India’s Coronavirus Vulnerabilities and Response

AYRES: Hi, everyone. We’re so glad that you’re able to join us this morning for our conversation on “India’s Coronavirus Vulnerabilities and Response.” This is now the new conference-call mode of my standing U.S. Relations With South Asia Roundtable Series. I hope to be able to do more roundtable events like this, either by conference call or by video conference. We’re adapting our own processes for this new world that we find ourselves in. And I hope everybody on the call is doing well and staying safe and healthy in all of our time of social distancing.

Just delighted to be able to welcome to today’s roundtable Dr. Ramanan Laxminarayan, who is the founder and director for the Center for Disease Dynamics, Economics & Policy; as well as Tom Bollyky, who as many of you likely know is the director of the Global Health program and senior fellow for global health, economics, and development here at the Council on Foreign Relations. I can’t imagine a better combination of experts to talk with us today not only about the broad landscape of what coronavirus means and the way it’s having an effect on all of us around the world, and then a deep dive on how this is unfolding in India and what to expect.

You will all have received in your meeting packets by email a link to a document with their more extended bios. So you all have that. You’ll see that they both are extremely well positioned to be able to talk with us today. As a final note before I ask Tom to provide some introductory remarks. I just want to remind everybody that this call is on the record. We don’t always do our roundtables on the record, but we’re doing this one in that way. So thanks very much, again, for being able to join us. Thank you to Dr. Laxminarayan and to Tom Bollyky.

And, Tom, if I could just turn things over to you and ask you to help us set the stage globally for this moment that we are in.

BOLLYKY: Great. Thank you for that kind introduction, Alyssa. And it’s a pleasure to be on the call here with Dr. Laxminarayan. The eyes of the nation, of course, are on what’s happening here domestically with COVID-19, the novel—the disease caused by the novel coronavirus. But we mustn’t lose sight of what’s happening abroad on this pandemic. If it wasn’t obvious to you already, it should be obvious by now that no country is going to escape this pandemic. There are now approximately 1.5 million reported cases of COVID-19 in over 180 countries and territories. We’re all likely somewhere on the same epidemic curve together. A handful of nations are ahead of us and slowing, like Italy and Japan. And then there are others behind us, like India, that are growing rapidly.

U.S. policymakers and the public would do well in surmounting this terrible outbreak if we learned from those ahead of us and behind us on that curve. That’s in part, for those ahead of us, because our models are informed—our disease models, our expectations based on what can happen on this pandemic—are informed about what’s happened abroad in places ahead of us, like China and elsewhere. And it’s good to be explicit about what we know about those settings and where the limitations are. What’s happening behind us matters also because what has become clear is that this pandemic, until there’s a widely deployed vaccine, is going to be with us for the long haul. Even countries ahead of us are starting to suffer resurgences from imported cases and learning from those behind us is going to be relevant for how the U.S. handles similar circumstances when and if we get to that point.

Beyond that, India matters, of course, for other reasons. It’s a hugely populous nation, 1.4 billion people. It has a strategic—of great strategic importance to the U.S. as well. But from a global health perspective, what’s happening in India may be more predictive of what’s going to come in this pandemic than what we’ve seen here domestically in the U.S. The U.S., from an issue of—there are three issues there that I’m watching that I think are going to be relevant. The first is on the urban dimension of this pandemic. The U.S. has had somewhat of an odd experience in that regard, where we’ve really had four different settings be hit by this pandemic.

Large, dense superstar cities like New York, industrial centers connected through supply chains like Detroit, tourist meccas, ski communities, the Hamptons, and the like, and also small and vulnerable populations. But in other settings what may end up mattering are more your traditional concerns around urbanization of deeply populous and dense environments. And India certainly has those. In particular, large informal urban settlements, slums, which are going to be relevant both for their own experience but from what we might expect in sub-Saharan Africa, or North Africa, or other settings, as well as this pandemic spreads there.

The second issue that I’m watching is chronic diseases. Age is certainly a critical factor, but so are comorbidities, other illnesses that people have. To some extent, these issues have been lumped together in the U.S. because in New York, for instance, many of those who have succumbed to this disease have been both older and having these comorbidities. India, of course, has a younger population, but also a high level of cardiovascular disease, diabetes. As low- and middle-income countries go that might be more predictive, again, of what we’re going to see in the future in other nations.

