While nations across the world struggle to contain the fallout of the human toll and economic consequences of the COVID-19 pandemic, public health experts such as Dr. Ashish Jha, K.T. Li Professor of Global Health at Harvard T.H. Chan School of Public Health, and the Director of the Harvard Global Health Institute, have been at the forefront of research and public policy guidance to public and private institutions dealing with the crisis. He shared insights into epidemiological basis of the pandemic and what policy solutions hold out hope for the future in India.
You have argued earlier that to measure the true impact of the coronavirus in India, we need to look beyond the official fatalities record of the government. Why do you believe this, and if we used a different approach, what sort of numbers would we be looking at?
There are a couple of issues here that are worth thinking about. First of all, the key metrics that we want to sort relate to how many people have been infected and how many people have died. Both of those are driven a lot by how carefully you look. If you have a lot of mild infections happening, and you are not testing extensively, you are going to miss those. Therefore, you might find that you have a very high case fatality rate because you are only testing the sick patients and finding very sick people. Alternatively, if you do not have a very good surveillance system for deaths, if every death is not thoroughly investigated, you might find that a lot of people die. You do not know why they are dying. You may think that your case fatality rate is really low, because you are missing a lot of COVID-19 deaths.
All of that is my way of saying that understanding both how many people have been infected with this virus in India and how many people have died of this virus in India is a tricky business. You cannot just look at the official statistics.
Is there any chance in India that the accuracy of recording deaths and causes of deaths is reasonably high and the estimated fatality rate is in the correct ballpark?
The way I think about it is this: We think the global fatality rate is about 1%, maybe a little less. When all is said and done in India, that will be the fatality rate in India. I actually expect that in India it will be lower than 1%, because India has a relatively younger population. But I am not particularly interested in fatality rate – I am interested in fatalities. How many people have died of this virus and how do we prevent more deaths from occurring?
Right now, the statistics suggest that around 20,000 people have died of this virus in India. That, to me, is very low. It is possible that we are doing a good job in India of ascertaining all the deaths, but I would not be surprised if we are missing a lot. The reason is that when I look at the U.S., UK, and Western Europe, all of those countries have a lot more deaths than they have officially recorded. If high-income countries with very good surveillance systems are missing anywhere from 30%-70% of deaths from the coronavirus, why would I not expect that India would also be missing a similar proportion of deaths? I would not be surprised if the number of people that died from the coronavirus in India is substantially larger than 20,000.
I also think that the current estimate of 7,00,000 people having been infected is almost surely a very substantial underestimate. Both of those numbers are going to be much larger. The key thing for us to track are how many people are going to get infected, and how quickly that is changing.
Is the government justified in conserving test kits and surveillance system resources over time, hence limiting testing to the numbers that we see?
There is this argument that a lot of people have made, that we need to conserve testing. I have to tell you that I find it puzzling – I do not understand it. First of all, there is no limit to how much testing a country can do if it makes investments in reagents and other supplies. It can do very large numbers of tests.
India has done about ten million tests so far. The U.S. has done about 40 million, Russia has done about 20 million. Why is India’s capacity less than Russia’s in terms of the ability to do testing? I just think it is a priority issue. If India decided tomorrow that it was going to invest substantial financial and intellectual resources into ramping up testing, I know nothing about India that makes me think it cannot do it, that it does not have the capacity.
This is not a place where I would try to limit and conserve, this is a place where we need to do a lot more testing to really understand where the disease is spreading, so you can be on top of it.
The concern might be that the political cost of revealing larger numbers of infection cases might be too high, it might raise questions about how effective the policies to contain the pandemic have been.
I’m not going to get into the politics of it, but I will say one thing because it has come up in many countries and the President of the U.S. has been making this case: that the problem of America is too much testing. This is incredibly short-sighted. Even from a political point of view, ultimately the political victory comes not from denying the spread of the virus but controlling the virus. Testing may in the short-run make things look bad, but in the long-run actually helps you get control of the virus. If you limit testing, for the next few weeks or months ahead it can look ok, but at some point, the disease outbreak will become so substantial that it will become undeniable, no matter how much you limit testing.
I get that sometimes politicians want to make the next news cycle look better, but they really should be thinking about what the news cycle will be in a month or two, or three months from now. Of course, in my opinion what they should be thinking about is the health and wellbeing of people in the country, but that is a different conversation.
Is the theory of herd immunity our only hope until a vaccine arrives? Could either or both of these halt the pandemic in its tracks? Please explain how they work.
Just to be clear, in some ways, vaccines is a way to get herd immunity. The purpose of herd immunity is that once you have 60%-70% of the population immune to the disease, then the virus cannot spread anymore, it slows down, and it does not completely extinguish but it becomes a much smaller problem.
