Professor Ashish Jha, one of the world’s well-known public health experts, told The Wire that India’s decision to prematurely declare “victory” over the pandemic in February and letting the guard down have resulted in a massive surge in COVID-19 cases as the second wave of the pandemic ravages the country.
In a video interview to The Wire’s Karan Thapar, Jha talks at length on various aspects relating to India’s handling of the pandemic, emergence of new variants, possible mitigation approaches, the road ahead for India and its vaccination strategy.
Below is the transcript of the interview.
Karan Thapar: Hello and welcome to a special interview for The Wire. With India caught in the relentless grip of COVID-19, we once again present an informed view from outside the country to try and understand how we got into this dreadful mess and how do we get out of it.
My guest is one of the world’s most highly regarded experts of global health, professor and dean of Brown University School of Public Health, Ashish Jha.
Professor Jha, in an article you wrote for the Hindustan Times on Sunday, which unfortunately didn’t get the attention it deserves because the Bengal state elections results dominated the news that day, you identified four principal reasons why India is caught in this dreadful coronavirus crisis. Can you for the benefit of those who missed the article briefly identify those four reasons?
Ashish Jha: Number one is the rise of variants. I am talking about two specific variants that are important – B117 from the UK and B1617 from India, the double mutant.
The second is the relaxation of the public health standards, and you saw this with people not wearing masks anymore and a broader attitude of the pandemic is over. When I was talking to a family in India in January and February, even March, you could see people acting like the pandemic was over with the large rallies, the Kumbh Mela. Kumbh Mela may end up being the biggest super spreader event in the history of this pandemic.
The third, of course, is the failure of the government to respond in any way when the data was very clear. As I was tracking the data, you can see by late February that the infection numbers had started to rise. By early to mid-march, it was extremely evident that India was heading for a second wave and how big a wave was going to be determined by policy actions. Even though the government had several weeks to respond, it did not – not until far along in April.
The fourth has been brought up by a few people, it is about seasonality. When humidity becomes lower, the virus becomes more efficient in spreading. In Delhi, in February and March, humidity levels tend to drop. Personally, I don’t think the season is a major driver.
KT: I want to pick up very briefly on the failure of the government to respond not only to the rising cases but also to the advice it was getting from its own scientific committees. Yesterday, Dr. Rakesh Mishra, the former director of the Centre for Cellular Molecular Biology and a member of the government scientific committee, confirmed in an interview, that in early March INSACOG had confirmed the government of their high concern that new variants were proliferating.
Almost exactly at the same time is the health minister on record claiming that India had reached the end game of the virus. Doesn’t that one example show that the government was deliberately deaf to the advice of its own scientists? Secondly, it had fooled itself to think India had defeated the virus.
AJ: I didn’t understand the “idea” that India has beaten the pandemic – no country has beaten the pandemic. It is an extraordinary claim that in a global pandemic, India is the one country that has the power to avoid it.
Second, the data by late February, early March were quite clear that things were heading in the wrong direction, so the failure to respond to that data is quite concerning. I do think it is important for the people in power at some point to explain why they chose to ignore that data and not act. Indian people deserve that answer.
KT: Let’s hope the Indians get it. At the moment, the secretary of the department of biotechnology has gone on record in the Economic Times to claim that no warning was given. Not only is the government refusing to explain why they failed to act on the data that was so obvious, but they are also now claiming there was no warning.
In your article, you also identified four things, the government must do. The first was – “We have to stop the spread of the infection” and there you identify three critical steps. Can you tell us what they are?
AJ: We know that this virus spreads most efficiently when people gather in large groups outside, even in small groups inside, without wearing a mask. So that’s what we need to stop – no large gatherings.
Along those lines, I would also like to stop indoor gatherings – close retails shops, restaurants. You can go for a national lockdown, but I feel you can be targeted in your restrictions and those can work just as fine as that number one.
Number two is the universal mask-wearing. High-quality masks make a tremendous difference and the government should help the poor people get them. Last but not least is testing. Tests can be a public health intervention if you do it effectively and find people before the disease spreads and isolate them.
KT: In your Hindustan Times article, you mentioned that people from different homes should not meet inside. Households should be separate.
