The CoViD-19 virus is presently the queen on the chess board. But, in chess, the focus should be on all the other pieces too. Western countries, the whites in the game, despite their good hygiene, and low population, majorly due to high old age and obesity, have been the worst affected than most of the Asian and African nations, the blacks on the board. While things are different on the white and black side of the chess board and the black is likely to win the CoViD-19 endgame, it will lose the tournament as lockdown will only lead to loss of livelihood and many lives which could, otherwise, have been saved had black not opted for the drastic measures imitating from the white side of the chess board, writes epidemiologist AMITAV BANERJEE
One of my favourite methods of teaching epidemiology and public health is to compare this fascinating field with the game of chess. While a clinician treating individual patients sees a disease problem in piecemeal, a public health epidemiologist has to see the larger picture.
In chess, the beginner gets fascinated with the power of individual chess pieces, the favourite of most being the queen. A seasoned player on the other hand, not only sees all the chess pieces but also the combinations of these pieces with each other. A novice player who focuses only on one piece at a time loses easily to an experienced player. In chess seeing one’s own pieces as well as the opponent’s pieces and their relationships to each other is important to win.
The CoViD-19 virus is presently the queen on the chess board. Most novice players and self styled experts have their vision firmly focused on it oblivious to the other pieces and their combinations on the chess board on which the CoViD-19 chess game is unfolding. Presently it is in the middle-game phase, ideal time for seeing the other pieces and analyzing their combinations on the chessboard.
Black is winning. A rapid look at data (as on 17 May, 2020) from a sample of Western, South Asian and African countries will make this apparent [Tables 1 – 3]
Western countries have better hygiene and sanitation with much lower population density than most Asian and African Countries, still they are the worst affected not even the royalty being spared. Most African and South Asian countries have very high population densities with a large part of their population staying in slums where “physical distancing” and “hand washing” the measures promoted to control spread of CoViD-19 is just not feasible. For e.g. the total slum population of India is over 6.5 crores, the size of most European countries. For more than a month this large slum population is confined indoors due to lockdown, in fact achieving the opposite of physical distancing and hand washing. Anyone who has visited a slum will see the crowded living conditions (5-10 persons in a room), the scarcity of water and common toilets.
Why the sky has not fallen on this population of 6.5 crores? Spain, Italy, UK and France with population equal to or less than 6 crores are having almost 30,000 fatalities from CoViD-19? India with a population of 130 crores, has below three thousand deaths so far. Lockdown cannot be the reason as explained because of the proportion of slum population size which is equal to most European countries.
The same pattern can be observed in almost all the countries in Africa and South Asia shown in Tables. Western countries which can indulge in the privilege of social distancing and frequent hand washing are having 200 to 500 times more fatalities from CoViD-19 than the crowded and unhygienic populations of South Asian and African countries.
What are we missing? Why are we insisting on one size fits all? Obviously something is very different on the white and black side of the chess board. Let us look at the other pieces on the board. As will seem striking from the Tables the Western countries have much higher median age and much higher levels of obesity compared to the Asian and African countries. Older age is associated with higher fatality from CoViD-19. So is obesity, it compromises lung function and also is a surrogate marker for other co-morbidities such as hypertension and diabetes, conditions increasing bad outcome from CoViD-19 infection. It seems that even a little higher prevalence of obesity increases mortality from CoViD-19. Among African countries Egypt and South Africa are having higher obesity rates and also higher mortality in Africa from CoViD-19 albeit far lower than the Western countries.
Some have also suggested that past infections with other corona viruses, likely in overcrowded living conditions may offer cross immunity against CoViD-19 – this has to be confirmed by proper studies.
It is possible that factors like lower age of population, lower prevalence of overweight and past infections with other corona viruses may be acting in combination (like weaker chess pieces) to trap the CoViD-19 queen on the black side of the chess board.
This is the middle game analysis… with the massive advantage so far… black is likely to win the CoViD-19 endgame. The serious concern is that it may have won the game but will lose the tournament. Due to lockdown there will be loss of livelihoods and many lives which could have been saved had black not opted for the drastic measures imitating from the white side of the chess board.
The take home message both in chess and public health is that we should see all the pieces and their combinations on the board to win and avoid the present zugswang state.
