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The Sandip Roy Show

What makes people tick? What are the stories they carry with them? In a world of shouting heads, veteran journalist, radio commentator and novelist Sandip Roy sits down to have real conversations about the fascinating world around us and the people who shape it. Catch these engaging interviews every other Sunday

Episode 48 April 19, 2020

What will it take for India to come out of lockdown? With Dr Giridhar Babu

As India enters the second phase of the COVID lockdown, the question on everyone’s minds is, when and how will this end? In this episode, Sandip talks to Dr Giridhar R Babu, professor and head of life course epidemiology at the Public Health Foundation of India (PHFI) about how we will know whether India is ready to come out of the lockdown on May 3, and the kind of new India that we will emerge into.  Bonus: Listen till the end for an audio postcard.
Transcript:

Sandip Roy
Hello and welcome to the Sandip Roy Show on Express audio.

[Music]

As India enters the second phase of the great COVID lockdown, the question on everyone’s minds is when and how will this end? We keep hearing about flattening the curve, but how will we know when the curve is flattened? Meanwhile, we stress out about how to maintain a semblance of normal life in the middle of a COVID scare. We sun our newspapers and currency notes, soak vegetables in saltwater and make homemade masks, but we still feel like we are floundering in the dark wondering what the roadmap is. How will we know if, on May 3, the country is actually ready to emerge from lockdown and what kind of new India we will emerge into.

Dr Giridhar R Babu is professor and head of life course epidemiology at the Public Health Foundation of India. He worked with the World Health Organisation for nearly six years during which his efforts include stopping polio transmission in the state of Karnataka and the initiation of measles surveillance. He joins us on the show.

[Music]

Dr Giridhar Babu, welcome to the show.

Dr Giridhar Babu
Thank you, thank you Sandip.

Sandip Roy
First off, is there any good news we should be aware of?

Dr Giridhar Babu
That’s a good question. So I think there’s definitely plenty of some good news out there. The entire world is looking up to Kerala in terms of how Kerala has been able to flatten the epidemic and what are the best practices in Kerala that can be followed in other places. Number two, I think as a country also we have done really well in terms of reducing the number of cases during the lockdown and we are in good shape in terms of both containing the numbers and also how we are continuing ahead in that trajectory.

Sandip Roy
Well, in an earlier interview of yours, you had said that a lockdown for 21 days would be a great social experiment. So tell us how, now that those 21 days are over, how do you think that experiment has fared?

Dr Giridhar Babu
The reason I said social experiment was…now a country of 1.3 billion, asking, you know, to stay voluntarily at home and then there’s also no movement, which we’re not used to. So definitely, I thought this was the biggest social experiment anywhere. Definitely there seems to be an effect in terms of reduction in the numbers that India could have had. Now with this extension, I think we’ve got another opportunity to contain the numbers. And that I feel should be the focus now.

Sandip Roy
So what do you think is the purpose of the second phase of this lockdown? Is it the same as what we had for the previous 21 days? Or do you think there is a new goal in this experiment?

Dr Giridhar Babu
In my sense, since this is an exogenous country in terms of each state having its own problems in both disease containment and mitigation, what I could sense is there are a few states which are still struggling in terms of screening and containing the cases. Therefore, as long as these states continue to grow exponentially, then the other states are also at risk. That’s one. Two, even in terms of health system preparedness, I don’t think we have sufficient capacity to probably deal with any immediate surges. And given there’s a huge social and economic cost to it, I think the pros and cons have been probably assessed by everybody in power.

Sandip Roy
Do you think we started early enough? The Prime Minister seemed to suggest that in his latest message to the nation.

Dr Giridhar Babu
Absolutely, yes. Early enough or little early or little late, these are very relative terms because the assumption here is we’re finding all the cases in the country at every given point of time. However, on a world scale, if you start comparing the way the curve starts picking up and the number of people getting admitted in hospitals, one thing for sure in India is that we are not seeing the kind of surge in cases that the other countries are seeing. We started at a time when the cases were very few and we prevented many numbers of new casualties.

Sandip Roy
But despite some of the hashtags going around, can this shutdowns, as people say, ‘break the chain’?

Dr Giridhar Babu
That’s very ambitious to say that shutdowns will break down the chain. So, the very objective of these kinds of mitigation measures, whether we call it shut down or we prefer any other term is to reduce the speed at which the infection spreads from one person to another at the population level. So, that objective is definitely met. However, even if you leave few people with infections in any part of the country, which seems to be the case, they will continue to then probably infect the rest of the population or susceptibles, which is called as containment. So both have to go hand in hand. So unless we do both together and both successfully enough, we’ll not be able to say that we have been able to ‘break the chain of transmission’.

Sandip Roy
So on May 3rd, assuming that it reopens, we could easily see another spike in infections?

Dr Giridhar Babu
The reason why I kept saying both the earlier phase and even now we have got golden opportunity…the opportunity is to find every active case out there and then isolate them…

Sandip Roy
Is that possible?

Dr Giridhar Babu
Definitely possible. We have done that for several diseases. And for several years now and even decades, in terms of how polio is eradicated in the country, how we have looked at HIV programmes in syndromic approach…this is definitely possible. But the caveat is, it’s not like a union system where the central ministry wants and things are done everywhere, equally well enough. So each state has to act in terms of how to find cases, find enough cases and find every case and isolate them and then also quarantine all the close contacts.

