Why India may not see the kind of Covid-19 outbreak rest of the world has seen

Dr Raman R. Gangakhedkar, head of epidemiology & communicable diseases at ICMR, examines various Covid-19 issues with ThePrint's National Affairs Editor Jyoti Malhotra.

Dr Raman Gangakhedkar (right) with ThePrint's Jyoti Malhotra | YouTube

New Delhi: While questions have been asked about India’s Covid-19 testing rate and apprehensions raised on rising number of undetected cases, Dr Raman R. Gangakhedkar, head of epidemiology and communicable diseases at the Indian Council of Medical Research (ICMR), tells ThePrint’s National and Strategic Affairs Editor Jyoti Malhotra why the nation is likely to fare well than most other affected nations.

He talks about various other issues surrounding the pandemic, including the nationwide lockdown to curb the virus’ spread.

Here is the full transcript of the interview

We really want you to explain what’s going on. There were 9,000 positive cases in India as of 13 April. In the last 24 hrs we have had 35 deaths, are you worried with the Covid-19 situation?

See, worry is a relative phenomenon. It’s like happiness, you can be happy, you can be happier but there is a background to the whole thing. If you ask me about the background that we have — we started where in — the first case was at the end of January, sometime around 27 if I recall correctly- 27 January.

Today, we are exactly around two and a half months into the outbreak. You know the population density of our country, you know the population size of our country, you know the high level of migration that you have in the country, you know the proportion of people who are below poverty line, who are staying in the slums and trying to make a living as such. If you actually look at the entire world today they are extremely worried — how is it that India is not showing so many cases, how?

How is it?

That’s what essentially I am trying to say is simple — that the governmental efforts have been so strong and timely that it didn’t spread as much as the world had expected. You look at the rest of the developed countries that you have currently which are facing the severe outbreak, you suddenly start finding — compare yourself with France, compare with Italy, Spain or you compare even with China for that matter.

If it is two and a half months of outbreak in China, things would had been different but we learnt from them that restricting international travel, going for contact tracing aggressively, trying to ensure that you limit the interaction between human beings, try and ensure that social distance is maintained by people and this humongous task has been so well compared to the rest of the countries. Today, we aren’t at the same cusp which we should have had minus these interventions, if you look at the other countries.

We learnt from China to restrict international travel, limiting interaction between human beings

So the lockdown has helped?

Of course it has helped, of course. See there is one thing that we have to realise, ours is a society where perhaps we never taught science in the best possible manner. We don’t know, if I ask any very literate person that how many chambers does your heart have or do you know that where could your spleen be — one of the most potent organs you know — spleen is one of the most useful organs that defends your body very strongly, it is part of what we call as reticuloendothelial system. People will not be able to answer.

Now if most literate people don’t know much about health and if you have to teach healthy lifestyle to every average citizen of this country, who may or may not have gone to school, he may be only functionally literate. There was no other way other than trying to enforce lockdown, trying to ensure that people understand social distancing. If you actually look at our society — our society used to express affection by putting hands around one another and in such a society if you start talking in terms of maintaining social distance, how would it be maintained?

So far what have been the gains from the 21-day lockdown?

I think the gain is very much visible. If you look at the curve, it has not yet peaked the way it should have had given the time.

What could it have been?

No, even if people say that China’s declaration that perhaps it started sometime in the month of December end is incorrect. Let’s assume for a moment that China had an outbreak sometime in the month of December itself — first week of December and then you calculate two and a half months time you will realise their numbers were far higher compared to two and a half months that we have spent in the outbreak.

So if you say whether this is something which has happened because of some other thing, I told you that our population didn’t know anything about social distancing. We have learnt a lot because of lockdown. My only feeling is it should continue over a period of time, people shouldn’t forget or prioritise it in a lesser manner that this is something which is my new learning, if I have to live in this world where infections are going to be there all the time. Now we can’t expect that Utopian world where there are no infectious agents, no viruses present and things like that.

You feel that the lockdown should continue?

Lockdown should continue in a balanced manner. Then it will happen because lockdown is something which is major and which will ensure that people don’t come in contact with one another. But at the same time you would also like to ensure that industrial productivity shouldn’t get affected in the worst possible way.

It’s not only industrial productivity, it’s agricultural production. Now if something hurts us badly, because they are, this is actually telling us very few things. One — every individual should have food to eat, he should earn if not huge excessive amounts, some amount of money to ensure that he will be able to feed his own family and the third thing it is telling you is that it’s not only food and money that will make you survive but our paramount importance is health. If I maintain my health well then like people used to say, that my parents, my grandparents used to tell how health hai toe jaha he (health is wealth).

