Bengaluru: “Does this virus have pandemic potential? Absolutely, it has. Are we there yet? From our assessment, not yet,” said Tedros Adhanom Ghebreyesus, World Health Organization (WHO) director-general, about the Coronavirus disease 2019 (COVID-19).

Although it is not yet pandemic, governments across the world particularly in South and SouthEast Asia, Europe and West Asia are on alert. There have been 80,239 confirmed cases and 2,700 deaths worldwide, of which 97% of reported cases and 99% of deaths have been in China alone.

India reported three cases, all in Kerala. The county’s “robust health surveillance system has been able to stall novel Coronavirus from entering”, said Harsh Vardhan, union health minister. Few tourists arrivals from the affected parts of China aided by a lockdown and travel slowdown during the Chinese new year “have helped to avert a far more dangerous situation”, said Gautam Menon, a professor of physics and biology at Ashoka University, Sonepat, Haryana, whose interests lie in modeling infectious disease and its implications for public policy.

Although details about COVID-19 are coming to light gradually, there is much we do not know about the disease and how it spreads, says Menon. The ability to expand current testing capabilities is crucial, and “we have been lucky so far, but this may not last”.

Communication in public health, especially where epidemics are concerned, is absolutely crucial. The scourge of “misinformation is a problem not just here but everywhere”, he adds.

Menon, who was the founding dean of computational biology at the Institute of Mathematical Sciences, Chennai, was awarded the Department of Science and Technology’s (DST) Fast Track Fellowship for Young Scientists in 2002 and the Swarnajayanti Fellowship of the DST in 2005. He was named a Department of Atomic Energy-Scientific Research Council Outstanding Research Investigator in 2010 and has served on scientific review committees of several international agencies, including the Human Frontier Science Program and the Wellcome Trust-DBT India Alliance.

In an interview with IndiaSpend, Menon talks about the response of stakeholders including policymakers, administrators, and researchers like himself to the COVID-19 challenge, India’s health and research infrastructure, and public communication design.

Is COVID-19 different from epidemics such as the Severe Acute Respiratory Syndrome (SARS) and H1N1? Is it more lethal, or does it spread more easily?

The virus resembles the SARS virus most closely, hence the recently approved name for it, SARS-CoV-2. SARS killed a larger fraction of the people it infected, around 10% versus somewhere between 2% and 3% as currently believed for the coronavirus, but it was contained and never recurred.

The SARS-CoV-2 seems to be spreading more easily, most likely because there is a longish window between an infected person becoming capable of infecting someone else, and themselves manifesting symptoms of the illness. There are some issues with the accuracy of current tests as well as with the understanding of how someone apparently cured might still harbour the virus and be capable of infecting someone else. There is much we do not know about the disease and how it spreads, but these details are slowly being filled in. In terms of ease of transmissibility between people, the coronavirus does seem to resemble H1N1 and related influenzas.

How do stakeholders such as policymakers, administrators and researchers like you piece together a response to a challenge like COVID19 that has more than 80,000 confirmed cases worldwide (as of February 25, 2020)? How do researchers ensure that a virus that has the potential to cause widespread panic and fatalities is given the highest priority by health administrations in various countries?

Researchers such as myself can only advise, based on the predictions of models that explore different scenarios, how the disease might spread in a population. For this, it is necessary to understand a lot of background--what is known about the disease, what is known about how it spreads, the nature of contact between people who are infected and those who are susceptible, the presence of any pre-existing immunity and so on.

Certainly a familiarity with what is already known about the disease and how others around the world are tackling it will help. No doubt the government is already being advised at multiple levels about what it should do. The Chinese experience and the experience of other countries in this regard will provide valuable pointers. However, Indian expertise in this area is still limited in terms of absolute numbers of people and resources. The number of people in India who do, for example, realistic modeling for infectious disease, is very tiny.

Are states in South Asia or Africa particularly prone to such epidemics? If so, why?

China is certainly the central source for two major epidemics in this millenium, SARS, and the new COVID-19 [disease caused by the coronavirus]. Both are zoonotic diseases [caused by viruses that have hopped from animals to man, usually from bats to humans via an intermediate host]. The reason is believed to be largely the Chinese demand for exotic animals, which forces different species to be in the sort of proximity, in large so-called "wet markets" [where an animal is freshly slaughtered instead of chilled] that they would never achieve in the wild. This proximity aids in transferring viruses from one host to another.

For humans, since these viruses are novel to us, we have no pre-existing immunity. This is the reason why the disease disproportionately kills the elderly as well as those who have pre-existing conditions that compromise their immunity. As China has grown richer over the past several decades, its citizens have become some of the most avid international travellers. This aids in spreading any disease that originates within Chinese borders.

"India's robust health surveillance system has been able to stall novel Coronavirus from entering the country,” said Harsh Vardhan, union health minister. Your comments?

