In March this year, director of the Washington-based Center for Disease Dynamics, Economics and Policy and Senior Research Scholar and Lecturer at Princeton University, Ramanan Laxminarayan, created a stir when he said that 60 percent of the Indian population—about 700 to 800 million people—could be infected by the raging coronavirus epidemic.
It led to outrage in India, where experts, not yet well versed in the art of the pandemic, questioned the epidemiologist’s motives in raising such bogeys. At least, that is what it seemed like in March; a relatively innocuous month as compared to the India of July 2020.
In an interview to this writer, Laxminarayan explained his methodology, which he believes was accurate. According to him, "60 percent was the highest end of the projections, but we estimated that with no intervention, the virus would infect between 200 and 400 million Indians. Serological studies from ICMR and private labs like Thyrocare indicate that even with a harsh lockdown that continues in many places, over 100 million Indians have been infected. We projected these numbers when the number of reported cases were 100. Does anyone think they were off the mark?"
For the past 15 years, Laxminarayan has worked to improve the understanding of antibiotic resistance as a problem of managing a shared global resource and to bring this problem to the attention of national and global levels. In 2003-04, he helped create the Affordable Medicines Facility for malaria, a financing mechanism to delay resistance and improve access to antimalarial drugs.
So, what, in his estimate, is the all India status of the pandemic today?
Frequently Asked Questions
A vaccine works by mimicking a natural infection. A vaccine not only induces immune response to protect people from any future COVID-19 infection, but also helps quickly build herd immunity to put an end to the pandemic. Herd immunity occurs when a sufficient percentage of a population becomes immune to a disease, making the spread of disease from person to person unlikely. The good news is that SARS-CoV-2 virus has been fairly stable, which increases the viability of a vaccine.
There are broadly four types of vaccine — one, a vaccine based on the whole virus (this could be either inactivated, or an attenuated [weakened] virus vaccine); two, a non-replicating viral vector vaccine that uses a benign virus as vector that carries the antigen of SARS-CoV; three, nucleic-acid vaccines that have genetic material like DNA and RNA of antigens like spike protein given to a person, helping human cells decode genetic material and produce the vaccine; and four, protein subunit vaccine wherein the recombinant proteins of SARS-COV-2 along with an adjuvant (booster) is given as a vaccine.
Vaccine development is a long, complex process. Unlike drugs that are given to people with a diseased, vaccines are given to healthy people and also vulnerable sections such as children, pregnant women and the elderly. So rigorous tests are compulsory. History says that the fastest time it took to develop a vaccine is five years, but it usually takes double or sometimes triple that time.
Laxminarayan says they are handicapped in the absence of data not being shared by the government. "It is really hard to get a correct picture because data is not being shared by the government. Without having the raw data on testing and outcomes, we can only guess. The summary figures seem to indicate a peaking epidemic in Delhi, Maharashtra and Tamil Nadu, a growing epidemic in some other places and a largely hidden epidemic in the largest states of UP, Bihar and Madhya Pradesh. States that are testing more are both doing better at containment and are also reporting more cases. I would consider case reporting to be an indicator of the quality of the health system. And states that are hiding cases and deaths clearly have weak health systems and inadequate testing."
There can hardly be an argument there.
There is a consensus that Delhi has managed to blunt the corona virus curve, as some experts and even political figures are claiming. How does he see it? According to Laxminarayan, "The virus was reaching a natural peak because Delhi’s population is not as high as compared to Tamil Nadu and Maharashtra. Also, the switch to the rapid antigen test, which is far less sensitive, has likely resulted in a lower test positivity rate, which also gives the impression that things are under control. Delhi has done quite poorly. It has been saved by its smaller population and the disease will soon run its course in this state."
Does he believe that India needs to ramp up its testing further? Points out Laxminarayan, who is assimilating India data: "India needs to test intelligently. Ramping up Reverse Transcription Polymerase Chain Reaction (RT-PCR) is not possible beyond a point. However, a combination of testing for comorbidities, severity markers, antigens, antibodies and RT-PCR in a systematic manner could help. But ICMR’s guidance does not even refer to differential testing for people with higher risk factors. The scientific guidance is lagging behind the epidemic."
What is the extent of the shortfall of India's ICU equipment? According to Laxminarayan, he knows only what is being reported in the media since the extent of investment in new equipment is not in the public domain. "The challenge seems to be on having trained doctors and nurses rather than on equipment alone. And given the low levels of testing, there are probably a lot of people who don’t make it to a hospital in the first place," he states.
Does he agree that the lockdown was a bit premature and the government could have waited for some more time? He believes "the evidence from cross country studies shows that earlier lockdowns work better. Certainly, the lockdown could have been better prepared to allow migrants to go home and for people to get prepared, but the timing certainly had a strong impact."
But, any which way, he believes, lockdown is a tough call. On the one hand, shutdowns have helped in other countries. "Every infectious disease model supports a total shutdown. Our own estimates from IndiaSIM, an agent-based model that has been constructed on Indian data over many years, suggests that a full and complete lockdown for three weeks could reduce the number of infections by as much as 80%," adding, however, that "On the other hand, a shutdown would exact tremendous economic costs across India."
But what other options did the government have? Laxminarayan believes that "India could have tested more and that would have allowed for more localised lockdowns. In my opinion, that would have been the better way to go."
In this brutal and never-ending fight against COVID, India’s health workers are at the end of their tether. How long, does he believe, can they sustain the fight against the virus, supposing it continues till the year end? "It's a good question. They are affected both by the long hours and exposure to the virus, but also of a greater likelihood of COVID disease and death, and stigma back in their communities. They need more than a banging of thalis once a year," says the man, who has done extensive research into the antibiotic resistance movement.
The experience of health workers in fighting the pandemic has increased, but has the quality of their anti-COVID kits undergone a change? Points out Laxminarayan: "We have certainly learnt a lot from other countries’ experiences in dealing with COVID patients and from our own experiences. There are better treatment protocols available and over time the mortality should come down."
Does COVID-19 present an opportunity to put into place a group of public health volunteers to fight this pandemic and similar other outbreak that may happen in the future? "This can’t be done with volunteers. If governments don’t take this opportunity to invest in public health, I don’t know when they will," says Laxminarayan, who has worked on topics such as vaccination, illness economics and disease.
Does he see 2020 as a wasted year, in the sense that the virus is unlikely to recede even by the end of the year? "NO year is a wasted year! But it is a different year than most others with benefits that may not be apparent to us. The virus will likely recede by the end of the year but will continue to be a threat in some places," he avers.Ranjit Bhushan is an independent journalist and former Nehru Fellow at Jamia Millia University. In a career spanning more than three decades, he has worked with Outlook, The Times of India, The Indian Express, the Press Trust of India, Associated Press, Financial Chronicle, and DNA.