Emma Ross
Good afternoon and thank you for joining us again for the Chatham House COVID-19 webinar series with our distinguished Fellow, Professor David Heymann. Today we’re looking into what’s going on in India. There’s a lot of global interest in India’s experience with the pandemic at the moment, with the official death toll passing 300,000 this week, an oxygen supply crisis, slow vaccine rollout, scores of other challenges, and news of a deadly black fungus epidemic among COVID patients. With us to explore these issues facing India and the implications for the world are two leading experts in the area, Sujatha Rao and Ramanan Laxminarayan. Sujatha is a former Secretary of Health and Family Welfare in India, who’s been commentating on the pandemic, critiquing government policy and advising state governments on their pandemic response. Ramanan’s an Economist and an Epidemiologist and he’s the Director and Senior Fellow at the Center for Disease Dynamics, Economics and Policy in Washington D.C., but he’s based in Delhi, New Delhi. He’s been a leading epidemiological modeller in the pandemic. So, it’s a real pleasure to have both of you here with us today. Thank you so much for joining us.
I’m going to do the housekeeping bit to start with. Briefing is on the record, there’ll be a recording afterwards that’ll be on YouTube and the Chatham House website. I do encourage you to ask questions of the speakers. You can do that by using the Q&A function on Zoom and upvoted questions are more likely to be selected, so please do upvote questions that are similar to the one you might want to ask.
Right, so, we’re going to dive in, and welcome to you both and it’s great to have you here. So, Sujatha, I was hoping we could start with you, on, really, an overview of what’s going on with the pandemic in India right now. There’s been a lot of coverage in the media, a lot of attention to it, but it seems to be moving quickly, as the pandemic does. But if you could brief us on what’s the situation now, what are the biggest challenges the country is facing in controlling the virus and how is the country approaching its response?
Sujatha Rao
Thank you, Emma. At the outset, I would like to thank you and Chatham House for having me here this evening. You know, well, coming to the – your question, right now, we seem to have got over the hump, the peak, and the pandemic seems to be – the virus infection seems to be coming down. We had almost a week to ten days of very high caseloads that crossed over 400,000 a day, and with deaths, more than 4,000 a day, so right – today we have about 200,000 cases. But then we must remember that these caseloads have been reducing in the context of nearly the whole country being under a lockdown. So that has made a big difference in us being able to disrupt the transmission rates and get our caseloads well under, well, some sort of a control, much better than what we had before.
But what is worrying is that almost six states, large states, Maharashtra and nearly every southern state and West Bengal, they seem to be having a positivity rate of more than 20%. That’s worrying, that’s huge. But then, Delhi has done well, it had more than 32 at the peak time, had more than 32% positivity rate, today it’s fallen to less than 5, it’s about 4.2 or something. So, there is some amount of improvement in the states, but as I said, these six states are still peaking. Whether it will continue to be – they have peaked already or they’re going to still climb higher, say in Tamil Nadu and Karnataka, or is it coming down, one can’t tell, one has to wait. But right now, we’re still clocking in 30/35,000 cases a day, which is quite high, and more than 20/22% positivity rate, and the testing, they’re keeping up the testing rate quite high. But the other states, barring these six, the rest of them are between 2-5% positivity rate, so we still haven’t reached the hallmark of less thank, you know, 1%, where we can, sort of, relax and say, “Okay, the pandemic is, kind of, slowing down really significantly.”
Now, every modelling exercise tells us that, unlike before, this time – because, you know, if you remember mid-September, we had peaked to 98,000 cases, but by October, we had sharply reduced. But they’re saying that this time the wave two is going to take its own time coming down and we can expect some amount of a more decent figure, like 16,000 or lesser, only around the end of July. So that’s a long wait, June and July.
Now, deaths, though the caseloads have been coming down, the deaths continue to be high. They have crossed 4,000 a day. Today it’s more than 3,500 a day. But, you know, these are – but what is really worrying are two factors. One is we don’t seem to know enough about what’s happening in the rural areas of the northern states, particularly UP and Bihar and these highly thickly populated states of India, and that, I believe, is going to be a challenge, which I’ll come to a little later for your second part of your question. But coming down to the – to see what is the new features of wave two, what we have found here is that, compared to wave one, more number of younger people and the penetration into rural areas, these are the two new features that we find, as compared to wave one.
But coming to your second part, what are your biggest challenges? Rather than challenges, I would say, what are the policy options which need to be addressed very urgently if we want to contain this pandemic from, again, going up, or as they are predicting a wave three, but a wave three which would be more benign than what we have faced in wave two. We will need to look at three, in my opinion, three very significant policies, which are also challenges, you might put it like that.
One is a close and a very rigorous research agenda to use this time when the pandemic – when the caseloads are reducing and the pandemic seems to be getting under some sort of control, we should really look at our data, which we need, because right now I get the impression that we are just fighting this war blindfolded. We don’t have enough of a grip on the data. Mid-wave two, we decided that – you know, we discovered it was B1617. Now, we should have known that, you know, what’s happening in the UK, we should have known how wave two was affecting other countries, we should have known that wave two was – must and was to be expected. How was it that we were caught off guard? So, we need to do a much greater dive down into our data. We have plenty of data today, whether it’s data on vaccination, which I will come to a little later, or whether it is data on where the deaths are taking place, because I do believe there’s huge undercounting. Today we are saying we have done about 28 million cases, and about 300,000 deaths. I’m quite sure, and I wouldn’t be surprised, if it was double the number of cases and double the number of deaths. And we need to know that. We need to know that and not push it under the carpet, because it’s politically convenient for us.
