Dr T. Jacob John is a celebrated virologist and former professor at the Christian Medical College, Vellore. Since the novel coronavirus pandemic came to India, Dr John has been a vocal advocate of more public health surveillance, smarter use of diagnostic tests and transparency in government decision-making. Karan Thapar interviewed him for The Wire on these matters and more over email. Dr John’s responses are presented in full below, lightly edited for clarity.
1. According to the Ministry of Health’s website at 9:00 am on May 22, India had 118,447 cases of COVID-19, which is 42% more than China. Also the daily average of cases and deaths calculated on a weekly basis is growing week after week. Doesn’t it look as if the fight against the novel coronavirus is getting tougher?
China’s numbers are to be taken with great caution. On a per capita basis, China’s number – below 90,000 – amounts to less than 0.007% of the total population. About 50-60% should have been infected for the epidemic to come to an end. This is the ‘Great Chinese Puzzle’ we wrote about in The Hindu on March 26. There are some reasons to believe they missed the early and massive epidemics in other parts of China but realised what was happening in December, when it hit Hubei province and its capital, Wuhan. So Wuhan was not the ‘debut’ but the climax, or finale.
By May 22, India had 124,794 confirmed infections – which is .0093% of our population. Let us look a bit deeper. By May 20, India had tested 2,279,324 samples and found 95,622 positive. That means that 0.017% of the population had been tested to find nearly 1 lakh positive persons. We do not have any method to extrapolate to 100% of the population. The real number of positive cases could already be in the range of 1 million (10-times higher) to 9 million (100-times higher). With such an uncertainty margin, we do not know the reality in India.
The sensitivity of PCR is about 50%, so we are missing one for every one detected. So you could double the numbers – to 2-18 million.
You must remember that the objective of testing is not to determine the infection burden but to trace contacts. When we try to guesstimate the total burden of an infection, we do not have a logical method, and do not have much confidence that we can even try.
The number of deaths is revealing. A person may die about 3-4 weeks after getting infected. That means, [given the cases and deaths data and accounting for the four-week offset], there will be 36 deaths for 153 infections (23.5%); 52 deaths for 531 infections (9.8%); 87 deaths for 876 infections (9.9%); 104 deaths for 1,228 infections (8.5%); and 127 deaths for 1,611 infections (7.9%). The internal consistency is obvious: the range is as narrow as 7.9% to 9.9%. The average 9.025%. Discard the outlier, 23.5%
This consistency is highly interesting, and even reliable, as the deaths are among persons found infected, then became ill, admitted to a hospital and then died. So they are really ‘infection-fatalities’.
These must be the world’s highest mortality figures. Globally the mortality is 1-5%, average 3.75%.
If deaths per 100 COVID-19 cases are considered, called the case-fatality rate – that may be 10% or more globally. It’s 14% in Italy. In India, the infection-fatality rate might be case-fatality rate multiplied by 3, around 27%, where 3 is a correction factor.
2. The government insists India hasn’t reached the stage of community transmission. But with over 120,000 cases that’s hard to believe. What’s your view? Is it credible to keep denying community transmission?
In a lighter vein, aliens may be coming at night, infecting people and then disappearing.
The term ‘community-acquired’ is used to qualify an infection that was not ‘hospital-acquired’. Community transmission is a concept, not a science.
Any new infection is ‘imported’ at first. If transmission takes place, it is ‘importation-associated’. If that infection is further transmitted to someone, the situation becomes ‘local transmission’, autochthonous transmission or indigenous transmission. This is community transmission. The concept is to warn people of indigenously spreading virus – so take care and take precautions.
In India, it seems to me that the government thinks to admit community transmission is to admit failure of all its efforts to interrupt the chains of transmission. It’s nothing of that sort at all. ‘Satyameva jayate‘ – honesty above false sense of honour. Honour is to be honest.
The real distinction is between importation-associated and indigenous transmissions. Another name for the latter is community transmission. What the government means is that they know every chain of transmission, so they define community transmission when the source of infection is unknown. It is for that reason that I stated that on March 18 that there was one infection in Chennai, the source of which was unknown.
If there is no community transmission, people underestimate the risk of transmission and lower their guard. Continuing to deny community transmission gives away the bias of government officials. It is not true, and it is not in India’s best interests. Please see [the author’s article in The Hindu on May 6].
