Why India's COVID outbreak is so big

Brown University physician Ashish Jha explains...
04 May 2021

Interview with 

Ashish Jha, Brown University


Indian flag


We’re close to a year and a half since the start of the COVID-19 pandemic. So far, almost 150 million cases have been reported around the world, and while some countries have - for the moment - eliminated the disease, others are in the throes of their worst outbreaks yet. Why have nations like India leapt out of the frying pan and into the fire? Ashish Jha, dean of Brown University School of Public Health, explained to Chris Smith...

Ashish - I think you set it up right, Chris - that there are some places that are doing quite well, but much of the world is really in the throes of some of the worst days of the pandemic. We are generating almost a million infections a day across the world right now. And of course, India and Brazil are really the two countries most affected, but many parts of Europe still seeing very, very high levels of infections; whereas both the UK and the United States - and a few select other countries, like Israel - have managed largely through vaccinations and public health measures to get the virus under reasonable control. So it's really quite a mixed picture, but I would say the world is still in the throes of this and nowhere near done with the pandemic.

Chris - Indeed - this was the heartrending news emerging this week from the world's second most populated country...

International help is being pledged for India as it battles a ferocious second wave of coronavirus, described by Prime Minister Narendra Modi as a "storm that has shaken the nation".

Chris - What's actually going on there, Ashish? Why do we think that India has become a victim not once, but twice?

Ashish - The second wave has really hit India very, very hard, and it's not done. It's probably going to get worse over the next couple of weeks before it starts getting better. There are, I think, three or four factors that have contributed to India finding itself with 350+ thousand infections per day... and by the way, surely a huge underestimate of the true number of infections. But how did we get here? We got here partly because there are new variants. The B.1.1.7 that originated in the UK is widespread in many parts of India; there is a variant in India itself, originating from India itself, that also appears to be pretty widespread. I think those variants are clearly causing a huge spike in infections. You also have a bit of seasonality, and seasonality around this virus has been very strange to wrap one's arms around, but it does appear that the virus spreads more efficiently during low humidity time periods, and many parts of India - February, March, particularly March and April - tend to be time periods where humidity levels drop, so maybe that's made transmission easier. And then the big thing in my mind - at least one of the big things - is that there was a sense in India, back in January and early February, that India had somehow beaten COVID; that it was over, the pandemic was over. And one of the things about this virus is, every time you let your guard down it punishes you. And that is what has happened in India. India more or less opened up, relaxed all public health interventions, and then saw these huge rallies, huge religious gatherings, and they have clearly fuelled a lot of the infections that are happening right now. So a variety of factors have contributed, but we are now at a point where things are really quite dire. And obviously we've seen those heartbreaking images of people dying in front of hospitals because there are no hospital beds, no sterile oxygen. I think India can turn this around, but it's going to be a difficult few weeks.

Chris - Of course the thing - and you mentioned that the scenes of people who are passing away - the thing that perhaps people haven't grasped yet is, this is the tip of the iceberg, because those people - 350,000 a day catching the infection - are going to translate into very significant numbers of people dying every day in three or four weeks' time.

Ashish - Absolutely. This has been the pattern of the pandemic: the infections precede the hospitalisations, which precede the deaths. And that will happen in India as well. Some of that lag is because usually we can get people into hospital care, and they die weeks later because we're able to prevent some of those deaths. If there's no oxygen available, those deaths are going to come faster and obviously be much more severe. So right now, officially, there are about 3000 people dying a day; unofficially, I think many of us believe that the true number may be five times that, so 10,000-15,000 deaths a day. That's going to go up quite substantially in the weeks ahead. Again, very, very hard times - arguably the biggest health crisis that India has faced in a century,

Chris - Obviously one of the mainstays of trying to stop this pandemic is the argument that prevention is better than cure. And that's where vaccines come in. And we've actually had some good news just in the last few days from Public Health England - their study shows that there is quite an impact on transmission. Here's the UK health secretary Matt Hancock speaking to the Guardian's news channel...

It not just reduces hospitalisations, but also it reduces the number of people who have COVID at all - even asymptomatically - by around two thirds.

Chris - Basically what they're saying is that they've now got good evidence that these vaccines do interrupt the chain of transmission of the infection. And that must be something that India is absolutely going to have to rely on, isn't it - getting vaccines into people quickly in order to cut down the numbers of cases?

Ashish - Yeah, absolutely. I think we've had pretty good reason to believe that these vaccines reduce transmission. But of course every vaccine is a little bit different; it's been good to see the data now coming out of the UK about the AstraZeneca vaccine, we've seen this with some of the others as well. This is one of the reasons why in the United States, for instance, infection numbers are dropping, despite the fact that public health measures are not really being taken all that seriously, and it's because we've vaccinated so many people. This is going to be crucial for India in the weeks ahead - getting large numbers of people vaccinated quickly will really make a big difference.

Chris - One of the interesting things about vaccines is that in some instances - you've mentioned AstraZeneca - it's been very much, "we will do this at cost, and produce enormous volumes of these vaccines, and get them to as many people as possible, because we recognise that not everyone can afford to pay extremely high prices, but also, it's not over 'til it's over everywhere." Some manufacturers, though, are charging premium prices for their vaccines. There've been calls for the patents on these vaccines to be suspended so that people can manufacture them just about anywhere, and therefore help to boost the supplies. Let's have a listen to what they're saying...

Over 100 Nobel laureates and 75 world leaders - former world leaders - have already signed a letter to the US president Joe Biden calling on him to suspend patents during the pandemic.

Chris - That was Canada's CBC news reporting. Is that the issue, though, here? Or is it actually just that we're already maxed out in terms of how fast we can make vaccines? It's not the patents that are holding things up - it's our ability to make them?

Ashish - Yeah, unfortunately I think the issue is much bigger than the patents. Because if it was simply an issue of patents, that'd be great, and I would of course support then making the patents open, because it would quickly allow us to scale up manufacturing and get the world vaccinated. There is no question in my mind that what needs to happen is we need to produce billions of doses of vaccines. We need to do it in a way that is free for people who are receiving it. I'm happy to have governments of various governments pay for it at different levels, depending on your income. And personally, I think that the rich countries can fund it for the whole world. I don't think money is the problem here. The fundamental problem is manufacturing capacity. Vaccines are very different than medicines that we usually think of. Lots of companies can make medicines; vaccines are biological agents that just are difficult to make reliably and effectively and safely. And that manufacturing capacity is not widespread. And especially when we think about the mRNA vaccines - the Pfizer/BioNTech vaccine, the Moderna vaccine - those are particularly difficult to make. And what you need is, you need the patents to be open, or you need patent transfer - but you also need technology transfer, you actually need the know-how to be transferred. None of this is saying, "you can't do this," or, "we can't expand," but I don't want to get distracted by what feels to me like a simple solution that actually won't make a difference - which is a fight over patents. What I want to do is figure out - how do we bring on more manufacturing capacity? How do you work with governments to identify who can make these vaccines, train them up, provide the technology, and get going on vaccine production? That's going to actually require the cooperation of the pharmaceutical companies that are making them right now, because they are the ones who have the know-how, not the governments. And that's why it's got to be much more cooperative than confrontational.


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