Covid Lockdown. Some Questions

By Omar Ali 19 Comments

When the novel Coronavirus started its spread outside of China very little was known about it and it is no surprise that countries acted to slow or stop the pandemic by locking down their citizens to various extents. Some countries (most notably UK and Sweden) tried to “push through” to herd immunity but then had a LOT of cases and transitioned to various degrees of lockdown. Others like the US tried a “worst of both worlds” response, with the President being skeptical of lockdowns, but reluctantly going along with them for a while  before shifting back to passive-aggressive sabotage of whatever his science advisors were telling him (whether they were correct or not is a separate issue). Pakistan’s PM had Trump-like instincts in this matter and unlike the US, his lockdown did not last long and was never very effective. This led to an early surge of cases and deaths (after Ramadan, when lockdown first failed) but to the surprise of most observers (including me), this outbreak then seemed to slow down and now there are ongoing cases, but the health system is definitely NOT being overwhelmed and the worse seems behind us. Meanwhile India continues to have varying degrees of lockdown (and because Indian officialdom has relatively more ability to enforce such things, these  also seem to have been more real than any Pakistani lockdown ever was) and is seeing a major increase in cases. When people talk about this they frequently bring up the fact that testing and tracking are not necessarily at “first world” levels in either country, so real numbers may be very different from what is being reported. This is true, but we do see what is happening in hospitals, so the fact that the system has not been overwhelmed is still something we can say.  Beyond that, I have no special knowledge or data. So I thought I would put up a post and get some answers from the hive mind:

  1. Where can non-experts like us find the best data on Covid? There are many sites, which ones do commentators prefer and why?
  2. Why is Pakistan NOT experiencing a dramatic health emergency due to Covid in spite of having given up on lockdowns? Is there pre-existing immunity? something else? Or just fewer old people? is there more to come?
  3. IF Pakistan is not seeing a major increase in deaths, should India continue its current level of lockdown? Do we expect Indian immunity and spread characteristics to be very different from Pakistan?
  4. What is the expert consensus now on various details such as “doing X is cost-effective, but Y should be abandoned”.. I mean what is the best source (sources) for answering such questions? One assumes that the “authorities” spend a lot of time analyzing information to determine what worked and what was just a waste of effort? Are the detailed recommendations evidence-based? Should any of them be changed? (for example, why is my dentist open for cleanings, but my barber is not? things like that, are they evidence based? and what does the evidence say?)

I look forward to being enlightened. Meanwhile, stay safe and happy.

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19 Replies to “Covid Lockdown. Some Questions”

  1. “Why is Pakistan NOT experiencing a dramatic health emergency due to Covid in spite of having given up on lockdowns? Is there pre-existing immunity? something else? Or just fewer old people? is there more to come? IF Pakistan is not seeing a major increase in deaths, should India continue its current level of lockdown? Do we expect Indian immunity and spread characteristics to be very different from Pakistan?”

    The average AGE difference between Indian and Pakistan appears non trivial, plus if we think there is some genetic component to immunity – it could also be that the Punjabis have it on both sides- as there hasnt been an explosion even in Indian Punjab – I AM JUST BEING HYPOTHETICAL – I DONT KNOW about the genetics.

    “This is true, but we do see what is happening in hospitals, so the fact that the system has not been overwhelmed is still something we can say. ”

    Personal Pune Experience:
    Covid has come in my close (inner) family. The hospitals are still holding up but barely. I check the Bed data daily and see atleast 40+ ICU ventilators available with around 1000+ bed with Oxygen available. But PMC has improved the capacity significantly since March. Had there been no lockdown post even April – OPENING SINCE MAY – I still believe the health systems would’ve been overwhelmed in July ITSELF. But i wouldn’t recommend hospitals for anyone at this time – the care provided is barely enough.
    Additionally we have had over 1000 cases daily for almost a month and the numbers arent going down. The Sero Survey of 5 densely populated low income areas in Pune found 50% + infection in those areas – SO I GUESS HERD IMMUNITY IS GOING TO VARY A LOT DEPENDING ON DENSITY & LIVING CONDITIONS across the world.
    It could be as high as 80% in my intuition for Indian slums (could be fantastically wrong here)

    BROADER comments:
    Day by day I am getting more worried about the mental health issues which may be left behind after the pandemic. Upbringing of pandemic children (I have one of those now), the uneasiness in crowds – these reactions people have nowadays might stay with them a bit longer, now a lot know this is how Influenza and other viruses spread. I personally have been primed to avoid all unknown people as if all are contagious – it’s getting mad in the brain. I guess most r facing similar issues.