So, it’s very, very important that, you know, there is – that the data analysis and data research is insulated from any other externality, like a political concern, and a very rigorous review of every parameter is done, which is brought out into the public. We have wonderful Researchers, we have wonderful institutions, we should just draw the best brains, the Epidemiologists, the public health, the Biostatisticians, all the experts, and in fact, even invite experts from around the world, if required, to help us analyse this huge amount of data, to say where are we, what is our future going to look like, and how do we contain this pandemic? Because it is not going to be possible for India to fight and put up a reasonable fight, if this were to go into the rural areas of the northern states and the north-eastern states. The system – the health systems are extremely fragile, and, you know, we will have a calamity on our heads, if really, what we saw happened in Bombay and Delhi were to happen in those states. We cannot afford that. So, we need to know the actual number of deaths that have taken place over there and we need to take policy actions to really tackle that.
The second most important is, of course, as you know, even David has been advocating masks and social distancing and hygiene. Well, social distancing and hygiene is quite tough to implement and enforce in a country like India, but mask wearing and behaviour change towards that is something that we need to rigorously enforce and that needs a huge behaviour communication campaign to be launched. And I’m afraid government of India has not done enough on that score. I think that should be done, as we did for HIV/Aids in promoting condom. That was only barrier for infection, just as mask is a very effective barrier to infection in this case.
But third is, of course, is related to prevention strategies and vaccination. I’m afraid we have bungled up on that score. We are now trying our best to make up for the lost time and get as rapidly as possible to get on top of the situation of the vaccination deficit and – vaccine deficit and try and do – I mean government has really not bothered. It has understood that there is a lot of – the policy mix itself, is quite confusing, and, you know, that’s a very big subject, and I don’t know if you want me to get into that issue, but we could.
But what I would like to say when I can link it up to my first point of data research is recently, we revised our – you know, that Covishield is a very popular and mostly used – Covishield is AstraZeneca, we call it Covishield in India, and that is mostly used in India, because they’re supplying us 65 million doses a month, as compared to the second vaccine that we have, which is only about 10-15 million doses. So, it’s basically, AstraZeneca that we are dependent upon as of now. So, ‘til now, we had a two-month period from the first dose to the second dose. Then, we revised it about two weeks ago to say three weeks to four weeks. Of course, partly also, on the grounds of inadequacy of vaccine and covering more people with one vaccine.
But why I’m saying data is so important is the findings that Public Health England has just come up with, saying that the first dose only gives – of course, the variance is quite – the confidence levels are quite wide, but nevertheless, whatever the sample size and whatever their survey was, showed a 33% efficacy for the first dose, and second dose, given after two months or so, was about 60 – 59.8 or 60% efficacy. Now, if that is the story, that means – I mean, we take 50% as a goal – as a, you know, hallmark for efficacy of a vaccine. Giving first dose of AstraZeneca, which is almost 12 million people we have covered, or 10 million people we have covered in the – 10% of our population we have covered in our country, is really of no use if you are going to keep them waiting for the next three months. So, this kind of data is what we need and why do we have to depend on UK for these insights, when we have vaccinated more than 190 million people with this? And our genomic sequencing is very inadequate, therefore. So, you know, we have done hardly 1%. I think, David, you believe that we should do 5 to 10%. In your last presentation I heard you say that. But we have just done about 1 or 2%. So, you know, and I’m talking about the efficacy of Covishield against 617, which is the predominant strain that is right now all over the country, except the few northern states, where we had the 117, but I’m talking about the dominant strain that is right now being faced by us.
So, these are the sort of, issues that are very critical for us to look at, because now we are going to get a window period. As it’s pandemic wave two, I’m quite sure that it’s going to come down, the peak is over, as far as I can see, and before a wave three comes up again, I really think that we ought to give a data and data analysis and expertise to be brought in of the right kind and get our strategies much more focused and much more evidence-based than what it has been so far.
So, I think these are the challenges that I would say, and the country’s response, as you’ve seen, has been a bit, I wouldn’t say – you know, it has – first, it started with hugely centralising the whole process, but now we have realised that, you know, we need to really decentralise further into the states and the low – below down, if required. Much more needs to be done on strengthening the policy response, of making it much more inclusive, allow more civil society participation, much more anchorage on the community and community participation, decentralised to local areas and local governments, because it’s just not going to be possible for Delhi to sit and say where my vaccination sites should be or who my vaccinators should be. That kind of centralised approaches don’t work in controlling a pandemic. So, I think has been – that they have realised now, and I hope that the policy responses will get more refined, with more data coming in and more data analysis coming in, which is done more rigorously. I’d like to stop there, Emma, and maybe we can carry forward again.
Emma Ross
Okay, no, thank you, Sujatha, that sounds like a very comprehensive accounting for what’s going on there. What – I just had one follow-up on that, as to whether there is anything special in India that is driving this, of who’s getting sick and who’s dying? I mean, I heard it’s mostly the middleclasses in the cities that are most affected, maybe even women. Is that true, and if that’s true, why do you think that is?
Sujatha Rao
You know, like, I can’t give you an empirical-based answer to that, ‘cause I really don’t know out of these huge caseloads how many are – I mean, we’ve added about 150,000 cases in a flat one month, and how many of them are middleclass or low, but we certainly know that we have affected the middleclasses like it didn’t happen in wave one, and that is a fact. And, you know, in wave one, we were really worried about slum populations and so on, but this time, it’s really gone directly into the homes of the middleclasses. But that is all a consequence of the enormous amount of complacency that we had allowed to be – ourselves to be set with – in, you know, when the caseloads came down to less than 16,000 and below, and that severely crashed to nothing much, and there was this feeling of exceptionalism, because in the media and in our own policy dialogue, we would keep comparing India’s performance with the Western world. We kept comparing ourselves per million to compared to the US, compared to Italy, compared to UK. Well, of course, we always did better. You know, the deaths 110 per million, whereas in the UK and USA it’s much, much higher, so we felt we were doing very well. But we should have been comparing ourselves with Vietnam, with Thailand, with our neighbourhood, to say that, why is it that we are having much more of this impact of this COVID-19 in India, as compared to, say, the – our neighbours? So, you know, this gave us a sense of comfort and complacency.