How do you get to 60%-70% immunity? The best way to do it is through a vaccine. If you do not have a vaccine — and this is what people usually refer to as herd immunity — what if you just let the infection run? 60%-70% of India’s population will have to get infected — the idea of nearly a billion people getting infected. If you take a 1% fatality rate, that is 10 million people dying, and tens of millions of people getting very sick, hospitals completely overwhelmed over the next year. That is a disaster. So, herd immunity is the policy of complete and utter failure. With millions of people dying and hundreds of people getting very sick, the economy will be completely destroyed.
I always say it is intellectually lazy for people to advocate for herd immunity, because basically it is giving up. It is saying we do not want to work hard on this, we know it is a problem, let us just let everybody get sick and lots of people die. I do not think that should be India’s strategy. It is not good for the Indian people and it is not going to be good for the Indian economy.
India has had among the most stringent lockdowns across the world. Would you argue that that has had a substantial impact?
Remember, the entire strategy here is to protect people until a vaccine becomes available. I believe a vaccine will be available for India sometime in 2021 and my hope is that it will be in the first half of 2021. But there is a lot of uncertainty.
Let us assume that it is in July 2021. We have about a year to go until that vaccine becomes available. I was very supportive of the lockdown. When it happened, I thought India was being very bold. But lockdowns only buy you time. You cannot be locked down for a year, it is just not possible economically and socially. The key is to use that lockdown to substantially ramp up testing, communicate to the people of India what will happen when the lockdown ends, how our behaviour must change, put in those policies, and ramp up hospital capacity. Then, when you unlock, you will be better able to handle what will surely be a surge of cases, as we are seeing in India right now.
Is this virus mutating, and if so,are there new strains and is that why we see new symptoms including blood clots and diabetes, and reports that the virus might be airborne?
Largely, no. When I talked to some of the leading virologists in the world, I asked them how many strains of the virus there are, and most of them say that there is one. Some of them say maybe there are two.
Viruses mutate all the time. That is how we track a virus’ spread, by looking at minor mutations. The real question is, does a mutation confer some sort of functional advantage or disadvantage? Does it make a virus more lethal? Does it make the virus easier to spread? There is some evidence that one particular mutation that we see in the European strain as opposed to the Chinese strain may make it a little easier to spread. But there is not much evidence that it is much more or less lethal, not much evidence that it causes very different symptoms. It just may be a little easier to spread, and even that is controversial.
We know a lot about coronaviruses, overall. I am not very worried about mutations and I am not worried about the virus becoming very lethal all of a sudden. The virus is lethal enough on its own. What I am much more concerned about is that as we learn things and are communicating them with people, that there is a strategy for dealing with this virus. The vaccine that we are developing, I expect it to work no matter what mutations happen in the next few weeks and months. Am I 100% sure? No, but I do not lose sleep over mutations right now, because I am not seeing the kinds of mutations that make me concerned about the virus becoming more lethal, much easier to spread, or resistant to a vaccine.
When do you see the viral spread peaking in India and then coming down, and, accordingly, what advice would you give to the Indian government?
What policymakers in India must understand is that the pandemic is still quite early in India. Because of the lockdown, things got delayed – and that was a good thing, we wanted a delay. But it is very early. If the question is, when will the peak happen, to me, the question back is what will cause the peak and the decreasing of cases?
Right now, less than 1% of the Indian population has been infected. What we have seen in other places is that left unchecked, that number will grow exponentially until we hit 60%-70% infection, which is a billion people.
Of course, it is not going to be left unchecked, and I do not expect that that is going to happen. There are things that India can do to really reduce the spread of this virus and slow down that growth. Increasingly, we have good evidence around mask-wearing. People should be wearing masks outside, and indoors in any public space.
Second, we have got to go after hotspots. Every time you detect an outbreak, you need to follow the testing, tracing, isolation strategy. That has worked in lots of places in India — in Kerala, and in Dharavi in Mumbai. There is no reason for me to think that that cannot be a really critical public health strategy.
Third, for the next year ahead, no large gatherings.
If India does all of that — the masks, the testing, getting rid of large gatherings, really rethinking indoor restaurants and other places where the virus can spread – then I think India has a pretty good shot at keeping the virus from getting into exponential growth that will cause us to get to hundreds of thousands of cases a day. That is what I want to avoid, because if you get into hundreds of thousands of cases a day, you are going to find very quickly that your hospital capacity of India is not going to be able to keep up with all those sick people. I expect that India will see increasing numbers of cases for many weeks and probably many months ahead.