Today is the time, we have to learn that part, today it is the time when we need to prioritise health. Why should a virus tell me that yes I have to invest more into the health sector, why should this virus tell me that it is a very difficult thing for people to handle, why should it tell me that it is going to infect so many people and therefore you should change.

I think it is time we should reflect what we are doing, invest more in health and investment is not only governmental investment, it should be your own personal investment too. Each individual should start thinking why am I getting this disease, whatever has happened to me, why did I get it…could I have prevented it? Could I have had the right kind of treatment for it? You know half of the people get guided. If you look at social media they will come up with all kinds of solutions.

One person had told me on the phone, ‘Sir iska solution toh bohot asaan hai‘ (sir, the solution to this is very simple). I asked ‘kya he‘ (what is it?) and he said ‘meri sirf aap ek baat maano, upas karna he isme, ek bar garam pani peeke karna he, dusre din thanda pani peeke karna he‘ (just listen to one thing I say – you have to fast. One day, it has to be after having warm water, the next day after cold water). Now if life was so simple!

Lots of things are being said, even urine therapy is being advocated

People could see, when you get so many people advocating different kinds of things which are unsubstantiated, it also taught to you about health literacy. How much do we trust science. It is time we have to look at that. If I was literate in terms of health, I wouldn’t say that for fever, you can consume little more of water. People will still go directly to take paracetamol. Now that’s a big change that you find even among people who may not be very literate. But that is the story, why can’t I have the right kind of scientific thinking coming into the population.

You said that we have avoided the peak?

I am not saying that. See I am not saying peak is avoided over a long term period because we are yet to see, we are like in the beginning stages of the outbreak. Because this is one infection, unless you have a vaccine or curative drug, this infection will keep on coming to you…it will try to affect all human beings one way or another. The numbers who will acquire it may differ depending on how much of delay have I caused to that outbreak which is occurring. It’s like H1N1. H1N1 did start and finally it ended up becoming endemic in different areas.

We lost 18,000 people in India from H1N1

What I am trying to say is each effort you’ll make will delay, it reduce the numbers that will get infected.

But you are saying we are only in the initial period of the outbreak

If you compare with other nations. We are nowhere. You compare their numbers with what we are today. We are in infancy kind of thing.

Does this mean it could get worse?

I don’t think so, honestly I don’t think so. I think the decisions that we have made are so comprehensive that we may not see the kind of outbreak that the rest of the world has seen.

I honestly don’t think it can get much worse, decisions we have made are so comprehensive, we may not see kind of outbreak rest of world has seen

You did the lockdown, what else did you do?

You know it’s so refreshing to me, now I am speaking more on a personal note. It’s so refreshing for me to see…when you see on TV channels that people are standing in queues, they have rings which are drawn apart.

Once I went to the market while coming back from a press conference and my driver went there and he hadn’t worn a mask. This is some two weeks back or so. People started running away. It’s a good thing, they are learning. I am not saying wearing a mask is going to be my final solution but the truth is that the population has started understanding the principles, dynamics of infectious diseases and which is a refreshing thing to my mind.

You look at small villages, you see all kinds of stories floating around that they are not allowing people to directly come in. There are stories where people say that if the father has gone out to bring a thing, the family members say, his own son or daughter might say that you know…’you wash your hands, take bath and then only come inside’.

Do you feel that we are flattening the curve or are we anywhere close to it?

See as I said, this infection will come in waves. If you actually see, for every country there was a first peak that comes larger, then you look at China, they still have a smaller curve that is coming after that because when you flatten this curve, every peak that should come, should be subsequently shorter in terms of its height every time.

This infection will come in waves. Every subsequent peak will be shorter. We are lucky that first wave is small because of efforts, unlike US & China

We should consider ourselves very lucky that our first efforts have been so strong that the first wave itself of this particular infection is small enough. It’s not at all as you see in China, US.

You should see the natural progression of the outbreak. Our interventions are non pharmacological right now. Now if they are non pharmacologic and these are producing so much impact when you compare with other countries I think we should consider ourselves as one society which has learnt very quickly, though everybody suspected this is a land of tigers and snakes.

Our people have proven the mettle, our government has ensured that they succeed in their efforts to enforce some kind of discipline in people.