In addition to that, government had set up a committee which – and they called it the Supermodel. They came up with a modelling exercise which seemed to have suggested – it was called a Supermodel – and it seemed to suggest to the government that we have won the battle, they declared success, and they said, you know, wave two, “Oh, nothing is going to happen.” And so, therefore there was this feeling of a sense of liberation, because the lockdown was pretty tough and vigorous. So, people started coming out, they started partying, they were socialising. Trains in Bombay, I don’t know if you know what it means, millions travel and commute in those trains, trains started, temples were full of people, and then, we had that grand ceremony, which was supposed to be held next year, but they preponed it, because next year is the election in that important state, politically very important state of UP. So, they preponed it to this year and allowed millions of Indians to go – Hindus to go and bathe in that river, and that became a huge super spreader. It was no-brainer to say that that should not have been done, simply no.
So, the other modellers who had gone and they said that, you know, “You have to be careful of wave two, it is going to hit us badly,” was set aside. We happened to believe in the Supermodel, clearly, that we were okay, and the middleclasses were only too happy to believe that, because they wanted normalcy to be restored really fast.
Emma Ross
Sure. Ramanan, you’ve done a lot of modelling on this. I wonder if you could, kind of, enlighten us of what you think? Why we think – why you think India is where it is today and what is the trajectory, what are you predicting of where it’s going at the moment? Well, first of all, how did we get here? Do you agree that it was complacency and they just let their guard down, or did something else happen, and where do you see this going?
Dr Ramanan Laxminarayan
Right, thanks Emma, thanks for having me, and thanks David, and to Chatham House, for inviting me. So, last year, in March, on March 24th, India imposed a very harsh lockdown nationwide and this was after, again, epidemiological predictions, which basically, said that there would hundreds of millions of cases. A lot of people didn’t really think it would happen, but the evidence shows two things. One is that in the case of a respiratory virus that is spread easily, especially in dense populations, that an earlier lockdown of the kind that India put into place was going to be very helpful. So, countries that did early lockdowns were able to control cases and countries that did late lockdowns were not really able to control cases.
So, if there was one thing that the Indian Government did correctly, it was to put in place that lockdown, which was done when there were only 500 cases and fewer than ten deaths. And it was a gutsy decision. It was probably poorly implemented in the sense that, you know, the migrant workers were not taken care of, there wasn’t really planning that was done, and that really should have happened, but one can’t fault the decision to lock down, because at that stage India didn’t have the testing capacity, it certainly didn’t have the healthcare infrastructure. It had all of the hallmarks of being a place where COVID would really take off. And we sit here today, where we stand, you know, based on a lot of knowledge, but at that time we had all kinds of, you know, excuses that Indians are more immune than other people, we have, you know, BCG vaccination, we have the summer heat that will kill the virus, we have hydrochloroquine [means hydroxychloroquine]. I mean, any number of reasons why India was exceptional and different from other countries.
Now, fortunately, that was not the advice that was listened to and there was a lockdown. And the data very clearly shows that the effect of that lockdown was to bring the reproductive number down from about 304, down to close to on, at .0 – 1.1 or 1.2. And this is based on, you know, a very large COVID epidemiology study that we published last year based on data from Uttar Pradesh and Tamil Nadu, and this year, again, we have more data, but it all shows the same thing, that that lockdown essentially saved India last year. But for that lockdown, India would’ve had the same, kind of, wall of cases that we see this year.
Now, of course, you know, the year went by, of course, people don’t really pay attention to the fact that projections are based on what you do with the projections. This is like saying if you’re overweight and then you lose weight, then your chance of, you know, being diabetic are much lower. And people say, “Well, you know, but you said there would be hundreds of millions of cases.” I said, “Well, if there were no lockdown.” But with the lockdown, certainly, it managed to bend the curve, but even so, India did have a lot of cases, and there was undercounting even back then. We had a peak around September, then it started coming down. The ICMR’s, the Indian Council of Medical Research, their own seroprevalence survey showed that infections to case ratios, reported case ratios, were between 26 to 32 as to 1, which means that for every reported infection, there were 26 to 32 actual underlying infections. And this was the situation in 2020.
Now, come January, of course, you know, people were asked, “Well, what’s going to happen after this?” And, you know, I, sort of – you know, for my part, I think I underestimated, or maybe I overestimated, the ability and the willingness of the system to lock down again very quickly. Because having experienced the overrunning of hospitals in Delhi and Mumbai last year, not so much in Delhi, but much more in Mumbai, that we would’ve learned a lesson from it, that this was not a virus to be trifled with, that we had no special immunity from this virus and that there would be a much quicker response. On that, I was wrong.
The second was in assuming that the planning for the vaccination had happened as was being, you know, portrayed in the media. I think, you know, if you had asked anyone, you know, I would’ve thought that India had all its vaccines procured, too, for this year, and it was a shock, come February or March, when we realised that almost nothing had been procured. And this was a shock, and the 60 million doses that India has exported were not really, you know, humanitarian assistance, for the most part. Most of these were commercial deals that had been done by the Serum Institute with other countries, because India had not bought the vaccine first and they had been sitting on a lot of vaccine stock, and most of these were not assistance, they were just commercial deals, and it was exported to about 70 or 80 countries. So, this, again, was, you know, surprising and a little worrying.
