Transcript: Episode 49

What's happening in India?

Vivienne Parry  0:03  
Hello, and welcome back to Coronavirus, te whole story, UCL's award winning podcast all about the pandemic and the groundbreaking research from the UCL community. I'm Vivienne Parry. I'm a writer, broadcaster UCL alumna and I'm here to bring you Well, the whole story. Now one thing that we've heard time and time again on this podcast is that Coronavirus doesn't affect everyone equally, individuals, neighbourhoods, businesses, whole countries, such as the UK and US have been able to vaccinate over half their population so far this year, the virus has been having a devastating impact in other parts of the world. Today we're going to be talking about the current crisis in India. They're deadly second wave and what can be done to help. I'm joined today by Dr. Vageesh Jain an NIHR academic clinical fellow in public health medicine at the UCL Institute for global health during the pandemic Vageesh has been working on the COVID-19 response at Public Health England, and last year was awarded the Bennett prospect prize for early career policy research. My second guest is Dr. Shikta Das, an honorary lecturer at the Institute for cardiovascular science. She is a genetic epidemiologist, we love those, and is currently working for see for x discovery, a drug discovery company on diabetes and neurocognitive disorders. She has been raising awareness of the impact of COVID-19 in India, and has spoken about the situation with her father, who lives in India on radio falls today programme. so shocked. We have to start off by asking how is your dad?

Shikta Das  1:43  
Thank you, Vivienne. My dad is doing well. At the moment. He has had an episode of Coronavirus, but he is fine. It was in the mild form because he was vaccinated.

Vivienne Parry  1:54  
Fantastic. Very good to hear. So now having made sure that your Dad's okay, let's start by getting the big picture. Shikta, just tell us about the second wave When did it start? And why did we think it's been so deadly?

Shikta Das  2:09  
I mean, I think we have been looking at the data. And when I say we it was mostly what we see in the media. And we observe that, you know, since the start of February, there has been some information coming through that the number of cases had started to increase. I think one of the biggest reasons we see the second wave was complacency. And we know that, you know, the second wave happened after a long gap. and India really enforced the first national lockdown in the first wave very well. We had relatively low fatality rate, and hence there was almost a sense of premature victory over the virus which was celebrated. And this really led to the lacks public health messaging. There was no preparedness for this new variant big gatherings were allowed. They were sort of political failings and most importantly, lack of preparation among officials was very clear. And important contributed could be also this new variant which is more transmissible. And of course, the super spreader events did not really help. We know there were big election rallies, Camilla, which is a religious event was allowed. Nothing was done to dissuade people congregating in large numbers. And this undoubtedly increased the transmission. And I must add that the healthcare system really collapsed. You know, under the second wave, what we really observe is that the oxygen supply failed massively short of the demand hospitals, were publishing details on the remaining oxygen supply in terms of hours. And this is a very hard situation in such a big country to have to lack of, you know, number of beds, oxygen drugs, these are terrifying and concerning situation, given the experience we have in UK, we know that from the first wave saving the health infrastructure is a key event and key point, you know, which we had really focused on. Whereas when you look at India, it has underfunded health services, you know, with just 1% of GDP going towards the public health financing, and that is very much exposed at the current moment.

Vivienne Parry  4:22  
Let me come to Vageesh and ask you, you know, wearing your Public Health England hat, how do you see this as someone of Indian heritage, sitting in London having experienced COVID here?