Our society has learned very quickly, although everyone thought we were a land of tigers and snakes, our people have proved their mettle

ICMR has tested about 150,000 samples approximately.

Almost two lakh.

Do you feel that this is enough, do you feel that you should test much more and also employ other containment measures?

Let me put it the other way. You can’t decide what is enough. If I ask somebody, diabetes is very common in India, should I test each and every human being for diabetes…perhaps not.

I will always choose the most vulnerable population and then offer the test because it doesn’t remain so cost effective. You have 130-135 crore people, if you want to find out how many of them are infected, am I going to offer that test to everybody? I won’t. That’s not being fair in our country, our currency will be weighed by its relative weightage outside the country.

Now if I go for wasteful expenditures which were not required, which were preventable, I need to be taking those prudent steps. So we had that guideline which was available. When people compare us with other countries, they have been testing a lot, but their outbreak levels were different. They were way higher.

Now you look at two lakh as our offer, as of now, of having it tested and you look at the highest number of tests that have been offered is in US, i.e. 16 lakh tests have been done.

Now, just imagine, look at the population base that we have, look at the numbers of infected people, look at the number of tests that we have offered. You could argue saying that the uptake of tests was low, though we were offering those tests, it took a pretty long period of time for them even to go for the conservative estimate of our ability to test, to overcome. We don’t have a problem in terms of scaling it up.

But are you able to scale it up? You have the test kits?

Very much. You could name a figure, we could do it. Test kits as of now we keep on saying we have test kits which are sufficient for lasting five weeks based on current trends. Five weeks is not a small time, we keep on trying to look at it because this is perhaps one of the most unusual times where everybody in the world is scrambling to buy test kits.

We don’t have a problem to scale it up, we have test kits lasting 5 weeks

There is a huge scarcity in the market. Globally, people are struggling to procure stocks, so you need to be dynamic and try to assess the time…how long will my stocks last. Five weeks is a sufficient lead time to procure kits because you don’t expect the rate at which others are having an outbreak…they will continue to have that at the same rate, their demands will also go down.

If you tested five or 10 lakh, maybe you would have a much higher incident? A better picture of the disease?

That’s what I am trying to say. Finally it comes to a cost effective solution, finally it comes to you know saying, what is my test yield? If I was to test for a rare genetic disorder and I test two lakh people and I find one individual infected by it, would you be happy on making such expenses? In any case, testing two lakh people and getting one, you would perhaps wait, have some kind of definition that fit those who fit into that. I will offer them rather than screening each and every person who comes.

What is the protocol today?

I think it’s broad enough. Now it’s no longer imported cases that we are looking at. We are also seeing those who have severe acute respiratory illness (SARI)…they will be tested, in places where there are hotspots we have said, even those who have influenza-type illnesses they will be tested.

Influenza-like illness is so mild, it could be either fever, cough and cold. Now these are so common symptoms. We know that the likelihood…that testing is going to be high will continue to remain low. But we deliberately chose that at least in those hotspots will offer that particular investigation if someone is actually having that infection. You look at healthcare workers or any person who feels like he has some symptoms, he can go ahead and get himself tested.

40 per cent of cases with severe acute respiratory illness don’t have travel history. Are you alarmed by that?

No…to be honest I come from HIV background. I knew…if you ask me to recall my early interactions to way back in the 1989 to 1996-97, any person who used to walk in the room he used to say ‘no I have not been exposed’. Now that was a guilt, I agree there.

At the same time, we also published a paper…one of my landmark papers that quotes ‘high prevalence and incidents among married monogamous women’. When we asked these women, did you have sex with anybody outside marriage, they used to say no, which was also true because she didn’t know her husband.

Essentially, I am trying to drive at one issue. When somebody reports there are multiple factors which can influence reporting, those factors need not necessarily be those where I take decision to misinform. Most often we won’t recall them correctly, unless there is an aggregation of such cases.

I won’t be worried if there is one case that has come and my intervention measures continue to remain the same. They are not going to change whether I say that this SARI has no travel history or has travel history. I am talking of the same…you isolate, social distancing at home if the person becomes symptomatic. You offer him with whatever you have at your end. If my intervention doesn’t change, unless there is a congregation I won’t be worried about it because you have to get sufficient numbers to say that now, I think I am fairly certain that the error in reporting is perhaps my own rather than the patient’s.

