with interests in economics and politics. I was in Chicago working in biomedical engineering and neurophysiology. His book on improving world equality – Imagine There’s No Country – was published in 2002. Surjit is now in the eye of the storm working on the epidemiology of T-cell immunity, a reappraisal of earlier viruses (the 1957-58 and 2009) and looking scientifically at India’s frightful plight with the second wave of Covid. He ponders the lead time to effective policy response: how much lead time did policymakers have and thinks about the 2021 Covid experience - across the world - and the fact that very few if any of the countries are going for a national lockdown – despite the fact that for 120 countries the maximum number of cases was higher in 2021 than in 2020 – and for more than 40 countries, the maximum per day caseload was more than twice that observed earlier. His focal interest is on India and the controversy about the “true” determinants of this second wave, i.e. what were the effects of farmer protests and large election-related gatherings on Covid diffusion. One comment I read relative to India’s response strategy is what not to do: use too oppressive policy measures which undermine communications which undermine public health prevention.
Two decades ago, SARS spread rapidly with a death toll of 900 (in Greece) or a mortality rate of 10% - a result of relatively few cases compared to Covid today. SARS was another demonstration of how health troubles in one part of the world provoke health and health system problems elsewhere and how disease spread can be facilitated by social and political arrangements of various kinds and at several levels. SARS underlined the complexity and multiple dimensions of disease and was one of the many wake-ups calls for society to socially, scientifically and economically prepare for what is to come. It was called China’s Chernobyl. One good response was mounted by Taiwan. It pointed to global needs for outbreak monitoring and universal global assessment of risk. My loud clang of the Leper’s Bell was an appeal for public health preparation.
Containment thinking is polarized between the elimination of hazard; removing it (no escape-no spread) or stopping the virus in its tracks, or suppression of its detrimental effects; achieved by mitigation and mainly by vaccines to confer herd immunity on the population. Science has worked at breakneck speed to produce a host of vaccines.
Infectious disease case numbers and death data until Covid showed that its effects on developing countries (low income) were worse than on more developed or high-income countries. However, Covid, with respect to death, seems to reverse this trend with, for example India and Asian slums coming off better than the USA. For both infections and deaths, the non-advanced economies have one-fourth the rate of the advanced economies (this assumes that data in both sets of countries is of equal reliability).
Comparing waves, namely, the second and third are only approximations. While the situation can get worse, life darker and living more difficult, there are still many questions to answer. Lockdown-lite, lockdown-late and lockdown-local are necessary here and now, but they may be insufficient. Covid’s current rage in India has acquired new drivers of more transmissible variants. The virus and its mutants have not yet been contained. Worth asking is what role has the large prevalence (X5) of asymptomatic cases played.
An earthquake in the Indian Ocean jolted the earth’s axis and triggered a large tsunami and a nuclear disaster in the poorly maintained Fukushima nuclear reactor. Radioactive fallout was enormous and added to that Chernobyl and there is no safe solution for the disposal of nuclear waste. Now with polar ice melting into the oceans as a result of denied global warming, the earth’s mass is being redistributed and its axis perturbed to a different dynamic equilibrium.
India is again in the eye of the storm with Covid as a more infectious variant takes an iron hold with a greater power of transmission. In just one week, more than 2m cases occurred; on April 30th, 400,000 were reported. The health sector is in collapse and lifesaving products are scarce and people have to fend for themselves. As oxygen runs out, patients are gasping for air and literally grasping for life. While the situation is utterly tragic-catastrophic, seen and felt in all its horror, it is far less so than what humanity has passed and forgotten; what it can potentially face in the future can only be imagined.
Covid has drawn attention to many problems (inequality, racism), two practical issues being the failure to prepare and a lack of funding for public health. But natural disasters now come faster, bigger, precipitate more damage and claim more lives. It has drawn attention to leadership failure, congested living in urban areas and how unpreparedness for crises contributes to the collapse of the limited surge capacity of the health sector. In India and just outside of health facilities, funeral pyres burn bodies of loved ones with others awaiting the flames while patients and families ravaged by Covid desperately, agonizingly, seek a bed, oxygen, a vaccine. World leaders and the international community are sending humanitarian oxygen and other needed materials to India, as several thousand per day find themselves in a sinking submarine gasping for breath from Covid. It is a horrible death.
When I wrote my Ode to the Lockdown Monster, I thought that I had said my all on Covid: Endings, turnings-yearnings and new starts beware of Cupid’s art, avoid sharp Covid’s darts. Art you’ll survive, the other mean brings agonizing demise and especially with my global health prescription and with my advice to Greece respectively:
Wear Covid out Quarantine, keep devils at bay
Wear Covid down lockdown, contagion give way
Trace, test, and test till we know, where the pest comes from, where do he go.
So once again, to Greece I say, do not unlock stay put,
Lay low, protect the loved ones that you know,
While in the words of a Nobel, noble poet
Just a little more and we shall see almond trees in blossom
Marbles shining in the sun.
Don’t frit away the glory that is there, coronavirus is not fair.
