'Not looking and not finding are not the same'

Interview with Prof. T. Jacob John, virologist.

Prof. T. Jacob John.

“THE proletariat was as much in needof protection from the epidemic as the well-to-do—for a contagious infection, such distinction is not good public health either, because humans, rich or poor, are the breeding medium of the microbe.”

The efficacy of the long nationwide lockdown aimed at controlling the spread of COVID-19 is now being questioned by several experts, given the spike in the number of infections reported on a daily basis. The differential impact of the lockdown on people has also raised questions on planning or the lack of it and the scientific opinion that informed the decision.

Professor T. Jacob John, former Head of the Departments of Clinical Virology and Microbiology at Christian Medical College, Vellore, is credited with establishing India’s first diagnostic virology laboratory and conducting pioneering research in infectious diseases, vaccinology, clinical virology and epidemiology. He is also well-known for his model of polio control in Vellore and North Arcot district, which became the forerunner of global polio eradication. A strong advocate for increased expenditure on public health, he says the lockdown should have been designed, planned and communicated better, and implemented only after the adverse effects were enumerated and steps undertaken towards mitigation. According to him, what happened in India is an example of how lockdowns should not be implemented. Excerpts from an interview he gave Frontline :

We are into the fifth phase of the nationwide lockdown with some relaxations even though there is little respite from the virus. Was this anticipated?

The objective of the lockdown on March 25 was, presumably, to slow down the epidemic. Victory in 18 days was implied while declaring lockdown. At the end of the lockdown, the epidemic had grown some 20-21 times in as many days, showing clearly that the objective had not been achieved.

The lockdown was extended repeatedly, but at no time was the rationale for either the lockdown or its extensions shared with the public. The expected result, likewise, was never shared. Without a clear understanding of what the reason was, people behaved as people do—obey the rule, but break it whenever necessary or possible.

Behaviour modification requires people to be informed why it is in their interest and that of their families. My conclusion is that there was some degree of consternation as the lockdown was not effective, hence some response had to be designed. Extension did that—it was tacit justification that the lockdown was needed in the first place and assertion that it would be effective if the duration was extended.

The obvious [solution], that is, to change your strategy if the battle is not going in your favour, was not realised or accepted. Another obvious response—how shall we make it more effective during extension?—was also not asked, answered. Lockdown did not result in physical distancing between the asymptomatic infected and the uninfected—the virus cannot spread if physical distancing actually happened.

Have there been any clear and known criteria that have decided the timing and extent of restrictions and their easing?

I do not know because communications from the leadership are not reaching ordinary people. Setting criteria would have been a good idea—that would have allowed some breathing time between declaration of the need for lockdown and its actual implementation.

Do you think that the relaxation of the lockdown and allowing domestic flights caused another round of increases in the cases, as was seen in Kerala, where the number of recovered cases was higher than the number of active cases for most of April and May?

That depends on what the government considers as essential services to be allowed when non-essential services and activities are prohibited, or whatever services and activities are desired as essential. We know how to prevent or minimise transmission of the virus since we do know how the virus is transmitted between people—and that is by respiratory and oral droplets. Those who are healthy and not with any COVID-19 symptoms (mainly fever, cough) could work for essential services, taking all precautions of transmission, since anyone could be infected and be without symptoms too. Once we know that we take precautions, the probability of transmission will be near zero. So, any service you want to be reactivated, you could, using knowledge of how the virus spreads and what the precautions are.

“Recovered cases” is mostly used to refer not to “cases” but to “infected persons”—minus those who have died and those who continue to be infected. That statistic is not useful to epidemiologists. It is a dynamic number, changing every day. Once you understand that “infection” and “disease” are distinct, better stick to disease as “case” but “infection” for the non-diseased. In infectious diseases, we don’t call an infected person a case, [in the context of] HIV infection and AIDS, for an example.

Actually, “recovery rate” is “cases minus deaths” as percentage. So, that must be in the 90s since mortality is only 10 per cent or less. “Active infections” indicate the duration of infection—when tested negative, one is no longer “active”.

Coming to the logic of the lockdown itself, as a virologist, do you think this was the only alternative we had?

Knowing that transmission is (1) during social contacts and (2) via droplets, there are two mitigators: (1) social distancing and (2) prevent shedding—exit and entry or inhalation of droplets.

Social distancing is the American term for what I describe as “physical distancing while remaining socially connected”. If you want both physical distancing and social disconnection, then lockdown is the way—it is drastic, destructive of normal life, economic activities, and so on. It is “inhuman” as we are “social animals”. Other countries that have used lockdown had taught people the rules of the game and the reasons of the rituals. Not so in India.

