Coronavirus Outbreak: It’s A Long Road To Normal, Says Leading Epidemiologist J Muliyil

Get used to social distancing, says one of India’s leading epidemiologists Dr. Jayaprakash Muliyil. “No large gatherings, you may not have big crowds, big weddings, big parties for probably another three more months,” the former principal of Christian Medical College, Vellore and one of India’s leading epidemiologists said in an interview to BloombergQuint.

The 21-day lockdown announced by Prime Minister Narendra Modi on March 24, was the only thing India could try, given the nature of the disease, India’s economic status and heath resources, Dr. Muliyil said. Two weeks would have been too short a time, 21 days is the minimum possible time, according to him.

The lockdown will help reduce the immediate load on healthcare facilities and correspondingly reduce the ‘avoidable deaths’. Those who die due to lack of facilities such as ventilators. But ultimately enough people have to become immune to the disease to meaningfully slow its spread. Dr. Muliyil estimates herd immunity at 55 percent—more than 5 of every 10 people will have to be infected by the disease for India to achieve herd immunity.

Till a vaccine is discovered, fighting Covid-19 will require a cultural shift, he warns.

Eventually, many precautions currently being taken in public places, office and factories may become a norm, at least in the medium term. Screening mechanisms, early diagnosis, isolation facilities — the doctor says now the approach is piecemeal but in time it will get institutionalised.

Watch | Dr. Jayaprakash Muliyil in conversation with Menaka Doshi

Edited excerpts from the interview...

Will This Lockdown Work?

How effective do you think this lockdown will be?

You’re starting with the toughest question. This is the only thing we could try, we have no alternative. Given the nature of the disease and the background of the country and the economic status, health resources, we have no choice but to try this. Because if you change the mean physical distance between two individuals on an average day’s contact significantly, there should be a reduction in the transmission of the virus and it will make some difference at least. How much is a question that is difficult to answer. It depends on the penetration we obtain in terms of informing people at all the villages and middle towns and panchayats as to how important it is to block the transmission. If that works and there is a reduction in the transmission rate, we will probably be able to avoid the number of cases that we are expecting in the absence of a lockdown.

Are 21 days enough?

At the end of 21 days, the advantage is we will know whether it has worked at all or not. Two weeks is two short. 21 is the minimum possible time. It may have to be extended but 21 is probably the right choice because we will have some indication whether it has worked to some extent.

Is 21 backed by science in some way?

The cases that will emerge during in the next one week would have been people who have been infected earlier. After the lockdown, if the transmission comes down, then the impact will start showing after one week. So by three weeks, we’ll be able to know if the rising trend of an inflationary, or what I call an exponential rise has been, has to some extent altered.

Last reported figure was 562 Covid-19 patients in India. Does that represent an exponential rise? Are we at that stage already?

I think we have chosen the time (for the lockdown) pretty correctly because we have established that there is community transmission. We haven’t gone into but are just about to enter into that phase. If we had waited some more time, it would have been a disaster.

And this 562 number – do you believe it accurately represents the number of infected in India?

It is a few thousand.

You’re saying at this point in time, we might already actually have a few thousand infected, but we don't know because we haven't tested enough?

That’s why this (lockdown) will work. This is all poised to shoot up. That’s why we have to interfere. You might ask why we couldn’t have interfered one week ago. I don’t know the answer to that. But if you would have delayed any further, it would have been not so nice.

Will We Need More Lockdowns?

Let me ask you a question that all citizens are asking, both from the point of view of health as well as their economic concerns. Is this likely to be the only lockdown that we will likely see? What happens after the lockdown is lifted?

The problem is that we are only going to alter the evolution of the epidemic. We are actually buying time instead of, say more than 100 million Indians getting simultaneously infected in the next three months can be altered to some extent. If it works out, it will change the way we are coping with the whole thing. The thing is if you if you really asked me what would be the impact of this in terms of saving lives — they’re actually aiming at the proportion of severely ill. You understand, that one proportion of severely ill who seek tertiary care at a second level hospital, and they need ventilator support, and if we are not able to provide you lose them. That’s where we would have been found wanting. So if you stagger them, as you know already, there is a good chance that we can reduce the number of losses of avoidable deaths.