Unless we reach that particular stage, we can’t say something like this. You look at the paradox that will come, if you get one case of SARI in one district where there is no travel history, the first instinct that people will have is to paint that entire district as one that has transmission that is continuing in the population. Would that be very fair? No one person can’t be representative. If one person was representative why do you want votes to be given by everybody. You could have said, any person who comes from the district, if he gives his one vote, it will be considered as representative and the MP could be selected based on it.

Several chief ministers are saying that they don’t have kits, they need to test much more, they are worried about the fact that kits aren’t there.

No, see there is a misconception. On one hand, I am saying, now I am making very strong conscious statements…on one hand I am saying that yes people are learning about health but on the other hand I am also seeing loose terminology being used from science.

One terminology is random sampling. I don’t understand, if you ask me as a scientist. Random sampling is a technique, it is not something which I can use to describe… everything that we do in science is based on random samples. Second term people are using is rapid testing, and they believe antibody testing is really great. I don’t have those kits but you have to understand one thing, those kits which are so called rapid diagnostic tests, rapid is in terms of quick diagnosis that you will get once you test an individual.

If you look at it, it detects antibodies. Those kits are currently not available, but you have to understand one thing, why those kits aren’t currently available. One, these are first generation assays, when you do first generation tests. First generation is, you know, the first time when you have developed a technique.

I don’t have access to rapid antibody test kits, but we have to understand that they are first generation and so not reliable

Then you become wiser and what comes next is second generation. So your approaches are a little better, they are refined. Then comes the third generation, you tend to grow, something like that. Now one of the things which we have to realise is there were some kits which were having both the antibodies, IgG as well as IgM.

Now any organism that enters into my body, the first response of my body is to produce IgM antibody which tells me there is recent infection. Once IgM is produced, after sometime IgG antibodies start predominating, and then when IgM falls down, IgG continues to remain in my body and IgG is actually an indicator that I have received, my body was invaded by a particular organism.

When I say something like this, you have to remember, one caveat in science that comes is where ever I put IgM antibody, IgM antibodies are little large in science and if they are large in size, the background that you will have becomes lesser, the contrast gets lesser. If the contrast gets lesser, the test doesn’t remain as sensitive, as specific.

So there were two kinds of kits that people first produced, one was using IgG and IgM together. Now when you use it together, the contrast will become less, so sensitivity and specificity both start getting affected.

Later, people started doing IgG as a separate line, IgM as a selection line. If it is IgM, it’s a recent infection, IgG is a chronic infection of the past. So if there is only IgG, you be happy and say this is an immune response. The person is no longer actively infected. But it comes to IgM, as I said the problem is if IgM lights up it’s good, you can actually see it well but if IgM lighting is not so good, it is because you are looking at IgM, so it doesn’t tell you whether this person is recently having infection or not having infection.

Are these rapid antibody tests reliable?

They continue to have lower sensitivity and specificity even to this date. Mainly because you have two different antibodies that you are trying to look at and when you try to look at two antibodies separately you will find that your results will be impacted to a larger extent.

That’s the reason why we say that rapid tests, so called…rapid rapid tests, are actually telling you about antibodies and that is being told pretty late in the course of the disease. If you look at the literature that exists now, it says, if you want to find out, if you want to look at 100 per cent of the people developing these antibodies or they will be positive by rapid antibody tests, I will give it in a simpler way.

If there are 100 people who actually have the virus inside and once virus is inside, everybody is going to try to make attempts towards producing antibodies against it. If I offer the test, you will find that 50 percent of them are likely to have these tests coming positive sometime around eight days or so. Beyond 10 days you are likely to find 80 per cent of them coming out as positive.

Now you tell me if I wait for 15 days for this infection to be shown by using an antibody test, your bigger worry would be that patient not die, it’s not an early diagnosis test. The early diagnosis can be made through RT-PCR.

So you are not relying on it too much ?

For individual diagnosis, early diagnosis will not be possible through it. But it could be useful for surveillance purposes, which you people call random sampling.

There has been a lot of controversy over hydroxychloroquine. You have said that it is being used only as a prophylaxis. So what is the controversy, is it only for frontline health workers, can it be used in critically-ill patients?

See I will tell you, if you actually read the literature that has come out, pre-publication copies are available, hydroxychloroquine was a drug that was used to treat those who are infected for the disease, for disease management. They said it reduces viral RNAs, no RNA copies or viral load as such is dramatically reduced to a large proportion of people. These are all very small studies, very small, 30, 40 or 60 people. These cannot be considered as large studies.

