David Nabarro, a British physician and public health expert, was in February named by the director general of World Health Organisation as one of the six Special Envoys on Covid-19 disease. Among his tasks is to provide strategic advice to countries, and engage in high-level political advocacy on the disease.
In this interview with Amitabh Sinha, Nabarro gave his assessment of the Covid-19 situation in India, the success of India’s containment strategy, and the key steps needed in the coming days. He said he did not see any vaccine coming to the help of mankind before the next two years, and it was crucial that countries and people learnt to live with the virus for at least that long.
Q: When you look at India’s numbers, what are the key indicators that you look at to get the best sense of the country’s situation? What are the indicators that best sum up India’s current state?
Nabarro: Of course, a lot depends on how much testing is being done. If widespread testing is being done, then the number of cases detected positive is very helpful. If there is not so much of testing happening, then it is necessary to use other indicators of the disease, such as the number of people who are unwell and coming to health centres, the numbers of deaths being reported, and so on.
One of the things that I look at from your country is doubling time of the number of cases. I was finding out as of a few days ago, the doubling time in your country seems to be about 11 days. That is a really good piece of information because what we know from other places is that if this virus does what it wants to do, and there is no effort to limit transmission, then the doubling time is about two-and-a-half days. So, if you have a doubling time of 11 days, then what it means is that opportunities for transmission have been substantially reduced.
Two things become evident. One is that it shows the effort to find cases and isolate them, trace the contacts and quarantine them. That has an immediate impact on interrupting transmission. The second thing it shows is that the movement restriction has been effective. Because if you can restrict movements, you reduce the number of people who are coming into contact with a person with the disease.
So, this combination of transmission interruption and movement restriction appears to be having a really powerful impact. Because an 11-day doubling time is quite remarkable. It means that there has been a real effort, and a successful effort, to slow the spread of this virus. So that’s why, I have been saying that I see signs of an incredible achievement in a country that is normally very populous in urban areas, and there is a lot of movement.
The second thing I want to know is where exactly is the virus located. The virus is in Maharashtra, particularly in Mumbai, in Gujarat, particularly Ahmedabad, in New Delhi, and in urban areas of Rajasthan and Tamil Nadu.
Now, at the beginning of the Covid outbreak, you do expect the virus to be pretty much in the urban areas, because it is getting imported largely by people who arrive in the country by planes. In India, even two months after the outbreak or more, it is an amazing thing again that early data is suggesting that the virus continues to be quite well localised in urban areas.
I heard that out of 750 districts in India, at the moment there is no virus in 450, according to the data. It is telling me two things. One is that India managed this disease quite effectively early on, and secondly it managed to restrict the spread of the disease to a relatively small number of urban areas.
Now, as the movement restrictions are released, and people start to move around again, more outbreaks in some locations are inevitable. And that would require this now very well-organised government response to be ready for it. You have got to suppress the new outbreaks really quickly.
The second thing is that the disease at the moment is in very densely populated areas of these cities, and I think it is really hard to manage the containment in densely populated areas. We are finding it all over the world that the whole Covid transmission builds up when you have people close together. So, in settlements that are super-crowded, like in parts of Mumbai, or in parts of Delhi or Ahmedabad, interrupting transmission and then suppressing outbreaks is absolutely difficult. And I think we are all watching and learning from what is happening in India, particularly in these densely populated areas. There is no magic solution.
I mean let’s take the example of Singapore. They have got the virus in very dense worker settlements. And the Singaporeans are having to put a very intense isolation and quarantine programme in place. And I think even then they are finding it a struggle. So, this is one of the tough things that just about every country is struggling with at the moment.
So as I look at India, what I find is that it is doing really well in containing the virus and stopping its spread. It has been at a huge cost, of course. There are massive economic costs of stopping people from moving around… it is enormous. But at least you have managed to hold the virus, though you have still got the problems in these densely populated areas.
But I am just totally impressed by what I am seeing being done in the cities that I talked about, what is being done across the country, the efforts to try to support poor people who are stuck in many places, between the cities and their home places. I understand there are tens of millions of people stuck. It is just a massive human challenge. And from here, all I have to say is that I am constantly impressed. I don’t have any other word for it because it is such a huge challenge.
Q: The epidemic seems to be over in China, at least for the time being. In many other countries, it seems the worst is over, while in India it is still starting to become big. Considering its size and population, do you think in the coming days India would be the main driver of novel Coronavirus spread?
Nabarro: That is the kind of question that I don’t want to answer, and the reason I don’t want to answer is that I don’t know the answer. I am just going to say a couple of things. India can live with Covid and can really keep the virus at bay only through doing the following.
One is that every single person in the country needs to be made aware of the virus so that they know the importance of interrupting the transmission as soon as an outbreak builds up. And, second, every panchayat and Zilla parishad in India should build up capacity to suppress outbreaks quickly.
That, of course, would have to be accompanied with providing support to the people who are affected by this suppression, because poor people get so much hurt by it. But having this capacity to suppress the outbreak while protecting the poor is the second requirement that India must have.
