Prognostication of devastation in the Dharavi slums of Mumbai – one of the most densely populated and economically blighted polities in the world – dominated early discussions of the COVID-19 pandemic in India. Within a few months, though, this pessimism was replaced with descriptions of the “Dharavi Miracle.” Even the WHO said, “Dharavi should be seen as an example across the world.” In the literature, studies pointed to the Dharavi model as the ideal strategy in contexts where social distancing is impossible or difficult to follow. But these glowing global portrayals don’t reflect first-hand accounts from family nor more recent literature – so where does the truth lie?
At the core of the approach to COVID-19 in Mumbai’s slums is a persistent apathy to the consequences of blunt approaches on vulnerable populations. Starting with the organizational response, we see a willingness to further limit the rights of the already vulnerable. Though barricades, drone surveillance, and movement restrictions are common in portrayals of fictional epidemics, Dharavi was the first time I encountered these things in reality – and receiving praise rather than censure. Equally overlooked is the economic impact of the government’s policies. Government intervention in Dharavi saw the closure of the shops, small factories, and markets that constitute its informal economy – and the psychological morbidity and mortality that “economic lockdown” induced cannot be underestimated. In India, the poorest wealth tercile had significantly higher rates of anxiety in response to COVID-19 than any other. By upholding the methodologies used in Dharavi as a model around which to shape future pandemic interventions, the literature justifies and, in fact, praises a response that ignores the impact of draconian policies on vulnerable populations.
As pathologists, we must also consider the impact of coinfection in masking COVID-19 rates in Dharavi. Evidence indicates that the anti-COVID-19 effects of tuberculosis are achieved by increasing mycobacterial fitness and consequently the conversion of latent to active infection. It’s also possible that COVID-19 infections in Dharavi are being ascribed to other “acceptable” conditions, such as diarrheal disease. The detection of SARS-CoV-2 RNA in the wastewater of Dharavi communities with ostensibly no evidence of COVID-19 – and the frequency of diarrhea in young children diagnosed with the disease – suggests that gastrointestinal COVID-19 may be present. In a study of hospitalized COVID-19 patients in New York, gastrointestinal involvement was shown to attenuate the severity of disease – offering another clue to Dharavi’s seeming success.
Finally, the Dharavi response embodies the longstanding process of using India’s citizens, particularly the most vulnerable, as experimental subjects. Consider, for instance, the polity’s introduction of hydroxychloroquine. It is well-known that monitoring patients on such medications is important because serious electrocardiographic abnormalities may arise, particularly in people who have serum electrolyte abnormalities, renal insufficiency, heart disease, or are on other medications. In Dharavi, where nutritional and infectious comorbidities are common, monitoring is even more important – but patients given hydroxychloroquine were not appropriately monitored. Indian regulatory bodies cite troubled times as a reason to trade stringency for timeliness, but such excuses have been used before to justify unsafe or unethical actions.
What emerges from our assessment of the “Dharavi Miracle” is an awareness that it is now increasingly politically acceptable to sacrifice the health, economic wellbeing, and privacy of the poor to secure the health of the more affluent. As long as some people are considered of higher value than others, life becomes a commodity and all are vulnerable to exploitation – with the approaches to that exploitation lionized as revolutionary solutions.
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