Now one of the things which we have to realise is that if this drug works, would it work as a virucidal drug. Virucidal is one which kills the virus. Though they claimed that RNA copies are reduced it is unlikely to be working as virucidal drug mainly because we have never found a single drug so far in our medical history which can kill viruses. It can inhibit replication of viruses but it cannot kill any virus no drug we have found.

So if I go by my past learning to say that this reduction that is occurring is because of the virucidal action it would have been wrong. So one of the things we thought, yes, if this drug is working, if we assume that whatever they are saying is working it may be that it is affecting either one, the virus replication or it is acting more on the immune system as in immunomodulator.

Chloroquine traditionally or even hydroxychloroquine is known to be immunomodulators. We use it in multiple diseases and that is almost a major response to medical side they let any new disease come one of the few drugs that is going to be tried is chloroquine, zinc, vitamin C yeah you name them. You will always find somebody has worked over this disease over this particular drug historically.

HCQ known to be an immunomodulator

So why is there such a big controversy in America ?

Of course no. That is what I’m trying to tell you that if this drug is not virucidal then there are two options which are left out. One is, does it replicate the inhibition of the virus? Perhaps not, because for inhibiting virus replication we know the enzymes that are involved in actually replication of the virus. Now this is a anti malarial drug. None of us ever know that does it work on let’s say polymerase…does it work on protease?

If we don’t know so far how do I assume that this is going to inhibit replication. So it acts like a immunomodulator if at all it is working. So one of the thoughts we had is, in that case, we try to provide, through a small study, try to find out that if we offer this medicine as a prophylactic drug, does it reduce the chance of accumulation of this infection?

And people that we thought would be good to do this study were healthcare workers, and second were those contacts who were exposed to a lab confimed case. If we come to know that this drug can actually reduce in acquiring this infection than perhaps we can move ahead and tell the population that you can take it by yourself because this drug is also toxic.

So this is not a drug to be used by anybody and everybody. Today, the panic is so high that people tend to clutch to any straw of hope that this medicine may work, why shouldn’t I not stock it or take it by myself.

People have to understand that, as they are learning about social distance and hygienic methods, when I wrote my own first prescription after MBBS, four and a half years of sheer hard work there, my hands were quivering because then I become accountable to what I am prescribing. Am I doing the right thing, have I diagnosed it well? And here you look at the paradox he doesn’t know anything and the person reading the newspaper or on a blog or somewhere on the social media and decides that he has to take it. He ways his own risk oh it could affect your sight. He’s not worried about it, it could affect perhaps your own heart he’s not worried about it,…woh toh baad mein dekh lenge (will take care of that later).

Today you think it is a risk worth taking…but when he will actually become blind he may think it was better being dead.

If it is prescribed by a doctor to a critically-ill patient then it is okay to take it as a prophylactic?

Absolutely. See, please remember one thing that people tend to think doctors are impersonal it’s not true. He will make his own or she will make his best possible effort based on whatever literature is available whatever guidelines are available they would try to do the best for the patient.

I will put it in one simple word. Every patient who dies there is a wave of depression that tends to come even in the mind of a doctor. Nobody likes it. When we go home…I worked in the field of HIV, where in the initial period we didn’t have anything to tell to the patient except that please use condom have good food do this and do that. There were no medicines.

So HCQ at the end of the day you would recommend that you only use it if a doctor prescribes ?

Absolutely.

Aur America mein jo itna ho raha hai ki (And everything that is happening in America) that it’s not good and it should not be used, you think that is their problem?

No, you see it also depends on the level of severity. If you find that the patient has landed into a complete mess where you find you don’t have any conventional remedy at hand. People try to use at least whatever is quoted that somebody somewhere has used it, maybe it might succeed.

There is an ongoing trial for tuberculosis. Do you think that it can be used or should be used for coronavirus ?

I still think we don’t have sufficient evidence. These are association studies. These descriptive studies that you do will give you an association of a factor. But it doesn’t tell you whether this could be a causation, whether this difference that have occurred is certainly because of some other thing.

Now if you look at BCG the difference that came out was dark enough but at the same time let me try and counter it the wrong way. The population that received BCG was less likely to make it to international travels. You look at the other population which didn’t receive BCG those which are worse affected, do you think this occurred because of lack of BCG ? Perhaps not. They were exposed to the disease agent because of their travel. They were far more exposed than compared to us.