AJ: Absolutely, because one of the things we see is that when we close restaurants, people meet at home for dinner, so that can become the source of spread.
KT: Now the second key step you mentioned in your article was the need to take great care of our patients. What is it that you believe the government should do?
AJ: Yeah, I think what people need to understand is that when you see somebody going to hospital, somebody whose oxygen levels are low, somebody who is very sick, they were infected seven to 10 days before. Whatever the number of infections, we are seeing today those people will need hospital care, a week, 10 days down the road. And we are generating three to four thousand known infections, known cases, and all the experts out there believe that the true number of infections in India is much, much higher than four lakhs a day. It’s probably somewhere between one and a half and 2 million cases or 15 to 20 lakh a day. There are some people who think it’s more than that, but that would be my best estimate.
And if you think about it, the fact that maybe 5% of those people need hospitalisation. That means every single day, we may be generating one lakh people who need hospital care and it just continues daily. Those people keep adding. As every day more and more patients come in, it is just going to get dramatically worse. So the government has to get ready for this and I have been saying this for almost two weeks that you need a lot more hospital beds, you need a lot more oxygen, you need to make sure that you’re well supplied on therapeutics.
And then here’s the part that you can’t import and that’s people, you need to protect, your doctors and nurses and other health care workers, because if they start getting sick, if they start getting tired because they’ve been working 12-14 hour days every day for weeks on end, they will get tired, they’re humans.
You can have all the beds you want, you can have all the oxygen you want, people will not get the care they need. So, this has got to be a very, very aggressive effort, some people have brought up the idea of whether to bring in the military to set up beds. To me, it doesn’t matter what mechanism, we need a lot more hospital capacity.
KT: Your third point is to do with vaccination. Hearing you say that the government must work with the Serum Institute to overcome the shortage of raw materials, and that is a critical shortage, as you point out, all over the world, what specifically do you think the government should be doing with the Serum Institute?
AJ: It’s not just the Serum Institute. But, India, of course, has a lot of capacity to make vaccines, and what I have heard as I have been talking to people at the Serum Institute and elsewhere is that there’s a set of raw materials that are necessary for vaccine production that are running in short supply.
India has no problems with the delivery of vaccines. The problem right now is production. So my understanding of why we cannot make more vaccines is it is about raw materials, it’s about things that the Institute needs to ramp up to further production. And those raw materials are many different, they’re even simple things like the liner bags that go into the machines, where the vaccines are stored temporarily as produce them.
And here, I actually think we need a global effort, but the Indian government certainly needs to be sitting down with the Institute and saying what do you need, where are your roadblocks, and then how do we get other industries and other companies in India to make them. There may be American companies or German companies that make them right, and the Indian government should be working with the Americans and the Germans and the French, and saying, help us produce more of these things and get more of these things to India, so that the Serum Institute can do what it needs. By the way, this is how the US government did it.
When the Biden administration came in, our production was going okay but not great. The Biden administration sat down with Pfizer, Moderna, Johnson and Johnson and said what do you need, where are your roadblocks, what are your challenges, and then they went out and found people who could meet those challenges and help solve the problem. It’s the government and the private sector working together, that solves these things.
KT: You make one more point in the article about India’s vaccination strategy. You say the priority should be older people and healthcare workers. Am I right in inferring from that, that you have a disagreement with the policy announced that became effective on May 1 in India, whereby everyone over the age of 18 now qualifies, given that you don’t have sufficient vaccines for them and that’s not a secret? Was it a mistake to open it to everyone?
AJ: I don’t. I don’t support opening it up to everyone until older people and healthcare workers have been vaccinated. What we know of this disease is that it is the older people who end up getting very sick and dying. If you want to relieve the pressure on hospitals, if you want to stop having people dying on pavements, outside of hospitals, the single biggest thing you can do is vaccinate high-risk people.
Young people can occasionally get sick, of course, and they do spread a lot of the disease, and so there is an argument to be made around young people, but it is but the evidence and the experience from the UK, from Israel, from the United States, from so many countries, is if you start with older people.