And then, of course, was the shock of actually having the messaging go off track, with allowing election rallies without people with masks, across the Cumilla. It is not as if these were the events that caused the second wave, but these events gave the perception to the common man, who has no access to epidemiology, does not read journals, you know, just observes what’s going on, and the message to them was, “Don’t worry about COVID, it’s gone, so go back to life as normal.” And people did do that. I was in Guwahati in February of this year, and this is in Assam, in the north-east, literally, I would say probably less than 2% of people that I saw wore masks, less than 2%. Assam is one of the worst-hit states right now, but back in February, which is just three months ago, nobody was wearing a mask. Why? Because that was the messaging back then.
And the last part of this is, also, that there has been no preparedness of any note. Oxygen, which is the, I would say, the biggest source of avoidable deaths in this wave, should’ve been prepared for, because oxygen shortages were not a surprise. They happened in Iran, they happened in Italy, they happened in France, they happened in the UK, they happened in New York, they happened in California. Now, what made us think that we were going to be different with respect to oxygen? And particularly for a country where a lot of people die, even normally, because of lack of oxygen, that was one.
The second is, the clinical guidelines were not based on evidence. And I would say even today, poor clinical guidelines have probably killed as many people as the virus itself. Hydrochloroquine [means hydroxychloroquine] is still on the clinical guidelines. Ivermectin is on the clinical guidelines. Remdesivir is there with very poor guidance on what really needs to happen. Plasma therapy, which the Indian Council for Medical Research had a very good study, published in the British Medical Journal, showing that it has no effect, is still, you know, not off the guidelines, so, this inexcusable. You – I mean, I think Sujatha is talking about the need for science, but even when the science is very clear, it is – it’s just unbelievable that this is not part of the treatment guidelines, because this is universally accepted that these things don’t work. Why is hydrochloroquine [means hydroxychloroquine] part of the treatment guidelines? I thought we did this – did away with this, you know, with 50 odd studies that were published, you know, last year.
So, these were three things that let things down and, of course, you know, the virus came back, and people think that the virus came back with a vengeance. I don’t think that’s true. I think what really happened is that we chased the virus with a vengeance and that’s really what happened. It was – it’s an entirely – it was an entirely avoidable situation and the fact that India actually did so well last year, despite the odds, was something to have been proud of, and only to lose the plot in February or March of this year, is really what is so disappointing about the entire thing.
Now, of course, I think that the number of deaths is hugely undercounted. Today’s New York Times has, of course, the estimate of about 1.6 million deaths. I think that’s a bit high. My best guess would be about 1.2 to 1.5 million deaths, somewhere in that range. But people are not being tested, they die, they don’t count as a COVID death. People who don’t even show up at a hospital, they’re only counting hospital deaths, you know, those don’t count as COVID deaths. And it not about the – you know, it’s not about whether, you know – the counting of deaths has an important value, because it communicates seriousness to the public. If you don’t communicate data to the public, they don’t take it seriously.
We’ve seen this with HIV. India did a great job on HIV, as did Uganda, as did Thailand, because there was transparency. South Africa and Botswana did not do well with transparency and therefore, they suffered much longer with HIV. So, it is not as if India does not have experience with vaccination, does not have experience with procurement, does not have experience with dealing with, you know, pandemics. It is just that the plot was lost and really, for, I think, no reason other than the need to manage the PR of the disease than the disease itself, and that’s really what is so sad about the whole thing, which is India was on track to do so well with COVID and that was not to be.
Emma Ross
Do you think, Ramanan, if India had hung on to its vaccine supplies, or if it had a huge supply of vaccines last year, that would’ve made a difference? With India making vaccines for much of the rest of the world, is it now paying the price for exporting those doses? I mean, would it have – even if you did have vaccine supply, would it have had the infrastructure to have delivered it in the country, even if you had the supply? Basically, would better supply and delivery of vaccines have averted this second wave as a problem, or is that not…?
Dr Ramanan Laxminarayan
So yeah, first of all, the delivery is not the issue. India can deliver 5X the amount of vaccines. That is not the great limiting step. I don’t know if that particular 60 million doses would’ve made the biggest difference, because that translates to 30 million more people vaccinated, which is again, a small number. But I think what India should have done is invested, like the US did, in some sort of Operation Warp Speed to massively increase the supply of vaccines and the production capacity back in September itself. And the failure to do that, and to treat this as a business as usual, kind of, vaccine procurement, which is this is how India procures vaccines for childhood vaccination, but this is not a normal time. This is an unusual time, and it would have been entirely worth it for India to sink $5 or $10 billion into increasing that supply, and it would’ve put India in a very different place right now, to have had something like, you know, 15/20% of the population vaccinated, would’ve made all the difference. So that’s why it is frustrating, because it – all the steps we’re talking about are things that are within India’s ability to do. And remember, India is a 2 trillion GDP economy. $10 billion is chump change for this country.
Emma Ross
And as far as – I’m going to move onto David now, on – do you think that what’s going on in India is particularly worrying relative to what’s going on in other parts of the world that are really having a tough time now, Brazil or other places? Is there something special about India that should cause the world particular concern? I mean, I’m just wondering why is there such a focus on India compared to other countries, ‘cause it seems there is? I know we have a variant that was first discovered in India, but is there something, particularly big implications of India not managing this well, David, compared to other countries? Why India?
Professor David Heymann CBE
You know, Emma, during this pandemic, the press has gone from country-to-country. They’ve looked for where the cases are most and where the problem is worst, and they’ve gone there and they’ve reported on it, and now they’ve stopped in India, after having left Brazil. So, the press is constantly bringing people’s attention to where the problems lie. India, though, is, as Ramanan said and Sujatha said, is an incredibly important country in the world and it’s got a good portion of the world’s population and a good portion of the world’s economy is being generated in India. So, it is important for that aspect, just as is the US, or as is Brazil or the United Kingdom, in many ways. So, it’s a – it’s not so much that India is more important than other countries, at present that’s where the focus is. But if you want to look at importance, it is important in the world, as are many other countries. I don’t know if that answers your question. I think we’ve had an excellent summary from both Sujatha and Ramanan and maybe we should really dig in deeper with them, because they really understand what’s going on in India right now.