The last issue I’ll raise before turning it over is health systems. India—this is where India, I think, may have a lot to teach the world—historically has been a country that has been able to innovate on health care delivery at large volumes and low cost, and adapt to more limited circumstances better than most other nations of the world. What India does in response to this pandemic, I think may set some very useful models and useful lessons not just for other low- and middle-income countries, but for how we might be able to start to provide services at scale as well.

And with that, I’m really looking forward to the remarks of Dr. Laxminarayan. And let me turn it over to him to take it from here.

AYRES: Thanks, Tom.

Dr. Laxminarayan.

LAXMINARAYAN: Thank you. Thanks for the—hi. Thanks for the kind introduction and also for laying out the lay of the land in terms of where India stands. And lots of similarities, of course, with what may happen in some other countries.

So let me begin at the beginning. India had its first case in late—actually, on January 30 from three students that arrived from Wuhan. This was part of evacuation flights, and the students were medical students. And then they were quarantined. And India really didn’t have any more cases that we were aware of for another month after that. But even right after that, flights to China was stopped as soon as somewhere in early—I’m sorry, mid-January. And then the actual wave of cases that seeded the epidemic in India came in the form of tourists from Italy. Obviously Italy was unaware that it had an epidemic going on right there. And Italian tourists had arrived. And there were clusters then that showed up.

You know, one cluster in Jaipur, which is a tourist area, and then there were other people who came into India from outside of the country. And in response India had airport screenings. Not particularly effective, because airport screenings are terrible for coronavirus just because most people are asymptomatic. But in fact they had to do that. But very soon there were restrictions on anyone from abroad coming into the country, and then, soon after they completely stopped issuing visas and so forth. And of course, during the lockdown all flights are also cancelled.

Now, it’s impossible to really stop the virus from getting into India, as it is impossible to stop it from getting into the U.S., just because a large country, about eighty thousand arrivals every day from Europe, but also from the Gulf States, where transmission had started already in February. And India has a large expat population in regards to—(inaudible)—in countries like Qatar. There are more Indians there than are actually Qataris. And these folks all came back to Kerala, there were people who went back to other parts of India. And, you know, absolutely impossible to figure out who had the virus and who did not.

Now, all of this unfolded, obviously, rather quickly after March 1, and was just about five weeks after that. And nothing much happened really in terms of preventing transmission within the country, because India was treating it as if this was going to be a case where you could use track, trace, and contain epidemiology, where you look at someone coming in, look at their contacts, and then you can isolate their contacts in quarantine. So part of this method was simply because India didn’t have detecting infrastructure within the government setup, and it just was not ready to expand this out into private sector either. But obviously for a country the size of India, it’s practically impossible to prevent transmission into the community.

So for a long time, India was also amongst the lowest, you know, on the test table—the testing for COVID. At one point it was, actually, the lowest of any large country, except for Indonesia. It had lagged in there. And, you know, all this continued, and—but of course, there was more seriousness about social distancing. Hard to do in India, except if you have the space to do it, because if you’re in a slum, and twenty people living in a house, how in the world do you socially distance or physically distance? There were a few that were made by the government to not have religious gatherings, and weddings, and so forth. But people really didn’t pay attention. I mean, everything continued.

Of course, some people stayed back, and some offices shut, but not everyone was really in compliance. And the only option really was that, you know, India had to sort of—and until that point, it was also a bit of a narrative to say that India’s different. You know, this is something that’s only in the northern hemisphere. India’s warm, so maybe the virus won’t be here. Or maybe it will be different. We’re already exposed to lots of other diseases, so coronavirus is something that we’re already immune to, or we have, you know, other sort of cures for these, whatever it might be.

Now, that narrative started falling apart quite quickly once it became quite clear that Indians can and do actually get infected. And of course, there were these issues about India having high rates of hypertension and diabetes. About a third of India’s adults are hypertensive, and about a tenth of India’s adults are diabetic. And then you also had the issue of respiratory illness. Even in the best of times, India has high rates of pneumonia, poor air quality. So lungs are not great. And when it comes to respiratory diseases, this is not really the place that you want to take a chance.

So the initial estimates which we had come up with were not dissimilar to what nearly every other modeling group said, which is about 25 percent of the population will be infected. Not all with symptomatic infections but, you know, most of them would be asymptomatic or with mild infections. But this is roughly ballpark for any country if you are not going to apply the brakes with a lockdown. But even—you know, if that were to be the flow, then the estimate was that there would be about ten million people with severe disease at the peak, most of whom would have to be hospitalized.