The first thing you do is you bring down your hospitalisations, you relieve the incredible stress on the hospitals. And, of course, vaccinating healthcare workers has the advantage of protecting them, so they don’t get sick, even if they’re young people, they don’t get sick. Because when they get sick, they’re out of commission, your healthcare system can’t function.
So, healthcare workers and elderly is what I would, what I have argued for, and that’s what I think every country that’s been successful has done. I would not be vaccinating healthy 23-year-olds right now, not when there are 70-year-olds who have not gotten a vaccine.
KT: Now the fourth key thing that the Indian government needs to do, and do urgently to control the crisis, is genome sequencing, and I want to quote from your article, you say “the United States and UK companies are ready to ship genomic sequencing supplies to India, but the Indian government must want it, and be ready to use them”. I take what you’re saying that the time has come to India, for India, to ask these companies for help.
AJ: First, let’s talk about genomic sequencing. Genomic sequencing is critical to understand variants. That’s how you identify variants, and that’s how you identify where variants are spreading. The UK sequences almost 10% of its infections, the US does about 2% to 3%. I think the US should be doing a little bit more. India is doing way less than one person.
So, basically, India is fighting this war with blindfolds. It doesn’t know which variants are spreading where? Genomic sequencing gives intelligence to figure out where things are heading, what’s causing problems. There are, of course, Indian companies and genomic sequencing capabilities in India, but you need so much genomic sequencing happening in India to really do this well that you need outside help.
This is fine, countries help each other in moments of crisis, and there are genomic sequencing companies here in the United States and elsewhere, who I know are happy, willing and able to send genome sequencers to India. But you can’t just send it, you need the Indian government to allow it. This should be done urgently, and the Indian government should be very proactive and saying, we want to scale up genomic sequencing. And then, of course, companies can help donate those machines.
KT: Now we’re coming to the end of this interview. On Monday, then again today, at the government press conference, the health ministry said that there are 12 or 13 states and union territories, which are showing what they call early signs of plateauing, and the states and territories that were identified, including Delhi, Punjab and Maharashtra.
Now you are someone who follows the trajectory of Coronavirus in India fairly closely. So do you agree that there are signs, or is this simply a reflection of the fact that the amount of testing has come down, therefore, the amount of cases identified has come down, and this may be a bit of an illusion?
AJ: I think, and maybe this is just my hope getting the best of me, but I think that I see early signs of plateauing. Now again you have to be a bit careful for exactly the reason you laid out which is testing is not going as well as it needs to, and I’m worried about the situation with testing.
So we may be overestimating what’s happening, but that said when I look at the data from Delhi and Maharashtra, and even Uttar Pradesh, UP, I’m actually a bit less confident about it, but Delhi and Maharashtra, I have been looking at every day. I really do think that they may be plateauing. That would be really really amazing. But there are many other places where things are still looking pretty tough. Once you get out more to Bengal, Bihar and Jharkhand and other places, even in the south, there are still places where the infection numbers are rising very quickly.
Let me make one other point – imagine that India does plateau at three and a half or four lakh cases, that is a tremendous number of new infections, because again, with the test positivity I’m assuming that India’s generating 2 million cases a day, or 2 million infections a day or something like 20 lakh a day that’s the true number.
As long as that’s the plateau, we will continue to see 150,000 new people needing hospital care every single day. We will continue to see 20,000 people dying every single day. The plateau just means you won’t get worse. And it’s sort of an unacceptable level of suffering, so plateau is not good enough. We have to bring these cases down and we got to bring them down quickly.
KT: Can I interpret what you’re saying? There’s good news in the belief, or may I say, that there are early signs of battling, only because it means we are not increasing, but maybe we plateau at three lakhs or 3.5 lakhs a day. That’s not just a horrendous number of daily cases, but it also means hospitalisations, and very sadly, deaths will also continue at very high numbers. So, there is clearly a very dark cloud around this silver lining to put the metaphor the other way around. So there’s both good news and bad news.
AJ: Absolutely. And here’s what needs to be done and here’s where I’m a little bit worried about. I’ve been watching the models the Indian government is looking at, and what they’re projecting. And, in their mind, they had this idea that, of course, cases went up very fast, they’ are assuming the cases are going to fall very first. I really really hope they’re right. We all hope they are.