Vageesh Jain  4:36  
I'm really worried and I think really what we've seen in India is is a warning to the rest of the world about what can happen if as Shikta brilliantly summarised, you really take your foot off the pedal and become complacent and let things like gatherings happen in a population that is still susceptible IE not immune. And I mean, just to build on the point really on the new variants, because I think this is an important part of what's happening in India. So the B 1617, which is the variant that is kind of commonly referred to as the Indian variant now is in about 40 countries, and it's really quite rapidly displacing some of the other variants seen in other states in India. So preceding this variant, that one of the most common variants in many states was the one that was originally found in Kent. And of course, we know that that is 50 to 60%, more transmissible than the kind of wild type original Coronavirus. And so the fact that that is being displaced is a cause of concern. We're seeing that in this country as well in the UK. And it does suggest that a big part of why this is happening now is down to kind of the biological features of this specific strain. And obviously, combined with easing off social restrictions, mass gatherings, as has been mentioned, and festivals that have kind of occurred earlier this year, all of these things have led to quite a worrying situation in India. And from our perspective, in the UK, obviously, there's many things that we can do.

Vivienne Parry  6:03  
I want to get on, if I may, to that in more detail a little later. But one of the things that's particularly difficult for India, which you know, if you've not been to India, it has both the best and the worst of healthcare in that you have some of the most ritzy well supplied and well resourced hospitals, probably in the world. But then you also have a total breakdown of health care in other parts of India and the issue with lockdown in India, it's not as easy as just saying everybody's got to go home. Because there are a lot of migrant workers, there were lots of issues. When with very little notice, people were asked to stop working and go back to their homes because many people had to travel hundreds of miles. And when you have a lot of people living in very difficult situations, lockdown is not that easy, is it?

Shikta Das  6:58  
Absolutely right, Vivienne, it's it's not going to be possible to have an extended lockdown based on what the big population of daily wages are in India. And you're absolutely right in suggesting that there needs to be more effective communication coming from government about how to manage COVID in terms of you know, mild and moderate symptoms at home. What we have also observed is this inequal health care systems, it has been pre pretty much dominated by the private hospitals, and there's not much safety net for poor they have to survive as well as protect their loved ones. And that is what we are observing in the numbers. Currently, we know that when these migrants will be going back home, they will be taking the Coronavirus with them to the smaller cities to the rural areas. And that's when the numbers will increase in terms of infection as well as that and that is not being captured at the moment you know what you just see in terms of numbers of very much big cities. And that was going to be a problem when you are doing epidemiological modelling or undertaking any kind of modelling to come up with substantial conclusions. And my worry is that really downplaying the threat of the virus at this stage will not do us any good. And it may lead to further waves,

Vivienne Parry  8:21  
it is a very difficult thing to ask people who perhaps live on the streets or who live in very difficult circumstances there is no isolation is there it's not possible

Shikta Das  8:31  
Now in terms of when you look at the household structure, and also the behavioural issues. you notice how the setup is so multifactorial, people live in big joint families, there is no space to isolate, also the information, the misinformation about the virus. One thing which commonly came out of India was this almost a fake news or misinformation, this false belief that the healthier and the younger people are less susceptible to severe symptoms or even death. And the disease itself is not very serious. And I would say that this was very much on hold in the early part of the pandemic of the second wave. And that really led to people believe that they can continue going out without masks without social distancing. This information had to be really provided by the government, which came from credible sources such as PHP, NHS, and one has to inform the public you know why these measures were necessary for stopping this wave further. And this is where I felt that the complacency was noticed, you know, in the second wave,

Vivienne Parry  9:39  
because Fergie's in the beginning of this outbreak in India, the first wave India was congratulating itself on really a very low death rate of 100,000 population. And I wonder why there was that low death rate at that stage. Was it about the variant that was circulating then was it something too Do with climate? Because, you know, we talk a lot about climate as perhaps something that's influencing the spread of Coronavirus around the world, as it does with flu, for example, what was it that was protective in that first wave?

