March 16, 2020 12:19:30 am
Director of Medical Research at Jaslok Hospital Dr Rajesh Parikh, internal medicine specialist and healthcare entrepreneur Dr Swapneil Parikh and clinical psychologist Maherra Desai are authors of ‘The Coronavirus: What You Need To Know About The Global Pandemic’, to be published by Penguin Random House later this month. They speak to Kavitha Iyer on the response to the outbreak and challenges ahead.
Is there some paranoia in the reaction of the public and government to the COVID-19 outbreak?
RP: The flu virus has been around with us for more than 100 years. It is predictably unpredictable. We know it is seasonal. We also know it mutates. But it is wishful thinking to assume that this virus will behave like the flu virus and that come summer, it will disappear, though this is something we are hearing from everyone ranging from Donald Trump to the person on the street, that it will go away. It might. It just may not. It may simmer down and resurface. We should certainly not be paranoid, but we should be concerned. Curbs on international travel, hotels reporting poor occupancy, this is not paranoia. These are fair measures.
SP: These measures don’t go far enough. If your house is on fire and you panic, you’re going to burn. But if your house is on fire and you’re not alert and doing something about it, you’re also going to burn. So the goal should not be to scare people but to wake up, start doing the right thing.
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This is not the first pandemic, so how is this different and is there cause for more concern this time?
SP: This is the first coronavirus pandemic.
RP: What has history taught us? The Spanish flu pandemic between 1918 and 1920 killed more people in four months than AIDS has over the decades. By the time it abated it killed more people than World War I and II combined. The estimates are anywhere between 50 million and 100 million. The population of the world at the time was 1.7 billion. It came to India too and in the book we mention an interesting side story of Mahatma Gandhi catching the Spanish flu and being too weak to speak or do anything when protests against the Rowlatt Act began.
SP: SARS was very different. In the case of COVID-19, 30 to 70 per cent of transmission happens with people who aren’t yet sick. With SARS almost everyone who got infected could be identified. Also remember that for SARS there was a very, very intense global programme to contain the virus.
The idea of the coronavirus being more lethal doesn’t hold credence. Ebola, for example, kills 40 to 60 per cent of those it infects, but it doesn’t spread that much, it is easy to detect, identify those sick. With this virus, it is invisible. We don’t know who is sick for many days.
What is the official view on the progression of the outbreak, given that in China, Singapore and South Korea it has begun to die down?
SP: With immense measures. For example, in China they shut down the country and economy for two weeks. We have to understand what social distancing does. It’s called flattening the curve. When you look at an epidemic curve, a flatter curve shows a slower progress in number of cases. With social distancing, this disease will eventually burn itself out when enough people become immune, through getting infected and producing an immune response. That’s what happens with viruses.
Pandemic strains behave different from seasonal strains. In seasonal strains, some people have immunity, so when there’s a change in weather and transmission decreases, it can burn itself out. But in a pandemic strain, nobody has immunity. So it won’t stop. This is the goal of social distancing — not to reduce the number of cases overall, but to spread them out. If we allow the cases to spike suddenly, a lot of people will die simply because they won’t get oxygen, medical care. Mortality rates will spike.
The theory that the virus spread will weaken as temperatures rise, is that true?
SP: We can only go by the evidence, and projections may change when evidence changes. Right now there is no evidence to suggest that it will decrease with the weather. Some evidence suggests that if this behaves like an influenza virus, it will in fact spike in the monsoon and post-monsoon period. We don’t know whether it will behave like the flu virus. We must draw a distinction between temperate and tropical countries. CDC data shows influenza virus cases clustering around the winter in a temperate region, while the opposite happens in a region where it is warmer. That’s why in some parts of India we actually give the flu vaccine in May or June, when the spike in cases occurs.
Certainly, it is unpredictable but going by what the world’s leading experts say, the projections are that in the post-pandemic period or even if it decreases with the weather change, the virus will keep coming back, every year or every two or three years, or will disappear till 2025 and come back then.
How vulnerable are we right now, and why?
MD: I feel we in India are probably more vulnerable than other countries because we are a more collectivistic society; we are densely populated especially urban areas; we live together; we almost think it is rude to do social distancing. It makes us more vulnerable. Our public health system is also not able at this point to cater if we have a sudden spike in numbers, so I think it’s very important for us to be more cautious. On whether we are paranoid and whether its justified, paranoia doesn’t help, doesn’t enable you to act more effectively.
SP: In Wuhan city alone, they have 1,800 teams with a minimum of five people each. These teams go and identify and test every single person who was in contact with anyone who was infected. One patient identified about 3,000 contacts, they identified and tested every single one. Another team elsewhere in China found a patient with 29,000 contacts, they found 99 per cent and tested them. South Korea does more than twice as many tests in a single day as we have done in total. They do 10,000-16,000 tests everyday.
Let’s take the model that says 20 to 60 per cent adults across the world could be infected. If even 20 per cent of adult Indians are infected, that is 156 million. WHO data suggests 5 per cent patients need ICU admission. Let’s assume only 1 per cent need ICU admission. That is 1.5 million ICU admissions. How many ICU beds do you think we have right now? About 1,00,000, including private hospitals. And we already need around 5 million ICU admissions in a year right now, with dengue, malaria, etc.
Are the preventive measures now deployed adequate?
SP: We need to move from containment to mitigation. Containment is the phase when you’re closing borders, doing contact-tracing, etc. Mitigation means that we accept it’s in the community, that we can’t stop it from spreading, people are going to get infected but we mitigate the damage, So we focus on protecting old people, diabetics, those with cancer, hypertension, maximising health resources. Also, of course it is a false dichotomy— we have to do both. We are doing a good job with containment, but the reality is we have to move into mitigation mode soon. Mitigation means we have to ask those with heart disease, old people, hypertensive people to stay indoors, minimise their contact with exterior world.
How far has the search for a cure or a vaccine reached?
SP: An incredible amount of research has been going on. Very early on in the outbreak, all medical journals dropped their paywalls, way ahead of news organisations, enabling many to access research papers. Rapidly, within the first month, there were 80 clinical trials registered for medications. In terms of a vaccine, it’s not realistic. Let’s say the vaccine we want to deploy is ready. We then need to test it on animals and humans, to know their side effects. then scale up production. And these are proteins, not tablets, scaling up production will be an extremely intensive process. Also, if even 20 per cent of the population is infected, it would mean over 1 billion doses administered. For measles, to disrupt transmission, you have to vaccinate 80 to 95 per cent of humans. So don’t think it is as easy as making a billion doses. For one, it is not going to be ready in time. And two, if it is inadequately tested, could you be worsening the situation.
Tell us about the genesis of the book.
RP: I was in the Sunderbans with a friend around January 24/25 and despite only intermittent Internet connectivity, I realised then that if a patient with this disease walked into our hospital, it would be a complete disaster, for other patients and for health workers. As soon as I came back, Maherra and I started on a Standard Operating Protocol for Jaslok Hospital on how to deal with a patient with this disease. Incidentally, I got a call from the publisher to who I had loosely promised two books a couple of years ago, and we discussed this subject. Maherra has worked with me for 12 years, she does a lot of the research and the first drafts of our research. I also asked Swapneil, whose field is internal medicine with an interest in infectious disease. We began to work with a deadline of two weeks and we managed to get it done in about three weeks.
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