Bhramar Mukherjee, Professor of Epidemiology, Biostatistics and Global Public Health at Michigan University, told The Wire that the present Covid surge has reached its peak but is plateauing at a very high level of cases per day.
In a video interview to The Wire’s Karan Thapar, Mukherjee talks about the undercounting of deaths as a result of COVID-19, the government’s refusal to classify itself as a country with community transmission, testing rates across the country and much more.
Below is the transcript of the interview.
Karan Thapar: Hello, and welcome to a special interview for The Wire. Do we have credible evidence to suggest that in fact the present surge of coronavirus has peaked and is starting to plateau, or is that a hasty and misleading conclusion that could lead us to a faulty analysis of the situation we face? That’s the key question I should raise today and my guest is someone who is uniquely placed to answer that question. She is a professor of epidemiology, Biostatistics, and global public health at Michigan University, and one of the most welcome guests on this program, Bhramar Mukherjee.
Professor Mukherjee, before I talk to you about how you see the next four, six weeks, Let’s start with the situation facing the country today. As of this Saturday, May 15, coronavirus has increased by just over 325,000 cases, deaths have increased by just under 4,000. But the government, both at their press conference today, Saturday the 15th, as well as two days early on the 13th, point out that in 20 states, the situation is plateauing. And the evidence they seem to offer is that in 316 districts, that trend in cases may be rising, but in 338, that trend is declining. So how do you respond to this view that although cases and deaths are still increasing by a worryingly large number, overall, the situation is plateauing.
Bhramar Mukherjee: Thank you, Karan, for that question. So we are all thinking about the situation and monitoring the situation in India at a granular level and I’m glad that the government is also doing so. So let me divide the question into actually four parts. So the first part is whether the peak has been attained at a national level. Actually, most models that I know of predicted the peak around this time, around mid-May. So I do believe that there has been a slowdown of the astronomic growth that we saw in April.
So the second part, do I believe that the reported numbers that are representing the height of the peak are accurate? The answer is an emphatic no. The third point is that India is really a nation of multiple nations within a nation. So I’m still concerned about many, many states, Tamil Nadu, Karnataka, West Bengal, among the large states, a cluster emerging in the northeast. So I think that let us not declare premature victory, yet another time and really err on the side of caution. The fourth point, if you get yourself used to a very huge number, like 415,000 cases, and 4,000 deaths every day, even 300,000 cases and 3,500 deaths seem small to you on a relative scale. But these are astoundingly large numbers, the largest daily reported numbers any nation has reported in the world so far. So it’s still a national catastrophe and a self-inflicted one, as the scathing editorial in The Lancet said. And I actually really think about these numbers as real people and real faces, and this is an astronomical humanitarian cost to society.
KT: Can I pick up on the second point you made? You said, Do I believe the numbers at the height of the peak and the answer is an emphatic no. Are you saying that, in fact, the actual number of cases is far far greater than the officially detected ones? And if we only focus on the officially detected cases, which, incidentally, is an increase of 326,000 as of yesterday night, then we’re misleading ourselves into believing it’s lower than the reality? Is that the point you’re making?
BM: Absolutely, the relative growth rate has slowed down, but the absolute numbers are still very high. With limited testing, we really do not know these numbers. And so there’s no room for complacency here.
KT: But you do accept that the relative growth rate has slowed. We’re still growing but we’re not growing as fast as we were a week or 10 days ago.
BM: Exactly. And I think that all the models did predict that this is going to happen in May.
KT: And does that, therefore, suggest that we’ve touched our peak and are plateauing? Maybe not declining but plateauing?
BM: I would say so, I would say so.
KT: Let me then at this point, raise with you two areas where the government and public opinion sees cheerful news and one, where in fact, we simply don’t know. But we’re very worried about the situation. The first of the two cheerful areas is Maharashtra. Maharashtra yesterday grew by under 40,000, which is a lot less than the 70,000 levels that have reached in April, Bombay grew in under 2000. The positivity rate in Maharashtra, the state is just over 17% and in Bombay is just over 6%. Do you get the feeling that Maharashtra and Bombay perhaps, in particular, are declining? And this is a good news story?
BM: Yes, yes, I definitely think so. And I tweeted about it, maybe a week ago. And I think that it’s stunning progress, and the R-value, the growth, and one of the measures of growth has declined from 1.7 in March to around 0.8 now. The test positivity rate is also come down from 24% to 17%, we’re doing a large number of tests, we do believe that the state of Maharashtra is doing about 250,000 tests every day. Still, 800 deaths are happening. And so we have to be really mindful of what we do as an exit strategy. As we come out of the shutter at home orders. I do expect our models are predicting by the end of May, we are going to see as he said 40,000. But it will even come down father to 10 to 15,000 cases. So that’s extremely good news.
KT: So Maharashtra will be down to 10 -15,000 cases in about two weeks’ time. That’s the end of May.