In order to do that, some states [are] doing exceedingly well. Like I said, Kerala being an example for the rest of the world. And there are some states who are not doing well. So I think in terms of the opportunity here, what we need to be doing is not just focus on, you know, the miseries which everybody is going through. Of course, this is a huge cost here. But to really focus on these states, which are not doing well, and then make sure that enough review mechanisms are in place so that they are also on the track. The ones that are on the track, I think we will be able to have a great quantum of relief by the time the extension phase is lifted.

Sandip Roy
But some states are being accused of deliberately suppressing numbers. That they’re saying that states that are as densely populated. For example, Bengal, I’m just taking that as an example, have rather suspiciously low numbers of infections and deaths.

Dr Giridhar Babu
The one thing about this virus or any virus for that matter is that we can try to suppress anything, we can try to fool any kind of, you know, systems, which have indicators, but we can’t fool the virus or its spread. So, you cannot in any way bury the numbers because once there is severity of cases and there are deaths, it automatically gets reported. By then it will be too late. So, should the entire country pay the price of, you know, extending lock downs and all these hard measures, because one state is not doing well or few districts want to suppress cases or somebody does not want to report the cases? This is not just for that state to answer, it is for everybody to answer. So, therefore, that’s the reason I’m saying the review mechanism at the central level now should focus only on how each state is doing. And if the state is not picking up enough cases, for me that is a hotspot.

Sandip Roy
I mean, what logic would a state have to suppress the numbers? Is it for fear of causing panic within the state?

Dr Giridhar Babu
I can’t really explain the reasons behind why would somebody want to suppress it? But then I would say whoever would want to do it, it is very inhuman because [it is] the greatest adversity for the people who are very vulnerable.

Sandip Roy
And there’s also been reports that in some cases, many cases, that deaths are being attributed not to COVID, but to other underlying factors. Whatever pneumonia…because because many of the patients who come with COVID and in a critical condition have other underlying diseases,

Dr Giridhar Babu
Yes Sandip. Based on my experience with several disease eradication efforts and disease elimination and disease control efforts, one thing I can definitely say…during the earlier phase of any outbreak, all these kinds of incidents can be sort of brushed off saying that, ‘Okay, I can ascribe this to that cause’…but then once it catches greater number of people, you just run out of your reasons. By then, already there would be too many casualties.

Sandip Roy
I’d read that the initial lockdown would help India prepare for what they’re calling the inevitable – ‘a rise in cases until we develop herd immunity’. Is that true?

Dr Giridhar Babu
These are two different concepts. So, the way populations will get herd immunity…the most beneficial principle is that people get some kind of vaccine and the vaccine gives the antigenic property which causes enough antibodies or gives immunity. At least 60 to 80% of the people get this kind of immunity. Therefore, when the real threat of the real pathogen virus or bacteria comes, the population is already protected. However, expecting the population to be infected with the real virus, not with the vaccine, and then expecting them to have immunity is the other extreme. And this is the same logic which was followed by a few countries and we know what the tragedy has been in those countries where they thought we can develop herd immunity and their leaders are being hospitalised now.

So therefore the key challenge there is, if you want herd immunity through the virus itself, then you need to have an appropriate health system response. You should have enough doctors out there, enough ventilators out there, enough health system response, so that if there is any surge in cases, you’re ready to prepare the system to such a level that you minimise all the casualties. Now if that’s not possible, if you don’t have it, then the alternative is lockdown, which every country is following. Earlier countries like Singapore said containment is the only way to go. But now even they have started some amount of lockdown in different forms or the other.

Sandip Roy
So if we were to go for herd immunity in a country like India without a vaccine, but with, as you say, the real virus in a country of 1.3 billion, do we have any sense of what kind of casualty figures we should brace ourselves for?

Dr Giridhar Babu
Sandip, I don’t believe in that model where we want many people to get infected and then see what the numbers are. I have not looked at any models, what their number of casualties will be there. But if just follow the epidemiology of this virus all over the world, nearly 15% require hospitalisation and 5-6% require critical care. And imagine 1.3 billion getting infected and 5-6% of them requiring critical care. Is that even possible?

Sandip Roy
Do you foresee the lockdown being extended beyond May 3? Or do you think till May 3rd gives us ample time?

Dr Giridhar Babu
Sandip, I’m an epidemiologist but in terms of the system’s response, I’m as surprised as everyone else in terms of such positions can be taken in this country, and that’s why I call this as phenomenal because nobody in this world would have imagined India would be doing a lockdown. One lockdown and then another extended lockdown. We have done that, there must be strong rationale behind it. And I’ve given you the explanation, what is the alternative we could have had…Because the alternative is so devastating, I think this is the current rationale. But beyond this it’s completely dependent on those few states whether they do well or not. If they don’t do, then again these difficult decisions have to be taken towards the end of this extension period.

Sandip Roy
So, what factors would you look at to decide whether to open up the country after May 3rd?

Dr  Giridhar Babu
Very simple. Every district in this country should have picked up a number of cases which is at least somewhere near to the national average. Through something called a syndrome approach. Just look at fever and respiratory symptoms and if you have, treat it as COVID-19 unless otherwise proved either in terms of testing or whatever. And don’t wait for the testing kits, do the syndromic approach now. This is immediately possible everywhere. Number two, make sure that everybody who has been suspected is isolated and all their contacts are quarantined. We’re doing these two in every state, every district. Even starting from today, we should definitely be okay by the end of this extension period.

