The war has begun. We are battling a malevolent enemy which spreads unseen, invading most victims with such stealth that they aren’t even aware they have been occupied, lurking in the shadows of our physiology to emerge in its deadly avatar when it strikes the sick and elderly. But our nation is prepared. With military precision, our weapons are leaving their factories under armed guard, transported with Coca Cola efficiency to the frontlines, in an epic struggle for our survival. The publication of the trials testifying to the safety and immunogenicity of two weapons, one of which is entirely indigenous, by prestigious medical journals, will soothe the frayed tempers of ethicists and scientists who fretted about short cuts being taken for political gains, while also pumping up national pride. Still, most of us are keeping our fingers crossed and hoping for the best.
Which brings me to an awkward question: How will we know if the vaccines are victorious if the enemy is not just in retreat but, if the past month is a reliable predictor, may soon disappear beyond the horizon much before we reach our vaccination targets? Addressing this question requires us to confront a baffling observation: Why is it that India, in contrast to most other countries, seems to have navigated the epidemic with just one wave and with one of the lowest mortality rates in the world? A review of sero-prevalence studies, which are the best indicator of true infection rates, offers a plausible reason. The paper, published in the current issue of the WHO’s bulletin, reports that sites in India had the highest infection rates on the planet. In Mumbai slums, for example, nearly 60 per cent of people surveyed many months ago had antibodies which indicated prior infection. These findings are replicated in a state-wide study conducted six months ago in Karnataka which reported that half the population had been exposed to the virus. Such astonishingly high infection rates also mean that the inferred mortality rates due to the virus are very small, less than 0.1 per cent, and similar low rates are also seen in our neighbouring countries.
For once, it seems, wealthy nations have been hit by an infectious disease much harder than the teeming billions of the poorest countries. Leaders of global health and public health scientists who predicted millions of dead bodies on the streets of Asian (and African) cities are bewildered by how much they were off the mark. These estimates had triggered the nationwide lockdown even when we had such few reported cases. But, in contrast to other countries, instead of “flattening the curve”, our lockdown was immediately followed by a monumental peak of cases. This has led some to wonder whether the virus had already begun to circulate in the community even before the lockdown, which then actually led to the infection spreading like wildfire in the densely populated slums of our cities. The subsequent policies to ferry millions of infected persons to their villages smoothly fast-tracked the infection across the country and, inadvertently, led us to herd immunity. And if hundreds of millions of people in India have already been infected, what saved us from an apocalyptic death toll was a combination of our youthful demographics and some other, yet to be deciphered, biological immunity to the infection. One thing we can say for sure is that this had nothing to do with drinking cow urine.
Regardless of the truth behind India’s unique tryst with COVID-19, it appears that we are about to vaccinate hundreds of millions of people to protect them from a virus which has already infected more than half of our population. Indeed, the government has itself indicated that the vaccination programme will intend to cover up to 60 per cent of the population to halt the epidemic, but all the data suggests we might have already crossed that milestone through vaccination by the virus itself. Moreover, this poses an existential question: Should a country whose health system is in such shambles, as illustrated yet again this month by a devastating fire in a district hospital which killed 10 newborn babies, which is still a long way from universal coverage of proven vaccines which protect children from deadly diseases, which is witnessing the highest rates of malnutrition and TB in the world, be spending so much money on a vaccination programme for a disease which may be well on its last legs and which has a vanishingly low mortality rate? Is this why there is mounting hesitancy to be inoculated? After all, many people might be sceptical about taking a jab of a new vaccine with the associated, albeit tiny, risk of adverse reactions, for a disease which is yesterday’s news.
But the horse has bolted and in the derby of whose country will be first to win the race, our weapons of microbe destruction are well on their way to a famous victory. Never mind my cynical quibble about this appearing like sending in your troops to battle an enemy which is on the retreat. Never mind that while we do so, countless more people will die of mundane diseases of poverty which could have been prevented or treated if we could show a similar commitment and allocation of money. So now, the best we can do is to pray that the campaign is fought equitably. In a country notorious for the shameful sight of its privileged watching vicariously or banging thalis as the biggest human migration since Partition unfolds on their TV screens with little compassion or outrage, we should be wary of the vaccine programme being hijacked by the wealthy and well-connected.
I applaud the government’s commitment that not a single dose will be allowed to leak into the private market until all the priority populations have been covered by the public system. Unsurprisingly, some of the pampered are grumbling about having to wait their turn, and rumours are flying around in tony residential colonies about who might once have had tea with or sat on a plane next to a Poonawalla. To them, members of my class, I have one plea: If there is one thing that the pandemic should have taught us, it must be to wait in line, patiently, with at least six feet in between. No matter when you get the jab, our victory is assured.
This article first appeared in the print edition on January 27, 2021 under the title ‘The pandemic endgame’. The writer is The Pershing Square Professor of Global Health at Harvard Medical School, and a member of the Lancet Citizen’s Commission on Re-imagining India’s Health System