And if you can have everybody at alert for interrupting the transmission and have widespread capacity for suppressing outbreaks, which would involve restricting movement, but in very local areas, then the rest of the society can live, can be joyful, can have their jobs. You can live with this virus in you midst. It is not going to be comfortable, of course, and the first few weeks and months after the lockdown ends, are going to be tough, but it is doable. And I think India will do it because the capacity that you had on so many issues to be organised at the zilla parishad or the panchayat level, at the local level… that is the key. And it is that capacity for the community level organisation that I think will mean that India will, after a pretty bumpy period, come to terms with this virus and be able to manage it.
So, I don’t think I am going to tell you that India is going to be the global driver of coronavirus cases because I am convinced that India, its people, its local authorities, its state governments and federal government, will actually find ways to keep this virus at bay.
Q: But the important thing, as you say, is to learn to live with the virus for at least two years, if not more?
Nabarro: Let’s be clear on the time. Of course, there are all these people saying that a vaccine will appear by the end of this year. But having the vaccine does not mean that you have got the answer to the problem. You have to test the vaccine to make sure that it works, to make sure that it is safe. And there is quite a big community out there which is very sceptical about the vaccine.
Safety is paramount. That means then that it would be a miracle to have a proven, safe and effective vaccine in less than 18 months. And then, you have got to administer it to everybody. And we know from small pox and polio episodes that having global immunisation of a vaccine is not easy. It’s a big job.
So I am saying to people that if we are lucky, we can have a vaccine and can enable people to access it everywhere in about two or two-and-a-half years. If we are unlucky, because of some problems in developing a vaccine, then it could take much longer. And we must remember that there is another virus, the HIV that causes AIDS, which we have known for about 25 years. And we still have not got a vaccine despite an expenditure of billions of dollars.
So I am going to stress to you that I am encouraging everybody to think in terms of living with this virus for at least two years. And that applies to all 7.8 billion people on our planet. It is going to be a universal learning process.
Q: The prime argument for imposing a lockdown has been that first priority for any country should be to save lives. When it lives vs livelihood or anything else, there is little debate on where the priority should lie. But what if it becomes lives vs lives? Is there a danger that by imposing a prolonged lockdown, we have opened up the possibility of many hunger-related deaths, or deaths from poverty-related or stress-related sicknesses? Is there a possibility that we could have endangered many more lives than we manage to save?
Nabarro: Let me start by saying that if this virus was allowed to move across the world with no effort to contain it, it would cause, we believe, an enormous number of people to become ill and die. We don’t yet fully understand many things about this virus. It does seem to be capable of causing more than just respiratory illnesses. It is known to have other impacts as well. All of us who are working with it, and have worked with other Coronaviruses as well, have learnt to be extremely cautious about these viruses.
I want to stress that there is another key feature about this pandemic. These outbreaks build up exponentially. They do not grow in a linear fashion. So the longer you wait to act on containing is, the more profound the problem becomes. Because of the exponential spread, it can increase many many thousand times just in four or five weeks. So, honestly, I am telling anyone who talks to me that the potential impact of leaving this virus to spread without trying to contain this is absolutely enormous. We have seen what is happening in the United States. It would not really be feasible for anybody with good conscience to say ‘Ok virus, do your stuff’.
At the same time, I want to be clear that the lockdown does not put the virus away. It just freezes the situation as it was. So whenever a lockdown is done, as India has shown, you must put in place all the things you need to defend yourself against the virus, such as training everybody about what they are dealing with, educating the people, setting up virus testing, making sure hospitals are ready.
There is a huge preparatory piece that has to be put together. And for countries like India, which imposed a lockdown early, the main reason for the lockdown is to stop the spread of the virus as much as possible and to get everything ready so that when you release the lockdown you are not overwhelmed by the large number of infected patients.
But I would be the first person to also tell you that lockdowns are brutal, they damage so many things, they damage livelihoods, they also have an impact on other health problems besides Covid, they undermine national economy. It is a terrible thing. So, for me the important thing is to get the health defences right, and quickly, so that the lockdown can be released rapidly.
Q: China reached about 83,000 cases more than a month ago. It has been more or less at the same number since then. These kind of epidemics tend to taper off slowly before ending, while China seems to have brought an immediate and abrupt halt to the epidemic. Are you surprised with Chinese numbers? What exactly has China done to bring such an abrupt end to the epidemic, at least for the time being? Are there any learnings from China, especially for a country like India?
Nabarro: I will tell you what I know, from hearing colleagues from China. It seems China has really implemented a nationwide network of community health personnel who are keeping a very regular watch on the cases, and it is backed up by testing. The moment they find a case, they isolate them immediately. They have really managed to get this right, across the country. This is what I am told.
Number two, they have really made sure that the entire population knows how serious this is. And number three, they are being very very cautious. Because they know they will have new people coming in to the country, and they are mindful that they are going to get multiple resurgences coming. So, they want to be ready to contain them as quickly as possible. I think India will have to do the same. Everybody should know what is going on.
My Chinese colleagues tell me that China has managed to get the public health preparedness everywhere, across the country. They are so Covid alert at the moment that any new case is acted upon really fast. I think that we are seeing the same thing in many other countries as well. And I think that is what it has to be for the whole world as well. We just would have to be alert for the disease everywhere all the time.
When I talk to colleagues from China, they don’t think this is the end. They know they are going to get more cases because as they open up and start movement and so on, they know the cases will come back. This isn’t something that is just going to disappear.
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