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‘It’s a new virus, it’s still evolving, still adapting. We still need to be cautious’: Dr Soumya Swaminathan at Idea Exchange

Soumya Swaminathan, who was appointed World Health Organisation’s (WHO) first chief scientist in 2019, has been an important voice in the world’s largest health agency.

Dr Soumya Swaminathan, Chief Scientist, WHO. (Illustration: Suvajit Dey)

Dr Soumya Swaminathan, Chief Scientist, WHO, on quitting the UN agency, the way forward with long Covid, and a desperate need for high-level governance to avoid a future pandemic. The conversation was moderated by Senior Editor Anuradha Mascarenhas.

Anuradha Mascarenhas: During the pandemic, you’ve been among the most significant scientific voices. You still had two more years left in your tenure at the World Health Organisation (WHO) when you decided to return. How was your stint at the WHO and what prompted your return?

When I moved to the WHO at the end of 2017, I was the head of the Indian Council for Medical Research (ICMR), and Secretary, Health Research. It was not anywhere in my plans to join the WHO in any capacity. When it came, I felt it would be a good opportunity. The Indian government, too, was very supportive and there was no question of a long-term commitment to the WHO. Now, of course, the way things turned out, I became the first chief scientist and built the science division. Then we were into the pandemic at the end of 2019. So the last three-and-a-half years were really about developing a vision, a strategy, putting in place the processes, and applying all of that to the pandemic.

The pandemic turbocharged the whole science portfolio of WHO and it became very visible and central. Today, health has become the front and centre of every global leader and politician’s vision and portfolio. So, in that sense, the WHO’s role and image were upgraded to the point where heads of state were, I think, for the first time, coming to the WHO on a regular basis. Earlier it was basically our interaction with the Ministries of Health.

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There’s never a time when you can say, ‘my job is finished, and I can go home’. But I do feel that I’ve put the science division, and some of the processes on a path where they’re very stable, secure and integrated. Now it’s time for me to take on a fresh challenge.

Anuradha Mascarenhas: A recent Lancet report commented on centralisation of power at the WHO with respect to the Director General’s office under Dr Tedros Adhanom Ghebreyesus. What was your experience like?

I think it’s very easy to make comments about personalities but Dr Tedros should be judged on his achievements. Various leadership styles are different, but if you look at his team’s achievements — managing the biggest pandemic we’ve had in 100 years with very strong global and science-based leadership, plus the moral authority, and the call for equitable equity at every turn — these are unprecedented. Everybody will agree that his leadership during this difficult, highly politicised periods of the pandemic was exemplary.

Over the last 30-40 years, the core funding of the WHO has gone down — less than 20 per cent. The 80 per cent is voluntary funding from countries and from philanthropic organisations, which means that the WHO does not have full freedom to work on its priorities

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What he’s also been able to do is elevate health, and the health discourse, to the need for investments in health. No previous DG was ever part of the G-20 or invited to G7 discussions. Probably, he was able to do this because he comes with that political background. The third bit is the sustainable financing of the WHO, which has been a huge barrier. Over the last 30-40 years, the core funding of WHO has gone down — less than 20 per cent. The 80 per cent is voluntary funding from countries and from philanthropic organisations, which means that the WHO does not have the full freedom to work on its priorities. The whole move to increase the AC funding, which are the assessed contributions from countries, which now the executive board has agreed to act upon, will increase gradually. This gives more power to WHO to focus on the areas which are otherwise underfunded. Next, putting science at the centre. The rest of the things are a matter of style. And one can always either appreciate them or criticise them.

Anuradha Mascarenhas: Experts tell us that the virus is going to be around but will be less fatal. What, according to you, is the possibility of an impact by future variants? Is there a need for a booster dose?

I’ve highlighted the need for a booster dose many times. The booster uptake in most countries is too low — I’m talking about the first booster, the third dose, which probably less than 20 per cent of people in India have taken. It’s clear now that you need that third dose to give you longer-lasting immunity. And of course, many countries are going into fourth and fifth doses, which we’re not recommending. I think, we still need to study the duration of protection and need more data. But in terms of what the virus is going to do next, there is still an element of unpredictability. We have been lucky that in the last 10 or 11 months, Omicron has evolved. And we’ve had about 300 sub-lineages of Omicron, which we are now tracking. Though a majority of them continue to evolve to be more transmissible, every time you get a new strain, it overtakes the previous one, and you get a fresh wave of infections. But that has not translated into increasing deaths. So our vaccines are working. But whether the next variant will end up being more clinically severe, we don’t know, we’ll have to continue to track it for some time.

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It’s a new virus, it’s still evolving, still adapting. This is why we need to be cautious. And we still need to do the R&D for new, better vaccines that can prevent infections because the current vaccines are good at preventing severe diseases, not so good at stopping infections or transmission. And this is why we say that the pandemic is not yet finished. The emergency committee had its last meeting in October, and they continue with the public health emergency of international concern.