    Economically we really can’t afford any more lockdowns – things r looking scary but atleast from the sero surveys in India – IFR is firmly below 1% – might be between 0.1 & 0.2 which is bad enough imo

    On the disease level too I have had very close experience – even the so called “Mild Cases” are fighting fatigue and something like PTSD weeks after recovery. The Moderate cases are much worse off. India is really in for dangerous months. Maharashtra currently I leading but I expect others would follow soon.

    On the other hand – masks are certainly working – I was curious to know what’s your take on the Whole Dose makes the poison chain of thought particularly what Siddhartha Mukherjee has been saying ? Could that explain the range of symptoms ? – from asymptomatic old people to severe youngsters ( After from Genetics) ?

    And is it time to bury the Fomite transmission theory ? Especially washing every freaking thing you take inside the house. I couldn’t find good literature to support the Fomite hypothesis in the first place for Influenza and other resp illnesses.

  2. some it is population density and hygiene. India is dirtier aka more public defecation. Pak is cleaner and feeds its people better. India is still a reeling socialist epic fail on those fronts though way better than past

    Mortality would likely be due to hypercoag gene differences and blood type differences also postulated. I don’t think it is big enough between Indian pops to explain much at all. Pak just handled it better and has age, density, amd cleanliness advantage, as well as better fed people and less dense overall also less air pollution so peoples’ lungs are less fucked at baseline

    Also West Eurasians have fared worse overall mortality wise. Italy and Spain vs. China. Yes I know biased reporting. But experts have even noted this. If anything, most east eurasian people doing bit better possibly?

    From what I see as a young resident doc, this thing doesn’t care much about race. That’ just anecdotal. But it fucks everyone pretty hard and mostly just comorbidities and population density and access to care explain who gets it and who lives after getting it

    1. Though Urban Pakistan also has huge pollution – so that cant be a difference
      “From what I see as a young resident doc, this thing doesn’t care much about race. That’ just anecdotal. But it fucks everyone pretty hard and mostly just comorbidities and population density and access to care explain who gets it and who lives after getting it”
      seems bang on money;

      A friend of mine who is 30 was in ICU for a week on Oxygen support; he had fever for 15 days and got better only after Remdesivir. (could be just coincidence though).

      1. Pak is less urbanized I think. And only Karachi is comparably dirty. Pak is cleaner overall and less dense on average I think.

        Pak does better on world hunger index too. And yes migrant workers is also a bigger thing in India that probably accelerated this.

        India’s mismanagement in many areas has a long record and the chickens have come home to roost with COVID-19

    2. Razib made a post about a Neanderthal variant which results in higher severity. It is almost non existent in East Asians, present in low frequency in west Eurasians and at higher frequency in South Asians. Probably only a fraction of the total varience however.

      1. weird that S Asians would have higher frequency of a neanderthal gene than more West Eurasian heavy peoples. Possible but weird

        1. East Asians have an even smaller amount. Razib and some other people have suggested that perhaps east Asian contact with corona-like diseases in the past could have selected against this variant maybe through contacts with animals that also host these kinds of diseases. South Asians wouldn’t have had this kind of contact so it has persisted.

  3. 1) Follow Prof David Spiegelhalter on Twitter

    2) I don’t think fewer old people is the only explanation for it. My own theory is that a) Pakistan as a culture is more socially distanced than Indian – certainly the women folk (which makes half of the population) but b) maybe also a function of less inter-connectedness. If one plots the distribution of how much a person moves (physically) from their place of birth in their lifetime, I reckon the mode of that distribution will be to the left of India’s. So the chance of spreader events is less.

    c) I think Pakistan is a bad model for India. Firstly the scale of the population is around an order-of-magnitude larger in India with multiple large metropolitan areas. Even the EU is not a good example because the local governments have more jurisdiction over their borders than Indian states, the scale of internal economic migrants is much smaller and per capita access to healthcare is far superior.

    I think Indians panicked a little too early and many instances of chalta-hai follow through were shoddy. I know cases of death of old relatives in my wife’s wider family caused by one of the office colleagues of their son being asked to start work (after a holiday abroad) despite their symptoms by the senior management of his firm in clear contravention of law. Due to the managers thoughtlessness, the entire family of the son (himself, wife, kid, elderly parents) had to be in ICU and the parents didn’t survive it.

    PS: there may be genetic / immune effects in place as well as maybe different strains of the virus (who knows!) but I think the stitch is largely down to probability of spreader events, social distancing and wearing of face coverings that saves nine.

  4. The main metric for Covid response effectiveness would be the proportion of excess deaths in a time period. Other than that, we either have statistics that can potentially mislead or anecdotes which are always unreliable when it comes to the bigger picture.