What should be the number of infected patients reported in the third week of this lockdown that will give you some degree of assurance that we’ve managed to avoid the exponential rise or might, to the contrary, tell you that we haven’t been able to do so?

The unfortunate part is, testing in general has been a weak arm in our mentorium. The first problem is the availability of tests. The second is the problem of implementing it. Now that the tests have become available, we are in a better position to test.

The second issue you're asking, how will you know it has made an impact or not. It's a tricky question, I understand. But the first two weeks’ cases will be an indicator compared to the previous week. First post-shutdown week would give you valuable data on the direction of the inflationary trend.

After three weeks if this lockdown is lifted, we will still have infected people in the system? Will we need another lockdown to curb the spread yet again?

The thing is, if you lock down and change the behaviour of the people, and in general, you keep this distance of one to two metres in general, you can make an impact. So, there are two things involved. During this three-week period, people learn to keep distance from one another. Education that to maintain close contact for some more time is dangerous. But as an epidemiologist, I know ultimately, people have to become immune. But the point is, if the transmission dynamics are slightly altered, we will be able to build up herd immunity and not at the cost of life. The recent statement from the Israeli Defence Minister — ‘We need to take care of grandma and grandpa, but from far away’ — now keeping the elderly away as the epidemic smoulders, not dies off, smoulders, will be one way of building up immunity without losing too many lives. I hope in the process, the vaccine will become available.

None of this is going to happen in three weeks.

It is just going to alter the shape of the curve. It will just flatten it somewhere. I agree it is not going to change anything. People will still get infected but you can reduce the R0 (reproduction number) by making sure the number of contacts per person- that infected person - is reduced because of behavioural change. We have to be invested in it, we have to demonstrate that it works and we should give hope to the people by keeping it that way. That’s how we can keep the disease down. Now, that will not be sufficient to eradicate it, I agree, but at least the rate of transmission will come down somewhat.

‘Flatten the curve’ has now become part of all of our vocabularies. What is the scientific definition of herd immunity and at what number of infected in India would you say we will achieve it?

The herd immunity of sufficient strength will occur within about 100 days. That is, you let things happen without any intervention, ignoring the whole thing. That will be a quick way to achieve that. My estimate is that, in that hundred days there will be about two and a half million deaths in that age group 60 plus.

Given this lockdown by when do you think we'll achieve herd immunity?

Well, that will be delayed and the delay and also what is the level we need is an issue. Now, I spoke earlier in another situation that it will be probably at 55 percent but there are other estimates which claim it can be less. There are even other estimates which say it will be higher, but I can't argue about it because I have no way of - but, let me say 55 percent is my expectation given that I'm making a very calculated guess R0 of 2.8. Many institutions have come up with models, they have used 2.4, and the most pessimistic of them is R0 5. So based on this, let's say 55 percent and then we get a respite, of the nature of the disease itself slowing down. Now comes the area of how to manage to direct the infection mainly in the active group, the isolated adult population, and the mature population is not all that get infected. So the demographic structure of our country is such that, there’s a very tiny top section of the pyramid and the bulk is younger. The younger people when they get infected, they become immune, or according to our hope immune forever, that will maintain the herd immunity. The senior citizens are the problem.

You say 55 percent; I hope I understood this correctly, you're saying 5 out of 10 people in India will have to be infected by this virus for us to have reached herd immunity level. Is that correct?

No. 55 percent is even more than half.

When Will Life Return To Normal?

Is there any science, Dr. Muliyil that suggests that the onset of warmer weather might actually help slow the spread of this disease?

I would like to believe in it, but I don't know. I don't think, but it is difficult to explain, I can understand to some extent this may not survive too long outside in the warm weather but please don't forget our body temperature is 37 degrees Celsius and the virus infection lives there and multiplies.

Even if we are able to slow the spread of this disease till we reach herd immunity, are we in for several months of social distancing? Six, seven eight to 10 odd months?

I don’t want to call it social distancing, I think you should still smile at people. I am only talking about physical distancing. All that matters to the virus is, there should be somebody close by for the infected person to transmit the virus to the other person You can still be waving at each other, be pleasant. The closer the conduct more the risk of transmission.

