Can India Get Back To Work?

Mumbai: As the number of COVID-19 cases continues to rise across the country, the clamour to open up the economy is growing. How can India get back to work and what does it need to do? How much is known about the spread of the disease today, what is going to happen when the economy is opened up, and what are the precautions that can be taken going ahead on that score? We speak to Giridhar R. Babu, professor and head of Life Course Epidemiology at the public-private collaboration, Public Health Foundation of India. He has worked in the past on polio transmission and initiation. He started out as a doctor at the reputed All India Institute of Medical Sciences (AIIMS), and then did his PhD at the University of California.

How much do we understand of the progression of novel coronavirus in India?

Compared with the rest of the world, India started off really well in terms of having a lower exponential trajectory, which means we have by far the lowest number of cases, we also have very few deaths, and the kind of predictions—which were scary in the beginning—that lot of people would die, we would need lots and lots of ventilators, India is going to be doomed, did not come true. However, this is not over. If you look at the way the number of cases are growing in the recent past, it only means this will continue, similar to the rest of the world. However, what we do now will determine whether we are able to continue the momentum at a lower exponential or will it flare up and result in a surge of cases. So far we are really well positioned. Now it depends on what we do, how we do it, how we go into the next few days and few weeks, which will determine the overall result.

India needs to start moving on the economy and livelihoods. How would India be best advised to do that?

The World Health Organization (WHO) and all the other leading organisations are saying a country needs to balance between life and livelihood. I am not an economist, I only know epidemiology. So, I can only speak from an epidemiological perspective. There are others who will have to weigh in with their expertise to give the country a holistic perspective. Having said that, each state in the country is at a different stage of disease progression. Some states have just started picking up their epidemic curve. Some states have already contained it well. So, action is already up to the state level now. So, when you take a decision at the national level—let us open up—then you are actually opening the gates from high transmission [areas] towards low transmission [areas], from urban towards the rural. So how do you then think of a situation where you can prevent an increase? That is where we say that containment is the way forward. 

So far what we have done is the lockdown; it is a mitigation measure, which is like a hide-and-seek game with the virus. During this time, we should have sought out the virus, wherever it is present, isolated the people who have the infection and made sure that it did not spread. We have done that in many states, but we have not been able to do that in a few states. Those few states are the states in focus now, and even districts that are very important. 

Within states there are districts that are very silent and have not reported a case, yet there are areas of high transmission. So, as we think of opening up, all the benefits that we have accrued over the extended lockdown should not be washed away. Otherwise people will say, why did we go through all this trouble, if so many cases had to come in the future? Therefore, we have had gains, but we need to make sure how we move forward. For that, surveillance is the only way forward. Detect the cases, isolate them. Pick up the contacts, quarantine them. Apart from all the other measures of physical distancing, which we can discuss later, this is the key ingredient of how we move forward.

As a doctor, what are the reasons the disease is spreading, would you say? For instance, even in the area where I am in the city of Mumbai, we are discovering new cases every day. Now as far as I know, most of these people have been contained or under lockdown for more than 28 days, which is roughly two COVID-19 cycles. So obviously, there has been some leakage somewhere. But in general, do you have a sense of why this continues to happen despite the fact that now most parts of the country have been under a lockdown for more than 40 days?

If this could happen during a lockdown, just imagine what could happen when we open up and relax all the measures that we have. I will explain how this spreads—the disease is caused by the infection of an RNA [Ribonucleic acid] virus; the incubation period, that is, from the time the virus enters the body to the time it starts producing symptoms, is around 14 days, roughly 5-7 days being the median. Most people in India do not develop symptoms, or they develop symptoms that are very non-specific. So, people may be still spreading the infection while they do not have symptoms. This is the best and worst thing about this infection. The good thing is that not many people get affected, they do not have to be hospitalised, they do not need to be in an ICU [intensive care unit]. However, they can continue spreading to people who are vulnerable. So, whatever spread we see now is because of both symptomatic and asymptomatic people coming in contact with someone else—among their close contacts or secondary contacts, and that is the only way it is spreading. See, this virus spreads only through droplets and these are heavy droplets that cannot go many meters and will settle down on a surface that is in close vicinity of. 