Additionally, in countries in which population density is high, lockdown cannot be efficient. India had such problems, knowing which the lockdown should have been well designed, well planned, well communicated, adverse effects enumerated and mitigation steps taken, and then and then only implemented. If these are not done, what happened in India tells us how lockdowns should not be implemented. For example, migrant labour became “vectors” of virus, with the exact opposite effect of slowing down of the epidemic, as they were allowed to travel back after they got infected as late as mid May or even later.

If lockdown didn’t produce the result you wanted, don’t blame the concept of lockdown but the manner in which it was implemented. In slums no lockdown will be effective.

But one lockdown, done well, would have given some time to plan for the post-lockdown period. That was not apparently done either.

Coming to an alternative: knowing droplet infection as the major mode, wearing cloth masks, by both the “unknowingly” infected, blocking broadcast of droplets, and the uninfected, blocking droplet inhalation, is a very effective method to minimise transmission. Plus hand hygiene to prevent virus transmission by fingers, mostly to the eyes.

Above all, thinking and designing ought to be done before implementation (or starting a battle) and not after you find the battle is not going in your favour.

Lockdowns in other parts of the world were accompanied with matching efforts at health outreach and economic sustenance measures. Does the “stay at home” approach work in the absence of such measures in controlling the spread of a virus? Would it be fair to say, for instance, that migrant workers in India became more susceptible to the infection and eventually also became the source of its spread because the lockdown was not accompanied by complementary measures addressing mass unemployment and already poor living conditions?

The question already contains the answer. In bureaucratising infection control, touch with the reality of the nation and its people was lost or ignored. For a democratic government that is not something that can easily be condoned. When class distinction is built in in a government action, something very disturbing distorts the very core principles of democracy.

The proletariat was as much in need of protection from the epidemic as the well-to-do. For a contagious infection, such distinction is not good public health either, because humans, rich or poor, are the breeding medium of the microbe. If you allow infection in the latter, the former will become the victims sooner or later. Equity is the synonym of public health.

According to the available evidence, China was able to mainly contain the epidemic in Wuhan and Hubei province, while the rest of the country saw relatively very few cases and deaths. Many other East Asian countries also appear to have been successful in keeping the numbers low. How does one explain this if one believes that a virus cannot be controlled artificially barring the administration of a vaccine, which is still not available?

My hunch is that China had the epidemic from October 2019, but missed most of the disease and deaths. For a minute, imagine India today with the coronavirus infection epidemic that was not known to the government. Do you think that this “new” infection would have been recognised and “registered” in the health management system?

If you don’t diagnose all diseases or count all deaths with causes of deaths, it would be easy to miss the whole epidemic. Do you know that India has tested less than 0.1 per cent of the population? Imagine what may be going on among the 99.9 per cent of the population. What the mind does not already know, the eyes seldom see.

No country is spared by this democratic epidemic. Others are asking how with 1,380 million people, India has only less than 200,000 infections. Do they know the reality? Do we know it either?

Hubei province and Wuhan were the last affected. When the epidemic ended in Wuhan, it ended in China; Wuhan was not its debut, but the finale.

Epidemics are biomedical problems for biomedical experts to design responses and also administrative/governance problems because many people with pneumonia will require hospitalisation and the healthcare system could be overwhelmed and healthcare workers will get infected.

So, not looking and not finding are not one and the same.

Different countries have applied different approaches, from no lockdown in Sweden to complete lockdown in India and New Zealand, partial lockdown in the U.S, the United Kingdom, Brazil, South Korea, Singapore. There are wide variations in outcomes too. In India, too, there are wide variations across States even though the same strategy has been applied. Is it possible to have a uniform approach while dealing with a virus? Do demography and economic factors play a role in this?

This is where the importance of “self-reliance” comes in. India began imitating and not making India-specific strategy, tactics, logistics. For example, this epidemic was not simply one epidemic nationally, but innumerable small outbreaks starting asynchronously in time and space like the forest fires in Australia, eventually all of them merging with each other.

But the lockdown was synchronous, fitting all stages at once, including Bihar and Odisha, for example, with very low infections. The lockdown’s migrant labour fiasco actually took the forest fire to all of northern-eastern region of India, Odisha onwards. One national lockdown was simple to promulgate instead of designing State by State interventions. That would have been more complex to design. But did convenience get the upper hand when scientific rigour was needed?

Please do not misunderstand: the virus had to reach everywhere, no escape as this is transmitted by (1) social contact and (2) via droplets. When humans behave like humans, virus transmits. We can control its speed and its mortality. These are in our hands.