Sandip Roy
Do you think adequate testing is being done yet? Because that was a big criticism in the beginning that we were not testing enough.

Dr Giridhar Babu
Testing is a tool, Sandip, to arrive at the diagnosis and then to start our management actions in terms of isolation and quarantine. What I’m saying now is whether we have enough kits or not, which is the major constraint all over the world, let’s get to the action. The action is to find out every suspect case and isolate. And we don’t require rocket science for this. You have health workers present in every part of our rural areas. Urban areas, we need to have other solutions. But this is definitely possible and that those efforts should start now.

Sandip Roy
So as the testing has been going up, the detections are also going up, obviously. So how will we know when it’s over? That we have peaked?

Dr Giridhar Babu
So by expanding, what we are also detecting is how fast it’s spreading and what is the extent of spread. After you assess what is the doubling rate and how many infections are there, you take a five day average or seven day average. Once this number, which is less than one, in terms of one person giving infection to less than one person, then we say, ‘Oh yes, now we have sort of gained control over this. Now, it’s no longer spreading to others’.

Sandip Roy
Is that what we mean when we keep saying flatten the curve?

Dr Giridhar Babu
Yes and this is not at individual, this is at the population level for the entire country.

Sandip Roy
Now let’s talk a little bit about some of the options that have been put out there. The Prime Minister for example, in his latest speech, told everybody to download the Aarogya app. Can you explain briefly what that app is meant to do in terms of this disease? Has there been any research on whether our BCG vaccinations are actually helping India fighting COVID? I’ve been seeing reports on that.

Dr Giridhar Babu
Yeah, I have read sufficiently about it. And I’m of firm conclusion that it is too early to, you know, even believe in that theory. This we call it as ecological fallacy, which is just to say that whatever you find as correlation in the group level, may not be true at the individual level. So as of today, it is yet to be proven, and there are trials being done in Melbourne and other places where they’re trying to see whether it will have any protective effect.

Sandip Roy
Is the same true about Hydroxychloroquine?

Dr Giridhar Babu
The world is divided in its opinion in terms of what it can do. However, currently whatever the evidence is available, there’s no immediate term adverse effects by taking Hydroxychloroquine. The benefit of taking it is initially proved in some of the earlier data that is coming from the trials, which I just read in the morning, you know, in one of these trials. So if that’s true, then the world has done something really ahead of even before science has been proven. But so far, it is neither harmful nor beneficial, but the earliest evidence which has come from today at least says that it is beneficial.

Sandip Roy
So then why has the government kept saying that this is only for health care workers, not for the general population?

Dr Giridhar Babu
I think once the evidence is absolutely clear, they might expand to all the other groups as well.

Sandip Roy
Now, I’m curious to ask you about a couple of things about which I’ve heard so many conflicting messages. So initially, at the beginning of the epidemic, we were told that masks were not that useful. That only health care workers or people who were actually positive should wear masks. Now we have directives in many states requiring everyone to wear masks. Now people are saying that, ‘Oh, it doesn’t necessarily need to be one of the surgical masks or the N95, but I saw a minister showing how you can make a mask at home with a piece of cloth. So I for am terribly confused about what mask I can or should wear.

Dr Giridhar Babu
So you’re not alone in this. And so what this virus has done to this world is…it is called novel Coronavirus, but it’s also displayed several novelties in terms of how limited a science can be and how fast things can change and what are the entire biases out there. So there are several things that this virus has proved. So the evidence, what is true for today, might change today afternoon or tomorrow. But that doesn’t mean that people are giving wrong advice. They’re also trying to learn as and when the evidence is being made available.

So, in the initial part of the outbreak, the understanding was that as long as the infected are wearing masks, that’s enough. However, the Asian countries showed that using masks, any type of mask, is going to reduce the transmission. Based on that, the recommendations were then started in terms of why not use some masks. Now, they could have said one type of mask, but then the immediate problem would then have been – where is this mask? What about shortages? Currently, people are only complaining about shortages of testing kits and ventilators. Now you also add shortages in masks. So I think it was brilliant and very innovative that people were taught how to make masks at home. How does it help? It helps because from the infected it doesn’t spread to others, number one.

Number two, when you are not following physical distancing because you’re in an overcrowded area like our slums in some of the urban areas. Then, by using a mask you’re also preventing the infection from reaching you. So therefore, whatever little benefit we have, any mask should be able to… let us not be more confounded by the type of mask. Any mask is fine to wear for now. That can be the message.

Sandip Roy
And what about this other thing that has been my other concern, which is when I buy vegetables and things from the market, I am getting all kinds of advice about what to…some people I know are soaking them in potassium permanganate solution, some people are soaking them for half and hour in saltwater solution and putting them out to dry. Some people….and I don’t know what I should be doing.

Dr Giridhar Babu
As long as you wash it with water. Anything else you add, I add, is extra. You don’t have to have some compulsion to keep washing with several other things because once it gets to the mind…but the easiest thing to do is wash ourselves in…wash your hands at least 3 to 4 times a day and then wash the vegetable. And this is what we’ve been doing for long. But now I don’t think there’s anything extra to add in terms of what to wash with, as long as you wash with water, that’s probably enough.

