Days before he resigned as head of the Indian SARS-COV-2 Genomics Consortium, virologist Shahid Jameel, one of the most prominent scientific voices on the pandemic, discussed what has led to the rise in India’s Covid numbers and when it can be expected to end. Edited excerpts from the Explained.live interaction.
On the Covid-19 numbers from April-May
Certainly the numbers tell us that we had a really devastating April-May. Although the curve seems to have flattened out, do realise that it has flattened out at a very high plateau. While it is showing some signs of coming down, I think it is a little too early to say much. We have to wait for some time to see whether this bit of a downward trend that we see is there or not. But at least it’s not going up at the rate at which it was going. Our figures in the month of April went up fivefold: we started around 80,000 and went up to about 400,000. If you look at the slope of the line, it was like almost a 60° climb, which is a very high rate of growth. So in a way we are relieved that we have sort of reached a plateau, but I’ll remind everyone that it is a high plateau and we have to be very, very careful not to let it go any further but to bend it down.
On what the elongated plateau means
One thing that immediately comes to mind is that we are looking at far more infectious variants this time than we were looking at the first time around. The first time around, it was really a very, very gentle virus; this time we have a very formidable foe. The virus has changed and that has given this curve. But don’t let me give you the message that it is the virus alone that has caused this mayhem. We allowed the virus to do this. As long as there are susceptible people, the virus will continue to infect. But the point is that we gave the opportunity to the virus not to just spread, but to spread too quickly, and that has really led to this very, very sharp increase. The virus is still circulating, it is still infecting, there are still a lot of susceptible people, so possibly that’s one explanation of why we are seeing such a wide plateau, and that also tells you that the other side of the peak is not going to be an easy climbdown. It is possibly going to be a more prolonged, long-drawn-out process running possibly into July, may be even into August. We’ll just have to keep an eye on it.
On what is wrong with the way deaths are being counted
Let me rationalise this by going to the natural death rate in India. How many people die natural deaths every day? The annual rate that the government of India reported to the World Bank and other organisations, the last rate that is available is for 2019 — and in 2019 our mortality rate was 7.3 per 1,000 per year. If you convert that into deaths per day, that turns out to 27,600 deaths per day. Now let’s say we have 4,000 deaths per day because of Covid. This number, 4,000, is only a 15% increase over the natural deaths happening. Now, with that small a difference you would not even notice it at crematorium grounds, at burial grounds. But what you are seeing is a completely different picture. You are seeing people waiting in line, not just to get into a hospital, but actually for their loved ones to be cremated, to be buried. That can only happen when even that system gets overwhelmed. You know — it will again be a guesstimate — I would think that unless the input at crematoriums doubles, we possibly will not see this kind of mayhem. And if you go by that logic, then we are looking at somewhere there is maybe around 5-10 times undercounting of deaths. And that is happening because even in the best of times, deaths are not registered very well in the country and our registry is weak. But also when the healthcare system gets overwhelmed, people are unable to get a Covid-positive test. There are going to be thousands of cases where tests don’t come in, you don’t count as Covid-positive. Even if somebody who is Covid-positive dies of a heart attack, it would be called a cardiac arrest death rather than a Covid death. So this sort of undercounting is happening all over the country, and that’s why I think the numbers are low.
On how this situation came to be
We are a cricket-crazy nation, and every budding cricketer is told, don’t take your eyes off the ball. We took our eyes off the ball, that’s basically what we did. In the five months from the peak in September to February, cases were going down — even at a time when we were going through the festivals of Dussehra and Diwali, and in between we had the Bihar elections. All through that time, as the graph was going down, we and our leaders started thinking that we have conquered Covid. But you just had to look around you: every single country in the world that peaked before us was having a second peak. A second wave was before us, but we were constantly fed this narrative. And we started believing in this narrative that somehow Indians are special. We get BCG shots when we are children, we get a lot of malaria and a lot of chloroquine, all sorts of arguments were there about why Indians are so special and that the curve has gone down. Well, the curve now, looking back, had gone down because the virus strain was not as virulent, and we were still observing Covid-appropriate protocol — so possibly a mixture of those two things. But then, what happened? By the time we came to December and the cases kept going down, we did start believing in this narrative, lots of super-spreading events happened — weddings, local body elections and state elections in many states, and of course the religious congregations. The Kumbh Mela is one example where lots of people gathered at one place. Most of this was happening in February-March. We now know that a more infectious variant was developing. We spotted it first in December, but then it was really miniscule and very little attention was paid to it. It kept increasing in January and February, and that is when our sequencing also started increasing and we started detecting it more and more. So I would say that is a combination… Let me just say that first we became complacent, and then this sort of variant virus caught us at the right time for the virus, wrong time for us. Finally, when we had the opportunity to get vaccinated in January and February, enough of us did not get vaccinated. By the time this peak hit us around the third week of February, when numbers started going up, we had very, very poor vaccine coverage — only about 5% or less, possibly about 2% of people who had been vaccinated.
