‘We Are Still On The Ascending Arm Of The Epidemic’

Mumbai: The number of cases in Mumbai is rising, but within that, the number of cases in highrises and building societies is rising much more than in slums or high-density population pockets. Of nearly 11,000 containment zones in Mumbai as of September 27, only 676 were in slums--this number had risen 86% in a month in buildings compared to 0.3% in slums and chawls--whereas the population of the city is roughly divided equally between slums and highrises. Why is this happening? What can this tell us about the behaviour of the disease or the behaviour of people, and the manner in which interactions lead to transmission?

We speak with Lalit Kant, former head, epidemiology and communicable diseases, at the Indian Council of Medical Research, and Shivkumar Utture, president, Maharashtra Medical Council, and an active practitioner.

Edited excerpts:

Dr Utture, why are we seeing this difference between the cases in slums and the highrises?

SU: The virus does not discriminate--you may be in the slums or in the highrises. The fault, I think, lies with the people and their outlook. There was a sero-study in Mumbai [in July], which found that 57% people in the slums had antibodies, whereas in the highrises, [the prevalence] was only around 16%. So maybe a majority of the slum dwellers have been infected in the past and gained some immunity. [This means that] in the highrises, about 84% people had not been infected.

Just as the peak had come to Mumbai first, but today the MMR [Mumbai Metropolitan Region, including the city’s surrounding municipal corporations] is much higher [in number of cases] than Mumbai, similarly, I feel the peak is coming in the [building] society areas. Another aspect is, of course, it has been six months since the lockdown. People have been cooped up in their homes for six months. We saw a lot of discipline in the initial phases in the highrises and the societies also. But slowly, either people have stopped getting scared of the virus, or the boredom has set in to such an extent that a lot of these people are coming out and they are mingling, mixing [with others]. Unfortunately, I would say, almost 30-35% of the people on the road in Mumbai today are not using a mask, in spite of being told to use it. So it is a combination of both these things. As far as the slums are concerned, surprisingly, there is discipline, along with, of course, a lot of people who are already immune to the disease.

Dr Kant, how are you seeing this phenomenon in Delhi?

LK: In the last six months, an enormous amount of epidemic evolution has taken place. When this epidemic came, it was brought in to India by people coming in from abroad. That was how it started. And most of the people who were coming here were staying in better off places, maybe in places where you have highrise buildings etc. And they gave the infection to the people who were there staying [or interacting] with them--drivers, helpers, maids, etc--and these were people living in the slum areas. So the infection actually started from those high-rise places to those slum areas, where we had conditions really conducive for the spread of the infection.

Now, over a period of time, when the infection had spread in those areas [slums], those people have developed some kind of immunity--they have had infection prevalence. But the highrises were the places where they had strict lockdown, and those people were not moving around or mixing around. And now, the [domestic] help people are coming back, and as the economy is now also opening up, the people living in those apartments are now moving out, working, mixing with people and also bringing in infection. So I think it's kind of an evolution of the epidemic. And if you see anywhere in the world, it always starts in places where the population density is much higher as compared to elsewhere. But ultimately, it goes to all areas, irrespective of whether the density is high or low. So I think it's just a matter of the evolution of the epidemic.

Dr Utture, the last time we spoke, we were talking about the number of beds that were available, and you said the government had allowed more clinics to open up and take in more serious patients as well. What are you seeing now?

SU: Over the past couple of months, definitely, the bed strength in Mumbai has been augmented tremendously. We have enough beds available. But in parallel, the number of cases is also rising fast. We used to see about 10,000-15,000 cases a day countrywide, which has now risen to lakhs--of which, if I'm not mistaken, almost one-third is from Maharashtra, and of that, nearly 30-40% is from Mumbai. So, we require a lot of beds.

But over the months, we have also learned a lot about this virus. This was a new virus, we didn't know what had hit us about six months back. But we have learned a lot about this virus. And today, a huge number of these patients--especially those who are mildly symptomatic or asymptomatic--are undergoing what is known as home-isolation and home-quarantine. So, [for] a majority of these patients--especially because they are from these highrises and societies--there is a facility in their house for them to be isolated. Three months back, any and every patient who was positive--asymptomatic or symptomatic--was rushed to the hospital and admitted. That is not happening now, at least in Mumbai. Also, there are a lot of facilities which have opened where you can be in direct contact with your doctor or a healthcare worker, and you get the necessary treatment in your house itself. They teach you how to monitor and when you should immediately report to the doctor.

So considering all these things, we are definitely quite comfortable in terms of bed strength. Only the number of ICU beds is a little worrisome--because as I said, when the numbers increase, almost 5% of them require ICU of which almost 1% require ventilators. But when the numbers go up in lakhs, the number of ICU beds [required] goes up hundreds and thousands. So that is a little bit worrisome, and we are still fighting on that front. But overall, generally, about 20-25% of the beds are going empty today in all these huge facilities put up by the corporation and the government.