3. In an interview to Mint, Randeep Guleria, the director of AIIMS Delhi, said the peak would come in June or July. Doesn’t that mean things will get worse for up to six weeks more before they start getting better?
Independently, and presumably using a different method of calculation, we have projected the peak will occur during the weeks of July to mid-August.
As I said earlier, our testing is not meant to measure or monitor the magnitude of the epidemic, hence the true picture may not be observed. Another way to put it: our positive results are determined by the number of tests – about 4-5% everywhere except in some samples in Mumbai and Chennai, where it may be up to 12%. In other words, the number of positive cases reflects the number of people tested but not the infection burden in the community.
4. How confident are you that the peak won’t come later? One reason I ask is because reports suggest the positivity rate of migrants returning to Bihar from Delhi, Haryana and Maharashtra is double, sometimes triple, the national average. And I presume that’s also likely to be true of migrants returning to other states like Uttar Pradesh, Odisha and West Bengal. So as more and more migrants go home, the spread of the virus could escalate, pushing the peak to August or September?[As of May 20, Bihar had received 6.1 lakh migrants. By end-May, it expects to have received 25-30 lakh, water resources minister Sanjay Jha told Economic Times on May 22.]
If transmission frequency is facilitated by … the [migrant labour] fiasco of the ‘panic-button lockdown’, then it may shave a week or two from the predicted peak, but we still feel it will fall within the six-week range we have described. It will not delay the peak.
5. A second reason the peak could be later than June-July is that the lockdown has been very substantially relaxed. Markets are open, trains are running and, from Monday, planes will be flying. Surely this will push up the number of cases and push back the peak?
You are right, it might push back the peak – but ‘back’ means earlier, not later. (Push forwards for delayed peak.) We are talking about some 400 million to 550 million infections cumulatively to result in the peak of the epidemic. One doubling at 200 million results in 400 million. So as the numbers climb, the time frame shrinks.
6. In that case, what have the four lockdowns achieved? We were hoping to flatten the curve but that certainly hasn’t happened – whereas Italy and China saw a declining trend after 40 days, which isn’t the case in India.
The first lockdown was from March 25 to April 14. By then, it was amply clear that the ‘toxic effects’ of the lockdown on the economy were as expected, but the beneficial effect on the epidemic was absent or imperceptibly small. The numbers grew 20-times in 20 days – from 536 to 11,487. Worsening the toxic effect for unlikely beneficial effect by extending beyond April 15 was unwise, and to my mind irrational.
I had proposed an alternative to the lockdown in early April: instead of extending the lockdown beyond the first one, universal mask-wearing and public education (social mobilisation) would have reduced the virus’s spread while protecting basic social and economic activities.
7. In the press briefings, Lav Aggarwal, joint secretary of the health ministry, draws a lot of comfort from India’s recovery rate, which is 41%. But Italy, with 32,486 deaths, has a recovery rate of 59% and Spain with 27,940 deaths has a recovery rate of 70.3%. So clearly a high recovery rate doesn’t rule out a disturbingly large number of deaths?
Recovery rates are not very useful. We saw an infection mortality of 8-9%. Therefore, the recovery rate should be 91-92%. The way recovery rate is calculated does not inform us of the risks of the disease among those who have been infected or have died.
I think the calculation is: all cases – deaths = recovered. That is a dynamic proportion that does not mean much in understanding the magnitude or severity of the epidemic. It is just a statistic.
8. Let me come to some other statistics that give us in India comfort and reassurance. Our mortality rate is 0.2 per 100,000 while the global average is 4.2 per 100,000. Our infectivity rate is 7.9 per 100,000 compared to the global average of 62 per 100,000. Finally, only 6.4% of cases need hospitalisation and less than 0.5% need ventilator support compared to around 3% globally. Does all this suggest the virus is less virulent in India or that Indians have better immunity for whatever reason?
As I have pointed out above, we have no way at all to find out our infection rate or mortality rate per 100,000 people. We did not design testing methods to get answers to population-based statistics. India does not practice public health surveillance, unlike other countries that can measure mortality due to specific causes or infection-density. Therefore such comparisons are self-deluding.
The 6.4% needing hospitalisation is credible: 100 infected, 20 with COVID-19, 10 self-recovering, 10 needing hospitalisation, 1-5 (average 3.75) dying in spite of ventilation. COVID-19 seems to be the same disease the world over.