Now, ten million patients with severe disease was just way too much compared to what India could manage. India has about a hundred thousand intensive care beds, and somewhere between twenty (thousand) and fifty thousand ventilators. Still unclear where that really is. But whatever it is, even if you have fifty thousand ventilators, you can’t take care of ten million patients. And you can’t take care of them with a hundred thousand intensive care unit beds. So this is where India sort of stepped in and said, listen—or, the government stepped in and said: We’re not going to take this hit on the public health side.

Although it wasn’t officially stressed that way, I think it was very clear that a lockdown was really the only solution. And a few options were thought about. But there were challenges with doing a lockdown only in some states and not some other states. You know, getting everyone to take the message seriously. And therefore India just imposed what I would consider a hard lockdown. And I have to say, even I’m surprised. It’s something which you don’t think is possible in a country like India, which in the best of times can be chaotic, and people don’t really follow the rules.

But the lockdown seems to have really achieved the purpose of not having people out in public spaces. So for the most part—there have been a couple of exceptions—but for the most part that’s actually happened. Now, the flipside of this is, of course, that the lockdown was imposed rather hastily. And to some extent it’s excusable because these are decisions that are being made on the fly. And the consequences of waiting a few days could have also been quite large. And it’s important to shut down when the contagion has not spread too much. So at the point at which, you know, India locked down, there were fewer than five hundred cases and just about ten deaths.

Literally no country, and none of that size, would have—or, had locked down based on such a small case sample. But it was pretty obvious to the folks working on this that this was just the tip of the iceberg, and it’s probably going to be much higher than this. Our own estimate was that at the time of the lockdown there were probably about twenty-one thousand cases—(inaudible)—obviously, a large proportion asymptomatic. But you know, asymptomatics also transmit, so it doesn’t really help you that much.

So that was the whole idea. And then we—you know, India’s been on lockdown since, I guess, the 24^th of—do I have the date right? I’ve lost track of dates, sorry.

AYRES: Twenty-fifth.

LAXMINARAYAN: I think it’s—yes, the 26^th or 25^th, or one of those dates. And it doesn’t open up till April 14. April 14 is when it actually opens up again. So that was a three-week lockdown, which is what is generally recommended. The economy has taken, obviously, a—you know, has tanked. Likely employment has dropped because unemployment rates have gone up a significant amount. There’s no official figures on this because India doesn’t really do unemployment the way the U.S. does, but all of the—you know, the private sector surveys clearly indicate that that’s the case. And you know, the whole idea was to buy states some amount of time to prepare of what would come next, because a lockdown only postpones the problem.

The lockdown doesn’t solve the problem. And certainly, a certain amount of preparation has happened in this period of the two or three weeks. But it’s still unclear what the endgame for COVID is going to look like, because it’s too late to put this genie back in the bottle and send it out. It’s just not possible. There are too many cases involved. But it’s not going to also be a situation where we easily get to the end by having continuous lockdowns forever and forever. So I think other countries are going to face the same issue. You know, China as well. Europe also, to some extent. And of course, the U.S.

So this is going to be a conundrum. How do we deal with the long game of COVID, now that we’ve maybe not been completely wiped out in the short game? And that’s where India finds itself. And the indications are that states in India, which also have considerable voice—and which are not of the same ruling party as in the center—are not really sure that they want to open up just yet, because they’re acutely aware that their health systems don’t really—are not really prepared for what’s coming up.

There’s obviously a lot of heterogeneity in India because some of the southern states, in Maharashtra, in Punjab, have really good health systems, relatively speaking. And Kerala of course you know, many advanced countries, or cities in advanced countries. And, you know, states like Bihar and Chhattisgarh are the opposite as well. So for all of that contained in a single country, it’s not clear how one would tackle this problem in some sort of a coordinated fashion, because obviously what happened in one state has consequences for other states as well.

So that’s just a brief introduction. And I can talk more about India’s health system and capacities if there are questions about it. But this is the COVID situation in India at this time.

AYRES: Thank you. That was a great overview. I’d actually like to follow up with something you spoke about a little bit. If you could give us a little bit more detail on the testing situation, because it seems that India has really begun to ramp up the testing only recently, including by pulling in the private sector. Can you talk a little bit about how this transpired, where is the testing going? It seems by all accounts that actually the most important thing needed to be able to get back to a normal life economically is going to be having that testing capacity.

LAXMINARAYAN: Yeah. I mean, even the U.S. doesn’t have testing capacity. If you think of India, which has four times the population and far fewer RT-PCR machines, testing capacity is a challenge. And then we’ve got to think about what we’re using testing for. So I think the thinking going forward would have to be along some lines of the following—along the following direction, which is: We’ve got to make sure that we’re getting the testing for early identification of the elderly population who are most at risk. So that’s where a lot of the RT-PCR will actually be going.