Lockdown, quarantine with its fuzzy logic, works and has worked perhaps best in China and reasonably well so far in Greece. However, where it was massive and enforced, it created delays of other treatments, increased inequality, and precipitated additional problems. One opposition to lockdown from Greece metaphorically stated was that we do not put out a fire in an apartment by razing the building to the ground, a reminder of a General, comment that the village was destroyed to save it.
Our snapshot of Covid deviates from reality, but we do not know by how much. Until we learn more, no country is out of the woods. My measure of normality is light-years separated from reality. Surjit and I have different but somehow overlapping metaphors for Covid’s waves he is an earthquake mine is a forest fire - just as a forest fire can suddenly take a new direction as winds change or firefighters reduce the fury of one front, the ongoing epidemic can shift course.
But first, Surjit. In a highly developed paper, he brings together a great deal of the available evidence to bear on the predominant strategy of containing the virus – lockdown and emphasizes that historically a lockdown strategy was never tried once separating it from quarantine which was tried tested and worked. He describes the year 2020 as a long journey into the unknown, a journey that the entire world has taken together. He is the Executive Director for India, Sri Lanka, Bangladesh and Bhutan of the International Monetary Fund. He argues that no matter what the test, the dominant result is that not only lockdowns were not effective, but that in a large of cases, lockdowns might have been counter-productive i.e. led to more infections, and deaths than would have been the case with no lockdowns. The paper rests dominantly on infections and models the reality on the ground, late 2020.
Surjit says that there are more unknowns than knowns and the only real known is that vaccination works! Until herd immunity arrives and approximate full vaccination of the population (66 % = 1-1/R0), India will continue to suffer. The post lockdown strategy in India, which worked, was tracing, testing, and containment (isolation).
He conducts a discussion of the 1957-58 flu (H1N2) epidemic, an event with close parallels to Covid-19. In the 1957 pandemic, 25% of the U.S. population became ill and excess mortality due to pneumonia and influenza occurred. The 1957-58 pandemic was such a rapidly spreading disease that it became quickly apparent to U.S. health officials that efforts to stop or slow its spread were futile. Thus, no efforts were made to quarantine individuals or groups, and a deliberate decision was made not to cancel or postpone large meetings such as conferences, church gatherings, or athletic events for the purpose of reducing transmission. No attempt was made to limit travel or to otherwise screen travelers. Emphasis was placed on providing medical care to those who were afflicted and on sustaining the continued functioning of community and health services. Respiratory illness with high temperatures brought large numbers of patients to clinics, doctors’ offices, and emergency rooms, but a relatively small percentage of those infected required hospitalization.
Covid experts at Imperial College, London, projected predicted that in an unmitigated epidemic, approximately 510,000 deaths would occur in Great Britain and 2.2 million in the US, with potential negative effects of health systems being overwhelmed as a result deaths. (Ferguson et. al., p. 7) These predictions under conditions of non-mitigation and health system pressure are several times (3-4) higher than reported deaths. One additional hypothesis to be tested would be that governmental mitigation was quite beneficial. However, actual cases and deaths far exceeded what was thought to have been achievable with lockdowns. the worst outcomes in terms of Covid deaths per capita are almost entirely in countries that leaned heavily on lockdowns and related nonpharmaceutical interventions (NPIs) in their unsuccessful bid to turn the pandemic’s tide. Avoid removing hope by an overemphasis of extreme outcomes associated with epidemiological models: "Instead, they should acknowledge that models are simplifications of reality and our best estimate based on a lot of moving parts."
Two documents both aimed at minimizing health damage from Covid namely, the Great Barrington Declaration (GBD) and the John Snow Memorandum (JSM) and written by distinguished scientists, researchers and healthcare professionals are divided by lockdowns. The JSM argues that controlling the community spread of Covid-19 is the best protection until we have safe and effective vaccines and therapeutics. The GBD presents what is called a more compassionate plan, a singular plan to return the world to normal life in the middle of a pandemic (not unlike the 1957-58 experiment and reality) with a better strategy than lockdown to minimize overall mortality and especially to lessen the disproportionate burden of lockdowns on the less privileged. Surjit’s article shows that in a minuscule number of countries (less than 10 in a universe of more than 160 countries), lockdown can (may) be shown to be effective. Surjit’s challenge is that given this data how can I lean towards the JSM? One answer is that there was only one fully compliant lockdown and in China, it acted swiftly, forcefully and people followed measures understanding that they are introduced to protect them. An extreme “suppression” model, triggered when a country reached 1.6 deaths per 100,000 residents.
Returning the world to normalcy with greater compassion is a highly desirable attribute and the goal of most. The right to be left alone is a good thing but now in India may be as effective as a prayer. Surjit says that the non-lockdown strategy – 3 T: Test, Trace and Treat– does not leave people alone. One reference point is the succinct appraisal of the GBD by James Naismith, who used humility and willingness to consider alternatives as hallmarks of good science, perhaps because of its reiteration of the proclamation, we have an opinion… let’s consider it ... if it is not confirmed, we can change it. Asklepios and his student Hippocrates advocated the strategy of treatment as first do no harm. These are concepts that characterize cultured minds, minds that had the capacity to examine a proposal without necessarily accepting it. Do no harm is the most appropriate phrase and society, and experts, have to attempt to answer it, with humility and the “knowledge” that everyone has been proven wrong with Covid assessments (the whole class failed) and that there are more unknowns than knowns (humility – or my “extreme” characterization – we just don’t know).