    That being said, all the other countries in South Asia have better numbers than India, deaths per capita are Sri Lanka (0.6), Nepal (8), Bangladesh (26), Pakistan (28) with India close to 50 now.

    Within India, globally and internally connected states like Maharashtra, Karnataka, Delhi and Tamil Nadu have seen the highest proportion of deaths. I think the sheer number of potential travel destinations does play a part. India, US and Brazil have a large number of cities with over a million population, and a mobile population.

    There is a lot of hullabaloo over political responses, population essentialisms, but I think once the virus had spread (which it probably had by late January), pre-existing structural factors determined the outcome much more than policies.

  5. On (2) and (3) i think Pakistan success can only be known once the pandemic is over and its studied further. It could be all the reasons listed above, a combination of them, or something else completely. Lot of what ails India, ghettoized living in urban space, health care infra etc are similar. One difference i see which is similar to Vikram’s is there are less avenues to “come in” to Pakistan and once you clamp down on specific routes, you can hold the spread. India biggest hotspots are also the places which see the maximum footfall both internal and from external migration. But anyhow this are all theories.

    BTW didn’t know that Bangladesh is doing similar to Pakistan, with less hullabaloo.

    1. BTW didn’t know that Bangladesh is doing similar to Pakistan, with less hullabaloo.

      It isn’t. If you look at a time series of deaths.

      https://www.worldometers.info/coronavirus/country/pakistan/
      https://www.worldometers.info/coronavirus/country/bangladesh/
      https://www.worldometers.info/coronavirus/country/india/

      Bangladesh is doing similar to India.

      Now within india some places like Mumbai have a similar graph to Pakistan. The slums in Mumbai are probably at herd immunity based on serological tests. What I heard anecdotally from people living there back this up.

      https://www.abc.net.au/news/2020-08-08/indias-biggest-slum-declares-victory-over-coronavirus/12518818

      Within the united states we can compare places that were hit early like New York
      https://www.worldometers.info/coronavirus/usa/new-york/

      To places like california where the virus is currently raging
      https://www.worldometers.info/coronavirus/usa/california/

      IMO the most credible explanation for this is herd immunity.

      This is a bit worrisome now for some countries like South Korea, New Zealand etc. They really need to hold the fort until a vaccine comes out.

      1. Bangladesh deaths never crossed the 60 mark on any given day. The number of cases is a very unreliable stat here because it depends totally on the number of tests being performed. At my relatives office in Noida, everybody has to take a Covid test once a week, whether they have a symptom or not.

        1. I think we need to compare deaths per 1000 ppl per day.

          Pakistan is doing significantly better than Bangladesh over the past week for eg.

          The pandemic is not over, different places maybe at different stages in terms of spread etc.

  6. I have not been looking at numbers since july, 2 months. Country is being opened up, schools are going to open in many states from next month. Once that happens, country will be opened up.

  7. How to make C19 virus (ask an adult for permission and do not attempt this at home).

    A SARS-like cluster of circulating bat coronaviruses shows potential for human emergence.

    Nature Medicine, 09 Nov 2015, 21(12):1508-1513
    DOI: 10.1038/nm.3985 PMID: 26552008 PMCID: PMC4797993

    Abstract

    The emergence of severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome (MERS)-CoV underscores the threat of cross-species transmission events leading to outbreaks in humans. Here we examine the disease potential of a SARS-like virus, SHC014-CoV, which is currently circulating in Chinese horseshoe bat populations. Using the SARS-CoV reverse genetics system, we generated and characterized a chimeric virus expressing the spike of bat coronavirus SHC014 in a mouse-adapted SARS-CoV backbone. The results indicate that group 2b viruses encoding the SHC014 spike in a wild-type backbone can efficiently use multiple orthologs of the SARS receptor human angiotensin converting enzyme II (ACE2), replicate efficiently in primary human airway cells and achieve in vitro titers equivalent to epidemic strains of SARS-CoV.

    Additionally, in vivo experiments demonstrate replication of the chimeric virus in mouse lung with notable pathogenesis. Evaluation of available SARS-based immune-therapeutic and prophylactic modalities revealed poor efficacy; both monoclonal antibody and vaccine approaches failed to neutralize and protect from infection with CoVs using the novel spike protein. On the basis of these findings, we synthetically re-derived an infectious full-length SHC014 recombinant virus and demonstrate robust viral replication both in vitro and in vivo. Our work suggests a potential risk of SARS-CoV re-emergence from viruses currently circulating in bat populations.

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