When my parents were born in the early decades of free India, my grandparents were probably afraid of a number of deadly ailments to which their children could potentially succumb. But by the time I was born, child immunisation had picked up in many parts of India, and my parents, in then relatively better-off Maharashtra, are not likely to have lost much sleep over the possibility of me dying of diphtheria or picking up polio. They lived in a chawl with good, if not stellar, sanitary arrangements, so even cholera may not have featured at the top of their minds.
For my parents and for many like them in the late 1980s, polio, diphtheria, cholera, etc. had effectively “ended”. It is not like the microbes causing these ailments had disappeared or that the diseases were gone for good. It is just that in the small worlds of these people, the probability of becoming infected with these diseases had fallen dramatically.
But then, India contains within it many small and big worlds. Though polio had almost ended in the world of my parents, it continued to devastate the worlds of many others. Only much later, in 2011, did the little worlds of most people in the country finally align, with India registering its last reported case of polio. Clearly, we will witness, and are indeed witnessing, a similar differential and variable temporality with respect to the “end” of COVID-19.
Today, after a months-long harrowing period when no end was in sight, except for a weirdly triumphalist prime minister who declared “victory” in January 2021, COVID-19 is gradually inching towards an end for a large number of Indians. Secure in the protection offered by modern science and its vaccines, many seem to have shed their fears about getting infected and have begun to attend parties, go to cinema halls and in general ‘get on with life’. While COVID-19 is more or less tottering on the brink of its existence in the little worlds of all these people, we also know that neither India’s epidemic nor the world’s pandemic is anywhere near the finish for most people of Earth.
The dominant way of conceiving the end has been the attainment of a theoretical herd immunity, which might be when around 70% of a geographic region’s population is fully vaccinated. This metric brings us to the first challenge about the ends of epidemics. Governments can choose to declare a symbolic end even when one-third of people (30%) are still theoretically vulnerable. In India, the 30% who remain are most likely to be underprivileged persons who had little to no resources to access vaccination centers or the smartphone-based registration system, and marginalised communities for whom the state itself has had little time.
A volunteer distributes food to migrant workers travelling home, at Kanyakumari railway station. Photo: PTI
It is also important to remember that herd immunity has often been interpreted simplistically in the public discourse. Without going into all the complexities and limitations of this metric, it will suffice to say that herd immunity, or ‘herd protection’, as a threshold does not confer a physiological immunity to any individual, but works to epidemiologically protect a community from the uncontrolled spread of disease. The ensuing protection is also influenced by the probability of reinfections and the prevalence of protective behavior like masks, physical distancing and washing hands.
The concept is better applied in smaller geographic and demographic areas. Even if, say, around 70% of the population in your larger state or country is vaccinated, what is more likely going to offer you herd protection is your town (or ward, if you live in a large city) attaining those levels of vaccination. If you live in a very densely populated area, then herd protection might require a larger fraction than the (anyway sort of imperfect) 70%.
Vaccine-induced immunity is, in most cases, good with the currently used vaccines in India, although for now we have to live with the uncertainty around how long it effectively lasts. More importantly, it is the primary way to live normally (in any sense of the word), so inequities in the distribution of such immunity will have significant consequences. This goes beyond disparities in vaccination access, in fact.
The most basic requirement to mount an immune response against any pathogen, even when one is vaccinated, is a well-balanced diet. In a country of a billion people where the level of hunger has been termed “serious”, the basic raw material for building immunity is itself missing from the diets and bodies of millions of children and adults.
Even with two doses of any vaccine, COVID-19 will not exactly end for most of India’s undernourished persons, as well as for persons with weakened immune systems.
Photo: Gaurav Bagdi/Unsplash
When you always walk outside wearing footwear, losing your shoes somewhere and walking barefoot for some time might feel like quite a trek, and getting new shoes after that might even occasion a cheer. For most of the privileged public, experiencing the COVID-19 pandemic could and can be likened to such a challenging healthcare trek when for a short while they were without the basic protection they had been taking for granted.
The end of COVID-19 – however we define it – will mark for them relief and freedom: to go to their favorite restaurants without being stressed, to take lots of pictures with friends and without masks, and so forth.
But what does the end of COVID-19 mean for a factory worker, an agricultural labourer, a rickshaw-driver, a domestic worker, a sweeper, a waiter, a watchman? For someone who has always been forced to walk barefoot on rough, harsh terrain, does the culmination of a marginally rougher patch elicit any great feeling of relief?
A recent article by historian Kavita Sivaramakrishnan might help us understand the worlds of people in which staying healthy and accessing healthcare has always been a painful, barefoot odyssey. Sivaramakrishnan writes that outbreaks of infectious diseases are common and frequent in many parts of India, and both these smaller epidemics and the communities they affect find little to no place in official records – much less the mainstream media.
For example, although Indian officials declared the plague to be in full retreat a couple of decades after independence, smaller outbreaks were still occuring in villages and market towns, like the recurring outbreaks in villages near the Kolar gold mines. But these did not feature prominently in official policymaking discussions.
Women scan residents from Dharavi with an infrared thermometer in Mumbai, April 11, 2020. Photo: Reuters/Francis Mascarenhas
The structural conditions that give rise to such outbreaks in marginalised areas and communities, like incomplete sanitary arrangements, insufficient health infrastructure, environmental degradation and persistent poverty and social inequalities, also continued to be neglected – in terms of investment and commitment, if not in terms of rhetoric.
As Sivaramakrishnan says, policymakers prefer to conceptualise epidemics as finite, circumscribed events with a beginning, a middle and an end. That helps them project achievements and successes in terms of disease control and eradication. But these neat boundaries of beginnings and ends just evaporate at the doorsteps of millions of Indians for whom structural factors have given rise to an almost permanent state of ill health and poor healthcare.
Even when COVID-19 is ultimately brought under control in India, outbreaks and epidemics of infectious diseases, old and new, will continue to occur in many parts of the country and will cause disproportionate, preventable suffering among members of underprivileged communities. Policy discussions risk losing sight of these constant outbreaks if they stop at some endpoints based on selective statistics.
What an administrator or an elite commentator considers to be an endpoint makes little sense in the life of a vulnerable person – for whom the endemic and structural risk factors frequently go far beyond the epidemiological transmission of a microbe.
Let us not forget that vertical public health strategies focused on the control of a single disease have never led to sustainable and long-term healthcare improvements. While eliminating a deadly pandemic is a noble goal, we should not lose sight of what needs to be our larger, consistent goal: the elimination of suffering and the eradication of the injustice and inequalities that give rise to such suffering.
Kiran Kumbhar is currently studying the history of science at Harvard University, focusing on the history of medicine in modern India. He is also a physician and a health policy graduate.