Now you look at the other fact we know for sure that BCG doesn’t protect you completely against TB, it only reduces the severe form of disease of TB. That’s also one association which was described earlier. This is one vaccine that you give. Normally what is the story… if I give you a measles vaccine I will be able to demonstrate throughout your life that you have antibodies against it. So one vaccine you are completely protected.

Now when it comes to BCG we don’t have specific markers which will say yes you are protected or not. But if I do tuberculin test, which is commonly done, people used to earlier say that 40-50 per cent people in India would come out positive for tuberculin. Which means that at any given age, overall frequency of positivity was 50 per cent. But it tells you another story. That 50 per cent of the people don’t have any immunity against TB because when you give PPD, PPD comes out as negative.

We recently started a TB prevalence survey which has to be stalled now in view of Covid-19, where we are also offering them the same PPD because we want to find out how many people have latent tuberculosis so that you can provide certain treatment to all those who have latent TB.

We found that 40 per cent was gross exaggeration. It is something that we were speaking of the past. Today that figure comes to, now I shouldn’t make tall claims because the numbers continue to be not powered to speak about the total population as of now because we had to stop half way which we will continue after Covid-19, they are coming to around 15 per cent.

What does that mean that even if I give BCG vaccine only 15 per cent have some immune protection against TB, which is actually a vaccine which is produced to prevent tuberculosis and not Covid-19. Because there is no association between these two vaccines by any means.

So people say could this be an immunomodulator. This vaccine, if I provide to cancer patients or to anybody, it changes the immune system in such a manner or it stimulates it so well that it will also protect you from other infections, one is Covid-19.

Let me put it the other way. If you look at BCG vaccine or read the literature, there are publications which tell that immunity tends to weigh earlier…that’s the reason why you find there is spurt of TB during adolescence. People tend to believe if you want to give BCG vaccine ideally to prevent TB, you may have to give one dose during adolescence.

And now you look at Covid-19, you find the majority of the people who are getting or succumbing to the same are from the older generation, they are not younger. They have lost immunity. So basically that association itself is in my mind, only an association, you will need adequate proof and people should not hang on to one feeling that yes I have BCG vaccine which I have received, I’m king of the world. No it can’t happen like that.

What is the R0 value of India ? How many people one Covid-19 patient can infect others, that you have found so far in your studies ?

No, we haven’t been able to do systematic studies for finding out R0. Because for R0 I need to know the true size of the exposed people, right. Why do we say I haven’t been able to do it. In this particular infection we don’t know as yet what is the true exposure. I will try to explain what I am saying.

True exposure is, he has walked in my room…can I say this is an exposure? No. Can I say he stood in this room for 15 minutes, I’m a novel corona…covid-19 patient, can I say if he has walked into my room stood there for 15 minutes and then walked off, yes it is exposure?

You need to define exposure truly well. Have you got that opportunity…no, we are firefighting at this point in time. In science you need to get some time to do such kinds of studies where you say ‘yes this person is currently exposed’ and that is why we call it as odds of association.

And then we actually say the relative risk that if you are sitting with me or you shook hands with me, the risk of you acquiring this disease is 1.2 times higher or whatever… given in a crude example.

We haven’t got so much of time globally because we are trying to work over…how do I provide the test or how do I ensure that they receive care. How do I reduce transmission and the triggers which it require…we haven’t got there globally.

People are coming out with some formulae. They say if we are sitting with so and so person for 15 minutes of time, it may be considered as exposure. But that still doesn’t have the trigger.

Now you look at the other side of the story. What we know from this infection, at least in India. The number of people within the family where there was more than one person who was infected has been low enough. We cannot conclude that just because the wife was staying more with the person, she is more likely to acquire it. No it has not happened.

Now why can’t I study that more? One of the reasons is we have brought in an intervention. We say you maintain social distance. Now, how do I know who is maintaining it, how much is the coverage, you know it is going to impact my R0 value, because now if my wife decides that I don’t want to stay with the gentleman, she stays in the other room, how do I calculate the R0? These are practical difficulties. So to me the R0 speculative value in terms of evidence that we know of today in India, you could say that this R0 is 1.5-2 and still get away with that because nobody is going to ask you ‘app yeh study batayein apne kya kiya kunki kisiko nah time mil raha hai nah woh kar raha hai’ (you tell me what you find out through study because no one else has the time to do or is doing).

Drug trials and vaccines. Is ICMR doing anything? Is there anything happening in India?

