K Srinath Reddy, President, Public Health Foundation of India
The second wave of Covid-19 is now abating slowly but steadily across India, with both new cases and deaths decreasing. Unfortunately, economic output and the potential for economic growth is also continuing to fall further, hurting tens of millions of Indians across the country. The Center for Monitoring Indian Economy has told IndiaSpend recently that almost 97% of Indians are now poorer thanks to Covid-19. In this context, how can we emerge from the various lockdowns in several states and resume economic activity? Given that only about 223 million Indians are partly or fully vaccinated, with the majority (80%) having received only one shot of a Covid-19 vaccine, what are the guardrails we should have in place to unlock? To understand the precautions we need to keep in mind, and what we should be doing to prepare for a potential third wave, we spoke with K. Srinath Reddy, president of the Public Health Foundation of India, adjunct professor of epidemiology at Harvard T.H. Chan School of Public Health, and former president of the World Heart Federation.
Are we really reaching the end of the second wave? Or are we misinterpreting some of these early signs?
From several indicators, it does appear that the second wave is subsiding. We are seeing the Covid-19 case counts dropping. Despite the challenges in terms of actual testing and interpretation, there's a consistent directional change towards a drop in cases. We are also seeing deaths dropping. Again, despite some undercounting, the trend is visible. We are also seeing test positivity rates dropping over a period of time. And, most importantly, we are seeing that hospitals are no longer so crowded with people in intensive care, or waiting outside desperately pleading for admission. So all of these taken together would suggest that we are actually seeing a substantial decrease, at least in the larger cities where the [second] wave started. Even in some of the smaller towns, I believe we are now seeing a downward trend. The [situation in the] villages is a little more difficult to gauge because testing is inadequate and our data systems are not good enough, but even there, we are not seeing as many horror stories as we were about two or three weeks ago.
But this is in a period where a good part of India is under lockdown.
So it's difficult for us to say with surety that this is going to be the happy state of affairs when the lockdown
is lifted. Because we saw in the first wave, that after the lockdown
was relaxed in June 2020, the cases went up and peaked around mid-September. Covid-19 deaths [also] peaked around September. We do not know how much of a rise will happen now, though compared to 2020, we have had many more people exposed [to Covid-19] and thus at least partially immune. Many are vaccinated, [even if] not fully, but again are partially immune. So given that, it is likely that the number of susceptible people will not be as large as when we opened up after the first wave.
But a countervailing factor is that now we have [Covid-19] variants, which are much more infectious. In fact, even in January, as we were celebrating what appeared to be 'the great escape' from the pandemic, the Kent variant, now called the Alpha variant, came in and that started ramping up the case numbers. Then we saw the Delta variant emerge in Maharashtra, and started seeing what the challenge was in terms of that particular variant spreading across different parts of India. So, we now recognise that we still have the Delta variant, which emerged in Maharashtra but has now spread all across India and in many parts of the world. It has been declared to be much more infectious than even the Alpha variant and certainly much more infectious than the original virus, [which is] still on the prowl. Given that, we cannot lay firm bets that the second wave has ended. We have to wait and see what happens when the unlocking process begins. We have to keep a careful watch.
In Maharashtra, we've been under lockdown now for almost two months. In Mumbai, the number of new Covid-19 cases has evened out to 900-1,000 cases a day. But it's been at that level for several weeks. Does that suggest that lockdowns only work up to a point? What is the utility of keeping a lockdown going for a long time?
I don't think we ought to really prolong the lockdown. We cannot get stuck in a rut at this point in time. I think the lockdown last year was required to get systems in place, to prepare ourselves, whether with testing kits, or personal protective equipment, or ventilators. [We had to] get the systems in order, get the multiple departments and the Centre and states to coordinate much better. And it helped.
The lockdown this time was because suddenly we woke up. We had actually taken it for granted that there wouldn't be a second wave. We had dismantled many of the temporary structures that we had set up for hospital care. We had sort of let the coordination mechanisms go into slumber. As a result, we were caught off guard when the cases went up in such a huge surge. We were overwhelmed. In order to catch our breath and get the systems back in place, I think we went into lockdown. Now everybody is fairly cautious in the unlocking process. You hear the Maharashtra chief minister saying 'not yet, let's watch out'. Even the Delhi chief minister, who has generally been gung-ho about opening up, is saying we will keep a careful watch and we'll [unlock] in stages. Once bitten, twice shy. So, it is important for us to unlock, but do it in stages in a graduated manner, so that we can recoup the territory if suddenly there is a problem.
But do the numbers suggest that the lockdown has worked, or for instance in the case of Mumbai has stopped working, in terms of the virus spreading?
During the lockdown, the virus doesn't have much opportunity to infect the various susceptible persons who may still be there in the population, because the person-to-person spread is greatly limited. Most importantly, the superspreader events are limited. So the lockdown has achieved that purpose.
