Health

Interview: India's Low COVID-19 Mortality Not Unique, Rural Spread Is Worrying

In conversation with Dr Shahid Jameel.

In an interview that will puncture the government’s claim that we are in control of the trajectory of COVID-19 and, additionally, is critical of the Director General of the ICMR, Balram Bhargava, India’s top virologist has said, “Obviously the situation is alarming”.

Dr. Shahid Jameel says there are two worrying aspects – first, the rate at which COVID-19 is growing and, second, the location where it’s growing. Two-thirds of the cases today are in rural India and in villages. He believes we could already have over 650 million undetected cases.

In a 42-minute interview to Karan Thapar for The Wire, Jameel drew attention to the dramatic increase in both cases and deaths over the last two months.

Read the full transcript below.

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Karan Thapar: Hello and welcome to a special interview for The Wire. With India’s COVID-19 cases soaring above five million and increasing at over 95,000 a day, my guest is the country’s top virologist and the CEO of the Wellcome Trust DBT India Alliance, Shahid Jameel.

Dr. Jameel, as I said in that introduction, we’ve crossed the five million mark, the Hindustan Times report said that yesterday – Wednesday the 16th – the country’s increased by over 97,000 cases, and no one knows when we are going to hit the peak. How do you view this situation?

Shahid Jameel: Well, obviously the situation is alarming. Let me recall the stats, India – this morning – had 5.11 million confirmed cases, 83,230 deaths – which is a case fatality rate of 1.62% – and 4.02 million recoveries – which is a recovery rate of 78.6%. Now, there are two most worrying aspects of the India story at this stage; the first is the rate at which the outbreak is growing and the second is the location at which it is growing – it is estimated that about two-thirds of cases right now are coming from rural districts and villages. So, I think that’s an alarming situation.

KT: One of the things I noticed, is the speed with which India crosses each one million mark seems to increase every time. For instance, we went from two to three million in 16 days, from three to four million in 13 days, from four to five million in just 11 days. Does that suggest that the spread of the virus is accelerating?

SJ: Absolutely. The rate at which the outbreak is growing is indeed worrisome. There is a clear sign of escalation in not just the cases but also in the number of deaths. You cited some statistics, let me add to that, that, at this rate, we will go from five to six million in the next 10-11 days. There is another way to look at this, and that is called the ‘seven-day moving average’; if you look at the seven-day moving average on September 16, you have 93,200 cases per day and 1,162 deaths per day. If you looked at July 15, which is two months ago, you had a daily average of 27,700 cases and 540 deaths; which means that in the past two months, the daily case load has increased by 230%, and the death has increased by about 115% percent  – one one five percent.

So, since mid-July, the outbreak has, really, significantly expanded. The other comparison I would like to make is to the US, who both our policymakers and the public consider to be the holy grail of COVID. Let us compare our growth to theirs. At this time, while India’s putting out about 93,000 cases daily, the US is averaging about 39,000 daily; at this rate, we will cross the US in about three to four weeks. Also, remember we are on a rising curve, US is on a falling curve right now so three to four weeks is an optimistic, sort of, estimation – we might cross them even before that. That’s worrisome.

KT: You know, you sketched out a picture about how you see the future which is, clearly, worrisome. Let me put another aspect of that picture to you as presented by the ICMR when they’ve released the results, or published the results, of their serological survey done in May. They said, that for every reported case, India would have somewhere between 80 and 130 unreported cases. Now, assuming that ratio continues to be the same today, wouldn’t it mean that when we have five million cases, the unreported cases would be somewhere between 410 million and 650 million?

SJ: Yes indeed, that is what one can extrapolate from this data. That would also be the presumed infection load, not the confirmed cases; it’s important to make that distinction. It’s also important to say that every country would have that window of uncertainty and we won’t truly know the total size of the infected population until good serological tests are available, they are widely applied – that will happen, possibly, after the pandemic is over.