We’ll probably use—some states have already announced that they might use pooled RT-PCR. Basically you pool samples from multiple patients, and then you’re able to identify clusters of infection, and use that for community containment. And side by side, we really need to do the serology to see who are—you know, the proportion that has experienced the infection and, you know, has converted. And therefore that would allow us to know how much of India has actually experienced the infection, without actually going through a symptomatic phase.

Now if you think of the positives for India, the big positive for India is that it has a relatively young population. So only about 6.5 or 7 percent of India’s population is above the age of sixty-five, which is astounding if you think of it. Even China, that proportion is about, you know, 11 or 12 percent, or Italy that proportion is 22 percent. Which means theoretically India could achieve herd immunity—I mean, I say theoretically because obviously—you know, making it happens requires a whole other kind of game—it could achieve herd immunity without a single person above the age of sixty-five actually being infected. And that just means that the virus gets knocked out because it’s running into too many immunes who are not going to be good carriers for the disease.

Now those are the advantages for India, but we won’t know that until we have a serological survey, which we don’t really have for any country at this point just yet. So it’s not just testing. It’s also testing for community containment within the Real Time-PCR. It’s also a question of having the serology testing, which, at least in my opinion, is probably the most important thing that India could be doing right now.

AYRES: How far away is India from being able to do the serology testing?

LAXMINARAYAN: It’s probably a week or so. I mean, it’s receiving high priority. And in fact, after I get off this call I’ve got to make slides for the government on this—(inaudible)—and so forth. So this comes—yeah, so this is high on the priority list.

AYRES: So it’s near term. It’s not two months.

LAXMINARAYAN: No.

AYRES: Let me follow on another issue that you raised, which was the fact that India does have a federal system, and you’ve got different kinds of health care capacity in different states. Can you give a little bit more detailed landscape of what that means, for our participants on the call?

LAXMINARAYAN: So India has a largely privately-based system, and the poor go to the public system. But the public system has been systematically underfunded for a very long time. India spends only about 1.5, 1.4 percent of GDP on public funds for health. Overall, it adds up to about 4.5 percent, but that’s including private out of pocket payments.

So anyways, as hard as it is to imagine, India is a more privately based system than even the U.S., which we think of as a largely privately based system. The U.S. has Medicare and Medicaid, and India doesn’t have that kind of a system just yet, although—the Ayushman Bharat is really meant to be that for the poor. Now, the number of doctors is immediately strained. There are only about six hundred thousand PHCs (primary health centers), about eight hundred thousand, you know, medical doctors in India. And, you know, of those, three-quarters are in the urban areas, the urban centers. So you have an overall ratio of doctors to patients of one per 1,600 patients—1,600 people across India. But that ratio looks a lot more like the U.S., which is one to five hundred in the urban centers and it looks much more like sub-Saharan Africa when you look at rural India, where the ratio would be one per eight thousand or one per ten thousand, which is the national average for Kenya, for instance.

So huge divide right there. Number of hospital beds—again, most of these hospital beds, 2.3 beds per one thousand population, only one hundred thousand ICU beds. Most of these are just in the urban centers. So if you’re not in one of the urban centers, you’re totally out of luck in terms of either getting the professional that you need, that I think is the first step, or then the bed that you need. So these are—it’s difficult.

A senior bureaucrat from Kerala, which is probably our best state in terms of health and education, said recently you can’t build a public health system to tackle an emergency in the middle of the emergency. And you know, he’s absolutely right. We are struggling in places like UP and Bihar because how in the world do you put in place a system in the middle of what’s already a massive crisis? And how well can you in two weeks round up the doctors, and the nurses, and the infection control protocols, and the beds, and the ventilators, and the oxygen flow masks, and the oxygen cylinders, and everything else that you need to make a system work? It’s pretty difficult.

AYRES: Yeah. I mean, I think that’s exactly why people are worried about how this may unfold further in India.

We have a lot of people who are on the call. Todd (sp), can you provide instructions for how people can ask a question, and then we can probably turn to opening up?

OPERATOR: Yes.

(Gives queuing instructions.)

AYRES: And let me just follow up with one question of my own again before we take the first call—question from our participants. The issue of air quality, this is something that people have mentioned as something that contributes to some vulnerability to COVID-19. Can you speak a little bit about that? Is that what you’re seeing so far in India? Or is there just not yet enough data?