Emma Ross
Well, I just, I wondered, Ramanan, maybe, or either you or Sujatha, on the economic front, and related to, Ramanan, my question to you on where do you think this is headed, is there a risk that this could really damage India’s ability to function, or is this – is that really a catastrophising thought? And, you know, where is this going and is it in danger of failing as an economy, or is that really, you know, a bit out there, a bit exaggerated risk? And if it is, what might be the implications of that geopolitically and economically?
Sujatha Rao
Do you want me to answer or Ramanan?
Emma Ross
Well, I – yes, you can, unless Ramanan – I mean, both of you, I’d love to hear from both of you on that. ‘Cause I’m trying to get to the implications of, you know, the importance of India as a country, not – I guess all countries are important, but it is a very strategic, geopolitically strategic country in the world, and I’m just wondering, is it in danger, is its function, is its standing, is its ability in danger or not? And if it’s not, we can move onto another question, but if there is a serious risk here, I’d like to…
Dr Ramanan Laxminarayan
Yeah, I think – I don’t think any country is done with – you know, until it’s done with COVID, that can actually go back to building the economy and I think that is true for every country and it’s true for India as well. We just have to be done with COVID, and we’ve got to be done with it through vaccination, and the vaccine supply problem does need to be solved. That is the fundamental one in front of us right now, which is why the Foreign Minister is in Washington right now, trying to figure out a deal, to see if they can bring, you know, the US mRNA vaccines to India. Now, the Indian economy obviously will not recover at the rate that it was expected to, but I have no doubt that once COVID is dealt with, India will come back strong, but we have to be done with COVID first.
Sujatha Rao
And I have two points, Emma, for your consideration.
Emma Ross
Sure.
Sujatha Rao
One is, you know, no one is safe ‘til everyone is safe, that’s a nice thought to think of and we need to say it again today. But I also would like to – you know, I’m reminded of the story, way back in 2000, I don’t know, David, if you weren’t [inaudible – 37:17] at the time, but that was a meeting to review polio eradication, and India had not – 2000 was a goal we achieved in India, with – along with another 14 countries, we had not achieved the goal. And Donna Shalala, Secretary of State Health from US, had come for that meeting and she told me very pointedly, I was with the Minister, and she told us very clearly, saying, “Don’t think that we are pushing you to achieve the eradication goal because we love you.” I mean, so candidly as that, “But because you have polio in your countries, we Americans have to spend $400 million on vaccinating our children.” So, there is a whole amount of self-interest involved. I mean, you know, it might sound brutally insensitive, but it’s a fact.
So, you know, if you ignore 1.3 billion doll – people and say, “It doesn’t matter if they are dying or they have B1617, we’ll come up with another mutant strain, and happily send it to the UK and USA, all your vaccines won’t help you.” So, you know, it’s something that, this is moment of solidarity where we must realise that the world is much, much more interconnected than it was before, and we cannot allow a large economy – we are the third largest economy in the world – for India, I mean, if you talk about India specifically, to fail. I mean, we are strategically poised in the middle of the world, as we would like to believe, but it’s between East and West, and, you know, we just cannot allow the huge market that India is, to allow to fail economically.
And finally, if India is helped at this moment, you know, with a patent waiver, which is pending with – for everyone’s consent, it gives the world a chance for us to be able to come up with generic medicines and much more affordable and cheaper vaccines. I find it appalling that the vaccine companies today should be thinking in terms of profiteering, at this moment, selling $20/$25 a dose, when they are not even able to assure us whether this immunity that this dose gives will be there at least valid for one year. So, you know, for a substandard, untried product, with the producer making money, I think India should be allowed – we supply 60% of childhood vaccines around the world and if we can get this waiver and our companies are incentivised, we certainly can produce it at a much more affordable level, the way we did for HIV/Aids, and save the world’s poor.
I don’t think US and a few countries in the West, in Europe, can take the whole burden of vaccinating everyone at $20 a dose. So, you know, I think we need to look at all these factors and take a good view, because I’m saying this because the patent waiver is with your part of the world, and I hope a quick decision is taken and a much more sensible, reasoned argument is made to adhere to that and agree to that request, which is affecting the world as a whole.
Emma Ross
Yeah, I mean, that’s the really hot question at the moment and…
Sujatha Rao
Yeah.
Emma Ross
…it would be interesting to see how that pans out. I’m going to move to audience Q&A now, questions, and I’m going to start with one from Richard Cash. Sorry, it’s a bit of a difficult one, bit of a challenging one. There’s this from Richard Cash, and he says, “The lockdowns in both Bangladesh and Pakistan were far less severe than in India, yet both have mortality and case rate less than half that of India. Please explain. Wouldn’t a well-crafted mask-wearing campaign have done just as well?” Ramanan, you’re smirking, let’s hear it.
Dr Ramanan Laxminarayan
No, no, I knew Richard would throw a curveball like this, so I’ll…
Emma Ross
Okay.
Dr Ramanan Laxminarayan
So, hi, Richard, as you know better than I do, the whole idea behind having a lockdown was to signal to people that they should protect themselves at a time when the data were not there to – you know, today, if I go outside my house, and of course, you’ve been here, so you know what it’s like outside here, everybody is wearing a mask. Not because there’s a cop around, but because they know that if they didn’t wear a mask, they’d be looking for a hospital bed in about ten days. So, that awareness exists today, which did not exist last year, in March, because, you know, how would people believe a disease that has killed ten people and how would they respond to that by protecting themselves? So, I don’t think a national mask campaign would have worked, at all.