As long as you maintain a minimum distance of one meter, and you are using masks, it should not spread that much. So as a country both these measures, physical distancing and use of masks, we have started. We have gotten used to both and if we continue, we can reduce the spread both in urban and semi-urban areas.

So you are saying that even as we get out of the lockdown, and we follow these two things judiciously, we will be able to contain the spread of the disease?

Yes

A lot of people want to know: if schools open in May, should they send their child to school?

All over the world Sweden is the only country that has allowed schools to continue. Otherwise most countries in lockdown phase and beyond have shut down schools. What we see from the disease itself is that children are not affected that much. However, they are carriers, and can bring the infection to the elderly and the otherwise vulnerable. Therefore, the best thing as we move forward is to continue the new normal—that is, try to have classes through video or correspondence as much as possible; work from home, study from home for some time in the future, so that we are in a better position. There is a lot of research going on about vaccines and into drugs to repurpose. So, we hope we are in a better state later, where we will be able to open up schools and other sectors. 

There is a lot of misinformation going around. Your advice?

Yes, I think there is a lot of misinformation. Number 1 is that we have a different strain in India that does not affect many people, does not cause severity. That is not true. And I have tried to look at the literature, I did not find evidence to know where this news is coming from. 

The second is that young people anyway do not get affected, so we can start going to offices and schools. This is not true. You might be younger and may not succumb, but then you are playing with the lives of the people who are at home, the elderly or the immuno-compromised. In India we have many people with coexisting diseases—one in three adults have hypertension. One in 10 adults have type-2 diabetes mellitus. So, in a country where co-morbidity is so high, we simply cannot take a chance to move on with our lives and let the disease run its course. I really get disturbed when I hear: let the disease run its course. Then there is no use of public health, there is no use for all these measures that we have taken. I think we need to be careful; we should not be complacent at this stage; we have had real good gains compared to anywhere in the world. So, let us not waste it. 

Finally, evidence is emerging that more people have been carrying the disease from much earlier and we did not know it, and that only testing will let us know, going ahead. What is your sense about India? 

As of now we are not in a position to say what is the extent of the spread apart from those whom we have tested and found positive. The reason is we have found in India nearly 70% and above as asymptomatic. But this asymptomatic category comprises three different groups. The smallest portion are truly asymptomatic, which means they will never get any symptoms related to this disease. The next big group is pre-symptomatic--we have tested them when they did not have symptoms, but they will go on to develop systems later on. And the third group has atypical symptoms. Just yesterday, CDC [Centers for Disease Control and Prevention of the US] included five more symptoms into the diagnostic criteria. So when you look at all of those we need to widen the kind of symptoms that we screen for.

Of course, you should expand testing, too, though testing is not a goal in itself, it is just a means. So, even before testing we should be looking at symptoms and making a probable diagnosis and start isolating people. This is the way forward, whether atypical symptoms or no symptoms; by doing this we should be able to isolate many people with infection. The remaining asymptomatic people can be prevented from spreading [the disease] by using masks and physical distancing. So that is the new normal now. 

Should we be worried about an upcoming onslaught, or will it mostly be a linear progression as it is currently?

We do not know beyond what the data says. When I said, before the disease hit, that we would not have the numbers that other countries did, people who had different modelling said that was not possible. But India took really unprecedented measures that cannot be matched anywhere in the world. As we move forward, we will be better than most countries in the world because of the policy direction that the country has taken. But this is the time for responsibility at the individual level, at the organisational level—measures like work from home should be continued. School managements must think innovatively in terms of how to continue in the times of this new normal. So, if we exercise these responsibilities carefully, I think we will continue at the same lower momentum for some more time until we flatten, and then we will have a vaccine or a drug. So, I am very optimistic about India’s progress, unless something drastic--some policy or implementation--occurs to cause us to lose all the gain. That should not happen. 