LAXMINARAYAN: So there’s not yet enough data. So first of all, if you look at the age profile of deaths from India, the average so far looks like the Italian profile, shifted down twenty years, right? So we actually have young people die. And that’s possibly because obviously a lot of people in India are young. So that’s possibly some of it. But the other part of it also is this notion of—(inaudible). When people are subjected to bad air quality, there’s a high rate of smoking, there’s poor nutrition, all of these mean that it’s actually not the case that Indians are less susceptible to infections. If anything, they’re more susceptible to infections. And we don’t know how that’s going to play out. So that’s one big unknown.

The second big unknown is seasonality. We don’t really have good data to know how much the heat in India is going to help us out in India, whether it follows a flu season kind of a track. So if that does, that gives us a bit of a reprieve, you know, for the next few months. But unclear how that plays out. We’re also not sure about how the virus itself evolves. India is a massive country. And if you really think about it, this is where the virus is really going to get shaped in terms of virulence, and so forth. And to some extent, the lockdown and the distancing in India could have an effect on how the virus itself evolves. So there’s many, many unknowns here.

And as this is sort of a global scale, we’re learning something literally very few hours, you know forget about every day. So—and there was a study out of Harvard from Francesca Dominici on air quality that, you know, U.S. counties which have bad air quality were more likely to lead to COVID deaths. But, of course, you know, that’s a big challenge because there’s a lot of—places that have bad air quality also have other characteristics that make people more likely to maybe not have access to health care, or something else that would make them more likely to die.

So it’s—the science is still evolving on this, but just as a matter of common sense it seems as if, you know, if you look at respiratory infections and—which is essentially, you know, manifesting as an acute respiratory distress syndrome, that having these sort of insults to the lungs would not be a good idea in terms of outcomes.

AYRES: Thank you.

Todd (sp), can we take our first question?

OPERATOR: Yes. We’ll take our first question from Marshall Bouton with Chicago Council on Global Affairs.

Q: Dr. Laxminarayan, thank you for—and Tom—thank you both for the comments.

I wanted to follow up on two related aspects of this. The first is, I think just as little as a week ago the Indian health minister denied that there was any community transmission in India, and said we’re still basically looking at a cluster vector in terms of the spread of the disease, and that the lockdown might enable that vector to be confined or to be kept as a principal means of transmission. I’d like to have you comment on that. And relatedly, I just listened to a talk by Zeke Emanuel at the University of Pennsylvania, where he describes the likely course of the disease as virtually every country, to a greater or lesser extent, as a roller coaster, with a high peak followed by a somewhat lower peak, followed by a somewhat lower peak. And the question is then are we going to get rebounds once different countries open up to different degrees? And what are the prospects for that in India? Thank you.

LAXMINARAYAN: Should I answer that or wait for another one?

AYRES: Please go ahead and answer it. We’ll go—I think we should probably take a question and you should answer, because not all the questions are likely to be the same.

LAXMINARAYAN: Sure. So I’ll try to be brief. So the second point that was made out of the University of Pennsylvania, that’s absolutely what a disease model would predict. And that’s going to be true for many countries. So I think as all of us think forward, regardless of country, we got to think of what that end state is going to look like. And that end state either ends with a vaccine that comes onboard soon enough and we’re able to protect the population against mass infections, or we see—we try to achieve herd immunity, but not in a not a U.K. sort of a model, but really in much more of a controlled—

You know, I tend to think of this as, you know, when you’re skidding and you’re driving your car and there’s ice, you apply the brakes sort of repeatedly rather than all at once, because then you spin out of control, and then you really don’t have the option of regaining it. You might have to do repeated lockdowns over a period of time in multiple countries. And that’s just a hypothesis based on what the disease models could look like. But I would agree with the fact that this is only, as someone else put it, you know, the first innings of nine. So we have a long way to go.

On the first one, it’s a bit of semantics. I mean, the Indian government is also trying to manage expectations and fear factor amongst the population. And the fear and panic are the serious problems, serious enough that people have been, you know, throwing stones at doctors thinking that they carry the virus or what have you. So there’s a lot of ignorance there. So they’re trying to sort of manage this by developing their own definitions of what community transmission is. And now they said that community transmission in their book will be when at least 30 to 40 percent of the cases that they may get reported come from the community without a trace back to an original COVID case or back to an incidence of foreign travel.

