Dr. K. Srinath Reddy discusses social media, data, migrant workers, and ecological concerns in the COVID-19 pandemic in the second part of his interview with Manjari Mahajan. This interview was originally published in Pandemic Discourses.
This is part two of the Interview with Dr. K. Srinath Reddy.
Mahajan: Can we talk about data and information flows in a pandemic? One of the striking things in the last couple of months in India has been that, in the absence of government-provided information, or trust in government-provided information, social media has taken on an unprecedented importance. The information shared on social media has driven community organizing, neighborhood actions, international fundraising, resource-targeting, accountability, and eventually, even policymaking. This is a new dynamic. Even when the pandemic was at its worst here in New York a year ago under the Trump regime, we got our numbers from the state governor and city mayor’s offices. But in India, we were seeing how lay people’s tweets, Facebook posts, and WhatsApp messages were responsible for directing ambulances and oxygen cylinders. They were creating panic but also directing resources. They became almost a substitute for an official, trustworthy flow of information and data.
What are your views on this role that social media has taken on?
Reddy: Well, as you’ve seen in the United States and as we are seeing here in India, social media can have multiple different strands. There is social media which is interested in reporting what it perceives to be the truth, and quite often, it is reasonably factual. And it alerts people to something that is hidden from view, either by the media or by the authorities. Or it tries to highlight a problem that’s really erupting in a particular area, which has not yet caught mainstream attention. And it at least helps to prevent obfuscation of the truth. Even then, it may be relatively limited, because its line of sight is pretty limited, it can’t cover the entire country. Urban areas get a lot of attention. Rural areas don’t get much attention. So those are limitations.
Then there are those sections of social media which have an agenda. Either they are there to condemn the government or inaction of the authorities, particularly if there is political polarization. Or they jump in to defend the government and basically, dismiss and deride any negative comment or even fair questions as being maliciously intended to defame the government.
You do not know how much truth there is because there is so much discord and diatribe. But having said that, and having acknowledged that social media has all this churning, it still does play a great role by bringing out facts that would otherwise lie completely hidden from sight.
So you have people caught in between. You do not know how much truth there is because there is so much discord and diatribe. But having said that, and having acknowledged that social media has all this churning, it still does play a great role by bringing out facts that would otherwise lie completely hidden from sight. So we should accept the fact that social media has been a useful addition.
Mahajan: This question of social media and the type of information it provides is linked to a broader issue of generating data in an epidemic. As is often the case in times of crisis, good data are both absolutely essential, but also often a casualty. In the Indian context, but not only the Indian context, there have been cases of how data are manipulated or suppressed. So within public health systems like India’s, what are the lessons for the kind of infrastructure needed for producing data? What kind of institutional norms and guardrails do we need so that data don’t get manipulated and co-opted for the most convenient narrative of the moment?
Reddy: I believe we require timely data and credible data. We need data which is relevant for policymaking and program decisions of a relatively immediate nature, for the medium term, and for long term reprioritization. The periodicity of data matters – you do surveys once every five years – but that may not give you the kind of data that you need for immediate action. So, you require different types of data, with different time scales.
You also require the data loops to flow in different spaces, so you require some essential data which can be locally generated, and be available for local analysis and appropriate action for quick responses at the sub-district, block or village level. You also require some additional pieces of data to flow along with this local data to the district headquarters, where supportive supervision can be done and mentoring can be provided. Then it has to go to the state capital level where you have possibly some corrective measures or resource reprioritization, and of course, to the national level, where again you look at interstate allocations and how the national programs are functioning and so on.
The quality of data matters. Data won’t be trusted if the people who are utilizing data do not appear to be openly sharing it or are being very selective in their choice of which data to use. On the other hand, if data is shared in a transparent manner, and the data quality is emphasized, then the people on the ground will realize that data is important.
People should not be pressured into submitting false or incomplete data or penalized for submitting data which is not pleasing to hear for the policymakers. That kind of assurance must be there, that people will get to hear the truth both from the people collecting the data and people who are actually sharing the data. So, I think that is important.
The other thing that we must ensure is that this data is disaggregated data, because a lot of local decisions need to be made on the basis of the local data and a local analysis of what the relevant issues are for health programs. You will require disaggregated data especially for assessment of equity issues.