Second, if you look at differences within Indian states which look at case reports and testing, the biggest determinant of cases is how much they test. So, I would not take Pakistan or Bangladesh as, really, you know – their numbers of infections are low, because they are reported infections and their reported infections just reflect inadequate testing. Their number of deaths reflect inadequate testing. You’d find parts of UP where deaths are probably zero, right? Doesn’t mean that the deaths are actually zero. And so, the best way to not have a pandemic is to just, you know, throw it under the carpet and you don’t have to worry about it, which is the approach taken by some other countries. I think that what we do om Tamil Nadu or Andhra Pradesh, or Maharashtra or Kerala are really the ways in which we should do it, which is it appears as if things are worse, but these places test at very high levels. In fact, Andhra Pradesh and Tamil Nadu actually have tested at levels which are close to that of the United States, you know, during the early part of the – you know, through to last June or July. And so, I think that’s the reason why, you know, things in Pakistan and Bangladesh are not what they appear to be.
Sujatha Rao
Yeah, Emma, if I may say a bit. You know, as a rule and as a principle, I don’t know what David thinks and what Richard feels, but the whole business of lockdown, if anything matter to me are the public health strategy. I mean, unfortunately, China seemed to show effectiveness of it, and so the whole world is following it. But do you know, a time has now come in India where we cannot afford this lockdown as a strategy. Last year, we made a monumental mistake of when, as Ramanan said, we had just 500 cases and 30 deaths, the whole country was brought into lockdown, when it could have well been contained by each – find the hotspots, and just contained it just over there. So, you know, with the result, it became so severe that that move then triggered a humanitarian crisis from which we are not able to recover. Hunger has increased, unemployment has increased, there’s a 7% shift from lower-middleclass into below poverty line and this is a huge price we are paying. Today hunger level, that’s one problem we have resolved in all these years.
So, there is this impoverished – I don’t think that lockdown, just to save a few lives, you put so many millions other at the stake. So, I think a much more calibrated policy, much more nuanced, much more refined policy mix, has to come, where we have to think of saving lives, but also look at livelihoods, by really doing much more at scale and compared to mine, everything of data and mapping where the – you know, increase our testing phenomenally more, and identify the positive cases, map them, which Kerala does beautifully, and Tamil Nadu, I think also doing, and then see where the hotspots are and really get up to that to see whether we can contain the infection within that perimeter of that hotspot, rather than just go around doing these lockdowns up and down, and, you know, reopening and locking down. It’s not something that is an affordable or a sustainable model for a country which is very fragile, like India. We have 94% informal workers, and we have to think of all these issues, too.
Dr Ramanan Laxminarayan
Yeah, Emma, if I can just respond to that. I think – oh, sorry, I was just going to say I don’t disagree with Sujatha, but, you know, the problem was that – and I would have certainly preferred the strategy that she’s espousing. The problem was that testing was kept artificially low all the way through to March and April of last year, for no other reason than appearing to hide an epidemic. India will – India has a capacity to do vast amounts of testing. First, it was just, you know, to the National Institute of Virology, then it was just to government labs. Why? We’ve got private labs, you know, all across the country. So, I think – I don’t disagree with anything that what she says, but you cannot simultaneously manage the PR of an epidemic and the epidemic at the same time. You have to choose, and you have to face the epidemic, and it you want to do PR, you’re going to lose the plot on the epidemic.
Sujatha Rao
Well said, yes.
Emma Ross
David, what do you think of that?
Professor David Heymann CBE
Yeah, Emma, I would just add that, you know, locking down took away the need for individuals to do their own risk assessment.
Sujatha Rao
Yeah.
Professor David Heymann CBE
It just locked them down. It forced them into a situation, and when they were let free of that situation, they didn’t, many times, have the knowledge or the capacity to understand how to do their own risk assessment, that was shown…
Sujatha Rao
Yeah, absolutely, absolutely.
Professor David Heymann CBE
…in the UK, it was shown in many countries. And as a result, people ended up leaving lockdown, not wearing a mask to protect others, not knowing how to protect themselves, and so they just took up life as normal again after the lockdown. What’s happening in the UK now, and in other countries, is that they’re trying to get the people to take the responsibility, because it is a personal responsibility. It’s a responsibility of each one of us to contribute to the control of this pandemic by doing our own risk assessment and modifying our behaviour accordingly, because you can have a variant which transmits very easily, but it still takes behaviour, poor behaviour, to make it transmit. It won’t transmit if behaviour is the way it should be. So, I think all countries, including India, maybe, and Ramanan, I think Sujatha may agree, and Ramanan you might not, that these lockdowns really, in the end, have been detrimental, many times, to long-term sustainability of a response to the pandemic.
Emma Ross
Yeah.
Dr Ramanan Laxminarayan
Well, I don’t disagree with that at all. I just think that, you know, we just – you – we got off on the wrong foot, and, you know, in fact I wrote an op-ed just two days before the lockdown, even though I did call for a lockdown, I said, “How about we do state-level shutdowns?” But, you know, by that time, you know, I think the trigger had been pulled on it, so it was what it was.
Professor David Heymann CBE
Yeah.
Emma Ross
On that question of what you said, Ramanan, about you can’t manage the PR of an epidemic and the epidemic itself at the same time, there’s actually question from Annapurna Sharma, who is asking, “Rural India already is the middle of a calamity, it’s just hidden by the government, especially UP. How can the government be enabled to admit that people died?” So, I guess, well what – how can we, you know, get this out in the open and get transparency and be able to tackle the problem rather than sweeping it under the carpet? And do you agree, first of all, that there’s already a calamity in the rural areas?