It is truly a “democratic infection”. All are equal to the virus. Only disease severity varies according to the vulnerability factors well known to everybody. Mortality is, to a certain extent, in our hands too. The speed of spread, likewise, can be interfered with.

Strategy planning and revising strategy when the battlefront behaves unexpectedly is “self-reliance”. For us, self-reliance is a good slogan but we don’t seem to have or perceive self-assuredness or self-confidence to act in a self-reliant fashion.

Do the incremental epidemic control benefits from imposing restrictions on activities remain the same as the level of restrictions are increased, or do they tend to increase or decrease beyond a certain threshold level? Or, is the evidence available so far inadequate to derive any conclusion on this?

On the other hand “hit early, hit hard” was a good idea, but thereafter leaders should have known how to gradually reopen social activities. Incremental hitting should not be used against a virus that spreads like the flu of 2009-2010. Incremental relaxation is the right way.

We were reminded of the Kurukshetra battle that was over in 18 days. That reminds me of Abhimanyu and the chakravyuha: launching was easy but getting out unscathed was the problem. In any battle, one must know the enemy well, and also your weapons well.

As we move to easing of restrictions, what is the implication of this for a decline in the number of active cases? Will it remain the same or will it be delayed further? What are the factors that will result in any such decline?

We must expect that after the peak, expected in July-August, the epidemic will slowly decline and then become “endemic” and probably seasonal. This is the most likely natural course of this pandemic. Since we do not have functional real-time disease surveillance, we will be flying blind for a while.

Is the sentinel surveillance of Severe Acute Respiratory Infections (SARI) adequate? What more should be done, in the long and short terms? There are experts, including some heads of state, who have been talking about more expenditure on public health.

It depends on what the objective is. If you want to know if the virus has reached a particular town, SARI is a good way to begin. When one case is diagnosed as COVID-19, you know the virus has reached that town. The purpose of “sentinel surveillance” is achieved. Then what? Ask the question: why did you ask if the virus has reached this town? The plan of action should have been ready before you looked.

Influenza and COVID are two distinct disease classifications. Each has its own diagnostic criteria. All doctors should have been taught from very early all about diagnosing COVID, mild, moderate and severe. No one had learned this infection/disease in medical college. One of the earliest functions of the Ministries of Health should have been to educate the medical profession all about this new infection and disease. All doctors are registered in the Medical Council, all are known in the registries. Leaving COVID-specific learning to chance or to personal devices was not a good idea. Lives have been lost because of it.

In any serious-minded country, the health management system (using scientific medicine) has three components. First and foremost is public health. Prevent all diseases that can be prevented. Second is healthcare. Treat all that were not prevented. Our healthcare centres are cluttered with preventable but unprevented diseases. That is the problem of having no public health; but that helps reduce the need for a large health management budget. Third is research. Every medical college must learn how to and teach how to, and actually conduct relevant and problem-solving research. Self-reliance demands no less.

All these, if taken seriously, for the sake of self-interest and self-reliance, will cost at least 5 per cent of GDP in normal years. If you spend only less than 2 per cent, that means the system is not robust enough to use additional funds. It is a chicken-or-egg situation. More money, without the infrastructure to absorb and utilise efficiently and effectively, will not succeed. The infrastructure will not grow and develop without extra funds.

Viruses, it is said, are here to stay and pandemics will occur in the future. Can lockdowns be a solution to pandemics of this proportion?

We had, in 2009, the H1N1 flu pandemic; in 2002, the Chikungunya pandemic; in 1986 the HIV/AIDS pandemic, in 1968 and 1957 flu pandemics (H3N2 and H2N2). All lessons learned in the past were forgotten in the fear and panic of this coronavirus pandemic.

That is the fallout from the worldwide web. Fear was instilled in us before we got to engage the enemy. Pseudoscience was used to predict that India would not be affected like all those foreign countries were affected. Secretly, anxiety and fear made us make decisions without war-room planning. Instant experts replaced available national resource of wisdom and expertise.

We got the frightening news and saw others doing various things, but we did not make cold, calculated, wise decisions. Communications ranged from trivialising the problem by messaging to demonising it through lockdown.

Lost in between were truthful information, science and social mobilisation for which India was the leader in 1986 when HIV/AIDS was confronted. Its legacy is still seen in all educational institutions as the “Red Ribbon Clubs”. Interventions against COVID-19 were “administrative” and “political” more than “public health”. Top leaders learned what they wanted, not what they needed. Let us hope there will not be a similar pandemic ever hereafter.