But even if the ICMR results are correct – and I have no doubt to believe that they are not correct – the real numbers are likely to be even higher simply because the outbreak in India has expanded since mid-July and the ICMR results that have come in are from the period of early May to early June.

KT: This is a very important thing you’re saying. On the basis that the outbreak has expanded since mid-July, you believe that the actual number of undetected cases could be higher than that margin I gave of 410 million at the lower level and 650 million at the higher – we could’ve crossed 650 million, we could be into seven and eight hundred million.

SJ: Well, looking at the data, the logic really demands that. I’m simply going by the data.

KT: Let me at this point, then, put this to you – almost exactly six months ago, on the 18th of March, I interviewed Ramanan Laxminarayan, the director of the Washington-based Centre for Disease Dynamics, and he said – and he was applying US estimates to India – he said in the worst case scenario, India could end up with 60% of the population infected; which would be, roughly, seven hundred or eight hundred million. At the time, he was not just criticised, he was ridiculed by BJP spokespersons but also by some very senior journalists. Today, it turns out, that actually, he was pretty close to spot-on.

SJ: Karan, I remember 18th of March very well and I remember it for a different reason. We closed our offices in Delhi and Hyderabad on 18th of March because we decided that public transport in both these cities were becoming very unsafe for our people to come to work. But then, I remember that in the evening all hell broke loose when Ramanan’s figures were put out in the public domain.

You know, even to many public health experts, his numbers looked ridiculous and, you know, I must say, a lot of energy was spent debating his numbers. Unfortunately, most of that energy was heat and there was very little light in the arguments that were put forward. I also remember a conversation I had with Ramanan after that and I congratulated him for having become so popular; you know, he said that all he’s doing is taking into consideration India’s high population density and poor healthcare infrastructure, and he said that only time will tell whether he’s right or wrong and, I believe, he appears to have been proven right.

KT: Absolutely, today he is vindicated. All I’ll say is that that estimate that he gave on the 18th of March was on this show, to me, and I’m very glad to be able to say today – as you’ve confirmed – his estimate has been vindicated.

But let me cite almost an opposite example – on Tuesday, that’s just two days ago, the Director General of the ICMR, Balram Bhargav, said, and I’m quoting him, “We distributed the curve in a way that we didn’t have a huge peak at all.” Now that seems to suggest that the Indian authorities believe they managed the curve, and it also seems to imply that we have no great problem with the fact that we’re increasing at ninety-three, ninety-four, ninety-five thousand cases a day. What do you make of Dr. Bhargav’s comment?

SJ: Well, Karan, how does one respond to that except to really feel sorry for ourselves? Dr. Bhargav is an important man, you know, his words mean much and, therefore, he must use his words very judiciously. I believe he’s also in the best position to advise the political leadership for which his only consideration should be public health, or rather I should say, the health of the public. ICMR and Ministry of Health’s position, even today, after five million cases, is that there is no community transmission in India; this defies logic. But beyond that, I think it has done harm to control efforts by just making the public very complacent, so I think people in important positions must choose their words wisely.

KT: I get the feeling that you’re disappointed both by the ICMR and perhaps – if I could add – particularly by Dr. Bhargav.

SJ: Oh, I think you’re being very kind. Yes.

KT: You mean you’re more than disappointed.

SJ: *chuckles*

KT: Alright, I think that laugh says it all.

KT: Now, on Tuesday, the very same day that Dr. Bhargav spoke, the Health Secretary, Rajesh Bhushan said that India has only got 3.6% cases that require oxygen, only 2.1% cases that require treatment in an ICU, and 0.3% cases that require ventilator support. Assuming that the figures he’s giving are correct and there’s no reason to doubt them, doesn’t that suggest that our cases may be increasing exponentially – practically at a hundred thousand a day – and we don’t know if the rate of increase will get even worse; but it also seems, side by side, that a vast majority of cases are either asymptomatic or very mild. Would you agree with that?