Sandip Roy
You mentioned problems that would be in urban slums and where social distancing is difficult. And we saw very recently this huge problem in Mumbai, where thousands of migrants showed up thinking the trains were going to be open. As an epidemiologist, how would you tackle a problem like that?

Dr Giridhar Babu
Yeah, so first thing, we should not use the term social distancing. Although it’s widely used It is physical distancing. And what we should advocate is for social cohesion and trying to be as supportive of each other. In physical distancing, it’s really tough to do it in overcrowded areas such as slums and also in the migrants. So we have to be very innovative. So some of the measures that the Maharashtra government is taking in Dharavi…the most innovative hand wash stations. Especially, you know, hand wash stations that can be operated by the foot. Then there are social group building and then confidence building measures such as WhatsApp groups being created in the slums. The leaders have been contacted to make sure whoever has a fever, they’re isolated at home and then seek healthcare. There’s masks which are being advocated to use in these overcrowded areas. With all these measures, we are not going to solve all our problems in one go. But then trying these things with complete conviction and then getting our systems to act on it, I’m sure we can reduce not just the COVID-19 transmission, but also other things which spread through such routes such as tuberculosis.

Sandip Roy
Are you also worried about the reports coming out right now that I’ve seen, for example, in Korea, about the possibility of cured COVID patients getting reinfected?

Dr Giridhar Babu
Yeah, as I said before, there’s a lot that is not known regarding the novel Coronavirus. Whether [there’s] reinfection possible, whether asymptomatics during their incubation period can keep spreading to the same extent as the symptomatics do, does this give lifelong immunity? This [are] the questions which we need to answer and in order to do that, I think ICMR is also planning zero prevalence surveys and then they also want to know, how long people are immune and what are the kind of measures that the country should be taking. So I think we are all…including the vaccine development, which is also India is participating [in]…I’m sure the research that is ongoing will give the results in the days to come.

Sandip Roy
So how do you visualise us coming out of lockdown, you know, what kind of staggered approach do you think will happen?

Dr Giridhar Babu
One day lockdown, Sandip. And which is that day will be dependent on how good every state and every district is doing. But once we come out, we are going to live with this virus forever. So, the virus is not going to just vanish away in thin air. So therefore, it is going to be a co-host and they will be affecting people here and there. Fortunately, we have realised it early enough and done the L-system response appropriately. Now, we should keep strengthening the health system to an extent where our surveillance system is very sensitive. Pick up cases whenever and wherever they come. And we do the same measures which were following as a country now, in terms of all these hygiene practices and physical distancing. So, this I say is the new normal and gone are the old days. Even if lockdown is lifted, the new normal has to take us into an era where I think we will be free of many other diseases, not just COVID-19.

Sandip Roy
You’ve said India has less than 5000 trained epidemiologists. Are we feeling this inadequacy during an outbreak like COVID?

Dr Giridhar Babu
Now whenever there is fire, then there are firefighters who are sung like heroes. But once there is no fire, we don’t know where the firefighters are. And this is exactly every epidemic, every outbreak. Every disease that is affecting human populations is treated as…and when there’s a crisis, you need people who understand the disease, who want to give some advice which we can use. And once that reactive phase is over, we also forget the need of such people. So as you see many state governments want to hire the firefighter epidemiologist, now the meagre salary of 20,000- 25,000. The moment COVID-19 is no longer a major problem, at least in attention, even these jobs will be gone. And there is nobody then to take care of anything in terms of any other diseases. Where more diseases which cause greater burden than this.

So from an evidence based public health policy and planning and implementation, the role of epidemiologist is as important as social scientists, bio statisticians and environmental health practitioners. There are several disciplines in public health who are definitely neither. It’s not just epidemiologists. But are we prepared? Are we even thinking in that direction even now, in the heat of COVID-19 crisis? I’m not really sure. We are still worried about the curative services, ventilators, critical care, and not focusing enough on preventing these and gearing up our systems in order to be resilient and then strong compared to anywhere in the world.

Sandip Roy
But and as you said that gone are the old ways…old ways in a country like India included enormous amount of things require that, you know, did away with physical distancing, as you would put it…our religious occasions have thousands and thousands of people coming together, cricket matches, huge wedding celebrations, all of these things. How are we going to deal with all of these things in the post COVID world?

Dr Giridhar Babu
Now, I think what I’m really confident about India as a country is whenever we are confronting any challenges, we have risen to the occasion. Be it a cricket match or a health crisis. So now people have gotten used to some of the new ways. And now, the most important point here is, they’re not just using the new ways but they also understand why they are doing it. This is most important and once they have understood it, I think it’ll change. See, now there are several people who on their own are saying, after all, this is over, whenever it is over, ‘We shouldn’t be doing this and we should be continuing this good habit’ or things like that. If the entire world is following India’s namaste, we also have to follow the other terms in terms of what kind of cough etiquette we should have, how should the minimum physical distance be maintained, even if you’re at a congregation…All these things are the things that we will learn. I think we will learn much better. We will have some initial challenges but I’m sure we’ll get used to the new normal.

Sandip Roy
Do you think Indians will finally learn to stand in a queue properly? (Laughs)

Dr Giridhar Babu
Oh, come on Sandip. We have been doing that in some places and we do it well.

Sandip Roy
But more seriously, if there was one lesson that you hope that we will take away from this experience with COVID as a lesson for a better practice for the next pandemic, what would it be?

Dr Giridhar Babu
Trust your public health people. Take care of them, they’ll take care of the nation.