BM: That’s what the models are predicting. So sometimes I bear good news also on your show.
KT: What about the other areas where people in India believe we are seeing clear signs of good news or talking of the capital Delhi? You may recall that roughly a month ago, Delhi was increasing by 20,000 a day, the positivity had reached an astonishing 36%. Today, just before we began this reporting, the chief minister announced that yesterday Delhi increased by under 7,000. And the positivity has fallen to 11%. Is Delhi becoming a second good news story?
BM: So I do believe that Delhi is less clear because they are doing 80,000 tests a day. It’s relatively little compared to the population of Delhi. But I have been watching these numbers like a hawk everyday. So even after controlling for the testing effect, I feel that there has been a genuine decline. And we have to be mindful that you know, deaths are a lagged indicator. And our models are predicting that Delhi will come down to about 1000 cases by the end of May. So, again, I hope this is good news. And these actually turn out to be true.
KT: Let me then at this point put to you one area, which we don’t know very much about and which is becoming an area of concern and I’m talking about rural India. The anecdotal reports whether it’s the people ill, whether it’s bodies floating down the Ganges all suggest that coronavirus has spread and the only confirmation from the government is the following: both today at the press conference and on the 13th, they’ve said that 516 out of 734 districts have positivity rates above 10%. That’s 70% of the districts of the country. Doesn’t that suggest that it has spread in rural India fairly widely? And the anecdotes that we’re hearing about various permissions bodies floating people being a part of that add up to this picture, it is now a major problem.
BM: I do believe so. And personally, I really feel appalled by the quality of data and reporting both in terms of infections and deaths in India, rural India is a big mystery and really accurate reporting, even if not test syndromic surveillance, wastewater testing, we could actually get some credible data from rural India, even if we do not have testing capabilities as much as the big metros. So It is very hard to see what is going on and good models need good data. But I do think that data transparency and more nuanced information, even if we do not have RT PCR tests everywhere is very much needed.
KT: So you’re clearly saying there’s a lot more that we could do to find out the truth in rural India and we’re not doing it?
KT: Let me raise with you a question that was raised by Shaheed Jameel in an article he wrote for the New York Times, just two days ago, on Thursday, he was talking about the nationwide situation, he said, and I’m quoting, “Data shows that testing is increasing at a fast slower rate than cases. In this scenario, numbers will reach a plateau, not because case numbers have stopped rising, but because testing capacity will be tapped out.” In other words, he’s saying that if we are reaching a plateau, it could be for the wrong reasons. And therefore this plateau may not be as comforting, as the government is trying to suggest.
BM: So I really respect Dr Jameel’s viewpoint. And we presented a very compelling visual graph in an article in The Hindu on May 4, where we actually plot the rate of growth of cases versus the rate of growth of testing in India, and compared that to the United States to compare a good testing strategy. And of course, India is not testing enough given the amount of infection it has. But I still do believe that the growth of cases in India is slowing down, even after controlling for testing effect. And we have run several simulation models to test that. But I’m completely with him that we are undeniably wasting only a small fraction of even symptomatic serious infection due to lack of testing, and due to this darkness of mystery in rural India. So there is no reason for us to feel good right now, because we are still in a very deep crisis.
KT: But if I can pluck out the silver lining in that answer, we do accept that the plateauing we’re seeing is real plateauing because cases are slowing down. It’s not plateauing, because we’ve reached the capacity for our testing and testing is not sufficient.
BM: I do believe so. I think I want to make that statement nationally. I think so in many places, there is extremely limited testing. So it’s very hard to say what is going on. Data from certain states look really surprising to me given how fast they have fallen. And I’m skeptical about some of those data points.
KT: Let me at this point put one more question to you about the situation that prevails today. According to the latest weekly report put out by the World Health Organization, which went out in fact, on Tuesday, the 11th, just five days ago, India refuses to classify itself as a country with community transmission. The report clearly shows that India insists upon classifying itself under the lower and less serious classification for clusters of cases.
Now, my question is simple. for the last 25 days, India has been growing faster than any other country in the world. Secondly, as the government confirmed this afternoon, the nationwide positivity rate is 19%. And thirdly, as the government said again this afternoon and two days earlier, 24 states have positivity above 15%. Apparently, 10 states have positivity above 25%. In those circumstances, as an epidemiologist can we really say there is no community transmission?
BM: Is this a joke? I come back to your show as a scientist and defend my science, defend my predictions and justify it. Let us go back to epidemiology 101. And the fundamental definition of community transmission. I really urge and welcome the officials to contact, trace and identify the source of even 10% of India’s let’s say 5% of India’s millions of infections. There’s absolutely no semblance of science in this claim.
