Drugs and Tests Aren’t Enough to Understand COVID-19

By Prof Ramila Bisht and Waseem Akber

Let us offer some counter-intuitive juxtapositions as food for thought over COVID-19. We believe we could surely resonate with some sections of society who would feel the ‘aha!’ on reading this, thereby opening a channel of a minuscule sort of liberation if nothing else.

Even before the invention of the microscope, some would have suspected the existence of microbes, too small to be visible to the naked eye. Undoubtedly, with its inclusion in the cultural range of tools, humans have developed a keen interest in understanding the intimate relationship between a host of micro-organisms and our species, thus reckoning to appreciate their multitude, the diverse niches they occupy and their complex ecologies. 

We do understand the importance of microbes on human health. Not all of them are pathological. Some produce oxygen and some help in digestion. They even exceed the number of human cells in the physical composition of the human body and hence, redefine humans as more than just idiosyncratic individuals. In return, a human host has a lot to offer to microbes with its  nutrient-rich and moist environment. Of course, our commune with microbes is not without imbalances and is not always mutually beneficial. A small percentage of microbes, which include viruses, bacteria, fungi, etc., are pathogenic, that is, they cause diseases in humans directly or through other species and may evolve to affect humans. 

Coronavirus-19 belongs to the same order of infectious pathogens. Interestingly, the current COVID-19 situation has mainstreamed the traditional model, famously known as the epidemiological triad in esoteric academic circles, for the infectious diseases that coalesce an external agent, a susceptible host, and an environment together to account for disease causation. The epidemiological triad or triangle is comprised of a susceptible host, an external agent and an environment that brings the agent and host together. In theory, there is a clear cut separation between infection by a pathogen and the disease that ensues. However, in practice, the arbitrary distinction collapses. And more so, the emergence of new infectious diseases, the re-emergence of existing ones and treatment-resistant infections have brought crashing down the “biomedical utopia” that promised the establishment of an institution of medicine to exterminate all diseases and solve the miseries of humanity. So, the question is how to deal with the situation.

Iconic Representation and COVID-19 

It is pertinent to mention here the role of the “glossy” image of COVID-19 widely circulated to grab the attention of the public. The rhetoric of photography, i.e. this is the virus, feeds into that imagery which is merely an illustration, not a depiction of the pathogen. Above all else, the virus is invisible, and its symptoms almost mimic many other common ailments like the common cold, various allergies, and so on. It’s this uncanny resonance that attributes the viral disease/infection an unknowable/unidentifiable character. Therefore, a lay person is caught in what Chiara Cappelleto calls “a double bind between” optical efficacy and the phantasmal quality of the image. To put simply, it could be called a double-blind between that visible to an eye and that which is made public for consumption. It means virus infects without palpable symptoms, in most cases, laying no mark of its presence or absence.

For the lack of any visible mark on the sick bodies, the ultra-search for the infected ones has pushed for the development of applications like Aarogya Setu to compensate for the imperceptible symptoms. And thus, new health wisdom percolates popular imagination in which everyone is sick. It flips the conventional thumb rule, health as the relationship upon which diseases impinge. Rather, now it is health that is to be maintained and achieved, spawning race for the consumption of “health” that could be bought in the market. We are proactively told that drugs are life now and it’s the drugs that can enable one to regain health. As if, health is encapsulated within drugs. In the case of COVID-19, that is yet to come but many drugs are in the pipeline.

Therefore, with almost no clinical intervention to prevent disease, the response to the COVID-19 situation should have been physical distancing. However, that would have granted meaning to all forms of care, attachment, and mobilisation of care initiated. There has been a call for social distancing which not only asks for negative performance, but also for proactive abandonment of all desires and gestures of contact. It calls for a cessation of all forms of sociation, that is, no hug, no handshaking, and so on. New rules need to be found to guide appearances and movements in the public sphere. Thus, social distancing is very much politico-aesthetic. 

Strangely, we are at a crucial stalemate where we observe a profound sense of disorientation and suffering. It could be partly due to the suspension of being “mobile”. “On the move” has been what we aspired for the “modern”. To be bound is traditional. Thus, we no longer experience our homes as the most welcoming spaces of all and, paradoxically, this unsettles the notion of home as the space of comfort.

Beyond the Language of Pandemics

The intention is not to dismiss COVID-19 crises as some quasi-faux and a matter of discourse. It is real. Everything has come to a grinding halt. The question is how to make sense of the standstill that the novel coronavirus has brought. And, the suggestion offered has been to read coronavirus morbidity and mortality figures of India in a more meaningful way by collating statistics of other infectious diseases, say tuberculosis. It’s said to put the current COVID-19 figures into perspective., In 2018, tuberculosis alone killed more than 4 lakh (400,000) patients in India excluding other comorbidities related deaths. Further, the mortality rate of COVID-19, which is 0.41 percent, is way below the mortality rate of tuberculosis that is pegged at 32 deaths per 100000 population. What it implies is that at any given time, 32 people will succumb to it. More interestingly, India’s COVID-19 cases per lakh population are 7.9 as compared to 199 cases of tuberculosis. The figures for tuberculosis would swell up substantially if the million missing cases are accounted for, which remain either undiagnosed or not notified, particularly by the private sector. 

However, sketching such a comparison between the two infectious diseases implies other infectious diseases require more attention than the COVID-19 crises. The problem with this framing is, one is caused by the bacteria and the other is by a virion species. Another issue with this sort of reasoning is discrediting complexity and interactive relation between various factors that go into its making. In reality, there exists a complex relationship that is obfuscated by the deployment of isolated standalone factors like pathogens, immunity, and so on. It is for this reason one should forgo COVID-19 crises as a pandemic, not in a spatial sense, as it cleaves the pathogenic virus and reproduces it as the sole cause of the infectious disease. In other words, there is a need for a multi-dimensional perspective that emphasises interactive and complex relation of pathogenic microbes with other infectious diseases, non-infectious disease, and other socio-cultural, economic conditions like poverty. 

Merrill Singer has conceptualised “syndemics” to reframe the historico-conventional understanding of a disease happening in isolation. Syndemics draws attention to why multiple diseases affect a certain group of individuals, the pathways through which they manage to enter biologically in individuals and within populations and thereby, amplify disease burden; and the ways conditions of social inequality, injustice lead to disease clustering, vulnerability and so on. Therefore, it’s no surprise that African Americans have died from the disease at almost three times the rate of white people. Syndemics is about co-presentation, the interaction of various diseases thoroughly intertwined in the social and environmental factors that amplify the negative consequences of disease interaction. For instance, if a person contracts HIV in India, what ensues is not only weakened immunity but susceptibility to contracting a tuberculosis infection. The composite of living under poor socioeconomic conditions with inaccessible, unavailable, and unaffordable public health services amplify their (disease) spread among the vulnerable groups, HIV, Tuberculosis, and Covid-19 form a syndemic, rather than three isolated pandemics. 

---

About the Author

Ramila Bisht is Professor at the Centre for Social Medicine & Community Health, Jawaharlal Nehru University. Her research interests centre around health policy and reforms in India, comparative health systems and policies, urbanization, environment and health and the gendered social and cultural determinants of women’s health. Most of her research has been in highland economies and in the states of Maharashtra and Delhi. Her research themes and their theoretical frameworks and methods have been located at the intersection of social sciences and social epidemiology with a focus on Marxist feminist studies.

Waseem Akber is a doctoral student at the department of sociology, university of Delhi. His research area is around medical diagnosis and infectious diseases.