But the most important thing is how do we emerge from the lockdown, keeping some of the safeguards in place while getting on progressively with the resumption of our normal activities. That is where you require personal protection in terms of masking. Now, it's incontrovertible that masks are protective. Therefore, if you wear a good mask the right way, then you're likely to be substantially protected. That will happen if almost everybody universally masks outside of the home.
The second thing is to try and keep to ventilated areas as much as possible. It's not always possible. But even in an office, you can reduce crowds by having shifts. Even in schools you can operate in shifts. Try and keep as much free air flow as possible. If you can keep the doors and windows open, that's fine. For offices which are air-conditioned and engineering cannot be redone at short notice, again try and reduce the amount of time people spend in an office and certainly reduce the crowd. Continue work from home as much as possible, except for the absolutely essential functions. Also make sure that unnecessary travel is restricted.
Most importantly, this temptation that seems to happen to everybody, from the ordinary family which wants to celebrate a huge wedding or birthday party, to the politicians who want to have big rallies and the religious leaders who want to have big celebrations and processions, that temptation must be curbed with an iron will at least for several months from now. Because what's the point of predicting that there could be a third wave in November if we allow it to happen? So we should try and reduce the impact of the possible resurgence, even if it is a trivial resurgence, of the second wave on opening up. And also reduce the impact of a third wave when it comes by taking some of these precautions.
But do resume the economic activities. We ought to be able to do several of the economic activities also with some of these precautions. Farming can be resumed without much difficulty because farming is open-air, there is no major issue there. I think allowing construction activities to take place was not a bad idea, because most of it is done in the open, not in confined rooms.
We've seen that cases are coming down everywhere, but in some places and states the fall seems quite dramatic. Should we believe these numbers? Or should we be asking the counterfactual question, not 'why are your numbers so high', but 'why are your numbers so low'?
I think there's definitely undercounting, both for technical reasons and possibly non-technical reasons. The technical reasons are very clear. Even if you test well with the best techniques and intentions, you will still miss a number of cases because the RT-PCR test has false negatives in about 30 to 40% of cases and the Rapid Antigen Test in [even] more cases, for a variety of reasons. If you test too early or too late in the infection, you don't catch the replicating virus. If you don't collect the throat or nasal swab properly, don't transport it or store it in the laboratory properly, again you will not be able to get a positive test even if the virus is present. Then there are a number of people who may be asymptomatically infected and may never turn up for testing. Even some people with mild symptoms may not want to get tested. So we'll definitely have an undercount there. But apart from that, is there undercounting because of inadequate testing numbers or falsification of testing results, we do not know. Those are possibilities, but we cannot really put an estimate on that.
However, what I would like to say is that, assuming that there has been a considerable amount of undercounting in the cases and deaths, it is the direction that matters rather than the absolute precision. As long as the noise-to-signal ratio is reasonably constant, you can still follow the direction. And I think the downward direction is fairly clear in each one of these indicators, and also because the indicators are all convergent. But if you ask me, is state X really telling the truth, or is state Y better at telling the truth? Yes. I have my own guesses that there are some states which are definitely undercounting much more than others, whereas some others are being more open and truthful than others. But if you take the all-India figures, I think the directionality is reasonably certain.
Is it therefore safe to assume that the downward directionality would apply equally across India? Because the second wave started in western India, in states like Maharashtra, and then spread eastwards and elsewhere. Would it ease off in the same direction or differently?
It differs partly because the places [where Covid-19 cases] started [rising] late are likely to also have subsidence later than the places [where cases] started [rising] early. The places which are much more rural, have less transport and economic activity are unlikely to have as many cases for many more days, unless there are super-spreader events. If you organise super-spreader events with local body elections, assembly elections and religious festivals, even those places will become vulnerable, as we've seen. But in general, some of the states which have been relatively economically backward and more rural will have slower transmission. Therefore the pace may be slower, and then you may not see it drag on for a long time.
India now has 223 million people who are somewhat vaccinated, i.e. many of them have got at least one dose of a Covid-19 vaccine and less than 50 million have got two doses. Can this be a contributor to the unlocking equation?
I would say that this is inadequate at the moment. But we have to live with the fact that we have to vaccinate many more people and much faster, while maintaining other precautions, which I've already mentioned, like masking, avoiding super-spreader events and so on. Because we still do not know what the threshold of protection is. We have already made big mistakes with the so-called herd immunity calculation last year and even early this year, because we depended upon natural infection to produce that herd immunity, which was a total mistake. And I have been repeatedly saying so.
Let's take two examples from Brazil, which are very interesting. In January this year, in Manaus, 76% of the people tested positive for Covid-19 antibodies in a serosurveillance study. [Even with] 76%, the epidemic was still raging, the hospitals were crowded, many deaths were happening, the pandemic was out of control. So there was virtually no herd immunity at all. On the other hand, if you take the example of another province Serrana, where they systematically went about testing the impact of vaccination versus an adjoining province, they showed that by having 60% vaccination, they reduced deaths due to Covid-19 by 95% and infections by 86% between February and April. This was on the basis of immunisation. So compared to the uncertain protection provided by varying doses of viral count in a natural infection, if you have good vaccination, then your protection is much better. Two days back, Britain declared that for the first time since March 2020, they had not a single death from Covid-19. And Britain has now vaccinated about 60% of its people with at least one dose. So we now recognise that probably around 60% [vaccinated] is a reasonably good threshold. That is when we can breathe a little more confidently and comfortably. But till that time, we ought to maintain all our precautions.