KT: That really strong. There is no semblance of science in this claim that we’re not in community transmission. And as you said, as you ask, is this a joke?. But let me put this to you. Experts outside India will be aware that India refuses to accept theres community transmission challenge. And all those experts like you have access to the truth, they follow India closely. There’s nothing about the pandemic in India that they don’t know about. So when they repeatedly hear the Indian government say, this is not community transmission, what impact does it have on experts like yourself, and many others in America and England?
BM: We do not have to go to America and England. I do think that Indian scientists in India, and epidemiologists and experts also disagree with this statement. And so they should speak, not the way expertise should count and statements meant by the government should really be guided by epidemiology, data science and viral transmission by experts. So you don’t have to go outside India. I think scientists in India recognize that this is not guided by science.
KT: Absolutely, Indian scientists should make it clear, they don’t accept this. Hopefully, they will. Let’s at this point, Professor Mukherjee turn to how you see the next four to six weeks. Your university and you, in particular, do some of the best mathematical modeling of India’s COVID trajectory. When I interviewed you last on April 22, you said you believed your projection show that India would reach its peak in terms of infections in mid-May. And in terms of deaths, at the end of May? I’m writing concluding from your earlier answers, that those projections and those dates are more or less coming true. We’re graduating, which suggests we’ve reached the peak of infections. And we’re probably going to reach the peak of deaths, two weeks from now. So do you believe your projections have been validated?
BM: So, of course, you know, the in terms of total number of infections, it is a moving target, because the 10 more you test, the more you find, but unfortunately, the projections for death where we said that around 4500 deaths a day at the peak have come true and I did not want that to come true. And I am sad to see that come true. I also had said that April is the cruelest month and where we are going to see the severe surge. So I also want to say that, you know, the deaths being a lagged variable, this is somewhat being untrue for India recently, because I think there is a delay in testing. And then there is healthcare capacity, bottleneck capacity. So the time from diagnosis to death have really been shorter. So you see that the cases and deaths peaking not like what you did expect, but at the same time almost.
KT: Now you’re absolutely right when you say that in terms of your model’s projections about deaths have come true. There have been days a couple of days ago when we were touching 4200 or 4300. But in terms of infections, you said to me that we would peak mid-May, somewhere between 800,000 and a million. At the moment, the highest we reached four or five days ago was 414,000. Is that because the model was wrong in terms of the quantum of infection? Or is that because as you said earliers, you don’t believe the figure put out about infections?
BM: So a couple of things is that I’m very happy to be wrong. I never wanted to be right in this case. This is one of those cases where I’m delighted to be wrong. Because if we can, human beings through their actions and policymakers, can beat their dire model projections, that’s where the success of a modeler is that people took you seriously and intervened. So I do think that our projections were under no interventions or the mild interventions that were going on in the country. Since then, there have been several stay-at-home orders. elections are over, West Bengal, Tamil Nadu, Karnataka have all entered into a semi lockdown or full lockdown mode. So of course, and of course, it is also a function of testing. But really the number of reported cases tells you the tip of the iceberg. There are a lot more infections and even serious infections that we are feeling to count and report for I do believe that but again, my summary is that I’m happy to be wrong on that account.
KT: Let’s move on. There are some people who say looking down the road that just as cases shot up like a rocket in April, they come cascading down equally sharply. There are others who say, no, it’s probably likely that they will meander down slowly that we will plateau at a very high for several weeks, and the tail will be quite a long one. Which of the two views do go with a cascading down? Or a plateau with a long tail meandering down slowly?
BM: Yes, so you put that beautifully, and I’ll put it in terms of numbers is that what we see in our models is that I do see sort of a, there’s a, if you look at this curve, they’re almost always sort of a symmetry, right? If you look at the first peak, there is a symmetry from the peak. So we do see that the cases are coming down at a reasonably decent rate. So we see in two weeks about 320,000 is coming down to 150,000 to 200,000. So 1.5 to two lakhs, but this is still high. But we do see about 3,000 deaths each day, even in two weeks. So I see a slower rate of decline in deaths. And if you think about it, compared to where we were in February, right, when we started seeing the uptake, that will still take a while. So I think hospitals systems will still have a large burden in the months of May and June.
KT: I’m just repeating what you said because I think it’s very important people should understand. You believe in two weeks, the increase in daily cases will come down to somewhere between 150,000 -200,000 a day. At the moment, it’s just over 325,000. So it will be a sharp decline, even though 150,000- 200,000 a day is still a lot of daily cases. And deaths, you believe that two weeks will come down more slowly to around 3000 deaths a day. Have I summed that up correctly?
KT: But you added that it will take a longer while, a much longer while, to get back to the position we were in February. I take it what you’re saying is that the actual petering out of this will take a lot longer than two weeks. When do you think that petering out will happen?