SJ: Yes, you know, it is indeed correct that the vast majority of cases in India are in the asymptomatic, mild, or moderate category – predominantly asymptomatic or mild – and thank god for that; but, you know, I would say that even with these low percentages, these low percentages can give rise to high numbers – high absolute numbers – if the total infection load is high. It really quickly translates into high numbers of people requiring intensive care.

Now, I don’t remember exactly how many beds we have available with oxygen, or intensive care, or, you know, ICU or ventilator support but, I am given to believe, that there is enough capacity in the country to deal with it. That’s very good; well and good. But the danger in dealing with percentages is that the absolute numbers become very high before you know it. Let me also add that mild infections’ good recovery rate is also a tribute to our doctors, our nurses, our other healthcare workers who have kept severity and mortality fairly low, and the recovery rate high. So, let us not forget people at the frontlines who are doing this.

KT: But you’re making a very important point; you’re saying that, even though the percentages – in terms of people needing oxygen, or ICU, or ventilator – are very, very low, because the total number of cases is growing, in absolute numbers, it can actually be a lot of people needing oxygen, a lot of people needing ICU, a lot of people needing ventilator support. And that, in a sense, is hidden – or disguised – when you only talk in terms of percentages and that’s a very important note to make.

SJ: Let me add that percentages don’t tell the actual picture. We may say that the case fatality rate in India is only 1.6% but somebody who’s lost a loved one, for them the fatality rate is 100%. So, we can’t be giving these percentages to make everyone feel good without realising the human problem behind it.

KT: That’s very true. Now, something else that’s happening is that the incidence of the virus is increasingly, and perhaps even at an accelerating rate, moving away from metropolitan India and into small-town India and into rural India, and you mentioned it yourself a moment ago.

But the problem is, in rural India, we don’t have hospitals – or what count as hospitals, what would be accepted as hospitals – and doctors are few and far between. How worried are you about what would be the outcome in rural India?

SJ: This is a real cause for worry. I mean, there is inadequate primary and secondary healthcare infrastructure and staffing in many areas including especially, actually, in rural India. You know, let me also add that over the past three decades, India has really made some impressive progress in healthcare indicators such as life expectancy, under-five mortality, we have made moderate gains in the percent of stunting and underweight children.

Around this, we have to really understand that public healthcare expenditure remains fairly low in India. About 80% of healthcare goes out of the pocket and this turns thousands of people below the poverty line every year, so let’s keep that into consideration. In India there’s also workforce crisis, a health-workforce crisis; the WHO recommends that there should be 22.8, let’s say 23, doctors, nurses, and midwives per ten-thousand population. India is just below that at about 21. But then, the most popular states, the northern states, in India are much below that average. Bihar is the absolute lowest with a figure of 5.3. So, you know, these are all concerns to worry.

KT: Absolutely.

Also read: RTI Shows the Government Did Collect Data on Deaths of Migrant Workers During Lockdown

SJ: Let me just finish about the healthcare workers issue. It is estimated that only about a third of all healthcare workers in India practice in rural districts or villages. The doctors are even a smaller percentage of this, and only 15% – fourteen or fifteen percent – diagnostic facilities are available in these parts of the country, so this is a real cause for worry. But there is also an opportunity here, as the outbreak is moving towards the villages. The opportunity is that villages are not as densely populated as cities and we can control the outbreak there far more effectively than we have been able to control in cities. So, let’s use that opportunity.

KT: So, it is, to use a cliche, a question of pluses and minuses; the minus is the very poor healthcare system in villages – accentuated by the fact that the virus is growing particularly in UP and Bihar where the healthcare is worst of all. But the plus is that the density of population in rural India is such that we can actually control the virus more easily than we can in urban India.