Dr Kant, how are you seeing the evolution of this disease? Are you seeing any signs of which way it is going?

LK: I see three things that are taking place. One thing that is happening is that it is moving from the bigger, metropolitan cities into smaller towns and into the hinterland. The other thing that's happening is that the states which were not reporting anything are now moving up that ladder. Third thing [is], [in] some states which had thought that they have been able to control it, the infection is coming back to those states in a big way. And I think these three things actually give the picture of the epidemic as it is today: that we are still on the ascending arm of the epidemic. We are still moving up--because we have still a big chunk of our population which has not been exposed to the virus and these people will ultimately get infected, unless we get an intervention--maybe a vaccine comes around that we are able to protect them [with]--because they will not have any kind of an immunity by themselves.

Therefore, it is important that we continue to press testing and continue to educate people that they must observe those interventions--wear a mask, keep safe distance and stay at home if you do not need to go out. I think it's very important and now, as it moves into those areas [smaller towns and the hinterland], those are the places where you don't have much access to expertise; healthcare facilities may not be there, doctors may not be there, the testing facilities may not be there. So these infections may just go unnoticed. And that's my main worry now, because it's now moving to rural areas.

Dr Utture, how are you seeing the trajectory within the city of Mumbai? The data--on new cases and containment zones--seem to suggest that it's slowing down in the slums. But could that change? And if that changes, particularly if we open up trains or there's a sudden increase in public transport, what happens then?

SU: All over the world, the second wave has started--in a majority of the places. And as Dr Kant rightly pointed out, we are still ascending in the first wave itself. So maybe, there will come a time where the first wave and the second wave will merge into each other. And that is, I think, the projection also--that in November, December, we may be seeing the highest number of cases coming in. This is expected once you start opening up.

We have seen, right in the beginning, [that] we could control the number of cases because of the very strict lockdown which was placed. But then, India being India, you have to think from the economic aspect also. So, the government had to take some decisions taking into consideration the pandemic on one side and of course, on the other side, the economic health of the families and individuals. And a majority of the families, as you know, we have [are in the] lower middle class and the working class, dependent on daily wages. So, they had to open up; there was no other way out for them.

Now, once you open up, definitely in a crowded place like Mumbai, it is very difficult to keep a safe distance from each other. We are going to come in contact with each other and the number of cases is definitely going to go up. But how I see it today is that in a majority of the cases, unlike what we were seeing around three months back, even if they get infected, very rarely ever [do] we find that they go in for gross symptoms and to get admitted etc. Somehow, we are finding that the virulence is not that strong as we were seeing it before. Or maybe our treatment facilities have improved--as you know, we start antivirals immediately within the first five days, then, we give all other supportive treatments. Maybe we are coming towards finding a treatment for this disease, luckily, we are finding that it is not as bad a state as we were about three or four months back.

But down the line, as I always tell everybody, we should stop looking at the numbers [of cases]. The only numbers we have to look at today are the deaths. If we can get down the deaths, then we have done a lot and we have somehow conquered this disease. So, stop looking at how many lakhs of numbers are going to be added to the figure and look how many of them we can really save by putting in good health facilities, as Dr Kant said, not only in the big metros, but even in the small areas. Unfortunately, because of the warped governments over the decades, they have absolutely not looked after the health sector at all, with the abysmal budgeting. And small towns and small villages have suffered because of that. So, that has to improve.

Dr Kant, three to four months ago, there was fear that we will be swamped with cases, particularly in slums, because everyone is in close proximity. That did not happen, for various reasons. And the data are showing that people have achieved some degree of immunity because they've already been infected. So, if you take a step back, what is this telling you in terms of the overall viral impact or capability of coronavirus? Is that something we should be feeling good about--without saying that we have to be less cautious?

LK: We need to be cautious, that is true. We cannot lower our guards at all. But as you said, and Dr Utture also pointed out, the mortality rate is coming down. People don't get as badly sick as they used to get in the month of March, April and May, when the mortality rates were very high. [The] other thing is that the doctors have also acquired those skills now. They are better skilled to manage cases and we also have better interventions available--those interventions weren't available in the month of April, May and June, when we were all very scared of mortality.

It also tells us that the people are developing some kind of an immunity--whether that immunity would protect against the infection or decrease the intensity of the infection, would it be for one month, three months or four months, that we do not know, but there is some kind of immunity that they're developing and they may also be helping for the people not getting that severe a form of the disease. So they may not require as many ICUs, ventilators etc. as they were needing a couple of months ago.