Vageesh Jain  10:14  
Yeah, it's a good question. I don't think really that there is a kind of robust answer to that, that anyone has. And it's a multifactorial thing, of course. And as you mentioned, the previous variant likely wasn't as infectious as what's currently circulating in India, that definitely played a big role. As far as climate goes, I think most of the evidence that looks kind of across countries and compares different longitudes, latitudes and climate, etc, is not particularly convincing. ie it suggests that there may be a small role for climate and seasonality as you'd expect with other infections, like influenza, but really compared to your other factors, like, you know, whether you have a large amount of social contact climate read does play quite a small role. And certainly, we would have expected bigger rising cases over December and January in India if, if that was the case. So why was India kind of not as badly affected in the first wave? It's difficult to say exactly why, but I think part of it is the variant and a lot of it was likely that people were much more compliant with social restrictions, mask wearing, and you know, isolation and the rest of it during the first wave, when there was this general perception of fear of the unknown of uncertainty and different as Shikta dimensioned, a very different kind of communication strategy coming out of central and state governments, which has changed in the previous few months.

Vivienne Parry  11:34  
So during this time, and given what was happening elsewhere in the world, particularly in Europe, and indeed, particularly in the UK, I imagine that scientists in India, were jumping up and down saying there's another wave coming. Why did that have no effect?

Vageesh Jain  11:54  
I would say that, as with most kind of big decisions, in this pandemic, there was not a homogenous view from experts. And that's because there is a large amount of uncertainty. So there were many public health experts who are clamouring for more widespread social restrictions and more care in reopening society, etc. But really, the influence of that was quite limited. And we've seen that in other countries like Brazil, where initially one of the ministers of health resigned because he felt he wasn't being taken seriously and throughout the world, really. So this influence of kind of political leadership and decision making, and where does the sort of epidemiologist and you know, the health economist, and he's the range of experts involved? Where do they sit in terms of influencing and the issue in India is that we do have quite a system that is heavily influenced by politics, not just that there were a range of other concerns that maybe are not as big concerns in in the west for various reasons, really. So for example, in India, as you mentioned earlier, many people cannot isolate because you know, 90% of the population are in the informal sector, for example. So the economic concerns or concerns about kids staying off school, and you know, the social costs of continuing to be cautious, are potentially different in different countries. And it's really up to political leaders to weigh all of that up and come to decisions. So, you know, I would say that the decision making on preventing the second wave or being more cautious, was not simple. It was complex and multifaceted. But arguably, there could have been more action taken and a better and more comprehensive voice for experts in those decisions.

Vivienne Parry  13:31  
The possibility of actually avoiding the second wave is probably one that would be impossible in a country of the size of India. But preparation for a second wave definitely could have been much better shape to what would you like to have seen done in preparation?

Shikta Das  13:53  
It's a very good question. I mean, I think I was very early on, I suggested that, you know, the only way out could have been if India had prepared better for the second wave by looking into hospital management logistics, supply chain issues with the vaccine. Also, with the privatisation allocation of limited resources. We know we had problems with BP, ICU beds, oxygen, ventilators, even medication. This is coming very much from my epidemiological background, which is about reliable data collection. If we had a better data collection capturing system, we could have had a better analysis of the plan to stop this resurgence of the cases. This is where I really believe that not just India, but globally we really have to emphasise now on better data collection for the pandemic use and also for other infectious diseases. As you can see, it has really helped in making informed decision even in our country in terms of public health messaging on physical distance mask using in public places or even explaining that airborne disease this had to be widely disseminated. It had to come from a reliable source, you know, like a COVID task force, which government has set up and should have been more active in India. I think it really explains, you know, what the risks are for individual, not much has been talked about the comorbidities in India and how to solve them. We know about the black fungus, this problem currently ongoing.

Vivienne Parry  15:27  
Just explain about black fungus, or perhaps the gauge, would you tackle what it is? Yes,

Unknown Speaker  15:32  
I was going to suggest Vageesh.