But, side by side with this problem is another one that hasn’t got attention because COVID is dominating our minds at the moment, and because COVID is dominating our minds, people who need treatment for other problems – heart, or diabetes, or TB, or blood pressure – are not getting it; and also, children are being born who, perhaps, are probably not getting the inoculations they need for diphtheria, whooping cough, and a whole lot of other things. We are, therefore, building-up – behind COVID – a whole lot of other problems that are going to hit us at some point of time.

SJ: Yes, absolutely true. You know, if you can’t do, let’s say, elective surgeries today, these become emergency surgeries tomorrow – that’s just one example. And, even though data from India is actually quite poor as to what have been the impact of COVID on maternal and child health, on immunisation rates, on something as critical as tuberculosis – which India has vowed to eradicate by 2025, five years ahead of the global goal – we have no idea what’s happening out there to all these diseases.

And, if you allow me at this point, to do some advertising, I will say that my own organisation – the DBT Wellcome India Alliance has found a partnership, which we call a ‘catalytic partnership for COVID’, with another organisation called Research Triangle International – their India office, and we plan to really use institutional resources to address the impact of COVID on exactly these sorts of things – other health systems, what is the effect on nutrition, rural health, NCDs, mental health, immunisation – this is a hugely important area.

Through your medium, I would really like to appeal to high-net individuals and to other organisations to come forward to support us, join us. This is hugely important for India.

KT: That’s a very important appeal you made, and I wish you good luck at the job you’re doing because I think it’s very important that all the other healthcare requirements that are being ignored are attended to, and attended to expeditiously.

But let’s come back to the here and now because, at the moment, the here and now is a matter of increasing concern and many people are very worried about the COVID situation facing the country. Now, the government takes great comfort and reassurance from India’s mortality rate which, as of this morning – Thursday, the 17th – is 60 per million but the truth is, that whilst the mortality rate may be low, that of all our neighbours is even lower still – so is it lower still when you look at countries further afield like Indonesia, Philippines, Thailand, Malaysia, and the whole of Sub-Saharan Africa’s is below us. So, the question I want to ask is this – first of all, our mortality rate being low is not an unusual factor, it seems to be a trend in all – if I can use that word – third-world countries; we’re not exceptional.

SJ: I agree entirely. I mean, if you look at the data, India – you yourself said – it’s fifty-nine or sixty at this time. You look at countries in our neighbourhood, Bangladesh and Pakistan have twenty-nine per million, Nepal has five per million, Sri Lanka has 0.6 per million; every single country in Southeast Asia is lower than India. We have this tendency to always look West, let’s try and look East and see what’s happening.

So yes, coming back to this, I believe there is a biological reason for it simply because a lot of people in this part of the world are exposed to all kinds of infectious diseases and, therefore, I believe our innate immunity is always stronger, can be mobilised quickly; and, it has been shown that this virus is very sensitive to innate immunity. So, if we can have good innate immunity, it controls the virus in our upper respiratory tract, doesn’t let it go into the lungs where it can cause severe disease – so I believe there is a biological reason.

KT: Let me ask you two quick questions about the mortality rate. First of all, do you believe that India is accurately counting COVID deaths or is it underestimated. There are many people, like professor Mavlankar of the Public Health Foundation, like people who’ve been writing articles in The Hindu – Hemant Shivade, Giridhar Gopal, Anant Krishnan – who firmly believe, although to a different extent in each case, that we are underestimating. Anant Krishnan has gone so far as to say nobody believes the figure.

SJ: So, let me just say that death would be undercounted in a pandemic all over the world simply because, sometimes, you know, you just don’t know. In India where, in the best of times, it is estimated that only about 20% deaths are institutional, registered, and a cause of death ascertained, we can expect the numbers to be underestimates. But I must say, in COVID, it’s hard to miss deaths because most of the deaths are happening in hospitals – at least the counted deaths – so it’s really a matter of debate how much one is undercounting but, let me say, there is undercounting everywhere.