BM: So, you know even if we try to normalise these large numbers, because we are getting used to large numbers every day, I think that it’s still like we are looking at about 100,000 more deaths in the next one month. That’s the key quantity that I want to focus on. I do expect by mid-June, we’ll see some distinct improvement. But we have to be really cautious because we are going to be lifting the lockdowns. And if we do not adopt the optimised, nuanced and strategic exit plan, then I think that it would be hard for us to maintain this declining trend. And then we also have to be set up to curb outbreaks if we see in the like, you know, in the foreseeable future. So it’s conditional on a lot of ifs, but I do expect that by mid-June, we’ll have a sense of improvement. But the whole summer we’ll have to deal with this pandemic.
KT: So you’re saying that over the next month, you see another 100,000 deaths? Another lakh of deaths over the next month, but am I right in interpreting it to say that by mid-June, that’s roughly a month from now we’ll see improvement does that mean the surge will have petered out by mid-June?
BM: So you know that you have to define like, you know, what do you mean like quantitatively that word where it has phased out? So as what I’m seeing is that I think May and June are still going to be full hospitals and then but you are in the numbers I think you’ll see a distinct improvement by mid-June. And then in July and August, we can expect if everything goes as planned, and again a lot depends on how we come out of these lockdowns, then we are going to be in a similar position that we were when the second search started. That’s it, thats the definition of petering out.
KT: So we have to wait till July and August to go back to the position we were in February before the surge started. In other words, the surge won’t peter out till July, August. And as you said May and June, we will still be seeing full hospitals. That means people will still be falling ill and needing hospitalization, ICU oxygen and ventilators, that will continue.
KT: One more question as this tantalizes people. Do you have any sense of when or what will be the total number of official counted cases and official touted deaths when we reach July-August?
BM: As you know that I have written much about it, I’m very skeptical about the official counted cases and deaths. And if I have to predict that, I think that, you know, I don’t want to stretch beyond four to six weeks, because I’m skeptical about these models and the reality on the ground and the interventions change so rapidly. So I think that by mid-June, as I said, in the next one month, we are going to have another 100,000 deaths. That’s our sort of models telling us right now. So then we’ll get to 360 370,000 total deaths by mid-June. And by that time, we are going to report our model, say about 30 to 32 million cases. So, but then there will be July, then there will be August. So we’ll probably be number one in the world.
KT: A dubious distinction, indeed. My last question. And you know, from your knowledge of India that absolutely no one in this country believes either the daily death count or the total death toll. And you only have looked at the evidence from crematoria graveyard, and obituaries in the newspapers to understand why. In interviews that you’ve done both with me and with other people, you’ve said that India undercounts deaths by a factor of somewhere between two and five. Do you have a clearer idea of that undercounting? Or is it still within that range?
BM: So I think that, you know, the estimates that I provided are from wave one. In wave two, we are hearing much more stories, particularly from rural India, where we do not have a good reporting system in general. So I believe that I’m siding more towards the higher end of that interval. And I will give you a quantitative estimate. And then I’ll also make a qualitative statement. So I believe that it’s four to five times the total number of deaths. So we are reporting about 260,000 deaths, total deaths right now. But I do believe that more than a million people, 1 million to 1.25 million deaths attributed to COVID-19 have happened. And there is tremendous variation in terms of this under-reporting across the geography of India.
But there is a way we could validate these numbers. So I really strongly urge, beg and request the Indian government to release disaggregated data across age and sex and hospital and on COVID-19 cases, hospitalisations and fatalities, as well as all-cause mortality data from 2020 and 2021 so far. So that we can see, given historical trends of mortality in India, how many excess deaths have happened? So you don’t have to rely on folklores put out by modelers and statisticians. And then the last thing I want to say is that this pandemic has left the lives of very few of us unaffected. That does not total upto 260,00 deaths, that experience
KT: It’s much much more. You’ve said it politely, not so abruptly. It’s time the Indian government started telling the truth to the Indian people, whether it’s about accepting the fact that we clearly have community transmission and it’s a joke to try and deny it whether it’s accepting that the number of deaths is much greater. We cannot continue with stories from Gujarat, the Prime Minister’s own home state, when increasingly you get proof that that deaths even of people who tested COVID positive are not being counted as COVID deaths, but being attributed to comorbidities that, again, is fooling the Indian people.
BM: So I always say that truth is better than fiction. And also, data transparency is really key to managing this pandemic. And it’s really the models used to predict healthcare utilisation of healthcare oxygen needs, so it can really save lives if we have good data. And if you have a good grip on the pulse of this pandemic. The IHME model is predicting like 1.25 million deaths in India by the summer, and many, many more infections. But I really think that there is a way to address this by setting up a data ecosystem. And this is an investment India needs. It’s a moral investment, and it’s an infrastructure investment that would really safeguard us against future health crises.
KT: Thank you very much indeed, professor Mukherjee. I hope the government is listening and more importantly, I hope they heed your advice. Thank you. Take care. Stay safe.