We should have a much lower case fatality rate on account of a younger population compared to every European and North American country. Why then do we have higher fatalities (case or infection)?
9. At this point let me ask you: how accurate is our mortality rate? There are reports that in Delhi, the municipal corporations are reporting more than twice as many cremations and burials of people with COVID-19 compared to the number of deaths due to COVID-19 reported by the government. I’m sure that’s happening elsewhere, too. And in rural India it will be even worse. So do we really know the virus’s mortality rate?
The news coming through the grapevine is that in many states, the unwritten rule is ‘don’t test post-death even if history suggests COVID-19 death. If any comorbidity such as diabetes, chronic heart disease, etc. is present and COVID-19 was confirmed, document the cause of death as diabetes or chronic heart disease, not as COVID-19’.
The health management system in India does not capture a majority of deaths and causes of deaths. I have been advocating public health surveillance in our health management system for over four decades, to bring us on par with Sri Lanka and Thailand.
I will suggest a simple exercise. Ask the health ministry or the Integrated Disease Surveillance Project on the web for any information on any disease during January 2020, to compare with the same period in 2019 and 2018. Were pneumonia deaths in March 2020 higher than in March 2019? Blank. We need a 20th century health management system before we upgrade it to the 21st.
10. Let me move away from statistics and see whether we can draw comfort from other facts. There have been reports that we haven’t seen any increase of patients with respiratory or influenza-like conditions in hospitals nor any increase in the purchase of medicines for such conditions. Are these reports accurate? And if they are, do they corroborate the statistics we’ve just discussed?
I cannot answer because I am not a user of these records. I have not explored these records. But why not derive comfort from the fact that the COVID-19 mortality is very low in those below 50? And 82% of our people are younger than 50. Only 18% of India’s population will be seriously affected, instead of about 50% as in Italy.
Among the 18%, 16.2% will be unscathed by COVID-19. That leaves 4.8% – rounded up to 5% – who will have medical need for healthcare. If 10% of India is cumulatively infected by now, 10% of 5%, which is 0.5%, have had medical care needs. Will our systems of any data be sensitive enough to pick up on these changes?
The problem is – don’t look back, project forward and think of the healthcare needs in the coming weeks and months. Is India fully prepared? That is the question you need to explore.
11. Let’s talk about measures the government needs to take here onwards. First, everyone says we need to ramp up testing. As of 9 am on May 22, the health ministry’s website said India had conducted 2.7 million tests and that we are averaging 103,000 a day. In absolute terms, that may look like a lot, but it’s only 1,823 per million compared to 65,000 in Spain and 51,000 in Italy. So do we need to sharply increase testing?
True – by May 21-22, for every million people, the UK had tested 45, Germany had tested 42,910 and India had tested 1,650. Before increasing tests, we must ask what the purpose of testing is. If comparisons must be done, testing’s purposes should be fairly uniform. Across Europe, where the health management system consists of both public health and healthcare, they have reliable data on health, disease and deaths. India has since independence refrained from establishing public health – with its paraphernalia, including real-time, action-demanding public-health surveillance – and has relied completely on healthcare.
In the absence of a data-generating system under public health, we will be unable to use any available data to interpret information generated through ad hoc methods.
In all those countries, when importations and contact-tracing were addressed by testing, the testing policy shifted to healthcare mode, to confirm clinical suspicions of COVID-19.
India has just recently announced that people with influenza-like illnesses and severe acute respiratory illnesses could be tested. Why test influenza cases instead of COVID-19 cases? That means we have not taught our doctors to diagnose COVID-19, as opposed to influenza. We need to be a bit more professional even in healthcare.
Unless such a policy shift happens, testing more will increase the number of confirmed infections proportionately: for every 1,000, tests 40 will be positive.
12. Is there a need for more random and less targeted testing so we get a better idea of how far and wide the virus has spread?
When we cook rice, we stir the pot well before randomly picking up a few individual grains, based on which we judge if the pot of rice has cooked well. If you do not stir the pot, you can’t extrapolate from the few to the whole.
If a condition is randomly distributed, random sampling will be efficient. For coronavirus, at present the distribution is not random. So we will waste a lot of reagents, and when we get results, we will not know how to interpret them.
Why do we want to know through testing how far and wide the virus has spread? Why not use tests to find out the prevalence and incidence of mild, moderate and severe COVID-19 cases? That is what all European countries did. They scaled up tests to confirm clinical suspicion of cases with mild and moderate symptoms.