I think that’s much more—how should I put it—it’s public health communications that the government wants to do. There is no such thing as a community transmission and a WHO sort of a definition of things. And if you would ask when there was transmission brought in the community, it probably started in early March. And that’s through no fault of India or the Indian government. This is just a highly contagious virus. There’s literally no country in the world that can control this from happening. So it’s not India, it’s just that’s what we’re up against.

OPERATOR: Thank you. We’ll take our next question from Teresita Schaffer with McLarty Associates.

Q: Thank you. I wanted to ask about lockdowns in India. Dr. Laxminarayan, you were quite optimistic about how the lockdowns had worked in terms of people playing by the rules. My question is more fundamental than that. When you have a large urban population that probably live in pretty crowded quarters, how effective can a lockdown be?

LAXMINARAYAN: You know, that’s a great question. And—(inaudible)—is to limit the opportunities for—you know, for transmission to happen. So every instance that you can reduce a bit means that you’re slowing it down. It doesn’t mean that you’ve done 100 percent. But if you shut down, you know, movie theaters, if you shut down workplaces, if you shut down weddings, mass gatherings, sure, you’ve not managed to control it in places where people live in close proximity, at least a lot of the large transmission has been shut down. So certainly there are going to be pockets where transmission will continue, like in slums and housing colonies, places where people live close to each other or noncompliance in rural areas.

But that said, the preponderance of compliance has been—you know, has been quite evident. So it’s really—all these other things that didn’t happen, and on average the transmission—the number of secondary infections that are, you know, one infected person generates has definitely come down. And you know, that’s all we can really do. It can’t be perfect, because if we can literally make everyone stand six feet apart from everyone else for a period of three weeks on the planet, that would be the end of COIVD.

AYRES: Can I just follow up quickly on Ambassador Schaffer’s question? We saw, I think, news today that Mumbai has announced that community transmission is definitely taking place in Mumbai. And there have been cases in Dharavi where it’s not possible for people to distance themselves. What does this suggest for how to provide appropriate care and to try to improve the ability to stop transmission in such truly dense housing circumstances?

LAXMINARAYAN: You know, I think the honest answer is it’s going to be pretty damn impossible. If you take a place like Dharavi, the three things that they could possibly do is section it out into multiple sections, do RT-PCR and figure out the sections with the highest rates of infection, and then, you know, try to focus social messaging—messages on distancing as much as they possibly can. But really, be prepared for a bigger outbreak in these slums, and have the health care facilities ready to tackle these. At some point, we can’t actually control everything about this epidemic, because, you know, it’s like it is given to us. It is—you know, as Ambassador Schaffer said, it’s really—you can’t stop transmission in these places. That’s just how it’s going to be.

In which case, we’re going to have to take some of this on the chin and have the facilities ready for the health care when the moderate cases come out, when the severe cases come out, because that’s just going to be our journey for the next—I mean, I say ours, as in everyone in the world’s journey—for the next six months, or eight months, or what have you. So I agree, there are places where you just aren’t able to stop transmission, I mean, short of pulling everyone out and putting them in a quarantine facility. Even there, there will be transmission. So these are real challenges. I don’t think there’s an easy answer here.

AYRES: Todd (sp), our next question?

OPERATOR: Thank you. We’ll take our next question from Sadanand Dhume with American Enterprise Institute.

Q: Hello. Well, thank you, Dr. Laxminarayan, for your very cogent comments.

I also have a question on the lockdown. If I understood your comments correctly, you suggested that community transmission had already probably begun by early March. And by the time the lockdown was announced your estimation is that there were probably something twenty-one thousand cases, as opposed to the official number which at that time was only about five hundred cases. Is that the case? And we’ve all seen these media reports of many thousands of people streaming out from urban India after the lockdown was announced and heading into their homes in villages across the country. How can we be confident that the lockdown has not in fact speeded up the community transmission, instead of shutting it down?

LAXMINARAYAN: You know, that’s a great point, and something that does worry me. And this is one of the paths which I feel that I wish the government had thought of the migrant workers before. They did address this problem afterwards when it became quite apparent in the media. This is something that they really should have just planned for before. And you’re absolutely right. Now, the only—you know, not counterargument—what I would hope for is that because the disease primarily enters through people who are of middle class or wealthier, that the poor were not that exposed to the disease in the early stages, for the first two, three weeks, because this was still transmitting, you know, primarily through—you know, and there’s a lot of class-based cohorting effect, and age-based cohorting. Contacts are much, you know, closer between people of the same age and people of the same class, as it is with many other countries. So my only hope is that the prevalence in that migrant population was hopefully not large. And if it was not large, then hopefully it didn’t damage too much in terms of rural India. But of course, this is just hypothesis. And we’ll have to see how it plays out.