The main challenge in TB is that we don’t have a good vaccine. TB is a more complex pathogen than Covid and rooted in poverty and undernutrition. There needs to be a global mission led by India and a few other high-burden countries to develop a better vaccine

Kaunain Sheriff M: The countries which have the mRNA technology are now using the bivalent vaccines, which provide immunity to the previous variant as well as Omicron. However, in India, the boosters are predominantly those that have not been tested on Omicron-specific variants. Although we are not seeing an increase in hospitalisations, what is the way forward for India? Do you think that we need to re-engineer our own technologies here?

There is no clear proof that these bivalent vaccines offer better protection. The studies, so far, have shown that they elicit neutralising antibodies, which you expect a booster to do. According to the Moderna results, which just came out, the antibody levels went up by five or six times. But if you give a regular booster with the original strain, the antibody levels go up severalfold. And there are no clinical studies with clinical outcomes to show that the bivalent boosters are better than this. So the concept was that they would broaden the immune response to a wider spectrum of variants. But there is a lot of research going on. I think even in India, the manufacturers are looking at updating their vaccines to include Omicron-specific antigens.

But I don’t think that countries that don’t have access to the bivalent vaccine boosters are at any big disadvantage as of now. There could be some very minor advantages to having that bivalent booster but the original spike protein is also giving you a broad immunity. What is interesting is that the mix-and-match approach, where you take mRNA with either a subunit protein or adenoviral-based vaccine as a booster, appears to be much better.

Kaunain Sheriff M: We are seeing a significant number of patients, especially the young, complaining of complications after a few months of Covid, presenting blood clots, brain fog, fatigue, and gastrointestinal issues. What is the way forward on long Covid and how do we tackle this at an international level?

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I think it has to be tackled locally, and not at the international level. In many studies from high-income countries, they have been able to follow up and document the fatigue syndrome, the neurological syndrome with the fog and not being able to concentrate or work. Then you have respiratory syndrome with breathlessness. But there are other issues which are gastrointestinal besides increased incidence of diabetes, cardiovascular disease, and stroke, which seem to be occurring six to 12 months after somebody has recovered. One of the reasons why we don’t want people to start taking it very casually and saying it’s another cold is because it’s not. Because even with an asymptomatic infection, there is a small percentage of people who can have these long COVID symptoms.

What we need is more of a systematic follow-up and studies. Plus, of course, the provision of care for people who are suffering from the symptoms in terms of it… mostly symptomatic rehabilitation, physiotherapy, etc, and guidance counselling, because I think there can be a large burden of this which is not recognised right now. And also, because in India there is a large burden of non-communicable diseases already. The baseline of hypertension and diabetes is very high among young adults and having had a Covid infection could actually trigger some changes. We know that it causes inflammatory changes, that it alters the coagulation pathways and causes vascular thrombosis. There could be the persistence of the virus. These are all possibilities that people have suggested which could be the causative mechanisms or pathogenetic mechanisms behind long Covid. It’s not yet proven, and therefore there isn’t a specific treatment for it.

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There are reports one sees in the media, where more people seem to be dying of stroke, but those anecdotal things are not evidence. So you need a controlled group that you follow and study.

Kaunain Sheriff M: The vaccines that we are giving are to reduce the severity of the disease but certain platforms like the nasal vaccine can potentially reduce the transmission. Do you think in the next phase, especially of the Covid vaccine development, we need to address the stopping of transmission of the virus?

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That would be ideal because then you don’t have post-Covid and asymptomatic infections. Also, more than people being ill, now when you test positive, you have to isolate. You’re off from work for five days, or your child can’t go to school. Or if you end up going, then you’re infecting other people. So it does have economic consequences, and therefore a vaccine that can actually prevent infection could be fantastic. It’s a long shot. There are very few vaccines that provide that kind of sterilising immunity or transmission-blocking immunity. But it’s possible that a combination of injectable and the nasal vaccine may be able to do that. Currently, the WHO Solidarity vaccine trial is testing the Codagenix nasal vaccine that’s produced by the Serum Institute of India. It’s possible that we will add other nasal vaccines to that trial. There are several nasal vaccines that are in trial now. We need to wait for the results.

Once we develop confidence in these platforms, the next step is to develop a pan-coronavirus vaccine or a universal coronavirus vaccine because you could have, at some stage, another outbreak or pandemic with another coronavirus.

Parthasarathi Biswas: When the vaccines were rolled out, the DG of the WHO was very critical of the advanced countries for hogging vaccines. In the run for vaccines, how are developing countries in Africa placed? Are we looking at a world where COVID will continue in some parts while in others there will be an excess of vaccines?