Sandip Roy
Dr Giridhar Babu, thank you so much for joining us today.

Dr Giridhar Babu
Thank you Sandip.

Sandip Roy
Dr Giridhar Babu is professor and head of life course epidemiology at the Public Health Foundation of India. He worked with the WHO for nearly 6 years.


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What will it take for India to come out of lockdown? With Dr Giridhar BabuAs India enters the second phase of the COVID lockdown, the question on everyone's minds is, when and how will this end? In this episode, Sandip talks to Dr Giridhar R Babu, professor and head of life course epidemiology at the Public Health Foundation of India (PHFI) about how we will know whether India is ready to come out of the lockdown on May 3, and the kind of new India that we will emerge into.  Bonus: Listen till the end for an audio postcard. Transcript: Sandip Roy Hello and welcome to the Sandip Roy Show on Express audio. [Music] As India enters the second phase of the great COVID lockdown, the question on everyone's minds is when and how will this end? We keep hearing about flattening the curve, but how will we know when the curve is flattened? Meanwhile, we stress out about how to maintain a semblance of normal life in the middle of a COVID scare. We sun our newspapers and currency notes, soak vegetables in saltwater and make homemade masks, but we still feel like we are floundering in the dark wondering what the roadmap is. How will we know if, on May 3, the country is actually ready to emerge from lockdown and what kind of new India we will emerge into. Dr Giridhar R Babu is professor and head of life course epidemiology at the Public Health Foundation of India. He worked with the World Health Organisation for nearly six years during which his efforts include stopping polio transmission in the state of Karnataka and the initiation of measles surveillance. He joins us on the show. [Music] Dr Giridhar Babu, welcome to the show. Dr Giridhar Babu Thank you, thank you Sandip. Sandip Roy First off, is there any good news we should be aware of? Dr Giridhar Babu That's a good question. So I think there's definitely plenty of some good news out there. The entire world is looking up to Kerala in terms of how Kerala has been able to flatten the epidemic and what are the best practices in Kerala that can be followed in other places. Number two, I think as a country also we have done really well in terms of reducing the number of cases during the lockdown and we are in good shape in terms of both containing the numbers and also how we are continuing ahead in that trajectory. Sandip Roy Well, in an earlier interview of yours, you had said that a lockdown for 21 days would be a great social experiment. So tell us how, now that those 21 days are over, how do you think that experiment has fared? Dr Giridhar Babu The reason I said social experiment was...now a country of 1.3 billion, asking, you know, to stay voluntarily at home and then there's also no movement, which we're not used to. So definitely, I thought this was the biggest social experiment anywhere. Definitely there seems to be an effect in terms of reduction in the numbers that India could have had. Now with this extension, I think we've got another opportunity to contain the numbers. And that I feel should be the focus now. Sandip Roy So what do you think is the purpose of the second phase of this lockdown? Is it the same as what we had for the previous 21 days? Or do you think there is a new goal in this experiment? Dr Giridhar Babu In my sense, since this is an exogenous country in terms of each state having its own problems in both disease containment and mitigation, what I could sense is there are a few states which are still struggling in terms of screening and containing the cases. Therefore, as long as these states continue to grow exponentially, then the other states are also at risk. That's one. Two, even in terms of health system preparedness, I don't think we have sufficient capacity to probably deal with any immediate surges. And given there's a huge social and economic cost to it, I think the pros and cons have been probably assessed by everybody in power. Sandip Roy Do you think we started early enough? The Prime Minister seemed to suggest that in his latest message to the nation. Dr Giridhar Babu Absolutely, yes. Early enough or little early or little late, these are very relative terms because the assumption here is we're finding all the cases in the country at every given point of time. However, on a world scale, if you start comparing the way the curve starts picking up and the number of people getting admitted in hospitals, one thing for sure in India is that we are not seeing the kind of surge in cases that the other countries are seeing. We started at a time when the cases were very few and we prevented many numbers of new casualties. Sandip Roy But despite some of the hashtags going around, can this shutdowns, as people say, 'break the chain'? Dr Giridhar Babu That's very ambitious to say that shutdowns will break down the chain. So, the very objective of these kinds of mitigation measures, whether we call it shut down or we prefer any other term is to reduce the speed at which the infection spreads from one person to another at the population level. So, that objective is definitely met. However, even if you leave few people with infections in any part of the country, which seems to be the case, they will continue to then probably infect the rest of the population or susceptibles, which is called as containment. So both have to go hand in hand. So unless we do both together and both successfully enough, we'll not be able to say that we have been able to 'break the chain of transmission'. Sandip Roy So on May 3rd, assuming that it reopens, we could easily see another spike in infections? Dr Giridhar Babu The reason why I kept saying both the earlier phase and even now we have got golden opportunity...the opportunity is to find every active case out there and then isolate them... Sandip Roy Is that possible? Dr Giridhar Babu Definitely possible. We have done that for several diseases. And for several years now and even decades, in terms of how polio is eradicated in the country, how we have looked at HIV programmes in syndromic approach...this is definitely possible. But the caveat is, it's not like a union system where the central ministry wants and things are done everywhere, equally well enough. So each state has to act in terms of how to find cases, find enough cases and find every case and isolate them and then also quarantine all the close contacts. In order to do that, some states [are] doing exceedingly well. Like I said, Kerala being an example for the rest of the world. And there are some states who are not doing well. So I think in terms of the opportunity here, what we need to be doing is not just focus on, you know, the miseries which everybody is going through. Of course, this is a huge cost here. But to