There are multiple things which are happening. People are looking at repurpose molecules, trying to find out whether there is a certain molecule which could still be useful.

Like, initially we used to say Boosted Lopinavir we found as one the best among all protease that we used in HIV. Apparently it doesn’t seem to have similar kinds of benefits because you do this docking studies on computers using certain softwares. You know the virus structure, you know how it replicates, so you essentially try to put that molecule and see that it binds well to that enzyme’s side.

Now there is a likelihood, there is a risk in that, not everything you see in the computer could turn out as one which is efficient. So we looked at Lopinavir, we looked at other molecules also. Molecules that we use in treating cryptosporidiosis, it also didn’t work even on the computer.

But we know one thing that if something works in the computer the probability that it could work in the laboratory is likely to be better than something which doesn’t work in the computer. So that effort is going on in multiple scientific groups to make their best effort to find out from their library which compound can work.

Since we have been able to isolate the virus in the month of March, that we did it ourselves in the National Institute of Virology (NIV). See coronaviruses are difficult to isolate and by isolation what we mean is from a patient sample you take it out and then you allow it to grow and replicate in an artificial system outside.

NIV has been able to isolate the virus in March. Coronaviruses are difficult to isolate

Now that’s like cultures that you do for any sputum culture. By sputum culture they are going to replicate inside so you have isolated the bacteria. Similarly, we have isolated the virus which was a tough task. So once you isolate the virus, I have a live virus so what I can do is I can put this drug on this virus in different concentrations and try to find out whether their replication is inhibited, does it kill the other surrounding cells, because it should not have a bad impact on the body, other cells should not die. So that effort has started now.

I think this is that we are two weeks into it in Pune at the NIV. Early experiments are been done with so called “claims” of good drugs. It is possible we may strike gold. It is possible this is science, you have to keep working hard.

So which are the drugs you are using then ?

I shouldn’t name them because not in today’s context, like chloroquine if you took the name everybody started ‘nahi’ (no). That’s not a good thing to happen. See, experimental drugs are experimental drugs. We have started doing it and this requires time, a minimum of 10-12 days. Because in seven days your first passage will be over.

For each individual experiment, supposedly someone gets a medicine, and you think it is working. So if you put on that particular system, you will require at least 10 days time to know whether it is effective or not because it depends on repetition it takes on the virus.

The issue is you have to setup experiment every time. No, I didn’t say a month’s time, March we isolated but then you need to develop assays to check whether they have produced more number of virus particles and then we call it something as PRNT.

We develop a PRNT test that we could do only in the first week of April. The PRNT was developed so the first test of experiments have started with whatever drugs.

So you will take a few more weeks?

For each drug, until the time you strike gold.

So that could be…what a few months?

We can’t say. See, if you feel the tablet that is used in glaucoma is going to work well, we will try and see whether it works.

So this will then hopefully lead towards the vaccine?

Towards a drug trial.

And what about vaccines?

See, we have this isolated virus. Now, once you have this isolated virus there could be multiple approaches. People could ask for attenuated virus that it doesn’t replicate then try to do their own experiments. People could actually get that live virus infected to different animals and then try to look at those antibodies that come. So we don’t have proficiency in developing vaccines.

One of our sister agency’s departments of biotechnology has strengthened that particular area, so we are working closely together. We hope that somebody wins because there is no point in running when you know your strength is somewhere else.

So you think they are able to produce a vaccine sooner than later ?

Yes, it all depends on how they strike as I said.

The Ministry of Health a couple of days ago said that it’s about been three weeks since we are in a lockdown and if the lockdown had not taken place then we would have seen a about 8 lakh or so cases. Today, we have about 8,000-9,000. I mean today we have crossed 9,000. So is that an ICMR study? Are you on board with that?

That I think they explained the next day. This is not an ICMR study. This was a calculation which they had done by themselves using, see these are modelling studies.

Are you on board with that assessment?

I have already said it in the beginning that if we were growing the same way China had been growing I would have been in a different spot all together. So lockdown and social distancing, they have created this situation that today you and me could speak with one another. Otherwise it wouldn’t have been possible you know, the numbers would have been the reason so much.

Containment hotspots are growing in Delhi and across the country everyday.

Hotspots will grow. See as I said, it’s not, it’s about numbers that occur in hotspots, it’s not about number of hotspots that come. Because if there is one individual in let’s say a population of 10 lakh people or 20 lakh people how would it matter because your denominator is too big for that once case to occur. If there is one place where there are multiple cases occurring then I should get worried.

