The Spanish Flu of 1918 killed off 18 million Indians, about 6-7% of the population. About 7% of Iran’s population was wiped out, about 5% of Mexico’s. Since estimates of the total victims of the flu range from 50 million to 100 million, it is difficult to say what the mortality rate was. The rate varied across the world, but the average is supposed to be 2.5%. It had to be substantially higher in India. Because India’s population was probably just around 26 crore. Between the 2011 Census and the 2021 Census, India’s population actually declined by about 1 million, whereas, the population had grown by about 6% in the previous decade and would grow by 11% in the 2021-2031 decade.
If the fatality rate was around 10%, nearly three-fourths of the population had to be infected. The higher the fatality rate, the lower the proportion of the population infected. The flu was brought to the country by Indians who had fought on the British side in World War 1, contracted the disease and were lucky enough to come back alive —of the million odd who went to war, over 74,000 died. We really have no idea how many of the demobilised war veterans bore the virus when they returned. Suffice it to say the Spanish flu epidemic gives us an idea of how much an infection of the kind can spread when not checked with the kind of measures in place now across the world.
If social distancing remains protracted, large parts of the economy would shut down. There would be a huge cost. To avoid this cost, should India as a nation try another strategy? Take the risk of allowing the epidemic to spread and treating those who fall ill? After all, only about a fifth of those who fall ill require hospitalisation and about 5% of those who catch the infection develop symptoms severe enough to require care in an Intensive Care Unit. India accounts for 27% of the world’s tuberculosis patients, of whom 1.5 million die every year. If India claims its fair share, we lose about 400,000 to TB every year. We allow diarrhoea and pneumonia to claim over two lakh lives every year. Annually, road accidents kill 150,000. Another 10,000 die of electrocution. So is a Covid19 toll a bearable risk for India?
Can India afford to take the route of avoiding economic lockdown and treating those who get affected? Let us assume that unlike the Spanish Flu, Covid19 would afflict only about 10% of the population without tough social distancing measures that involve protracted lockdowns of towns and severe disruption of the economy. That would mean 0.5% of the population would require ICU care. India’s population is upwards of 1,300 million. The number of ICU beds that Covid19 would claim would be 6.5 million. Assume a patient has to stay in for two weeks and the epidemic would stretch out over eight fortnights. India would still require over eight lakh ICU beds, just to treat Covid19 patients. India currently has fewer than one lakh such beds (the latest figure I could spot was 70,000). For India to attempt any strategy other than to suppress and contain the disease is to let at least 5.5 million people die.
The Spanish flu was unique in that it was most deadly for the young, aged 20-40. Conventional flu poses the biggest threat to the elderly and the very young. Covid19 tends to spare children, yield to youthful vigour and settle for the elderly and those with underlying conditions. The median age for Italy’s Covid19 victims is over 80.
India is full of people with underlying conditions. It is the world’s tuberculosis capital. About 5% of the population is diabetic, which means all their organs are less than robust. A large proportion of children are malnourished and even women in affluent families are anaemic. The death rate in India could be higher than in other parts of the world. It could be higher than even 5.5 million.
The US currently has 70,000 ICU beds, for a population of 330 million, reportedly with a third lying empty at any given point of time. If 5% of the population fall ill without severe restrictions that would squeeze economic activity, the Americans would need a little over 100,000 ICU beds to treat Covid19 patients alone. So, if they double their existing number of ICU beds, the Americans could actually afford to adopt a strategy that focuses on treatment rather than suppression and containment of the disease via lockdowns that cripple the economy.
The Wall Street Journal is not entirely callous to discuss such a policy.
Things are a bit different in India. Unless we are willing to countenance mass culling of the poor and the elderly — the rich would have access to ICUs, the elderly are the most vulnerable — there is no alternative to containing and mitigating the disease with severe measures even if these constrict the economy. It would be morally reprehensible and politically suicidal to make a tradeoff between avoiding economic damage, on the one hand, and millions of lives, on the other, in favour of money. Far better to spend some money to assuage the hurt caused to the economy.
But India needs to prepare for future pandemics. That means building up capacity to treat patients by the million. Hospitals with the flexibility to convert normal wards into ICUs — seal off sections, selectively allow for continuous replacement of the air, put in place the additional equipment. Invest in raising immunity levels, through good diets, discouragement of gluttony, especially in relation to starchy foods, public health engineering involving sanitation and safe drinking water, and promotion of an active lifestyle, distinct from active watching of live sports on TV.
With traditional, non-state safety nets still mostly functional, India is better placed than the West to face up to pandemics. But the state has to create in an effective, extensive healthcare system, not outsource that to the private sector, while restricting its role to paying for insurance. That capacity can be built through both state investment and through policy that induces the private sector to invest alongside. This would include not just physical infrastructure, but also personnel — doctors, surgeons, radiologists, pathologists, nurses, paramedical staff, medical technicians, bioinformatics specialists, bioengineers, synthetic biologists — and systems and institutions for governance and transparency.
The state must invest in harvesting data at state-run hospitals, anonymise it and make it available for data scientists to produce the logarithms that can create the intelligence to vastly improve healthcare. The private hospital chains must do likewise with their data, the larger the pool, the better the artificial intelligence that would be created.
Without the ability to develop and run algorithms that can identify reagents that test for identified proteins of pathogens as well as vaccine and drug candidates, India will not be able care for its teeming millions in the face of new medical threats.