Dr Ramanan Laxminarayan
There’s a huge calamity in rural India, and in fact, you know – but the anecdotal evidence is very clear, the media evidence is very clear, and, you know, it’s just that – I don’t know what to say. I mean, at the end of the day, governments are democratically elected, they do what – you know, they’re accountable to the people, at the end of the day, and people are not going to vote on the basis of the total death count. They’re going to vote on the basis of, when they needed oxygen, when they needed the bed, if they needed help, did they get that help or not? And I think that many people in UP and Bihar have found that they have not received that help when they really needed it.
They have faced the brunt of a weak and unprepared health system, which, you know, even at the best of times would’ve done poorly, but this time was just completely unprepared, even though it had one year’s, you know, full notice. And it is quite something to – you know, I think we’ve all experienced this in these last few weeks, thankfully, not the last ten days, but before that, I’m sure Sujatha has as well, of receiving endless messages from people begging for a bed, begging for drugs, begging for oxygen and we’re in the cities, where we have access to resources, we have access to so much. Can you imagine that person in rural India without any of the connections that we would have, and just, you know, choking to death without oxygen, something as basic as that?
So, I – you know, an Epidemiologist would want to know what the total death count is, because then we’re interested in the science of the disease, but the average person doesn’t care about the total death count, that’s irrelevant to them. They want to know what happened to their family, their mother or brother, or sister or father, and that’s the story of COVID, which is that it has left a deep mark on people’s psyche. I’ve seen that, I’ve been, you know, outside ICUs where people have died, I have known people who’ve died, and it is that which is really going to be the – you know, that’s what’s going to live behind as people’s memory of COVID, having lost both their parents to COVID. I know so many of these people. There are states that have set up facilities for COVID orphans, there is such a thing, COVID orphans, people dying in their thirties and their forties, and, you know, how can we forget something like this? This is like, you know, someone who lived through the 1918 flu pandemic, when the excess mortality was much less than during COVID, because their baseline of mortality was already pretty high, so the excess mortality wasn’t as high.
I think this is an event that will take years, if not decades, to really, you know, recover from in some ways, and I think we’ll do the death counts, but I think the psychology of this, of what this leaves behind, is going to be – is going to last for a long time, I think.
Emma Ross
Hmmm, yeah, that’s – that was going to be another question of, you know, what can we look forward to on this? But before I do it, I’m going to go to the most upvoted question at the moment and it’s from Charles Clift, and I think maybe, Sujatha, for you, “Why do Indian Doctors seem to use a multiplicity of drugs for COVID treatments, including those that have been demonstrated to have little or no benefit?” This is something that’s come up about all the treatments that have been used and have been proven not to be right. Why is that happening, and…
Sujatha Rao
Well…
Emma Ross
…what’s at play to make this such a big feature?
Sujatha Rao
One policy gap that I can see is, and which I am unable to understand and is inexplicable to me, is why the ICMR or the Ministry of Health did not come up with a detailed treatment protocol quite – you know, and kept – and kept updated, because after all, this was a virus which no one understood around the world, and everybody was experimenting with, let’s face it. It’s not as if we knew all about it last year, in March. So, this was something that people were working on, but even so, they could have come out with this advisory, which is what is normally done, and why they didn’t is something that I’m unable to answer clearly, but that is where they have to do – they need to come up with a treatment protocol and make it mandatory for all Doctors to follow.
Now, what am I to say, why do they prescribe remdesivir? Because it’s in short supply, there’s so much of black marketing going on. At the low level, I don’t mean the big hospitals, they get a kickback from the people who are black marketing it and so, there is a whole vested interest that’s involved, and then there, even though it may have nothing much to do with the treatment outcome, they will still administer it on the patient. So, these kind of things happen. There were also genuine misunderstandings, because partly, I would blame the media channels, which every day, bring in specialists from all over the place and each one will give their own experience of the drugs they’ve used for treating a patient. And the patients and the people listening to it will pick it up and begin to demand those drugs to be used for their treatment.
So, you know, this kind of situation has developed, and I think this needs to be contained. You know, for example, of late, this whole business of CT scanners as a diagnostic tool has been coming up, where, you know, where the tests are not being able to diagnose, RT-PCR is not able to really get the virus, detect the virus, it’s, kind of, the report comes as negative, but every clinical symptom shows and suggests that the person is infected, so then he is marched off for a CT scan. So, the conditions under which you order for a CT scan should have been very clearly specified and a lot more training of our Doctors on how to handle, because I do mean that – I do believe that 90/95% of our Doctors were struggling and doing their best. It’s not at all my case that the one and odd fellow was trying to exploit the situation. They really, really work hard, and we can only salute the Doctors and Nurses for what they’ve gone through, it’s amazing.
So, it was incumbent on the government to come up, not only with guidelines, but also providing tele counselling and, also, training to the telemedicine group. I’m afraid they didn’t do enough of that. And why I’m saying this is that’s what we did for HIV, when, you know, the medications or the dosages kept changing, with new evidence and new knowledge, and then we had this, kind of, interchange with the private sector and with the public sector and kept updating them. And I think the demand was much, much more in this particular case, because almost every day there was a discovery that this is not useful and that is not useful, this is not workable and that is not workable. I think this ought to happen at best, and I hope it does – it is addressed very quickly.
Emma Ross
Hmmm, okay, so – thank you for that. This is probably one for David, maybe, to start with. Mayank Gupta, “What is” – going back to the black fungus – “what is the root cause of increased incidents of mucormycosis, the black fungus, or are there opportunistic fungal infections epidemic in India? Is it underlying health issues, such us uncontrolled diabetes or obesity, or dirty tubing of ventilators and air con ducts, or of a cocktail of potent and unnecessary drugs prescribed in and outside of hospitals? What do you think is driving this?” And while you’re at it, if you could say is this particularly worrying, or is this just something that happens, I don’t know, it’ll pass? Is this a particularly dangerous complication of what’s going on here?