On the vaccine shortage
I must say that the government’s programme to vaccinate was a very sensible programme, because you want vaccines to do three things in a pandemic. The first thing you want to do is protect your frontline workers. The second would be to reduce mortality, and we already knew that people above 60 and people with comorbid conditions like diabetes, for example, were more at risk of dying. And finally, a pandemic vaccine is supposed to break the pandemic, turn things around. Now when vaccinations started for us, at that time we were constantly hearing a couple of messages. One message we were hearing was Indians are special, we have conquered Covid. So, it was very logical for most people to think, well, Covid is gone, why should I take a vaccine that has taken only less than a year to develop whereas most other vaccines have taken 10 years or more to develop? Maybe this vaccine is not tested enough, may be it is not safe enough. However, many of us were crying hoarse that these vaccines have been tested for safety as well as for any other vaccines, please go get a vaccine. Now, along with that we had messages coming out of Europe that the Oxford/AstraZeneca vaccine is causing blood clots. But we did not pay attention to numbers: How many people were getting blood clots? If you actually start computing the relative risk of dying from a blood clot after taking a vaccine, that risk varies between 1 out of 150,000 and 1 out of 330,000. Do you know what is the risk of dying out of a lightning strike? It is 1 in 140,000. So you are more at risk from dying from a lightning strike than you are dying after taking a vaccine. And everyone thought in January and February that they would be the ones to die with a blood clot. Again, our messaging was mixed: we did not really say very clearly that that is not going to happen. By the time vaccination was opened to people above 60, I have so many family members that really did not want to take a vaccine. Many people are still not vaccinated.
Why did we come to a vaccine shortage? Well, if you look at all the countries that have vaccinated their populations to a large percentage, all of them booked vaccine doses around mid-2020. India didn’t do that. We did have a big vaccine enterprise, but our biggest vaccine companies are private limited companies. The private sector does not work on charity; it needs to be given orders to be confident of building facilities to make vaccines. And that is where we took our eye off the ball. They did get orders, but they got orders in January or maybe December last year. Serum Institute, for example, got $300 million support from COVAX, and they had to commit certain number of doses to the COVAX programme. They put $270 million of their own money into building facilities to make Covid vaccines, and our public vaccine distribution system did not give them any orders till December or January. When vaccine orders were not there, vaccine supplies went down. We were a vaccine-surplus nation, and we really showed what India can do. We gave out about 66 million doses of vaccines to 95 countries, roughly 10.5-11 million doses we gave free to neighbouring countries. So we were looking very tall as a nation, but unfortunately taking our eye off the ball made us a country that is now importing vaccines. That’s a tragedy. Yes, funds have been given, $400 million given now to Serum, $200 million to Bharat Biotech, they are expanding facilities, but it will take about July, by the time vaccine supplies normalise.
On breakthrough infections
The first fact that we must all understand is that no Covid vaccine has made a claim that it can prevent infections. Most infections will only prevent disease. Yes, breakthrough infections are happening because the numbers are so high, and we are in a pandemic, where everyone is sensitive to it — the moment you start coughing you get an RT-PCR test done; normally that wouldn’t happen. So yes, breakthrough infections are being seen much more than earlier. But it is also a fact that at least a very large majority of breakthrough infections are leading to either asymptomatic or mild disease, which can be controlled simply by staying at home and taking normal precautions. It’s very rare that someone who has had two doses of the vaccine will get into a hospital and go on oxygen and further. Breakthrough infections happen; they will continue to happen.
Audience Questions
On the link between percentage of people vaccinated and decline in cases
Data that we see from countries like Israel and Germany, which have vaccinated very large fractions of their populations, suggest that once you vaccinate roughly 40% of your population with both doses, maybe about 50-60% with one dose, you start to bend the curve. We are very far from that yet. But let’s hope that we continue to vaccinate at scale. It is a little disappointing that we had gone up to about 4 million doses every day in April, in early April, but since then it has been a constant decline, and at this time we are giving somewhere between 2-2.5 million doses every day. That’s not an adequate number. We really need to be vaccinating at a rate of about 7.5-10 million doses every single day to be able to reverse things.
On the use of natural remedies
Definitely yoga leads to a more healthier lifestyle, and the breathing exercises in yoga increase your lung capacity, so certainly it helps. And it helps in your general well-being, and if you eat well, if you exercise, light exercises especially like in yoga, your general disposition is better, your general immunity levels are better, and you are less likely to be infected, and it is less likely that the infection will progress from your upper respiratory into your lungs where it causes most of the mayhem. So yes, certainly those things help, but if you ask me whether once you have been infected and you continue to do that and you will kill the virus, I would be sceptical of that. But certainly it is helpful for good health.
Transcribed by Mehr Gill
Edited excerpts
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