Increase in hotspots is not a big worry. I would be more keen to see that whether the new infection number increases in last one week in a given hotspot. That tells me where is this infection, is it still growing in that particular area because in the last seven weeks I should be able to see more of those contacts coming out.

So have you seen that ?

Still not that much. I wouldn’t say this is happening.

So you would say that there is no need to panic and that perhaps the lockdown can be lifted gradually?

Panic, I would put it the other way. I think panic is not a good state of mind. Panic is a state which makes us take irrational steps. Panic is something which should be avoided at every level. Hindi mein ek gana rehta tha (there was a song in Hindi). Bachpan pe mera mumma bolta tha ki jab hum woh exam pe jaate the na…medicine is a tough line (My mother would say earlier whenever I would go for that exam…medicine is a tough line).

Each book is this thick for whatever exam you go and then there used to be some of your classmates who used to come and say woh padha kya uske upar aane wala hai (have you studied, there could be questions from there), you lose your strength.

So hum bolte ek Jeetendra ka picture tha, darr lage toh gana ga (there was a Jeetandra song, if you are scared sing a song). If you panic you will not be able to write anything. If you panic you will not be able to do anything under the sun.

Panic is not a good state of mind, will make us take irrational steps. Needs to be avoided at every level. If you feel panic, remember the Hindi song, ‘Dar lage toh gaana ga !’

A soldier who will stand on the border should never ever panic, he has to respond. Response can be only rational response otherwise you will fire bullets everywhere and not the target ahead of you. Do you want to be in such a stage? No. We need to understand how I can prevent rather than panic.

We need to understand we don’t have to think that cure kaise ayega, vaccine kaise banega. Jiska dhanda hai woh kaam kar raha hai, unke upar bharosa rakho. Har cheez toh mein nahi kar sakta. Mere ghar mein TV kharab ho gaya mein jitna bhi padha likha aadmi hu TV durust thodi kar paunga mein ? Jyada se jyada kya kar sakta hu. Bandh karo phir ek baar chalu karo, mein usko dhakka laga ke dekho chal raha hai ki nahi (We need to understand that we don’t have to think how there will be a cure, how a vaccine will be developed. The people who are responsible for it are doing it. I can’t do everything. If the TV in my house stops working, no matter how educated I am, I can’t repair the TV. What more can I do other than switching it off and turning it on again or push it once to check if it’s working or not.)

Is that rational response ? No. Rational response in such circumstances is that have faith in people who have that expertise, hope for the best and try to ensure that your steps are adequately taken by most of the population to ensure that they don’t acquire it. If you acquire it, you will end up in the best place, the person is also going to do what’s best for the person. Have trust, trust in everybody.

Chahe flatten curve ho ya nahi ho (even if the curve is flattened or not)

Flatten curve ka kya sawal hai. Dekhiye jab woh soldier ki baat kiya na, if he’s outnumbered, right, does he get scared ? Nahi. Uska kaam kya hai. Saamne se jitno ko leke ja sakta hai, leke jana hai (What is the question about flattened curve. See, when I spoke about the soldier, if he is outnumbered, does he get scared? No. What is his job. He has to take down as many enemies as he can).

Toh abhi aap outnumbered toh nahi hai na (You have not been outnumbered, right)?

Kahi nahi hai. Aap yeh kyun worry ? Aap bhi number dekh rahe hai, aap bhi padh rahe hai. China ki waiisa nahi hai. America ki waisa nahi hai. France ki waisa nahi hai. Na Germany ka waisa hua hai na Spain ka waisa hua hai. Usko mein nahi dekhu. Mein kya bolu yeh na kuchto mein gadbad hai. Kuch toh mein bhi nahi ho raha hoga. Mere yaha toh hona he hona hai. Hum aise toh baad baad nahi sochte, agar kisike yaha chori ho gayi Amritsar mein pata chala toh aap Delhi mein rehke yeh toh nahi sochenge ki Amritsar mein chori ho gayi arrey mere ghar mein bhi ho gaya. (Not at all. Why do you worry? You are seeing numbers, you are reading numbers. It’s happened in China, France, America, Germany and Spain? What should I say, that something must be wrong? If there is a theft in Amritsar, you are staying in Delhi, you won’t think that just because there is a theft in Amritsar, there is theft in my home in Delhi!) We can’t have that attitude. That’s panic.