KT: Let me put to you another concern about India’s obsession with the mortality rate; the word obsession was used to me by Aashish Jha, a professor at the Harvard Global Health Institute. He says this is puzzling, it’s not meaningful, and his explanation is that when, in the fullness of time, we know how many infections there were and we know how many death there were – the mortality rate, he says, will be roughly the same for every country – around one, one-and-a-half, two percent and, therefore, this obsession – to use his word – with the low mortality rate is misleading; it’s almost deceptive.

SJ: So, I do agree with Dr. Jha. He’s talking about the infection fatality rate, not the case fatality rate. What we are talking about today is the case fatality rate. In India, for example, the case fatality rate is 1.6% when the average case fatality rate the world-over is roughly three-and-a-half percent. So, we are talking of different things but I do believe that once the outbreak is over, once we have the tools and the time to do proper surveys, the infection fatality rate – which is really a reflection of the virulence of the pathogen – is going to be roughly the same all across the world.

KT: Let me, at this point, raise two issues that are matters of great interest – maybe even of concern – to audiences because, as you know, audiences are learning more and more about COVID and there are two things, in particular, they are focused on. The first is this question of herd immunity, given it is quite possible that the total number of undetected infections in India could be six hundred million, maybe seven hundred million – are we getting close to herd immunity levels, or is herd immunity a concept to do with vaccinations which is wrongly applied in this case?

Also read: COVID-19 Deaths and ICU Admissions Are Again Rising in Delhi

SJ: So, there are a couple of issues here. You know, herd immunity applies more to vaccination, not to diseases; it also applies to closed groups, communities, or ecosystems and you can’t really talk about herd immunity – about the whole country or the whole world, you know, as one entity, you know, conditions differ. The other thing to remember is that people are always moving in and out of these communities, so a clear answer whether herd immunity would develop at fifty percent, or sixty percent, or twenty percent is just not possible. I think we should simply get away from this business of herd immunity and focus on controlling the growth in the outbreak now without worrying about whether we will achieve herd immunity and when we will achieve her immunity.

KT: Let me ask you one more question connected, in a sense, with herd immunity and it’s to do with Dr. Karl Friston’s concept of immunological dark matter. This theory says, that up to fifty percent of any population of any society is not susceptible to a virus, for reasons such as cross-immunity or geographical isolation. How do you view this theory?

SJ: Well, Friston’s dark-matter hypothesis does make sense but I don’t agree that we can put fifty percent value to people who are to susceptible for every infection. There are many variables here, most importantly the ability of a given pathogen for human-to-human transmission, and the duration of effective immunity. So, it would vary from one pathogen to the other. It is true that the entire population is not susceptible but what percent of the population is susceptible is really very hard to predict or calculate.

KT: That’s a very clear answer. We don’t know whether the percentage of population that’s not susceptible is as large as fifty percent, but it is undoubtedly the case that some percent of all populations will not be susceptible to viruses. Let me then put to you a second issue that is also one of great concern to audiences as they learn more and more about COVID.

How much immunity does an infection confer? I noticed that, last month, Hong Kong university confirmed the first re-infection and, since then, we’ve had several reports of second infections from within India itself. What happened in the case of the Hong Kong person is that her or she got re-infected four-and-a-half months after the first infection; did that surprise you – that the immunity from an infection was just four, four-and-a-half months?

SJ: No, it doesn’t surprise me. Actually, if you look at results that are being published lately – in some very respectable technical journals – they show that protective anti-bodies to COVID-19 virus wane off in about four or five months. There are other anti-bodies that stay longer but those anti-bodies don’t really protect from infection.

The other aspect is cellular immunity or, what we call, ‘T-cell immunity’, and also, a memory response in immunity, which means that when somebody is exposed to the same pathogen – or a related pathogen – again, there is recall in the immune response and this recall is far quicker than the original response. So, it may not protect against re-infection, but this will protect against disease and, I believe, that is what we are seeing.