The scourge of Covid is presented by Surjit via a colossal and impressive gathering of data (or Big Data as current phraseology goes). Surjit’s study offers counterintuitive conclusions and if we ignore boundary conditions a paradoxical and best outcome occurs; lockdown measures should be applied close to infinity or a long, long time after Covid strikes. Αll models, while useful to thinking and experimental design rarely predict better than extrapolation, useful but mostly wrong. At present, Surjit is working some more on the present Indian crisis and data - and trying to see if the exponential second wave was (is) related to "mass gatherings" - Kumbh Mela in UP and election rallies in West Bengal, Assam, Kerala and Tamil Nadu. A related and intertwined problem for Surjit is the "suddenness" of the Covid spread (new strain). A lot of work went into Surjit’s analysis. His conclusion - there are more unknowns than knowns, or maybe, perhaps, we just don’t know.
Covid is a colossal problem space with much unknown, containing many variables, some still unfolding, some uncontrollable. Where there is uncertainty, data are missing and models are supported by assumptions of what if. New explanations are needed as a virus mutates and behaves differently. Different models are necessary for different agents such as influenza and Covid. How do you measure suffering, the number of shed tears? Already to its name-credit, it has a voluminous information base and has collected several models that have wrongly predicted both where the pandemic has been and where it is going. There are different opinions from religion and the media and many voices on where it came from, how it spread and where it strikes.
Like most problem fields we are interested in quantity (size); number of cases (currently, 147,810,736), its distribution or spread (worldwide=pandemic, 220 countries and territories) over space and in time (waves, 2nd & 3rd), number of deaths (currently, 3,123,003) and its death or fatality rate (crude death rate 3,123,003/147,810,736) approximately 3%. The number of recovered cases (currently 125,375,246) and approximately 80% of the total. This means that there are about 18m current cases, of which more than 100,000 are critical. One way of comparing countries is through a measure of the total cases per 1m of the population (19,000) and deaths per 1m of the population (400). There are effects as a result of income and with respect to age and gender.
We live in a strange world where we can predict with a P=1 that disaster will occur, but in the case of earthquakes and infectious disease, we don’t know where, or their magnitude or their duration. We do know that aftershocks and mutations will occur. We know where the seismic areas are and where a new infectious disease is more likely to emerge. We know that both are extremely complex phenomena. In complex situations, cause, effects, affects, measures and interventions can comingle into the mind and in models—weaponized model uncertainty.
In a complex problem space like Covid, we may infer that an imposed and mistaken measure like lockdown has gone viral when only its cause - a coronavirus - has gone viral. Imposed and official measures to combat its spread have given rise to different approaches and opinions in the scientific community. So far, what has been learned will be extremely useful in dealing with the second and anticipated third waves and in the problematic interval between now and the arrival of an effective vaccine? Some may accept a world controlled by big government and support lockdowns; some accept a business dominated society and accept big tobacco as a natural stakeholder in health; some may call for less government and accept a limited public health function.
May Day, May Day, the world has gone mad. Markets and money have gained overwhelming control of people and natural resources. Nothing though can compare to the potential devastation posed by nuclear weapons, the greatest hazard to life on earth. The risk of absolute disaster comes closer to certainty to when millions of years of evolution will unravel and human consciousness and culture disintegrate. At 90 symbolic seconds to midnight, the world is in graver danger than even from Covid in India, whose horror is beamed out by fire and media for all to see. At the dreaded moment of a button pressed, the world will become a sinking submarine with one hour’s worth of oxygen at a depth that no olive branch can save.
The escalating health crisis in India could spread to neighboring countries and calls for political pause and a sensible democratic reset that cannot be accomplished with the expensive redevelopment of New Delhi in the Central Vista Redevelopment Project, which started late in 2020. The allocated funds should be reallocated for pandemic relief and to save citizens' lives. No greater concern and respect can a prime minister show for his people than by giving up self-aggrandizement for their benefit.
Burkle F.M. Jr. “Declining public health protections within autocratic regimes: impact on global public health security, infectious disease outbreaks, epidemics, and pandemics”. Prehosp Disaster Med. 2020;35(3):237–246.
Levett Jeffrey. Societal Dementia, Now and Then, Watched communities, side stepped expertise?, Wall Street International, 17 September 2019.
Levett Jeffrey. “Disastrous Events and Political Failures”. Prehosp Disaster Med. 2015;30(3):1 2.
Levett Jeffrey. Severe Acute Respiratory Syndrome (SARS): Loud Clang of the Leper’s Bell, 2003.
Lockdowns and Closures vs Covid–19: Covid Wins, Surjit S Bhalla.