I suspect the reason is more prosaic. There simply is not that much significant traffic between those parts of China [which have a high number of infections] and India and a relatively small number of Chinese tourists visit India.

Further, the lockdown in China post the start of the epidemic as well as the customary slowdown at the beginning of the Chinese new year would have reduced travel between India and China anyway. I do not see, for example, reports of visitors being turned back from our borders yet. And flights between India and China have been restricted for a few weeks now. All of these have helped to avert a far more dangerous situation.

What must India do to improve response?

Certainly, having robust screening procedures, including checking passengers’ travel history and identifying those who have had close contact with infected persons, at airports and other entry points is absolutely essential, now that an increasingly large number of new cases are from outside China.

Of course, if the current epidemic reaches the status of a pandemic, with independent person-to-person transmission happening independent of an original case with a China connection, then even more restrictions on entry of another country's citizens or flights from that country [or countries] would be called for. Having clean, safe, and well-administered quarantine facilities for those suspected of being infected with the virus is also important. Robust and carefully monitored protocols for health workers who are on the front lines, as well as the availability of both protective equipment and good facilities, is also important. Finally, having the ability to expand current testing capabilities is crucial. We have been lucky so far, but this may not last.

Does research on such emergency responses to pandemics get adequate government support in India?

No, not nearly enough. Ideally, research on zoonotic viruses should be well-funded and should happen even in the absence of an outbreak. This does not happen. Further, recent reports of a government crackdown on the funding for Karnataka’s Manipal Centre for Virus Research, a highly regarded centre which was on the frontlines of testing for the Nipah virus, speaks to a general sense of paranoia on behalf of the government. We simply cannot afford that at this time, or indeed at any time. A number of high-profile virologists in India have spoken out against this senseless move.

How must the State design and implement a strategy to fight misinformation, and also simply communicate to the public in countries such as India and China that have large (migrant) populations?

Communication in public health, especially where epidemics are concerned, is absolutely crucial. Misinformation is a problem not just here but everywhere. It is the responsibility of all of us to call it out when we see it. Again, we should learn from the example of Singapore, where public health response has presented a united front across all areas of governance and media.

If people trust the messaging they receive from their governments--and governments must earn this trust--the job of combating misinformation becomes much easier. It is also important to see that migrants are not scape-goated in any way, since a common response to a public health crisis like this one is to find someone to blame.

Although there have been only three confirmed cases in India, how do you assess India’s overall response to COVID-19, vis-a-vis the response to the Nipah and H1N1 outbreak? H1N1 has already taken 14 lives in India this year (as of February 16, 2020), per government data.

I would say our response has not been tested yet, since numbers are small. That was also the situation with Nipah, where stringent health measures in addition helped to contain it.

The real test would be whether we can respond to the sort of situation that Wuhan [the epicentre of COVID-19 in China] faced, with hospitals and clinics simply being overwhelmed by the number of patients. H1N1 is now a regular feature of the influenza season, so its impact is much the same as any other influenza which leads to a small percentage of fatalities, especially among the old.

Kerala, which has a vast international migrant population, could be in imminent danger of outbreaks like COVID-19. But its primary health infrastructure has withstood Nipah and COVID-19. What are some factors that have stood out from your perspective?

I think that the public health system is trusted more and actually also delivers more in Kerala vis-a-vis several other Indian states. Where required, local and national health authorities have acted decisively, as in the Nipah case. This element of trust is crucial for effective public health response.

Are the lesser developed Indian states prepared?

In my view, again, probably not. But we have the advantage of learning from the Chinese experience of how we need to plan ahead. Singapore is a fine example in this regard. Post-SARS, Singapore put a premium on outbreak preparedness, stockpiling personal protective equipment (PPE) used by frontline health workers. It has implemented very stringent conditions on people gathering together in common spaces, examines incoming tourist traffic very carefully, and quashes rumours immediately.

How important is state health infrastructure? Was China ill-prepared as there have been reports of suppression and censorship of information by government authorities, which exacerbated the situation?

I think the Chinese response this time has been exemplary, compared to their earlier attempts in the cover-up over SARS. That lesson has certainly been learnt. I doubt any country, even in the Western world, would have been able to mount a similar response in the face of the sheer numbers of cases.

What is less clear are those areas that non-Chinese media or even Chinese media have little knowledge of, for example, the status of the million-odd Han Muslims currently believed to be confined in cramped and crowded detention camps. That would be a natural breeding ground for the virus, and the proximity of large numbers of people might even make it easier for the virus to become less controllable as it adapts better to humans.

Correction: The story has been updated to say that China was the central source for SARS epidemic--and not H1N1, as we erroneously said--in addition to the novel coronavirus (COVID-19).

(Paliath is an analyst with IndiaSpend.)

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