I must say that there is only that Hong Kong report and, lately, there are are two reports from India which provide best evidence of actual re-infection by sequencing the virus and showing that the virus which infected the first time and the second time were different viruses.

So, we may be seeing re-infection – and that happens in a lot of acutely infecting viruses, it’s nothing to be surprised about – point is, that you’re not getting disease the second time around and all we care about is disease, we don’t care about getting infected.

KT: That’s a very important distinction you’re making, and I’ll repeat it for those who haven’t, perhaps, heard it clearly, that there may be instances – and those instances may grow in number – of re-infection but none of them have actually got the disease a second time, and that’s the important thing; it’s not the infection we should be worried about but the disease, and if the disease doesn’t happen a second time, that also suggests – as you said – that even if the COVID anti-bodies that come with the infection wear off after four, five months, there is the T-cell immunity and there is the memory response immunity, and both of those continue to protect people from disease. They may not prevent infection, but they protect from disease.

SJ: Absolutely.

KT: Then let me ask you this, Dr. Jameel. If the anti-bodies wear-off after four, five months, does this have implications for the vaccine that is being developed?

SJ: At this point, I don’t think it would have much of an impact. A good vaccine will raise sufficient memory to protect against disease in future, and that’s how most vaccines work. Vaccines don’t protect against infection – most vaccines – they protect against disease, and I believe it’ll be the same case here.

KT: Now, Dr. Antony Fauci has gone on record to say that he personally believes that a hundred percent effective vaccine is unlikely, and I want to ask you two related questions. Do you agree with him, that a hundred percent effective vaccine is unlikely? And secondly, what does a fifty or sixty percent effective vaccine amount to?

SJ: Okay, so first of all, there is no vaccine being used currently which is a hundred percent effective; there is nothing called ‘hundred percent’ in biology, so let us understand that. Even the hugely successful oral polio vaccine, which has eradicated polio from not just India, but almost the entire world, also causes polio myelitis – the disease – in one out of a million cases of vaccination. So, let us understand this, that there is nothing called ‘hundred percent’ in biology.

Now, there has to be a threshold for how effective a vaccine can be, and this efficacy is determined in phase-3 trials. The U.S. FDA has gone on record to say that they will not approve any vaccine that shows less than fifty percent efficacy. So, if there is a vaccine that, let’s say, fifty or sixty efficacious, it will at least afford that much protection and it will blunt the disease; and that’s good, that’s important.

KT: Now, on the question of vaccines, the Russian’s have made one called Sputnik; it’s reportedly been given to President Putin’s daughter but there is enormous controversy in the West about the effectiveness and safety of this vaccine. I know that the makers of this vaccine have published, in Lancet, their phase-1 and phase-2 results but those, in turn, have been challenged by some academics as well. We read now, in the papers, that Dr. Reddy’s is going to be doing phase-3 tests for Sputnik in India and will also be distributing the vaccine. What’s your feeling about this vaccine? Is the criticism it’s faced in the West justified, or is it being criticised because it’s come from Russia?

SJ: No, so firstly, all the three vaccines that you talked about – the Sputnik and the two Chinese vaccines – that have received emergency approval in their own countries, have not yet gone through phase-3 trials. Phase-3 trials is where you determine how efficacious a vaccine is.

Now, the criteria should not be whether the president’s daughter has been a volunteer or otherwise; by that criteria, I think, all national leaders should ensure that they produce at least one daughter. That’s a ridiculous argument to make. You know, I think it’s good that Dr. Reddy’s is going to be producing this vaccine and doing a phase-3 in the country. One hopes that the phase-3 will be done properly and, in the end, we will find that this vaccine is safe and efficacious; we are all looking towards multiple options to be available to Indians as well as everyone else in the world-

KT: Can I interrupt?

SJ: Yes.

KT: Do you share the criticisms western academics have levelled against the Russian vaccine?