really focus on these states, which are not doing well, and then make sure that enough review mechanisms are in place so that they are also on the track. The ones that are on the track, I think we will be able to have a great quantum of relief by the time the extension phase is lifted. Sandip Roy But some states are being accused of deliberately suppressing numbers. That they're saying that states that are as densely populated. For example, Bengal, I'm just taking that as an example, have rather suspiciously low numbers of infections and deaths. Dr Giridhar Babu The one thing about this virus or any virus for that matter is that we can try to suppress anything, we can try to fool any kind of, you know, systems, which have indicators, but we can't fool the virus or its spread. So, you cannot in any way bury the numbers because once there is severity of cases and there are deaths, it automatically gets reported. By then it will be too late. So, should the entire country pay the price of, you know, extending lock downs and all these hard measures, because one state is not doing well or few districts want to suppress cases or somebody does not want to report the cases? This is not just for that state to answer, it is for everybody to answer. So, therefore, that's the reason I'm saying the review mechanism at the central level now should focus only on how each state is doing. And if the state is not picking up enough cases, for me that is a hotspot. Sandip Roy I mean, what logic would a state have to suppress the numbers? Is it for fear of causing panic within the state? Dr Giridhar Babu I can't really explain the reasons behind why would somebody want to suppress it? But then I would say whoever would want to do it, it is very inhuman because [it is] the greatest adversity for the people who are very vulnerable. Sandip Roy And there's also been reports that in some cases, many cases, that deaths are being attributed not to COVID, but to other underlying factors. Whatever pneumonia...because because many of the patients who come with COVID and in a critical condition have other underlying diseases, Dr Giridhar Babu Yes Sandip. Based on my experience with several disease eradication efforts and disease elimination and disease control efforts, one thing I can definitely say...during the earlier phase of any outbreak, all these kinds of incidents can be sort of brushed off saying that, 'Okay, I can ascribe this to that cause'...but then once it catches greater number of people, you just run out of your reasons. By then, already there would be too many casualties. Sandip Roy I'd read that the initial lockdown would help India prepare for what they're calling the inevitable - 'a rise in cases until we develop herd immunity'. Is that true? Dr Giridhar Babu These are two different concepts. So, the way populations will get herd immunity...the most beneficial principle is that people get some kind of vaccine and the vaccine gives the antigenic property which causes enough antibodies or gives immunity. At least 60 to 80% of the people get this kind of immunity. Therefore, when the real threat of the real pathogen virus or bacteria comes, the population is already protected. However, expecting the population to be infected with the real virus, not with the vaccine, and then expecting them to have immunity is the other extreme. And this is the same logic which was followed by a few countries and we know what the tragedy has been in those countries where they thought we can develop herd immunity and their leaders are being hospitalised now. So therefore the key challenge there is, if you want herd immunity through the virus itself, then you need to have an appropriate health system response. You should have enough doctors out there, enough ventilators out there, enough health system response, so that if there is any surge in cases, you're ready to prepare the system to such a level that you minimise all the casualties. Now if that's not possible, if you don't have it, then the alternative is lockdown, which every country is following. Earlier countries like Singapore said containment is the only way to go. But now even they have started some amount of lockdown in different forms or the other. Sandip Roy So if we were to go for herd immunity in a country like India without a vaccine, but with, as you say, the real virus in a country of 1.3 billion, do we have any sense of what kind of casualty figures we should brace ourselves for? Dr Giridhar Babu Sandip, I don't believe in that model where we want many people to get infected and then see what the numbers are. I have not looked at any models, what their number of casualties will be there. But if just follow the epidemiology of this virus all over the world, nearly 15% require hospitalisation and 5-6% require critical care. And imagine 1.3 billion getting infected and 5-6% of them requiring critical care. Is that even possible? Sandip Roy Do you foresee the lockdown being extended beyond May 3? Or do you think till May 3rd gives us ample time? Dr Giridhar Babu Sandip, I'm an epidemiologist but in terms of the system's response, I'm as surprised as everyone else in terms of such positions can be taken in this country, and that's why I call this as phenomenal because nobody in this world would have imagined India would be doing a lockdown. One lockdown and then another extended lockdown. We have done that, there must be strong rationale behind it. And I've given you the explanation, what is the alternative we could have had...Because the alternative is so devastating, I think this is the current rationale. But beyond this it's completely dependent on those few states whether they do well or not. If they don't do, then again these difficult decisions have to be taken towards the end of this extension period. Sandip Roy So, what factors would you look at to decide whether to open up the country after May 3rd? Dr  Giridhar Babu Very simple. Every district in this country should have picked up a number of cases which is at least somewhere near to the national average. Through something called a syndrome approach. Just look at fever and respiratory symptoms and if you have, treat it as COVID-19 unless otherwise proved either in terms of testing or whatever. And don't wait for the testing kits, do the syndromic approach now. This is immediately possible everywhere. Number two, make sure that everybody who has been suspected is isolated and all their contacts are quarantined. We're doing these two in every state, every district. Even starting from today, we should definitely be okay by the end of this extension period. Sandip Roy Do you think adequate testing is being done yet? Because that was a big criticism in the beginning that we were not testing enough. Dr Giridhar Babu Testing is a tool, Sandip, to arrive at the diagnosis and then to start our management actions in terms of isolation and quarantine. What I'm saying now is whether we have enough kits or