We've seen breakouts like black fungus, we've also understood now that diabetes is a core contributor [to severe Covid-19], which you pointed out yourself in earlier interviews with us. Knowing all of this now, how can we be better prepared for the next wave?
I think it's very simple. Firstly, we ought to continue some of these precautions till we are sure that that third wave is coming or not, and what magnitude it will attain. Secondly, we ought to prepare our systems much better. Our primary healthcare systems must be much stronger for early detection of cases. You must have health care teams with citizen volunteers because our primary health care team is still understaffed. With the help of citizen volunteers, household surveillance of people with symptoms, or people with a history of very close contact with [Covid-19 positive persons] must be isolated on suspicion but also tested for verification. That early catching of cases is going to limit the spread.
Then, those who require it should be provided monitored home care with telemedicine, but the frontline health workers should also play a supportive role in that. And those who require hospitalisation must be assured of emergency transport so that they don't have to search for taxis which will charge them Rs 20,000, but be taken immediately to a hospital where they'll be assured of hospitalisation. And those hospitals must have adequate oxygen, drugs and other supplies. These are the things that we must ensure. No state should be caught unprepared at this point in time, after what we experienced in the second wave, and say that we will not have enough oxygen, or medicines, or ventilators, and so on. That's going to be critical, preparing all of that.
We may be over-prepared, for all we know. People are saying you must prepare a lot more paediatric intensive care units. Maybe children will not be affected in such large numbers and not seriously, we do not know. But we can never be over-prepared in a place like India, where our health system is anyway under-equipped and understaffed. If not for Covid, they'll be useful for something else. Children or adults will require hospital beds for something else. So by investing in improving our healthcare infrastructure from primary, secondary and tertiary care levels, making sure that hospitals have oxygen, we are actually going to be building into a more stable and steady health system. Covid or no Covid, it will all be in good stead.
In terms of medicine protocols, when you talk to doctors from other parts of the world, the feeling is that the medicines that doctors prescribe for Covid-19 in India, apart from over-prescribing, don't seem to be in sync with what is being practiced elsewhere. This causes its own problems, as we've seen with steroids. How can India address this going forward, in a more structured way?
Unfortunately, there is a virtual laissez-faire system that operates in most hospitals in India. While guidelines may be prepared by the All India Institute of Medical Sciences, or by the Indian Council of Medical Research or the National Task Force: Covid-19, they're not binding on anybody. Each state, each hospital, each doctor can adopt his or her own strategy. There is a certain degree of individual judgment that comes into play but some broad, standard management guidelines should be followed, saying that this has evidence behind it, this has no evidence behind it. Those which are evidence-based must be used. Those where there is clear-cut evidence that they don't work, should not be used. Where there could be a slight grey zone in which evidence is a little uncertain, but could be of potential use, then individual judgments can be exercised based on the patient's profile. If you look at Britain, for example, there is the National Health Service, which, with the help of different experts from an institution called NICE, comes up with standard protocols. Most people follow those standard protocols. There could be some individual exceptions, of course. Depending on the patient, the treating team can make some exceptions, but those exceptions are very few.
Here, there is a system virtually which I call laissez-faire. I can even call it anarchy. The private drug and equipment companies can actually influence the medical practitioners' behaviour and sell drugs at exorbitant costs. And ultimately, the honest doctor also may overprescribe because they are anxious to do something and others may be in nexus with the pharmaceutical companies. So we ought to prevent that by having very clear cut, evidence-based guidelines, which are prepared with the help of experts from all across the country, not necessarily only in Delhi. All wisdom
doesn't lie in Delhi, whether in medicine or in any other field. So consult people from everywhere, and then get the best of expertise, and then prepare those guidelines.
Keep constantly talking and openly debating. There can be differences of opinion, but they should be aired. And then we must come up with clear-cut guidelines saying that, this is where we have absolutely certain evidence of benefit, or harm, or no use. And here, there are some flexibilities where you can use [this drug]. But they should generally be applicable across the country. And as experiences are being gathered in different parts of the country, that experience must constantly feed back into this process. If some doctor in Kerala or in Hyderabad or in Bhopal finds something is very useful, then that must be tried out and critically appraised. But again, just case series or individual experiences, that 'in my experience this has happened', doesn't really stand up as medical evidence. It should be subjected to scrutiny trials, even case series must be critically appraised. Those are the kinds of things that must be institutionalised across the country. And if we can bring in those standardisation elements, then we will find a lot of misuse and abuse of drugs being prevented.