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

Mumbai: The number of cases in Mumbai is rising, but within that, the number of cases in highrises and building societies is rising much more than in slums or high-density population pockets. Of nearly 11,000 containment zones in Mumbai as of September 27, only 676 were in slums--this number had risen 86% in a month in buildings compared to 0.3% in slums and chawls--whereas the population of the city is roughly divided equally between slums and highrises. Why is this happening? What can this tell us about the behaviour of the disease or the behaviour of people, and the manner in which interactions lead to transmission?

We speak with Lalit Kant, former head, epidemiology and communicable diseases, at the Indian Council of Medical Research, and Shivkumar Utture, president, Maharashtra Medical Council, and an active practitioner.

Edited excerpts:

Dr Utture, why are we seeing this difference between the cases in slums and the highrises?

SU: The virus does not discriminate--you may be in the slums or in the highrises. The fault, I think, lies with the people and their outlook. There was a sero-study in Mumbai [in July], which found that 57% people in the slums had antibodies, whereas in the highrises, [the prevalence] was only around 16%. So maybe a majority of the slum dwellers have been infected in the past and gained some immunity. [This means that] in the highrises, about 84% people had not been infected.

Just as the peak had come to Mumbai first, but today the MMR [Mumbai Metropolitan Region, including the city’s surrounding municipal corporations] is much higher [in number of cases] than Mumbai, similarly, I feel the peak is coming in the [building] society areas. Another aspect is, of course, it has been six months since the lockdown. People have been cooped up in their homes for six months. We saw a lot of discipline in the initial phases in the highrises and the societies also. But slowly, either people have stopped getting scared of the virus, or the boredom has set in to such an extent that a lot of these people are coming out and they are mingling, mixing [with others]. Unfortunately, I would say, almost 30-35% of the people on the road in Mumbai today are not using a mask, in spite of being told to use it. So it is a combination of both these things. As far as the slums are concerned, surprisingly, there is discipline, along with, of course, a lot of people who are already immune to the disease.

Dr Kant, how are you seeing this phenomenon in Delhi?

LK: In the last six months, an enormous amount of epidemic evolution has taken place. When this epidemic came, it was brought in to India by people coming in from abroad. That was how it started. And most of the people who were coming here were staying in better off places, maybe in places where you have highrise buildings etc. And they gave the infection to the people who were there staying [or interacting] with them--drivers, helpers, maids, etc--and these were people living in the slum areas. So the infection actually started from those high-rise places to those slum areas, where we had conditions really conducive for the spread of the infection.

Now, over a period of time, when the infection had spread in those areas [slums], those people have developed some kind of immunity--they have had infection prevalence. But the highrises were the places where they had strict lockdown, and those people were not moving around or mixing around. And now, the [domestic] help people are coming back, and as the economy is now also opening up, the people living in those apartments are now moving out, working, mixing with people and also bringing in infection. So I think it's kind of an evolution of the epidemic. And if you see anywhere in the world, it always starts in places where the population density is much higher as compared to elsewhere. But ultimately, it goes to all areas, irrespective of whether the density is high or low. So I think it's just a matter of the evolution of the epidemic.

Dr Utture, the last time we spoke, we were talking about the number of beds that were available, and you said the government had allowed more clinics to open up and take in more serious patients as well. What are you seeing now?

SU: Over the past couple of months, definitely, the bed strength in Mumbai has been augmented tremendously. We have enough beds available. But in parallel, the number of cases is also rising fast. We used to see about 10,000-15,000 cases a day countrywide, which has now risen to lakhs--of which, if I'm not mistaken, almost one-third is from Maharashtra, and of that, nearly 30-40% is from Mumbai. So, we require a lot of beds.

But over the months, we have also learned a lot about this virus. This was a new virus, we didn't know what had hit us about six months back. But we have learned a lot about this virus. And today, a huge number of these patients--especially those who are mildly symptomatic or asymptomatic--are undergoing what is known as home-isolation and home-quarantine. So, [for] a majority of these patients--especially because they are from these highrises and societies--there is a facility in their house for them to be isolated. Three months back, any and every patient who was positive--asymptomatic or symptomatic--was rushed to the hospital and admitted. That is not happening now, at least in Mumbai. Also, there are a lot of facilities which have opened where you can be in direct contact with your doctor or a healthcare worker, and you get the necessary treatment in your house itself. They teach you how to monitor and when you should immediately report to the doctor.

So considering all these things, we are definitely quite comfortable in terms of bed strength. Only the number of ICU beds is a little worrisome--because as I said, when the numbers increase, almost 5% of them require ICU of which almost 1% require ventilators. But when the numbers go up in lakhs, the number of ICU beds [required] goes up hundreds and thousands. So that is a little bit worrisome, and we are still fighting on that front. But overall, generally, about 20-25% of the beds are going empty today in all these huge facilities put up by the corporation and the government.