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.

Mumbai: As the number of COVID-19 cases continues to rise across the country, the clamour to open up the economy is growing. How can India get back to work and what does it need to do? How much is known about the spread of the disease today, what is going to happen when the economy is opened up, and what are the precautions that can be taken going ahead on that score? We speak to Giridhar R. Babu, professor and head of Life Course Epidemiology at the public-private collaboration, Public Health Foundation of India. He has worked in the past on polio transmission and initiation. He started out as a doctor at the reputed All India Institute of Medical Sciences (AIIMS), and then did his PhD at the University of California.

How much do we understand of the progression of novel coronavirus in India?

Compared with the rest of the world, India started off really well in terms of having a lower exponential trajectory, which means we have by far the lowest number of cases, we also have very few deaths, and the kind of predictions—which were scary in the beginning—that lot of people would die, we would need lots and lots of ventilators, India is going to be doomed, did not come true. However, this is not over. If you look at the way the number of cases are growing in the recent past, it only means this will continue, similar to the rest of the world. However, what we do now will determine whether we are able to continue the momentum at a lower exponential or will it flare up and result in a surge of cases. So far we are really well positioned. Now it depends on what we do, how we do it, how we go into the next few days and few weeks, which will determine the overall result.

India needs to start moving on the economy and livelihoods. How would India be best advised to do that?

The World Health Organization (WHO) and all the other leading organisations are saying a country needs to balance between life and livelihood. I am not an economist, I only know epidemiology. So, I can only speak from an epidemiological perspective. There are others who will have to weigh in with their expertise to give the country a holistic perspective. Having said that, each state in the country is at a different stage of disease progression. Some states have just started picking up their epidemic curve. Some states have already contained it well. So, action is already up to the state level now. So, when you take a decision at the national level—let us open up—then you are actually opening the gates from high transmission [areas] towards low transmission [areas], from urban towards the rural. So how do you then think of a situation where you can prevent an increase? That is where we say that containment is the way forward. 

So far what we have done is the lockdown; it is a mitigation measure, which is like a hide-and-seek game with the virus. During this time, we should have sought out the virus, wherever it is present, isolated the people who have the infection and made sure that it did not spread. We have done that in many states, but we have not been able to do that in a few states. Those few states are the states in focus now, and even districts that are very important. 

Within states there are districts that are very silent and have not reported a case, yet there are areas of high transmission. So, as we think of opening up, all the benefits that we have accrued over the extended lockdown should not be washed away. Otherwise people will say, why did we go through all this trouble, if so many cases had to come in the future? Therefore, we have had gains, but we need to make sure how we move forward. For that, surveillance is the only way forward. Detect the cases, isolate them. Pick up the contacts, quarantine them. Apart from all the other measures of physical distancing, which we can discuss later, this is the key ingredient of how we move forward.

As a doctor, what are the reasons the disease is spreading, would you say? For instance, even in the area where I am in the city of Mumbai, we are discovering new cases every day. Now as far as I know, most of these people have been contained or under lockdown for more than 28 days, which is roughly two COVID-19 cycles. So obviously, there has been some leakage somewhere. But in general, do you have a sense of why this continues to happen despite the fact that now most parts of the country have been under a lockdown for more than 40 days?

If this could happen during a lockdown, just imagine what could happen when we open up and relax all the measures that we have. I will explain how this spreads—the disease is caused by the infection of an RNA [Ribonucleic acid] virus; the incubation period, that is, from the time the virus enters the body to the time it starts producing symptoms, is around 14 days, roughly 5-7 days being the median. Most people in India do not develop symptoms, or they develop symptoms that are very non-specific. So, people may be still spreading the infection while they do not have symptoms. This is the best and worst thing about this infection. The good thing is that not many people get affected, they do not have to be hospitalised, they do not need to be in an ICU [intensive care unit]. However, they can continue spreading to people who are vulnerable. So, whatever spread we see now is because of both symptomatic and asymptomatic people coming in contact with someone else—among their close contacts or secondary contacts, and that is the only way it is spreading. See, this virus spreads only through droplets and these are heavy droplets that cannot go many meters and will settle down on a surface that is in close vicinity of. 