By Indian culture, the physical contact in general is limited. So, we already keep a little distance in our general work space and in our neighbourhoods. My worry is in our culture majority of people have no notion of virus, bacteria, herd immunity nothing. What story do you tell them to make them understand? How do you get them to play the game with us; and make them trust that this game they're playing, saves them contamination. Everywhere, they will be playing with each other; they'll be interacting with each other. This is a country where Measles is a mother goddess, do you know chickenpox is another goddess. It's difficult to communicate the notions of the virus, multiplication and transmission and things like that. So that is where we know we need grass root level transformation. I think we need volunteer organisations, people who are already in the field in various ways, and a multi-sectoral approach to make the story understandable for them.

Even if we are able to flatten the curve, how many months of physical distancing will we need? To sort of arrive at some sort of safe position in this country? The reason I ask you this whilst we might still be able to influence people through cultural change, social interactions, what happens to the economy? Of factories being able to come back online, people being able to commute to work in crowded trains?

I don't have any argument with you. In fact, in an earlier communication I have said that a strict clamping down would lead to social unrest, it will be detrimental to India. But the government move has been gentle enough so people can do it. Because an excess of it is going to have the people react badly.

I told you all we have to do is, wash your hands is fine but more importantly, keep physical distance. So there's no harm in walking on the road, no harm in going into a grocery store, no harm in going to the office as long as you keep distance from one another and this is the only inexpensive method. You don't have to invest anything in it. But make people believe that this will work and it does work. There's no doubt about it. So the intervention required doesn't cost any money. Life can go on without people getting too close. I'm not talking about family members.

The greatest relief is that the younger people are pretty safe from the disease. So you put that into equation. I think we should programmatically. I think this idea of telling people that don't get too close, followed by gradual build-up especially in the younger groups, without hurting people may save lives. Ultimately, we have no other option except to go for this huge increase, exponential increase where millions get infected and millions die.

So if I understand this correctly, if the data in the third week of this lockdown suggests that we have succeeded in flattening the curve...

...With community support. We can prolong the battle by keeping the distance and encourage them to do it for some more time but it will gradually go and gradually return to normal.

And what about factories and workplaces?

They will go on, they will go on. There'll be some screening mechanisms in factories with large numbers of workers, early diagnosis and isolation of people. Now they do it piecemeal - we don't even have places to isolate people in a humane way.

I wanted to talk to you about the current capacity in India's healthcare system to be able to deal with this kind of herd immunity. We may be able to flatten the curve and take the load off the healthcare system in the initial months. But are we equipped to deal with it over the course of the next six or nine month? What needs to be done on a priority basis?

You have asked me a very painful question. The healthcare expenditure has been pretty low throughout. This is a kind of clarion call to say, ‘Hey, Buck up, do something differently.’ I think this message should go in. These care centres, what we call silo hospitals, first referral units- something like that - are our main stay of the country. Now, we did under the Matritva action something to improve the facilities for pregnant women and babies. I think it would need the next step of improving facilities. But care of a person requiring ventilation is going to be very difficult, the need to transport people. There should be some sort of a thought about having some district-level care centres which are capable of absorbing some of this, or else it will be too risky to say these things without giving it adequate thought. But we are woefully lacking to meet the demand in the context of a big influx of cases - that we are aware of and we feel sorry about it.

The government just announced a Rs 15,000 crore allocation to healthcare facility and many state governments are suggesting they might have Covid-19 dedicated healthcare facilities - are those good measures to begin with?

That is good. It will be Covid today and it will be something else tomorrow. I think we have to increase our facilities. The point is no country in the world can face an influx that Covid-19 has created. You know that. So you don't have to feel sorry about it. But it really brings out that how hardly anything is available in many parts of the country. So it's quite good at least we make a new beginning with this.

Only issue I want to leave with you is that everybody should at the end of the day understand the power to reduce the intensity of this epidemic. It lies in your hand, my hands and each Indian’s hand. If we individually, each family, fight against the disease, it will make a difference. No government, no International agency, nobody can help us. We have to do this work ourselves. For this, the only requirement we are asking is to be meticulous in terms of protecting yourself and protecting others. If you can pass this message instead of worrying about where the ICUs will be, there won’t be any. It itself will make a big difference in the difficult scenario here.