not, which is the major constraint all over the world, let's get to the action. The action is to find out every suspect case and isolate. And we don't require rocket science for this. You have health workers present in every part of our rural areas. Urban areas, we need to have other solutions. But this is definitely possible and that those efforts should start now. Sandip Roy So as the testing has been going up, the detections are also going up, obviously. So how will we know when it's over? That we have peaked? Dr Giridhar Babu So by expanding, what we are also detecting is how fast it's spreading and what is the extent of spread. After you assess what is the doubling rate and how many infections are there, you take a five day average or seven day average. Once this number, which is less than one, in terms of one person giving infection to less than one person, then we say, 'Oh yes, now we have sort of gained control over this. Now, it's no longer spreading to others'. Sandip Roy Is that what we mean when we keep saying flatten the curve? Dr Giridhar Babu Yes and this is not at individual, this is at the population level for the entire country. Sandip Roy Now let's talk a little bit about some of the options that have been put out there. The Prime Minister for example, in his latest speech, told everybody to download the Aarogya app. Can you explain briefly what that app is meant to do in terms of this disease? Has there been any research on whether our BCG vaccinations are actually helping India fighting COVID? I've been seeing reports on that. Dr Giridhar Babu Yeah, I have read sufficiently about it. And I'm of firm conclusion that it is too early to, you know, even believe in that theory. This we call it as ecological fallacy, which is just to say that whatever you find as correlation in the group level, may not be true at the individual level. So as of today, it is yet to be proven, and there are trials being done in Melbourne and other places where they're trying to see whether it will have any protective effect. Sandip Roy Is the same true about Hydroxychloroquine? Dr Giridhar Babu The world is divided in its opinion in terms of what it can do. However, currently whatever the evidence is available, there's no immediate term adverse effects by taking Hydroxychloroquine. The benefit of taking it is initially proved in some of the earlier data that is coming from the trials, which I just read in the morning, you know, in one of these trials. So if that's true, then the world has done something really ahead of even before science has been proven. But so far, it is neither harmful nor beneficial, but the earliest evidence which has come from today at least says that it is beneficial. Sandip Roy So then why has the government kept saying that this is only for health care workers, not for the general population? Dr Giridhar Babu I think once the evidence is absolutely clear, they might expand to all the other groups as well. Sandip Roy Now, I'm curious to ask you about a couple of things about which I've heard so many conflicting messages. So initially, at the beginning of the epidemic, we were told that masks were not that useful. That only health care workers or people who were actually positive should wear masks. Now we have directives in many states requiring everyone to wear masks. Now people are saying that, 'Oh, it doesn't necessarily need to be one of the surgical masks or the N95, but I saw a minister showing how you can make a mask at home with a piece of cloth. So I for am terribly confused about what mask I can or should wear. Dr Giridhar Babu So you're not alone in this. And so what this virus has done to this world is...it is called novel Coronavirus, but it's also displayed several novelties in terms of how limited a science can be and how fast things can change and what are the entire biases out there. So there are several things that this virus has proved. So the evidence, what is true for today, might change today afternoon or tomorrow. But that doesn't mean that people are giving wrong advice. They're also trying to learn as and when the evidence is being made available. So, in the initial part of the outbreak, the understanding was that as long as the infected are wearing masks, that's enough. However, the Asian countries showed that using masks, any type of mask, is going to reduce the transmission. Based on that, the recommendations were then started in terms of why not use some masks. Now, they could have said one type of mask, but then the immediate problem would then have been - where is this mask? What about shortages? Currently, people are only complaining about shortages of testing kits and ventilators. Now you also add shortages in masks. So I think it was brilliant and very innovative that people were taught how to make masks at home. How does it help? It helps because from the infected it doesn't spread to others, number one. Number two, when you are not following physical distancing because you're in an overcrowded area like our slums in some of the urban areas. Then, by using a mask you're also preventing the infection from reaching you. So therefore, whatever little benefit we have, any mask should be able to... let us not be more confounded by the type of mask. Any mask is fine to wear for now. That can be the message. Sandip Roy And what about this other thing that has been my other concern, which is when I buy vegetables and things from the market, I am getting all kinds of advice about what to...some people I know are soaking them in potassium permanganate solution, some people are soaking them for half and hour in saltwater solution and putting them out to dry. Some people....and I don't know what I should be doing. Dr Giridhar Babu As long as you wash it with water. Anything else you add, I add, is extra. You don't have to have some compulsion to keep washing with several other things because once it gets to the mind...but the easiest thing to do is wash ourselves in...wash your hands at least 3 to 4 times a day and then wash the vegetable. And this is what we've been doing for long. But now I don't think there's anything extra to add in terms of what to wash with, as long as you wash with water, that's probably enough. Sandip Roy You mentioned problems that would be in urban slums and where social distancing is difficult. And we saw very recently this huge problem in Mumbai, where thousands of migrants showed up thinking the trains were going to be open. As an epidemiologist, how would you tackle a problem like that? Dr Giridhar Babu Yeah, so first thing, we should not use the term social distancing. Although it's widely used It is physical distancing. And what we should advocate is for social cohesion and trying to be as supportive of each other. In physical distancing, it's really tough to do it in overcrowded areas such as slums and also in the migrants. So we have to be very innovative. So some of the measures that the Maharashtra government is