Professor David Heymann CBE
Yeah, thanks Emma, and thanks Mayank. Yeah, mucormycosis is a fungal disease and it’s an opportunistic infection. So, it occurs in people whose immune system is diminished, and it occurs because there are spores that are formed, and those spores then transmit the infection to others. These spores could be in the hospital setting, they could be in the community, they could be in many different places. But because the principal treatment for this infection, for SARS-CoV-2 is dexamethasone, it, of necessity, decreases the immune response and therefore, people are more susceptible to this infection. So opportunistic infections look for the opportunity and they take it, and that’s, unfortunately, what’s happening with this infection, which is present in India, which may be present in some of the hospital or treatment settings, and which can transmit easily by spores, and therefore, cause disease in those who are immunosuppressed. But others may want to add to that, living in India. Sujatha, you…
Emma Ross
Yeah, can I just – can I just push you to say, the opportunistic, what opportunity has been created here, specifically?
Professor David Heymann CBE
The opportunity is the decrease in immune response due to the dexamethasone in patients who are being treated, and it’s also the fact that it’s in – present in the environment, in possibly hospital settings, and therefore, it has the opportunity to infect those people who are seriously ill.
Emma Ross
So, IPC, infection prevention control, cleanliness of hospitals, is that part of the…?
Professor David Heymann CBE
Well, it may be part of it, but there’s no evidence yet that merits [inaudible – 59:07] and it would be wrong to say that. But IPC, infection prevention and control, is just a basic for all health facilities, whether you’re able to transmit other infections there or not.
Emma Ross
Okay, Ramanan/Sujatha, do you want to come in on this, and also say is this a huge danger or is this a, kind of, minor thing that we really shouldn’t worry – get too het up about?
Sujatha Rao
Well, I would just say that I don’t think in this pandemic, the way it’s evolving, we should take anything lightly. And if we just measure only by caseload, okay, we have 1,200 cases or so of black fungus, but that’s not it, now we’ve found white and yellow. So, you know, I think every infection, every case that is a new presentation, must be taken very seriously and researched to see what exactly are the causative factors and remedial action should be taken. But what we are hearing is it’s diabetics and also infected tubes used for oxygen, you know, administration. That could well be, particularly in the northern states, where, you know, if oxygen supply – you see the kind of environment in which there was this huge rush of patients and beds were few and in fact, there were hospitals where a bed would be there with one or two patients, and there’d be a line in front of a bed waiting for one of them to die so the other one could hop on, or die or get well, whatever it be. So, in those, kind of, situations, I don’t know how much of the cleanliness infection control measures were possible, at all. It was just, kind of, constantly being on the ball.
So, I think there’s a lot of, again, work that needs to be done to say what are the causative factors, once we get over the hump and control the situation, and to take the remedial action so that it doesn’t happen again.
Emma Ross
Ramanan, briefly, do you want to come in before we wrap up?
Dr Ramanan Laxminarayan
No, no, I just – 30 seconds. One is – I’m just looking at the chat as well. So, I – you know, the main thing is, again, what I already spoke about, which is irrational medicines. Steroids being given too early is really a causative factor. Fungal spores are [audio cuts out – 61:28]. They got infected even before they come in and they carry the fungal spores. [Audio cuts out – 61:37] by early and overaggressive administration of steroids. [Audio cuts – 61:43] you know, with positive [audio cuts out – 61:50] and I think [audio cuts out – 61:53].
Emma Ross
I think we’re struggling – you’re struggling with your internet connection. Is anyone else having trouble hearing him? Ramanan, I think you’re frozen. Okay, sorry about that, but we’re going to move on to wrap up. So, we’ve pretty much run out of time, but I want to squeeze in one-liner, Sujatha, really, really quick, on where you think, or fear or hope, that the Indian epidemic is going. Where do you think it is going? Are we heading – are you pessimistic, are you optimistic? Really, really quickly, and then we’ll say goodbye.
Sujatha Rao
I think I’m cautiously optimistic, because I do think that finally the government has got on top of the situation where vaccination is concerned. They’ve got a very rude shock with what devastation wave two has caused, so, you know, there’s no getting back into any kind of complacency now, and that’s a good thing. I mean that – the needed the jerk, and they got it. So, I think now, with more vaccination we can address it, although I do want to see upfront that I don’t believe that the vaccination is a panacea. It’s just one of the most cost-effective and cheaper methods that we have…
Emma Ross
Okay.
Sujatha Rao
…to try and contain the infection, but also mask-wearing and so on. So, really think that hospital is just…
Emma Ross
Okay, that’s right. I’m going to give Ramanan the opportunity also. Ramanan, while you were offline, I said – we’ve run out of time, I’ve gone over actually, a bit naughty, but I’m going to give you a one-liner opportunity to say, as a wrap up, your final word on where you think the Indian epidemic is heading? Are you optimistic, pessimistic? Where is this looking like it’s going to go? Briefly, briefly.
Dr Ramanan Laxminarayan
I think India’s learnt a lesson from the second wave. Hopefully, won’t lose its plot of the third and hopefully, we will fix the vaccine supply, and that’s really the only path out.
Emma Ross
Okay, great. Well, thanks for succinct – and thank you both, for a really great insight into what’s going on in India, what are the drivers, what are the issues? And I think a great conversation between the three of you, and to the audience, I thank you for your time, thank you for joining us. I think this was a really great, deep conversation, there. We’re sorry – loads and loads more questions that we could have got into, so I’m sorry, we’ve run out of time. And thank you all for joining us for this pandemic webinar, and wishing you a great rest of the day, evening, wherever you are. Thanks so much.
Sujatha Rao
Thank you.
Professor David Heymann CBE
Thank you.
Dr Ramanan Laxminarayan
Thanks, Emma.
Sujatha Rao
Thank you, Emma. Bye, Ramanan, see you sometime soon.
