Expert View: The art of war against the wily Coronavirus

We should use vaccines judiciously. What works in a small, sparsely populated & developed country may not work in a large, densely populated and developing county. It may not be cost effective either

Expert View: The art of war against the wily Coronavirus
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Dr. Amitav Banerjee

Parallels have been drawn between the present pandemic and the pandemic of 1918. The flu pandemic in 1918-1919 had caused 50 million deaths at a time when the world population was 1.8 billion as against 7.8 billion currently. These figures are alarming enough to cause mass hysteria and panic, which is what has happened.

However, this comparison is inappropriate for several reasons. The flu pandemic of 1918-19 occurred when no antibiotics were available to treat secondary bacterial infections, which is a common complication of any viral pneumonia. Moreover, the global impact of the Great War on health of people, along with lack of antibiotics, precipitated the crisis.

Over the next decades, discovery of penicillin and other antibiotics which became freely available after the second world war saved many lives. However, for several decades, lethal viral diseases even in the absence of secondary bacterial infections, continued to cause havoc.

Smallpox caused by a viral infection is a case in point. It had a case fatality rate of 30% and 80% of the survivors had deep scars the rest of their lives. Some went blind. The eradication of smallpox in 1980 was therefore a huge relief. The history of this victory however spanned centuries, not decades or years.

It all started in 1796 when Edward Jenner noted that milkmaids who recovered from cowpox never contacted smallpox. To test this hypothesis, he inoculated material from cowpox sore into the arm of a nine-year boy. Subsequently, he exposed the boy to smallpox virus but the child never contacted the disease. No present-day institutional review board would however have approved such a study!

From the discovery of the smallpox vaccine to eradication, the journey was exceedingly slow, as if travelling by horse cart (called Tonga in Hindi), of an earlier era. It took more than 200 years and a worldwide vaccination program to eradicate it. Smallpox was the first and to this day remains the last disease of global public health importance to be eradicated.

Besides having a really effective vaccine (no masks or physical distancing were needed after vaccination), there were a number of other factors which enabled the eradication of this human scourge.

No sophisticated tests were needed to detect smallpox; even a lay person could identify it. There were no asymptomatic cases or hidden carriers who could transmit to others unknowingly. The virus was confined to humans and never infected animals or survived in the environment for long.

In spite of it being highly lethal, the smallpox virus lacked the guile of other viruses such as the poliovirus or the SARS-CoV-2 which generate a large number of hidden infections. Being straightforward, clearly, takes neither humans nor viruses very far. Comparing smallpox with Covid-19 is like comparing Hitler with Gandhi. It took centuries of hard work to eradicate smallpox.

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On the other hand, the novel coronavirus, having its origins in China, is true to the teachings of Sun Tzu. This warrior-philosopher from China wrote The Art of War, 2000 years ago. Sun Tzu emphasized the role of deception in war and wrote, “A military operation involves deception. Even though you are competent, appear to be incompetent, though effective, appear to be ineffective...When you are going to attack nearby, make it look as if you are far away...”

This deception was aptly illustrated by the unexpected second wave in India! With each passing day, the virus which is barely in its second year is getting deeply entrenched in the community aided by all the deception at its command. We have to reconcile ourselves to a low intensity and long drawn conflict.

From smallpox virus to the coronavirus, we have come a long way. Vaccines which took centuries, decades and years to be rolled out in the community have been developed within a year, an unthinkable and laudable feat. Extraordinary advances in genomics and precision medicine have driven this miracle in vaccine production. In record time we have a strong weapon against the SARS-CoV-2 virus.

To get a level playing field against this deceptive and strong enemy, we can take lessons from Sun Tzu’s Art of War which cautions about use of strong weapons and says, “those who are not thoroughly aware of the disadvantages in the use of arms cannot be thoroughly aware of the advantages in the use of arms.”

We should preserve the vaccine and use it judiciously. Like a good General, we should survey the lay of the land. What works in a small, sparsely populated and developed country may not work in a large, densely populated and developing county. Moreover, it may not be cost effective either.

Evidence is emerging that natural infection is as robust to vaccine-induced immunity, if not better. Densely populated countries like India with congested slums and congested marketplaces, where social distancing is difficult, provide ideal conditions for fast community transmission of natural infection.

The key to community control of viral infections is herd immunity. This can be obtained either by natural infections, slowly, or by vaccines, swiftly.

Natural herd immunity can be compared to the tonga (horse-cart of a bygone era), while vaccine immunity can be compared to a modern, motorised bus.

Data from some parts of the country already indicate that large swathes of the population have developed antibodies against SARS-CoV2 in the aftermath of the second wave. In Ahmedabad in Gujarat, one of the worst affected states, more than 70% of the population were found positive for antibodies in the last week of May 2021, a sharp rise from the 28% detected in February 2021.

The Indian Council of Medical Research is planning the next round of country wide serosurvey. Based on the findings, a more targeted vaccine policy may give more bang for the buck. Excluding people with antibodies for the time being and including only the susceptible will achieve herd immunity faster at less cost.

The tonga of herd immunity at the moment appears to be ahead of the bus with vaccines.

(The writer is Professor & Head, Community Medicine and Clinical Epidemiologist at Dr DY Patil medical college, Pune. Views are personal)

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