If you look at global coverage, it’s around 70 per cent with the primary course of vaccination, and it is only 25 per cent for the low-and middle-income countries (LMIC). In the LMIC, India’s average is also quite high. But you will find that in the low-income countries group, which is a World Bank classification, they are significantly lower than the other three groups. So we’re talking only about primary vaccination here, there’s no question of boosters. There’s a long way to go. Even if you look at coverage for those above 60 and healthcare workers, it is around 30 per cent to 40 per cent in those LICs. There’s a lack of health system capacity, manpower, and chronic issues of conflict. Many of these are in conflict countries, so it’s very complex. They have made improvements. Through Covax, we set up a vaccine delivery partnership, led by UNICEF and all the other partners, to go to these 34 countries with less than 10 per cent coverage at the end of 2021. The DG’s goal was to have 40 per cent coverage of all populations by the end of December 2021, and 70 per cent by June 2022. Now, having worked very intensively, and provided a lot of support — technical, financial — there are now maybe nine or 10 countries left that still have less than 10 per cent coverage. Many of them have now significantly moved up. In some countries, yes, vaccines are now being discarded because of excess stocks, which have not been used. In high-income countries, the US, for example, the coverage is not as high as it could be because they have access to vaccines. It is the vaccine hesitancy and the politicisation of the vaccination programme that has resulted in a very, unfortunately, significant proportion of the American population not being vaccinated. There has been an analysis showing that 200,000 deaths in the US could have been prevented if those people had taken a vaccine. They had access to it, they just didn’t take it. And while the anti-vax agenda may start in one country or be driven by some political ideology, unfortunately, these things have a way of spreading. They are now beginning to even impact routine immunisation coverage in countries in Africa. It’s a very dangerous trend.

Rinku Ghosh: A recent report said that climate change and the melting of polar ice caps are releasing more viruses and bacteria into our ecosystem. What is the kind of future you foresee with the multiplication of returning viruses?

Yes, global warming is melting ice caps, which are releasing bacteria, viruses, and fungi that have been under snow. But deforestation, increasing urbanisation, the contact of wild and domestic animals, illegal trade in wildlife, as well as globalisation enable a virus to travel from a remote village to the world in 36 hours today. Because we are connected.

In the case of global threats like climate change and pandemics, and antimicrobial resistance. No country can do it on its own and hope to be successful. You need a high-level governance of how would you look at these threats. It needs to be a multi-sectoral, multi-department, multi-ministry, and multi-disciplinary approach. Then, you have to narrow it down further and ask what we need in terms of surveillance. Are we doing good animal, environmental and human health surveillance? How do these systems talk to each other? What are the signals that you would pick up as being a warning? For example, the WHO has a system called the Epidemic Intelligence from Open Source (EIOS). It means you use AI to scan the media, grey literature, press and reports and you come up with 4,000 or 10,000 signals in a week. Out of that, somebody has to go through and find which signals are significant enough for us to investigate. Then you investigate a few 100 of them. And maybe one or two of them turn out to be bad ones, which turn into an outbreak or something. That has to be systematically established. Today, using digital tools, you can do a lot of this. Then you need the analytical capacity and the authority to act. This ability to act has to start from the district level besides being able to communicate very rapidly. So that’s a pillar of surveillance. Then you have a pillar of clinical care — what do you need to do if suddenly there’s an outbreak of a hemorrhagic illness or a respiratory viral illness? We can learn from states like Kerala that managed Nipah very well. Then, you have a pillar of R&D to have some capacity to develop the countermeasures, whether it’s diagnostics or drugs or vaccines. Then you may have a pillar of community engagement and then risk communication. You could think of those verticals but the most important is that it involves all the veterinary, animal, environmental as well as human health, people including social and behavioural scientists, who will be very keen to deal with that community-level approach. So while you can organise it top-down, you also have to build this awareness from the bottom-up.

We cannot stop outbreaks. I think that’s beyond the capacity of human beings. But we can act early to prevent them from becoming larger epidemics or pandemics.

Ankita Upadhyay: As India has reported very few cases of monkeypox, should we still remain vigilant? 

Monkeypox is going down globally. We definitely need to continue to monitor. The cases in India, I think, were probably imported cases, with infection acquired abroad. They were detected and isolated. So we were able to break the chain of transmissions. I think that way, it was very good. It shows you why countries need to be alerted. As of now, I think there’s not a great worry in India.

Anonna Dutt: India has set 2025 as the deadline to eliminate TB. Is that possible? Does the vaccine have a role to play in this quest for elimination? 

In terms of TB, the goals are aspirational. So we may not achieve that exact goal by 2025 because we are far from it. But it’s important to set an ambitious goal and try to do everything to achieve it. The main challenge in TB is that we don’t have a good vaccine. So we need much more investment. India can do a lot more in developing new vaccines, particularly using the new platform technologies and its capacity in the public and private sectors. There needs to be a global mission led by India and a few other high-burden countries to develop a better TB vaccine. TB is a more complex pathogen than Covid. TB is not a simple biomedical disease. It’s very much rooted in poverty and undernutrition. It requires a multi-sectoral approach. But I think India has not only high-level political leadership, but also the resources to find better tools, and also to do more field and implementation research.

Why Soumya Swaminathan

Soumya Swaminathan, who was appointed World Health Organisation’s (WHO) first chief scientist in 2019, has been an important voice in the world’s largest health agency. A pediatrician who is globally recognised for her research on TB and HIV, Swaminathan has served as Secretary to the Government of India for Health Research and Director General of the Indian Council of Medical Research (ICMR), before taking up the post of Deputy Director General (Programmes) at WHO. With the setting up of a science division at WHO, she has been a pathfinder during the pandemic

First published on: 28-11-2022 at 04:17 IST
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