13. We don’t know how many, but undoubtedly a large number of Indians are asymptomatic carriers of the virus. How much of a concern are they? Initially it was believed they could easily infect others but now there’s increasing doubt about that. What’s your view?
The contact time and intensity between a symptomatic case and healthcare workers will be more than casual contacts of the public with asymptomatic infected persons. Since asymptomatic people will outnumber symptomatic patients five to one, those with asymptomatic infections become the engines that drive the epidemic during community transmission. In hospital settings, the transmission will be driven by people admitted with COVID-19.
Because of the presence of many asymptomatic virus spreaders, people should wear masks. And because no one knows who is infectious, those who aren’t infected should wear masks to reduce the probability of inhaling any virus in the air, released by infected people. This is the rationale of my longstanding advocacy for universal masking. Hand-washing is a must as well.
14. We know from Lav Agarwal of the number of hospitals and COVID-19 testing centres that have been created, but now that migrants could carry the virus into the villages of rural India, do we have the healthcare infrastructure in places like rural Orissa, Bihar and West Bengal to handle a growing number of cases?
I do not know the ground realities there to answer.
15. Another issue as the number of cases and sadly deaths increases is the need for timely and transparent information. In other countries, ministers hold regular press briefings. In India, they’re held by bureaucrats, and in the last two weeks they’ve become pretty irregular. If the aim is to contain anxiety and fear, don’t we need better briefings?
The old saying is that it is better to hold your tongue and be considered wise and knowing than to open your mouth and dispel any doubt.
The first step, in mid-January, should have been for the health management leaders – in the DGHS, NCDC, DHR, ICMR, health ministry and PMO – to learn as much as they could, seriously, of the technical subjects of infection, disease, epidemiology, geographic growth of a pandemic, non-pharmacological interventions, scope of physical distancing protocols, maintaining essential services and essential supplies, need for biomedical products for diagnosis and research, and be thorough enough to teach the Indian people what they should know for social mobilisation, behaviour modification, etc.
The next step should have been teaching these to state health management systems. Then divide the social mobilisation tasks between Centre and states. This could have been February’s agenda. The top leaders had to understand the concept of a social vaccine.
Knowing my country well enough and realising the need to give some guidance, I wrote of ‘A COVID-19 control plan made simple‘ in The Hindu on March 12.
Citizens deserved to be well-informed instead of ill-informed, and left to their own misinformation and disinformation.
All these leaders missed their responsibilities to themselves and to the nation. No point in harping on “what should have been…”. Let them start from now, with true social mobilisation.
16. Finally, there is the sort of information given at these briefings. On May 20, Lav Agarwal compared India to the 15 worst-hit countries on the grounds that, taken collectively, their population is roughly the same as ours. He then pointed out they have 34-times more cases and 83-times more deaths. His conclusion was that this “says a lot about measures taken by us to manage the situation”. Does it? Or is this meaningless and unintelligent?
I can empathise with Shri Lav Agarwal for standing in for the entire central government’s machinery that is charged with developing and implementing policies, as the senior-most official to address the nation.
Comparisons between countries must be made very carefully, not casually. We ought to be thorough with our own data, the strengths and weaknesses, and about comparability.
Country-wide epidemics happened in asynchronous fashion. We had more time before those countries started their epidemics. Many of them have already peaked but our peak will be in July-August. If we want to compare India with other countries, we should take their profiles two months before their respective peaks. This kind of scientific interpretation requires epidemiological intelligence.
Our approach was not like one country with one national programme but with many state programmes and with many variations. That showed poor planning and design of the so-called ‘war’ on the epidemic.
Who misguided the PM for him to believe that a 14-hour ‘janata curfew‘ (on March 22) would interrupt transmission?
Who made the PM push the panic button on March 24, forgetting about the need to plan well before implementing a lockdown?
What was the rationale to extend the lockdown beyond April 15?
The citizens deserve to be respected as citizens and informed well, every day. That would have shown the seriousness of purpose and the professionalism in the nation’s response to a once-in-a lifetime opportunity to make Mother India’s face shine, when this big crisis put all countries at great risk.
India had the expertise and talent to lead the entire developing world in strategy design and implementation.
But that requires self-assured confidence in ourselves and our experts. Pride in ourselves sans arrogance of past glories.