OPERATOR: Thank you. We’ll take our next question from Sanjeev Mehra with Periphas Capital.

Q: Thank you. Dr. Laxminarayan, thank you for your comments.

My question relates to reports in the media of a group of religious leaders getting together in New Delhi in the midst of this social distancing effort, and over a thousand people apparently who have since been dispersed and have gone back to other locations. How big an impact do you think this will have on the spread?

LAXMINARAYAN: So India was undertesting anyway. And so these folks—so, just so that so everyone knows, this was a sect of Muslims called Tablighis. And they happened to have a convention which they’d organized at a time when there were no actual restrictions on convening. They had people coming from abroad, so Indonesia and other countries in the region, and other countries. And the day that this was taking place there were two thousand of them holed up in one building in old Delhi. And of course, they all dispersed to other parts of the country before the rails shut down. And then subsequently they were found to have transmitted the disease to every—literally, every corner of the country. There were a thousand cases. And I think to date about seventeen dead just from that one explosion.

Now, my point is, yes, do I wish it had not happened? Absolutely. Do we know that it’s not happened in other instances that have not come to life? I mean, India is a complex country. It’s large. It’s hard to know what’s going on with 1.4 billion people. And this could have happened in other areas as well. All these kinds of explosions of many epidemics are what we consider in these models to sort of say that, you know, the—reproductive number or the rate of transmission in India is always going to be higher than it is in other places, like in France and Germany. The people—there’s a huge amount of people. Just physically it’s a lot greater in all respects. And this all feeds into that kind of an average.

So it’s hard to know how much this alone contributed to the epidemic. I would suspect it’s not going to be that significant. Obviously it shows up in the official numbers because these guys do get tested. But I think the bigger questions are really going to be around asymptomatics. I mean, if India finds—does a serology survey and finds that a lot of people have actually experienced the infection and are already asymptomatic, that would be the kind of good news that I’d like to share, because that means that we haven’t taken a big hit in terms of cases for that, even if they were underreported right now. But at least we’re closer on the pathway to getting to, you know, immunity at a broader scale.

So there’s a lot of unknowns here, to be sure. And this is, again, the attribute or the impact of this is certainly a big one.

AYRES: Our next question?

OPERATOR: (Gives queuing instructions.)

We’ll take our next question from Mansoor Shams with MuslimMarine.

Q: Yes. Hello.

Well, I guess what I want to understand was how is India working to prevent misinformation and people not taking the virus seriously, particularly like through venues of WhatsApp and Facebook. Being of Pakistani background myself, I get these random forwarded messages that are coming to me all the time—(inaudible)—and so on. And then, the second part of misinformation, that this lab—that this was a virus that was created in a lab in the United States or in China in an effort to achieve further global power. Thank you.

LAXMINARAYAN: You know—(laughs)—India and Pakistan are essentially the same. You see basically the same problem. People have, you know, lots of time on their hands on lockdown. They are spending it on Twitter or on, you know, watching movies, or of course on WhatsApp forwards. So it’s a dangerous time, you know, from all of those perspectives. And certainly when I talk to—you know, to my gardener, for instance, he is convinced that this is a Chinese plot to wipe out the rest of the world. It depends on who you talk to. There’s a section of the Muslim population that chased down health care workers because they were convinced this was a plot to make them impotent.

So there’s all kinds of rumors floating around there. And I think the government is trying to do what it can. But of course, it doesn’t have control of the information flow that’s clearly on WhatsApp. So this is—I mean, what can I say? It’s a global phenomenon. And even in the best of times there’s now things going around. At a time like this, it’s just many times over.

AYRES: Dr. Laxminarayan, that actually suggests to me the question of what are you aware of that’s being done on the sort of social media or tech side to try to—to try to promote real information and do away with or debunk this kind of false information?

LAXMINARAYAN: So, to the extent possible—so there are two ways in which it is being addressed. I think there’s a lot of positive social media stuff. There’s a lot of positive communication by states. You know, there are cops in every city that are basically putting out these messages on a constant basis. I have to say that I’ve been quite impressed at the response by government in terms of how seriously they’re taking this, and how well they’re responding even on the social media stuff. But you know, you can’t control what goes out on WhatsApp. And that’s something which has a life of its own and certainly—I hear about it in all of these sort of—you know, for all of these theories going around. And some of them start from pretty high up, like the whole chloroquine story, or BCG, or, you know, that—you know, what have you. There are so many things, right? And this is not a time when people have the time to look into scientific experts. Everyone has their own theory. And literally everybody has a Ph.D. in COVID—(inaudible)—at this time. So what can you say?