You require not just pure digital literacy and fancy apps, you require a lot more on-the-ground work. So, epidemiology requires both shoe leather and smartphones.
Finally, you need to supplement your quantitative data with qualitative work. There need to be at least some key informant interviews, if not focus groups and so on. Because you may find out what the problems are, but you do not know why the problems exist unless you supplement the quantitative data with qualitative work. So you do require mixed methods research as well. For instance, why are people not wearing masks? Why are people reluctant to take vaccines? It doesn’t serve any purpose to say that only 30% are willing to take vaccines. Why are the other 70% not willing to take vaccines? What are the kinds of misconceptions? So for that, you require not just pure digital literacy and fancy apps, you require a lot more on-the-ground work. So, epidemiology requires both shoe leather and smartphones.
Mahajan: What would your report card for India be on matters of data in the context of the pandemic?
Reddy: Well, India has improved over the years in aggregate terms in its data quality, its data periodicity, and the digital ability to gather data. But I’m not sure whether data are being appropriately collected and adequately reported at the ground level.
We must be very clear that during a pandemic situation, sometimes it is not the precision of the estimate that matters, it is the directionality of the estimate that matters much more. So I’m repeatedly challenged about the cases being underestimated or the deaths being underestimated. Of course they are most likely underestimated. And there is likely to be a considerable noise-to-signal ratio. But if the noise to signal ratio is relatively constant, then you can at least talk about a trend – whether the pandemic is still on the rise or whether it’s on the descent. You will not get the precise estimates. But at least the directionality can be shown. There is no doubt that we have to really improve the precision of estimates. But sometimes for decision making and tracking, you may have to live with some imperfections as long as they’re not affecting your overall judgment of the direction of the pandemic.
Mahajan: There is a foreboding that the pandemic is now moving through rural India. You wrote in a recent article in The Indian Express about the health infrastructure being much more rudimentary in rural India. And you also noted that the attention that rural India is likely to receive is, at the best of times, limited. So what do you think the country should be doing to address the pandemic in rural India?
Reddy: Firstly, try and restrict unnecessary movement between rural and urban areas. Last year, the rural areas were relatively protected. But since then, local body elections attracted political parties from the state capital and other urban centers. Assembly elections were even worse. Religious festivals had people traveling to and fro. All of these actually ensured that the virus had easy passage into the villages and small towns.
Secondly, the state has to support local communities in providing services. Simply because state services do not have the capacity by themselves to provide all the services. So you have to support community based organizations which have a ground level presence, even as you’re bringing in your primary health care teams, and possibly mobile labs and mobile hospitals.
You have to apply slightly different approaches to rural and urban areas. Repeating tests every few days may not be possible in rural areas. So you have to take a syndromic surveillance approach for diagnosis. You do a test if you can, but also go by clinical symptoms. You have to ensure that you have a well structured and dependable transport system to take patients to nearby places for care.
But the most important thing is to try and reduce the transmission rates.
And when vaccines become more available, make sure that they get the vaccines without having to go through the maze of trying to register on a smartphone, which they may not have, or which they may not always be comfortable with using.
Mahajan: What you’re saying about travel and transmission points to the issue of being able to sustain migrant populations in cities in a way so that they don’t feel compelled to go back to their villages. That was what we saw in the first wave.
I think that is a lesson to urban dwellers from the middle class and upper income classes that they must learn to treat migrants, on whom they depend upon for so many services, with much greater respect, and provide much greater support for their dignified and safe living.
Reddy: Very much so. I think that is a lesson to urban dwellers from the middle class and upper income classes that they must learn to treat migrants, on whom they depend upon for so many services, with much greater respect, and provide much greater support for their dignified and safe living.
This is not a problem peculiar only to India. You saw this in Singapore and in other countries where migrant workers were treated pretty badly. And then the migrants became sick but also became the sources of infection for others. The microbe doesn’t respect your class barriers. So people paid a price for treating migrants poorly.
It leads to the whole question of how do we redesign our cities?
It leads to the whole question of how do we redesign our cities? How do we redesign our way of living so that we’re not always dependent upon migrant labor? Certainly some factories will have to run with people who come in from elsewhere. How do we make it easier for them? How do we provide better living quarters even if they are temporary residences? How can even seasonal migrants be looked after much better? So the whole area of urban design and planning has to undergo change.