But I am worried that is not what is going to happen, that we will hit this plateau, and then we will very slowly meander down. And what is going to happen is that for weeks, we will just continue seeing floods of patients get sick and die and the chronicity the long term effects of this is going to be that you’re going to see the collapse of the health system, that people will not be able to get care they need, not just for Coronavirus, but all the other needs that people. So I am very worried about the next month to six weeks.
KT: We’ve discussed in detail how in February, early March, when there were clear signs, including advice from the government’s own scientific advisory community, that there was a second wave and that the cases could rise exponentially. At that point in time, the government was blind and deaf to the advice and the data.
However, today, Wednesday, the government’s principal scientific adviser said at the press conference, there will be a third wave. No one knows when the second is over, and he’s already publicly admitted a third wave is inevitable.
Is that a good sign that we are at least now beginning to accept reality and even though we’re not over the second, the government is already admitting there will be a third thereafter and we need to prepare for it? Does that suggest that there is reality dawning on the government?
AJ: It is really good to see this acceptance that India is not an exception to the world, and Indian people are susceptible to this virus like every other population in the world. It is always good to prepare for a third wave, but first and foremost, we just have to get through the second wave and we are still early in the second wave here. We are not anywhere near done. So it is fine to acknowledge that, and of course, prepare for it.
I believe, on the other hand, that it is possible to avoid the third wave. How do we do that? By vaccinating. If we can get 500 million more Indians vaccinated, I think we can prevent a third wave. It’s not lost on me how hard this will be, but I think it is doable. I think India has the capability and the Indian government once we get through this horrendous time should put all of its resources. The central government has to lead, and understand that this is not a state thing. We will have to put all of our resources, effort nd energy into making enough doses to vaccinate people.
KT: Two quick small clarification questions when you say that one way of perhaps avoiding the third wave is if 500 million Indians can be vaccinated. Do you mean with a single shot, or do you mean with both jabs? And secondly, does that figure of 500 million include the 160 million that already have had one jab or on top of that?
AJ: Good question. I mean, on top of that, 500 million additional Indians need to get vaccinated. And I think one jab alone is fine for now. Look, the UK, to shut down the horrible outbreak that they had in December, January, by doing a one shot first strategy, where they vaccinated more than half their population with a single shot, and now they are going back and giving the second shot.
I think that’s a very good strategy for India. One shot gets you a lot of protection. And so if India says okay, we will make 500 million doses and give 500 million people their first shot, and then over time we will go ahead and give them the second shot.
KT: The UK is giving the second job, in the case of AstraZeneca, eight to 12 weeks after the first. The government initially insisted on a four-week gap, and now they’ve made it an eight-week gap. But to hit that figure of 500 million more, should the Indian government accept, and do what the UK is doing? What incidentally the WHO has officially advised and to make sure that the second job is somewhere, eight to 12 weeks later?
AJ: I think we should. I think that something closer to 12 weeks actually – probably – is the optimal time, so it’s even from a biology and immunology point of view. It is probably better to do it closer to 12 weeks than to do it close to eight weeks. And, of course, it opens up the possibility of getting more people their first jab before you’re giving a lot of people their second, so I would go to 12 weeks. And I would just vaccinate as many people with their first jab as possible.
KT: Thank you very much, Professor Jha. I hope the Indian government hears you. I hope they heed your advice. I know that the Indian people will be watching very carefully because you said a lot that is potentially reassuring.
At a time when the situation looks not just grim and gloomy, but also terrifying – there are early signs which could be plateauing. The dark cloud around that silver lining is that if you plateau at three or three and a half lakh cases a day, that’s not just a horrific number on its own. It also implies a very large number of severe illness, and a very large number of deaths.
The answer to avoiding the third wave is to vaccinate 500 million more people. It doesn’t matter if they’ have only had one jab, and to make sure they all get that one jab, extend that gap between the first and second injections, up to 12 weeks. Those are critical things, which I hope the government listens to. Thank you very much for joining me. Take care, stay safe.
AJ: Thank you very much for having me back and stay well and stay safe, and I look forward to our future conversations.
KT: So do I. Thank you very much indeed.