As long as you maintain a minimum distance of one meter, and you are using masks, it should not spread that much. So as a country both these measures, physical distancing and use of masks, we have started. We have gotten used to both and if we continue, we can reduce the spread both in urban and semi-urban areas.

So you are saying that even as we get out of the lockdown, and we follow these two things judiciously, we will be able to contain the spread of the disease?

Yes

A lot of people want to know: if schools open in May, should they send their child to school?

All over the world Sweden is the only country that has allowed schools to continue. Otherwise most countries in lockdown phase and beyond have shut down schools. What we see from the disease itself is that children are not affected that much. However, they are carriers, and can bring the infection to the elderly and the otherwise vulnerable. Therefore, the best thing as we move forward is to continue the new normal—that is, try to have classes through video or correspondence as much as possible; work from home, study from home for some time in the future, so that we are in a better position. There is a lot of research going on about vaccines and into drugs to repurpose. So, we hope we are in a better state later, where we will be able to open up schools and other sectors. 

There is a lot of misinformation going around. Your advice?

Yes, I think there is a lot of misinformation. Number 1 is that we have a different strain in India that does not affect many people, does not cause severity. That is not true. And I have tried to look at the literature, I did not find evidence to know where this news is coming from. 

The second is that young people anyway do not get affected, so we can start going to offices and schools. This is not true. You might be younger and may not succumb, but then you are playing with the lives of the people who are at home, the elderly or the immuno-compromised. In India we have many people with coexisting diseases—one in three adults have hypertension. One in 10 adults have type-2 diabetes mellitus. So, in a country where co-morbidity is so high, we simply cannot take a chance to move on with our lives and let the disease run its course. I really get disturbed when I hear: let the disease run its course. Then there is no use of public health, there is no use for all these measures that we have taken. I think we need to be careful; we should not be complacent at this stage; we have had real good gains compared to anywhere in the world. So, let us not waste it. 

Finally, evidence is emerging that more people have been carrying the disease from much earlier and we did not know it, and that only testing will let us know, going ahead. What is your sense about India? 

As of now we are not in a position to say what is the extent of the spread apart from those whom we have tested and found positive. The reason is we have found in India nearly 70% and above as asymptomatic. But this asymptomatic category comprises three different groups. The smallest portion are truly asymptomatic, which means they will never get any symptoms related to this disease. The next big group is pre-symptomatic--we have tested them when they did not have symptoms, but they will go on to develop systems later on. And the third group has atypical symptoms. Just yesterday, CDC [Centers for Disease Control and Prevention of the US] included five more symptoms into the diagnostic criteria. So when you look at all of those we need to widen the kind of symptoms that we screen for.

Of course, you should expand testing, too, though testing is not a goal in itself, it is just a means. So, even before testing we should be looking at symptoms and making a probable diagnosis and start isolating people. This is the way forward, whether atypical symptoms or no symptoms; by doing this we should be able to isolate many people with infection. The remaining asymptomatic people can be prevented from spreading [the disease] by using masks and physical distancing. So that is the new normal now. 

Should we be worried about an upcoming onslaught, or will it mostly be a linear progression as it is currently?

We do not know beyond what the data says. When I said, before the disease hit, that we would not have the numbers that other countries did, people who had different modelling said that was not possible. But India took really unprecedented measures that cannot be matched anywhere in the world. As we move forward, we will be better than most countries in the world because of the policy direction that the country has taken. But this is the time for responsibility at the individual level, at the organisational level—measures like work from home should be continued. School managements must think innovatively in terms of how to continue in the times of this new normal. So, if we exercise these responsibilities carefully, I think we will continue at the same lower momentum for some more time until we flatten, and then we will have a vaccine or a drug. So, I am very optimistic about India’s progress, unless something drastic--some policy or implementation--occurs to cause us to lose all the gain. That should not happen. 

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.


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