taking in Dharavi...the most innovative hand wash stations. Especially, you know, hand wash stations that can be operated by the foot. Then there are social group building and then confidence building measures such as WhatsApp groups being created in the slums. The leaders have been contacted to make sure whoever has a fever, they're isolated at home and then seek healthcare. There's masks which are being advocated to use in these overcrowded areas. With all these measures, we are not going to solve all our problems in one go. But then trying these things with complete conviction and then getting our systems to act on it, I'm sure we can reduce not just the COVID-19 transmission, but also other things which spread through such routes such as tuberculosis. Sandip Roy Are you also worried about the reports coming out right now that I've seen, for example, in Korea, about the possibility of cured COVID patients getting reinfected? Dr Giridhar Babu Yeah, as I said before, there's a lot that is not known regarding the novel Coronavirus. Whether [there's] reinfection possible, whether asymptomatics during their incubation period can keep spreading to the same extent as the symptomatics do, does this give lifelong immunity? This [are] the questions which we need to answer and in order to do that, I think ICMR is also planning zero prevalence surveys and then they also want to know, how long people are immune and what are the kind of measures that the country should be taking. So I think we are all...including the vaccine development, which is also India is participating [in]...I'm sure the research that is ongoing will give the results in the days to come. Sandip Roy So how do you visualise us coming out of lockdown, you know, what kind of staggered approach do you think will happen? Dr Giridhar Babu One day lockdown, Sandip. And which is that day will be dependent on how good every state and every district is doing. But once we come out, we are going to live with this virus forever. So, the virus is not going to just vanish away in thin air. So therefore, it is going to be a co-host and they will be affecting people here and there. Fortunately, we have realised it early enough and done the L-system response appropriately. Now, we should keep strengthening the health system to an extent where our surveillance system is very sensitive. Pick up cases whenever and wherever they come. And we do the same measures which were following as a country now, in terms of all these hygiene practices and physical distancing. So, this I say is the new normal and gone are the old days. Even if lockdown is lifted, the new normal has to take us into an era where I think we will be free of many other diseases, not just COVID-19. Sandip Roy You've said India has less than 5000 trained epidemiologists. Are we feeling this inadequacy during an outbreak like COVID? Dr Giridhar Babu Now whenever there is fire, then there are firefighters who are sung like heroes. But once there is no fire, we don't know where the firefighters are. And this is exactly every epidemic, every outbreak. Every disease that is affecting human populations is treated as...and when there's a crisis, you need people who understand the disease, who want to give some advice which we can use. And once that reactive phase is over, we also forget the need of such people. So as you see many state governments want to hire the firefighter epidemiologist, now the meagre salary of 20,000- 25,000. The moment COVID-19 is no longer a major problem, at least in attention, even these jobs will be gone. And there is nobody then to take care of anything in terms of any other diseases. Where more diseases which cause greater burden than this. So from an evidence based public health policy and planning and implementation, the role of epidemiologist is as important as social scientists, bio statisticians and environmental health practitioners. There are several disciplines in public health who are definitely neither. It's not just epidemiologists. But are we prepared? Are we even thinking in that direction even now, in the heat of COVID-19 crisis? I'm not really sure. We are still worried about the curative services, ventilators, critical care, and not focusing enough on preventing these and gearing up our systems in order to be resilient and then strong compared to anywhere in the world. Sandip Roy But and as you said that gone are the old ways...old ways in a country like India included enormous amount of things require that, you know, did away with physical distancing, as you would put it...our religious occasions have thousands and thousands of people coming together, cricket matches, huge wedding celebrations, all of these things. How are we going to deal with all of these things in the post COVID world? Dr Giridhar Babu Now, I think what I'm really confident about India as a country is whenever we are confronting any challenges, we have risen to the occasion. Be it a cricket match or a health crisis. So now people have gotten used to some of the new ways. And now, the most important point here is, they're not just using the new ways but they also understand why they are doing it. This is most important and once they have understood it, I think it'll change. See, now there are several people who on their own are saying, after all, this is over, whenever it is over, 'We shouldn't be doing this and we should be continuing this good habit' or things like that. If the entire world is following India's namaste, we also have to follow the other terms in terms of what kind of cough etiquette we should have, how should the minimum physical distance be maintained, even if you're at a congregation...All these things are the things that we will learn. I think we will learn much better. We will have some initial challenges but I'm sure we'll get used to the new normal. Sandip Roy Do you think Indians will finally learn to stand in a queue properly? (Laughs) Dr Giridhar Babu Oh, come on Sandip. We have been doing that in some places and we do it well. Sandip Roy But more seriously, if there was one lesson that you hope that we will take away from this experience with COVID as a lesson for a better practice for the next pandemic, what would it be? Dr Giridhar Babu Trust your public health people. Take care of them, they'll take care of the nation. Sandip Roy Dr Giridhar Babu, thank you so much for joining us today. Dr Giridhar Babu Thank you Sandip. Sandip Roy Dr Giridhar Babu is professor and head of life course epidemiology at the Public Health Foundation of India. He worked with the WHO for nearly 6 years. You can follow us and leave us feedback on Facebook and Twitter @expresspodcasts, or send us an email at podcasts@indianexpress.com. If you like this show, please subscribe and leave us a review wherever you get your podcasts, so other people can find us. You can also find us on https://www.indianexpress.com/audio.
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