The World Health Organization (WHO) and public health thinking in general works with fixed ideas of wealth and hospital resources in evaluating health issues. But Covid-19 reduced to nothing the resources of the world’s richest and most technologically advanced countries. This bears some reflection.
Even though we think of richer countries as being healthier than poorer ones, the annual death rates of countries are surprisingly similar, despite the massive disparities in wealth. Going by figures given out by the WHO, the death rate for most countries of the world is close to 1 percent, with a few countries at the lower end at about .5%, and even fewer countries at the higher end at 1.5% (Source: WHO burden of disease figures for 2008).
The picture that emerges is by no means one of a conquest of death or disease as countries get richer. Rather, there is an epidemiological shiftof the burden of disease from infectious to non-infectious disease as countries transition from lower to higher levels of wealth. This led to a lack of experience with infectious disease in higher income countries that cost them dearly when Covid-19 came to their shores.
Doctors at the epicentre of the Covid outbreak in Northern Italy were quick to intuit the misalignment of their current medical practice, with the exigencies of a highly contagious disease like Covid-19: “Coronavirus is the Ebola of the rich…..The more medicalized and centralized the society, the more widespread the virus…” (At the Epicentre of the Covid-19 Pandemic and Humanitarian Crises in Italy: Changing Perspectives on Preparation and Mitigation, Nacotiet al., NEJM Catalyst, 21 March 2020).
“The Coronavirus epidemics should indeed lead to a number of reflections on the organization of healthcare and the way contemporary medicine has lost sight of some diseases, such as infectious ones, that were, probably prematurely, seen as diseases of the past….We have definitely not won the fight against infectious diseases, but we have probably forgotten about them too soon. In a high-technology setting, it is all too easy to forget the overwhelming, often dark power of nature” (Hospitals as health factories and the coronavirus epidemic, Giorgina Barbara Piccoli, Journal of Nephrology (2020) 33: 189-191, 21 March 2020).
Covid-19 is a good reminder to countries like India not to lose sight of infectious disease as it goes up the income ladder.
The WHO and public health field will look at the numbers of physicians or hospital beds per thousand of population as a determinant of the strength of a country’s health sector. But a closer look at the state of medical services in different countries reveals that there is no straight line between a country’s wealth and its hospital resources, physician density; or its ability to combat infectious disease or manage a high volume of patients.
Cuba probably has the most medial resources per capita, its physician-per-1000-of-population ratio is the world’s highest at eight, the second highest is Sweden’s whose figure is only half that of Cuba’s at four (World Bank physician density figures).
Going by the World Bank’s Gross National Income threshold, the relative wealth of Lower Income to the least wealthy Higher Income Countries is 1:12, but their beds-per-1000-of-population ratio is 1:3.88. The number of beds-per-1000-of- population of Upper Middle Income Countries at 3.41, is close to that of High Income Countries; and that of Lower Middle Income Countries at 2.08, is only just under half that of High Income Countries(data for beds-per-1000-of-population from The Global Impact of COVID-19 and Strategies for Mitigation and Suppression, COVID -19 Response Team, 26 March 2020).
If you compare the incidence of tuberculosis as a percentage of the number of tuberculosis deaths given by the WHO, you get a figure of about 8.5% for India, which is about the same as the figure for Italy and Germany (about 8.5% and 8.3%, respectively), and lower than for France at 10.6%; and only double that for the USA, 4.6%, and UK, 4.3%. The figure for Kenya and South Africa, 4.3% and 4%, respectively, is as good or better than that for the USA and the UK. The figure for Mexico is about 11%, which is close to that for France. The figure for Sweden is exceptionally high at nearly 17%.Even accounting for cases missed in South Asia and Africa, this says something about how well doctors are coping with the cases that do come to them, despite the relative lack of resources, and larger number of cases.
Norway has shown zero tuberculosis deaths in recent years, but the number of tuberculosis patients has remained unchanged at about 300. This might be indicative of some difficulty in its ability to cure tuberculosis, even while keeping its victims alive. 2002 was a terrible year for tuberculosis in Norway, with 100 tuberculosis deaths estimated in that year against an estimated incidence of 280 cases, giving a crude mortality of over 35%.
The four-times higher doctor-to-patient ratio of Sweden to India’s did not stop it from having more Covid-19 deaths than India as late as mid-May.In early July, Dharavi in Mumbai, Asia’s biggest slum, had recorded about 2300 cases and 82 deaths from Covid-19. This is nearly a third of the Covid deaths and about a quarter of the cases in Norway, even though Norway has about the same to half the population of Dharavi (depending on how many migrant workers fled from Dharavi during lockdown).
The calculations here of tuberculosis death rates are not from the WHO, they are my calculations are based on the WHO mortality estimates and case incidence for this disease for the year 2008, and in the case of Norway, for the year 2002. The WHO and public health officials will say that you cannot compare the country-wise data, or even the year-wise data. But if that is the case, then why are they doing exactly this when it comes to Covid-19? What do the numbers mean, if you can’t compare either year-on-year figures for a country, or country-to-country figures with each other?
In Covid times, it is also important to recognise the value of our experience with large numbers. In a given year, developing countries in South Asia and Africa see an infectious disease incidence numbering in the lakhs and crores, while developed countries like the UK, Germany, Italy or Spain see mere tens of thousands of cases. In absolute numbers, even the incidence of non-communicable disease in developing countries is much greater than that of developed ones.
At the 2400-bed All India Institute of Medical Services in New Delhi, the average daily footfall is 15,000. According to its Annual Report for 2018-19, it saw about 38 lakh outpatients, 2.5 lakh in-patients and conducted 2 lakh surgeries. Compare this with the USA’s biggest hospitals:according to a site called Becker’s Hospital Review, the New York Presbyterian Hospital/Weil Cornell Medical Centre,which has 2200 beds, sees 43,000 emergency room patients and conducts about 77,900 surgeries annually; the Florida Hospital in Orlando sees 32,000 in-patents and 53,000 out-patients annually; the Methodist Hospital in Indianapolis sees 97,000 patients a year. This is not to say that poorer countries have some kind of magic formula by virtue of seeing more cases. But a better understanding of the kinds of numbers developing countries face as a routine, would have helped both them and richer countries respond more sensibly and moderately to the Covid-19 crisis.
We are not seeing the relevance of the differences in hospitals and medical practice that grow out of the differences discussed above in the disease profile of countries at different stages of development. Led by the world’s leading authority on disease, the WHO, we think of the differences only in terms of rich and poor; and resource-constraint or resource-abundance. We fail to see that the nature of medicine, hospital management and disease control practiced in developing countries with a large burden of infectious disease and an endemic lack of resources might actually have lessons for all of us in Covid times. We need to pivot for answers from looking at the richest countries in the world, to looking at the poorest ones. They are the ones with the relevant experience, whereas the richer ones have virtually none. We should have been speaking to doctors who function with less and not more resources, because Covid-19 dwarfs even the world’s best resources.
Suranya Aiyar is trained in mathematics and law. Her paper, Covid-19: Dodgy Science, Woeful Ethics, is available on covidlectures.blogspot.com.