We have actually centralized everything, not just in terms of the central government but also state governments. We don’t have strong local bodies, because everybody who is at the top concentrates power in their hands. So city mayors are largely powerless. If we do not decentralize in a democratic fashion, we will not pay attention to some of these problems of how to redesign our cities. We have to ask how we ensure that our way of living in cities is going to be respectfully accommodative of people who migrate from rural areas.
Mahajan: I think that’s such a crucial point. It leads to bigger questions of re-thinking consumption patterns and lifestyles that have wrought ecological devastation. At the very outset of the pandemic, many commentators were talking about how COVID-19 would force a reckoning about how disruptive our current patterns of consumption were. Do you see those kinds of narratives – that emphasized ecological imperatives – finding space in India? How would one build those narratives that are attentive to how global health intersects with ecological questions?
Reddy: Well, these narratives had started coming in when there was increasing mention of zoonotic diseases in the media. There were questions regarding where did the virus come from? Why are zoonotic outbreaks becoming more and more common? Are we violating our ecological boundaries, and allowing hitherto confined viruses and vectors to come into contact with human populations due to unplanned urbanization? But I think the struggle of dealing with the pandemic as a medical problem overtook everything.
The moment you start talking about ecology, you get the push back that – no, no, this is a virus that has been created in the lab. So that silences the whole idea of a zoonotic disease. However, we do need to bring back the ecological and environmental question.
The ecological debate also gets drowned out by the controversy regarding whether the virus is lab generated or from the wild. The moment you start talking about ecology, you get the push back that – no, no, this is a virus that has been created in the lab. So that silences the whole idea of a zoonotic disease.
However, we do need to bring back the ecological and environmental question. Because this is not the only virus of zoonotic origin. There have been so many zoonotic epidemics in recent years.
And there are so many issues that connect ecology to health – our consumption patterns and disrupted supply chains in a pandemic situation have shown how we have been flagrant in our violation of ecological sensibilities. At another level, we know that more polluted the air, the more likelihood of COVID-19 mortality; we have seen that in Lombardy versus rest of Italy. Even when you bring it down to the microbiome that is in our gut, we learn that our diets and habits affect the microbiome and its ability to combat infections. So I think the need to tie all of this is very important. And that is sometimes very complex to conceptualize. But unless we start tying all this complexity together, we’ll fail to find adequate solutions. So we do need to bring the environment back into the discussion on many fronts, including the whole area of being respectful of ecological boundaries.
Mahajan: These broader narratives and frames – of the need for equitable and broad -based primary care, the need for institutions and political norms that generate good data and information, the need for tying together public health and ecological concerns – are so crucial to take away as lessons from the pandemic. But it entails refraining from the temptation of seeing what’s happening purely as a medical issue. Instead, the pandemic has to be understood in broader social, political and ecological terms.
Reddy: Absolutely. I mean, Rudolf Virchow said that in the 19th century, and it still holds very, very true . . . that unless we start looking at the political and social dimensions, medicine will remain where it is, it will not transition into public health.
Mahajan: At one level, these are not new ideas. But the challenge is, how do you create the narratives and frameworks so that these ideas take hold and yield sustained policy and institutional change?
But we need to address the pandemic, not only from the point of view of the microbe and medicine, but in terms of how we are going to be configuring our society as we move along.
Reddy: These ideas have not become irrelevant; these concepts have been aired before. But they do not take hold because of the nature of economic forces that are driving our society. These economic forces do not let people pay attention to social, political and ecological elements, because all imperatives have to be related to economic growth. And some sections of society benefit much more than others from economic growth, and in fact, there are growing disparities. And therefore, when problems do arise, you tend to position only technological innovations as the ultimate solutions. You don’t look at the ecological component as part of the solution. You dangle a new toy, which is seemingly a very important and attractive toy, but you dangle the new toy in front of the people and say – this will take care of you. But we need to address the pandemic, not only from the point of view of the microbe and medicine, but in terms of how we are going to be configuring our society as we move along.
Prof. K. Srinath Reddy is President of the Public Health Foundation of India. A cardiologist and epidemiologist by training, he is a Foreign Associate Member of the National Academy of Medicine, USA.