AMITAV BANERJEE is Professor at Dr DY Patil Medical College, Pune. An epidemiologist, formerly with the Mobile Epidemiological team of the Armed Forces Central Epidemiological Surveillance Centre at AFMC, Pune, he has experience of control of epidemics at different locations of the country such as outbreaks of pneumonia, hepatitis, typhoid, German measles, food poisoning and tribal malaria. https://www.youtube.com/watch?v=bZOWByfbYNY . He can be reached at amitavb@gmail.com
Opinions expressed in this article are of the author’s and do not represent the policy of The Edition. The writer is solely responsible for any claim arising out of the contents of this article
Tags: #Covid-19 #CoronaVirusOutbreak #Lockdown #GameTheory #HerdImmunity #Chess
The Edition 
Thank you very much for the thought-provoking in-depth analysis of the COVID- 19 pandemic in a lucid manner. I believe that everything has got some merits and demerits creating a delicate balance in this world. Otherwise, the deprived nations of Asia and Africa might extinct from the earth. We should come forward to plan and carry out research to identify and characterize the factors playing role in differential expression and impact of COVID-19 illness in different parts of the world. You can lead such an effort in South Asia, the hub of nearly 1.5 billion people.
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Thank you Professor Islam for the very kind words. I have tried to explain the distinct patterns across the different continents…even other Asian countries such as China and Japan where we expect better reporting have lower death rates than the Western countries. I have a feeling that obesity is a strong predictor of fatality from Covid-19 as age profile of Japan is comparable to West but their overweight prevalence is almost half. However, such ecological studies can only generate hypothesis and as you rightly say we need good research. Regards and wishing Happy Id to all. Amitav.
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This is an interesting read, well written, nice blend with Chess game. Appreciate for producing a nice editorial – I enjoyed reading, but I’m afraid if the theme is correct. Although the amplitude of the outbreak witnessed in USA and other developed nations has far exceeded those of low and middle-income countries (LMICs), the discrepancy is purely an accounting error. LMICs lack the resources for routine testing. In some instances, citizens are reluctant to be tested out of fear that they will be socially isolated and taken into quarantine. Moreover, in LMICs, most people die at home, without a concrete diagnoses or an attributable cause of death.
A note on the technical aspect – the web screen is red (if that is only the case in my desktop?) which is truly distracting the reader.
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Dear Dr Narayan. Thank you for your insightful comments. Asian and African countries are likely to have many times more subclinical and undetected cases due to younger population who survive much more often and difficulty in testing the whole population. Because of this it would be more accurate to compare the death rates as deaths are required to be reported in all countries by law. So underreporting by itself cannot themselves explain the huge differences in rates of death. Regards. Amitav
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It is an interesting read but I still feel that it is lacking on specifics
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Thank you Mr Sanjeev. Would be able to address your concerns if you pinpoint them. Have limited to hard data available in the public domain and which can be verified. Regards, Amitav
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Are you sure that the official numbers of the Asian countries are the real ones? For example, here in Italy it is said that behind each positive tested there are at least ten other positives that have remained invisible!
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Dear Mr Davini, Thanks for your interest in the oped. Your point is very valid. Yes official numbers are subject to inaccuracies. If in Italy there are ten undetected positives for evey one detected positive the corresponding ratio in Asian countries is likely to be many times more due to our younger population who survive much more often and difficulty in testing the whole population. Because of this it would be more accurate to compare the death rates as deaths are required to be reported in all countries by law. Regards. Amitav
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Excuse me professor if I bother you again! But how do you know if the COVID-19 mortality rate is the real one if the post-mortem test is not done? Most of the symptoms of COVID-19 are nonspecific!
In addition, age is only one of the factors involved! Social status and exposure to air pollution are also very important! In the United States most of the deceased are African-Americans and Hispanics, that is, the poorest classes in society!
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Thank you Mr Davini, you are most welcome. I agree with you about the non-specific symptoms and that there are many other factors besides age such as air pollution and social status. But many of these factors go together for instance low socioeconomic status and poverty would deprive one of treatment of their comorbidities such as hypertension and diabetes which in turn increases fatality from the virus. As we are yet to know fully the natural history of the disease the oped was based on whatever hard data was available in the public domain and identify clear patterns. The glaring differences in deaths and associated factors such as age and overweight prevalence seem to tell a story which need to be confirmed by scientific studies. Idea was to stimulate the research questions for such studies. To this end your valuable inputs will also contribute and thanks for the same. I would be glad to address any other concerns. Regards. Amitav.
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