Vageesh Jain  15:35  
it's an infection, basically fungal infection called mucormycosis. So fungal infections typically happen if you're immunosuppressed for some reason. And so there's, I've seen various theories about why this might be happening more commonly the moment in India in sort of COVID patients as a complication. So one of the theories is that many people in India have diabetes, much of those undiagnosed, unfortunately, not only is that crucial risk of COVID, but it can also diabetes can suppress your immune system essentially. And because of in combination with the fact that potentially people with COVID are now being given steroids. dexamethasone is an example of steroids that can further suppress your immune system. And there is a theory that that may be in part responsible for this fungal infection. One of the other theories is to do with the fact that this particular fungus is found in soil, and is there kind of some exposure, some, you know, natural herbal Ayurveda exposure, that people are using some reports of people applying particular things on the skin or whatever, again, another theory that really hasn't been proven. And then the final thing is really do with oxygen supply. So as oxygen is being supplied to their various systems and the operators that there are concerns that maybe there's some opportunity for infection to spread through that process, we don't know exactly what's happening. And we actually don't know whether the proportion of those cases of mucormycosis are higher than we saw in the first wave. There are definitely more cases in absolute terms, but then there are many more COVID cases in absolute terms as well. So I think there's a lot more work to be done on really understanding that particular issue.

Vivienne Parry  17:06  
So both of you were in the UK through January, Christmas and January when our wave really exploded. And it must have been terrifying for both of you to see what was going on here. And know that that was the fate for India. How did you both feel? Let's start with you Shikta. Because your dad's a doctor, isn't he?

Shikta Das  17:32  
Yes, he is Vivienne and it has been terrifying if I can be honest, I have felt a mixture of grief, anger and hopelessness completely oscillating between waves of emotion currently, because I feel quite powerless to do anything. When I observed the second wave here and the news about UK variant reaching India I immediately called my mother and told them to prepare themselves with stocks of medication which they need for their diabetes as well as high blood pressure, both comorbidities quite significant for Coronavirus. But you know, as as it usually goes, I, you know completely fell on deaf ears. They were celebrating by this time and I was told that they had very high vitamin D content and they will not get a second wave. I again insisted a beginning of March when I could read some news articles about the increased number of cases. And that's when actually my father started mobilising things. And he started observing people falling ill around him. One of the worst bad news came when the neighbour opposite died. A very, very close friend of my father, he lives just opposite to us. He's very well known person in the neighbourhood. And it was quite a shock because everything unfolded within three days of him falling ill to him dying. And that really affected my parents severely. I had to talk him out of it. And I had to explain that, you know, this is pandemic situation and being a doctor, he should still follow physical distancing and masking and double masking in India's case. So it has taken a toll on me To be honest, it feels quite surreal. And it's a stark contrast, because my own situation in London here is very much going back to normal. Whereas I feel guilty that you know, India is going to it has a long way to come to normality.

Vivienne Parry  19:26  
Long Way to go. And how Vageesh, how about you?

Vageesh Jain  19:29  
I think it's been really tough. So I actually was in India in January for kind of a family emergency, and it's done a complete U turn. So when I went in January, things were not too bad. I remember the state that I was in there were maybe 40-50 cases in the entire state in a day. And so there was a general perception, which I don't think is necessarily an unfair perception, the worst was over and that people with other needs social, economic, etc. needs people were ready to kind of reintegrate and unfortunately that did lead me To people kind of dropping their guard. And so it has been very difficult watching India go from where it was, which was a good place to to where it is now. And I don't I don't necessarily think it was inevitable that there was a new variant. But you know, I think the very, very fact that there's been a huge variation across states in India in terms of how bad this has become, just demonstrate that there are various things as Shikta dimension in terms of the health system in terms of planning, in terms of messaging, various things that could have been done earlier, and thankfully, are being done now. And we're now you know, starting to see a corner turn, hopefully, in terms of new cases every day.

Vivienne Parry  20:35  
So we know that vaccination is important. And I think that's a global effort. And those are things that we need to think about globally. What's the more practical things that people perhaps in the UCL community could do? For instance, I was with a lot of healthcare scientists yesterday, and they were talking about doing videos, which would tell people in professionals in India, what things they had learned during COVID. And what would be the best way to tackle things things like proning and how to how to do that, what you could do, what pressures you could use on oxygen all those kinds of things. What else can we do?