Dr Kant, how are you seeing the evolution of this disease? Are you seeing any signs of which way it is going?

LK: I see three things that are taking place. One thing that is happening is that it is moving from the bigger, metropolitan cities into smaller towns and into the hinterland. The other thing that's happening is that the states which were not reporting anything are now moving up that ladder. Third thing [is], [in] some states which had thought that they have been able to control it, the infection is coming back to those states in a big way. And I think these three things actually give the picture of the epidemic as it is today: that we are still on the ascending arm of the epidemic. We are still moving up--because we have still a big chunk of our population which has not been exposed to the virus and these people will ultimately get infected, unless we get an intervention--maybe a vaccine comes around that we are able to protect them [with]--because they will not have any kind of an immunity by themselves.

Therefore, it is important that we continue to press testing and continue to educate people that they must observe those interventions--wear a mask, keep safe distance and stay at home if you do not need to go out. I think it's very important and now, as it moves into those areas [smaller towns and the hinterland], those are the places where you don't have much access to expertise; healthcare facilities may not be there, doctors may not be there, the testing facilities may not be there. So these infections may just go unnoticed. And that's my main worry now, because it's now moving to rural areas.

Dr Utture, how are you seeing the trajectory within the city of Mumbai? The data--on new cases and containment zones--seem to suggest that it's slowing down in the slums. But could that change? And if that changes, particularly if we open up trains or there's a sudden increase in public transport, what happens then?

SU: All over the world, the second wave has started--in a majority of the places. And as Dr Kant rightly pointed out, we are still ascending in the first wave itself. So maybe, there will come a time where the first wave and the second wave will merge into each other. And that is, I think, the projection also--that in November, December, we may be seeing the highest number of cases coming in. This is expected once you start opening up.

We have seen, right in the beginning, [that] we could control the number of cases because of the very strict lockdown which was placed. But then, India being India, you have to think from the economic aspect also. So, the government had to take some decisions taking into consideration the pandemic on one side and of course, on the other side, the economic health of the families and individuals. And a majority of the families, as you know, we have [are in the] lower middle class and the working class, dependent on daily wages. So, they had to open up; there was no other way out for them.

Now, once you open up, definitely in a crowded place like Mumbai, it is very difficult to keep a safe distance from each other. We are going to come in contact with each other and the number of cases is definitely going to go up. But how I see it today is that in a majority of the cases, unlike what we were seeing around three months back, even if they get infected, very rarely ever [do] we find that they go in for gross symptoms and to get admitted etc. Somehow, we are finding that the virulence is not that strong as we were seeing it before. Or maybe our treatment facilities have improved--as you know, we start antivirals immediately within the first five days, then, we give all other supportive treatments. Maybe we are coming towards finding a treatment for this disease, luckily, we are finding that it is not as bad a state as we were about three or four months back.

But down the line, as I always tell everybody, we should stop looking at the numbers [of cases]. The only numbers we have to look at today are the deaths. If we can get down the deaths, then we have done a lot and we have somehow conquered this disease. So, stop looking at how many lakhs of numbers are going to be added to the figure and look how many of them we can really save by putting in good health facilities, as Dr Kant said, not only in the big metros, but even in the small areas. Unfortunately, because of the warped governments over the decades, they have absolutely not looked after the health sector at all, with the abysmal budgeting. And small towns and small villages have suffered because of that. So, that has to improve.

Dr Kant, three to four months ago, there was fear that we will be swamped with cases, particularly in slums, because everyone is in close proximity. That did not happen, for various reasons. And the data are showing that people have achieved some degree of immunity because they've already been infected. So, if you take a step back, what is this telling you in terms of the overall viral impact or capability of coronavirus? Is that something we should be feeling good about--without saying that we have to be less cautious?

LK: We need to be cautious, that is true. We cannot lower our guards at all. But as you said, and Dr Utture also pointed out, the mortality rate is coming down. People don't get as badly sick as they used to get in the month of March, April and May, when the mortality rates were very high. [The] other thing is that the doctors have also acquired those skills now. They are better skilled to manage cases and we also have better interventions available--those interventions weren't available in the month of April, May and June, when we were all very scared of mortality.

It also tells us that the people are developing some kind of an immunity--whether that immunity would protect against the infection or decrease the intensity of the infection, would it be for one month, three months or four months, that we do not know, but there is some kind of immunity that they're developing and they may also be helping for the people not getting that severe a form of the disease. So they may not require as many ICUs, ventilators etc. as they were needing a couple of months ago.

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


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