SJ: Well, I did see the paper that came out in The Lancet, which showed the phase-1 and 2 trial data for the Russian vaccine, and my first response to that was that it was very underpowered. Only forty volunteers were tested in phase-2, so it was really underpowered. Secondly, I’ve also seen some of the criticism that many of the data points in the figures in that paper were identical, and that does raise concerns, you know, I hope that the people who have published that data will clarify it. Because, you know, it’s a matter of credibility of their vaccine if there is data duplication in their paper.

Also read: ’76 Days’: An Affecting Record of Life Under Siege in Wuhan After the Outbreak of COVID-19

KT: One quick question, President Trump, yesterday, announced that America could have a vaccine in three or four weeks. No one else seems to believe that but you think it could be as soon as that, or is this another one of those ‘Trump claims’ that needs to be taken with a pinch of salt?

SJ: Well, President Trump is going for an election in November and his entire focus is on the elections. What I also heard yesterday is, for the very first time, a reputed journal in America – called Scientific American – has endorsed Mr. Trump’s rival because they believe that Trump is against science and detrimental to U.S. interests. So, it’s an interesting time in U.S.

KT: Yes, and if I recall correctly, that endorsement by the journal is the first time it’s happened in the journal’s history which, I believe, is a hundred-and-seventy-five-year history. My last question, Dr. Jameel. A paper recently published by the New England Journal of Medicine hypothesises that mask wearing could become a form of variolation which could help reduce the severity of the virus and, in turn, it could help ensure that an increasing proportion of infections are asymptomatic. How do you view this hypothesis?

SJ: Well, I don’t know about that but, you know, variolation is a term that is used for active protection which means vaccination. It was used by Jenner in the eighteenth century when, you know, he used cow pox to vaccinate against smallpox. Masks would certainly be a barrier to respiratory infections. There is already a culture of wearing masks in many countries when one is going through a cold so, you know, that’s a good practice and I believe that this culture will be adopted elsewhere in the world but whether it reduces the virulence of the virus I’m not too sure. Viruses such as this virus – acute respiratory virus [40:05 – unclear] – reduce their virulence in a population simply because it helps the virus spread better and also because increasing numbers of people get infected and, therefore, are protected from disease.

KT: So, mask wearing, you believe, will become a habit because it’s a good practice.

SJ: Yeah, yeah. It would be a cultural thing.

KT: But you question whether mask wearing will reduce the virulence of the virus. You question, therefore, this claim of variolation?

SJ: Yeah, I don’t think mask wearing is going to reduce virulence of the virus. Virulence of the virus will reduce when the virus has infected enough people and has, therefore, raised immune memory responses in people. You know, on the cultural side of it, and, you know, just to end on a funny note, my wife was telling me the other day that women’s dresses were now being sold in the market with masks made out of the same cloth so, matching masks. Maybe somebody should pay attention to men as well and, you know, at least make sure that we have matching masks for our shirts and blazers.

KT: Absolutely, Dr. Jameel. They used to say that gentlemen ensure that their shirts and socks match; now maybe gentlemen will have to ensure that their shirts, socks, masks, and tie match.

SJ: Absolutely, absolutely.

KT: And, let me add, for a sardarji maybe the pagdi and the mask will have to match. You can’t have too many contrasting colours.

SJ: Yeah so actually COVID is starting a new fashion trend.

KT: Absolutely, and that is probably one small unintended benefit – that we’ll all become conscious of how we look.

SJ: Right.

KT: On that lovely note of humour, thank you very much, Dr. Jameel, for this interview. And, in particular, for your insight, into how you believe COVID is going to fare over the coming weeks and, in particular, for pointing out that the total number of undetected cases would be much higher or, at least, higher than even the extrapolation from the ICMR figures that we could be somewhere near seven hundred, or even eight hundred million. I think it’ll make people sit up and think very carefully about the situation the country faces. Thank you very much indeed. Take care, stay safe.

SJ: Thank you.