Shikta Das  21:13  
So Vivienne, I think the one thing I have personally done is translate all the information which we were circulating from NHS and Public Health England, I have been translating those information in Hindi and disseminating it to India through a charity. As you mentioned, this particular South Asian charity has also translated a lot of hospital management information from conditions here in UK. With the experience and I have organised webinars for Indian doctors and clinicians to learn from the experience. As an epidemiologist, I have tried using COVID taskforce in the Royal Statistical Society to help modelling with Indian scientists, you know, giving them my experiences in terms of modelling and how to understand the data more clearly, and also have policies around it. And I'm feeling that, you know, a lot of UCL scientists could help in this particular modelling aspect, because we are all best we have gone through this pandemic before. And I think that would be very, very useful for Indian scientists.

Vivienne Parry  22:17  
Vageesh, what kind of things would you suggest?

Vageesh Jain  22:20  
I think everything she said is really fantastic and needs to happen. And of course, at UCL, we do have strengths and kind of research and education. And we should be looking to collaborate with partner institutions in India to see what help we can provide, the only thing I would say is that we have to be careful in kind of assuming that there is some knowledge deficit, even for things like clinical management, there's a huge amount of expertise in India itself. And so we can obviously contribute to that. But I think in the short term, really, what's needed is the kind of supply the logistics, to give them the capacity to do what they can do. Part of that is has to be through government. So the Foreign Office has obviously been sending supplies to India, have been very engaged in this kind of process. But I think there is more that that can be done through through policymakers through those of us working kind of at that research policy interface, to help inform those plans and to help kind of direct resources and allocate resources to where they are most needed most urgently. And of course, part of that is through the Covax facility through the WHO to help distribute vaccines, and there's certainly more that we can be doing as a country and, you know, as a university to feed into those kind of policy processes and, and that, I think, really needs to be a priority in terms of short term meeting the short term needs in India.

Vivienne Parry  23:37  
I know that in the UK, the experience of Italian doctors was incredibly important at the beginning of the pandemic, in explaining what were the best things to do. And actually, as you get more and more patients in, your options become ever more limited. So actually, the experience of others suddenly becomes both incredibly important, and actually really comforting that, you know, others have done it, and there is light on the other side.

Vageesh Jain  24:09  
So I agree with what you said and really the key bit will be the recovery now, you know, what's this kind of pool of susceptible individuals decreases then there's a lot that we can do in the UK and from UCL and through collaboration with with global bodies to really help India recover and build back and make sure that you know, we prevent another wave happening in the future.

Vivienne Parry  24:31  
Shikta, a final word from you.

Unknown Speaker  24:32  
My final word would be within that this is a global problem. This is not just India's problem and a pandemic life course we know that if it if this wave happens in India, it can spread quite easily which what we are observing here. I would say another important issue which nobody would ever consider being an Indian myself is mental health. I don't think anyone is even thinking in that terms. So that is something we would have to work on in future with India, and as Vageesh correctly said, there will be issues further on which we can help with as

Vivienne Parry  25:04  
well. Thank you both for caring today and let's do all we can to help and just make sure that that message about this is a whole globe effort has been received. You've been listening to Coronavirus the whole story. This episode was presented by myself Vivienne Parry, produced by UCL with support from the UCL Health of the Public and UCL Grand Challenges and edited by the lovely Cerys Bradley. I was joined today by Dr. Vageesh Jain and Dr. Shikta Das. If you'd like to hear more of these podcasts from UCL Minds, subscribe wherever you download your podcasts, or visit ucl.ac.uk forward slash Coronavirus. This podcast is brought to you by UCL Minds, bringing together UCL knowledge, insights and expertise through events, digital content and activities open to everyone. Hope to be with you again soon. For what will be our 50th edition. Bye for now.

Transcribed by otter.ai