|Ahead of print publication
COVID-19 endgame: Do we go for a win or a draw? Lessons from chess and the art of war
Department of Community Medicine, Dr. DY Patil Medial College, Hospital and Research Centre, Dr. DY Patil Vidyapeeth, Pune, Maharashtra, India
|Date of Submission||02-Mar-2021|
|Date of Decision||05-Mar-2021|
|Date of Acceptance||10-Mar-2021|
|Date of Web Publication||31-Mar-2021|
Department of Community Medicine, Dr. DY Patil Medial College, Hospital and Research Centre, Dr. DY Patil Vidyapeeth, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
In chess, the “hardest thing to win is a won game.” This quote is attributed to Emanuel Lasker, a mathematician, philosopher, and World Chess Champion for 27 years., Controlling a pandemic requires strategic planning, not unlike a game of chess. An ambitious goal of eradicating COVID-19, which the world medical community appears to have ventured upon, is as tough as winning a won game in chess.
We seem to have got hold of the winning piece, i.e., vaccines in record time, a laudable feat. However, in chess, more important than the winning pieces are the right moves, or more appropriately the combination of right moves.
The COVID-19 pandemic is playing out throughout the globe in varying patterns. Every game of chess has the same pieces but different combinations of moves depending on the situation of each game. Thanks to commendable efforts, we presently have a robust surveillance and monitoring system for COVID-19. Early and appropriate treatment protocols have been refined. All these, along with the vaccine, the queen in the game, make for heavy arsenal against the novel coronavirus. The efforts of researchers, laboratory scientists, and clinicians assembling the assorted pieces in record time are noteworthy.
What is the way forward? All the pieces having been assembled, the game should be handed over to public health experts and epidemiologists who are trained to see the whole chessboard instead of focusing on individual pieces. While researchers, laboratory scientists, and clinicians perceive a particular problem in piecemeal, public health epidemiologists are trained to see the big picture.
Let us take a hard look at the so-called strong piece, i.e., the vaccine against the context of the big picture. Entrepreneur and multibillionaire Elon Musk remarked that he and his family will not take the COVID-19 vaccine. This type of extreme position can adversely impact our fight against the pandemic, just as unplanned and hurriedly executed mass vaccination campaigns. Vaccine is now a strong and important weapon in our war against the coronavirus. Moreover, like all strong weapons, it should be deployed judiciously and not indiscriminately otherwise it may cause collateral harm.
“Therefore 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” – Sun Tzu (Art of War).
We should preserve our ammunition, i.e., the vaccine. Like a good military commander who surveys the terrain and layout to plan his war strategy, using these factors to his advantage and conserve resources, we should consider the terrain and layout on which the battle against corona is being fought in our country.
Unlike the Western countries, we have a number of advantages which should help us plan our strategy efficiently. What are these? First, we have a young population which is far less susceptible to the ravages of COVID-19. Second, the proportion of the population with high body mass index is around 20% in India, compared to about 60% in Western countries. Obesity is a major risk factor for high mortality from the novel coronavirus. Third, it has been postulated that infection with other circulating coronaviruses gives cross-immunity against COVID-19. Researchers have found T-cell immunity to COVID-19 in people who have never encountered the novel coronavirus.
All these factors perhaps can explain not only the low impact of COVID-19 in India compared to the West, but also in our neighbors such as Bangladesh, Pakistan, and Sri Lanka, and other Asian and African countries. Even the impact of the “first wave” was one-tenth in our country vis-a-vis the West. Moreover, as brought out in population-based surveys for immunoglobulin G (IgG) antibodies against COVID-19, the first wave in our country has conferred some proportion of our population immunity against the novel virus. The results of the third serosurvey also indicate that restrictive measures to control the virus do not work as evidenced by widespread IgG positivity in the country. It also tentatively refines the infection fatality rate to 0.05% given 21% or 30 crores in India having encountered the virus with cumulative fatality of around 1.5 lakhs.
Going by this evidence coupled with the fact that even the impact of the first wave in our country was much low compared to the West, there is no reason why we should expect a second wave. It would be wasteful use of resources to go for mass scale population vaccination in our country.
Like a good military strategist using firepower judiciously, we can afford to wait and watch conserving our resources. We can launch “surgical strikes” with the vaccine once our intelligence (monitoring and surveillance) indicates any regional spikes resorting to “containment by ring vaccination” instead of “containment by physical barriers.”
Mass vaccination is only justified when a disease has high lethality and poses a public health problem. Policymakers need to give a hard look and decide whether the infection fatality rate of 0.05% from the novel coronavirus justifies the disproportionate allocation of resources to eradicate it. It will divert resources from other more important public health problems in our country. Large-scale vaccinations in resource-crunched countries can have other hazards. There have been epidemics of hepatitis C following mass injections as a disease control government policy on the advice of the WHO in Egypt.
The present strategy should be to roll out vaccination in a phased and cautious manner rather than on a campaign mode. Initially, health-care workers, frontline workers, people with comorbidities, and the elderly can be offered vaccine on a voluntary basis and not by propaganda or coercion. A state government has threatened salary cut for refusal to get vaccinated. Those who refuse vaccines should not be threatened, ridiculed, or shamed. Such measures backfire in the long run and lead to polarization. Instead, people with “vaccine hesitancy” can be convinced by hard data with the nonacceptors acting as “controls” to evaluate the efficacy and safety of the emerging vaccines which have hit the ground running and still need hard data to establish their efficacy at population level.
Finally, do we go for a win or a draw? History of medicine does have any account of eradication of any disease in such a short period as is being attempted for COVID-19. Like in chess, it is very difficult to win a won game as exemplified by aborted attempt at malaria eradication in the seventies, and our protracted fight against the poliovirus for years in spite of an easily administered and effective vaccine. The efficacy of vaccines is also mired in uncertainty. The Bacillus Calmette–Guérin vaccine against tuberculosis being administered for years has hardly any impact on the prevention of tuberculosis in our country.
Given these gray areas, it would be more realistic to opt for a draw and learn to live with COVID-19. Once we take care of the vulnerable and the elderly as with other respiratory infections such as influenza, the novel coronavirus should cease to be a public health problem in India.
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