AYRES: You mentioned BCG (Bacillus Calmette-Guerin vaccine for tuberculosis). Can you speak a little bit about that, or—

LAXMINARAYAN: Well, I mean, I’m no expert on this. I mean, I just know the literature from before, that BCG does have a generalized impact on reducing—(inaudible)—of other infections for reasons that we don’t really know. These have only been epidemiological studies. But the idea that BCG is protective against infections other than really TB is not that—is not so wacky, because there’s been some studies on this. They all typically come from the same group. So never been replicated, but at least the idea has been around there before.

What I find perplexing about this idea that countries that have universal BCG are somehow protected from other countries is that, you know, many countries that don’t have universal BCG now, like Germany now, for instance, did actually do universal BCG before. So—and I forget about Italy. I think it probably had universal BCG as well. So the relevant data point is many people had gotten the BCG shot when they were younger if they were, like, fifty-five years old now. Then I would believe that it’s protective. But looking at countries’ BCG guidelines and saying that somehow that is protective of some countries doesn’t seem to make sense to me. And I have to admit, I’m certainly not an expert on this. But generally, if I were to get a paper on something like this, I would be very skeptical about accepting it. It’s a classical ecological study, with all the ecological fallacies that would make drawing some conclusion quite challenging to do.

AYRES: And the other one, obviously President Trump has been speaking daily about hydroxychloroquine. India’s a big producer of hydroxychloroquine. Can you also talk a little bit about who’s taking that, if at all? If it’s being recommended in India? Are people reserving judgement on it for the time being?

LAXMINARAYAN: So actually hydroxychloroquine has been recommended by the Indian Council of Medical Research for health-care workers. And not everyone in India is sure that that was such a good idea, because the benefit/cost issue for chloroquine in the time of malaria was very different. I mean, there were—you know, it has this impact on arrhythmias. And that’s fine if you’re preventing people from dying of a deadly malaria infection. For an uncertain benefit but for a certain actual population-level risk, it’s not clear that you’d want to do it. I think that’s why Dr. Fauci doesn’t want to say anything more about it, because it’s simply unproven that way.

And even if the benefit were really small, there actually is a known risk associated with chloroquine. Sure, you know, when you had malaria being highly prevalent, it was mixed in with common salt in some countries and it was given out at a population—(inaudible). But it was very different back then. You know, people didn’t have a lot—there were—the rates of heart disease were not that high back then. People didn’t live that long. So the calculus is very different right now. And I don’t—I mean, I would trust WHO or NIAID to issue the appropriate guidance here. And since neither of them has recommended either hydroxychloroquine or the combination—(inaudible)—I would stick with (inaudible).

AYRES: Todd (sp), do we have—

BOLLYKY: Can I actually—

AYRES: Oh, sure, Tom, go ahead.

BOLLYKY: I’m sorry, Alyssa. Do you mind I do a quick follow-up on that question? I completely agree with the assessment. I wanted to ask about the use of export restrictions. With the government having threatened one over the weekend or tried to impose one and then at least partially backed down, obviously India plays an important role in the pharmaceutical supply chain generally, particularly for poorer countries. Do you see what has happened with exports controls in this instance, somehow being suggestive of what might come in the future, particularly if we get to the point where we have a need for low-cost therapeutics, once one is proven to be effective, or even if we get to the point of vaccines. I know people have been hoping this year the Serum Institute of India might have been one of the manufacturing centers for a production of a vaccine at scale.

LAXMINARAYAN: So I think these companies are already gearing up for precisely those scenarios. There are four Indian companies, including Ipca, which is the biggest one, that makes chloroquine. And you know, some of it is short-term posturing, because Indians had been willing to export, and then they quickly turned around and they said, well, we’ll export to this country if they’re really in need. Obviously there’s only a few countries that are actually demanding this drug, and the U.S. is one of them. And then of course, there’s been the back and forth between President Trump and India on this.

So I wouldn’t take any of that—(inaudible). And in a longer-term sense I think the Indian manufacturers do have the capacity to scale up production of generics quite significantly, and also for vaccines. And I think they are looking at the opportunity for a coronavirus vaccine when it does come on board—(inaudible). But not just here. Bharat Biotech is another company that makes a lot of virus vaccines available more widely, and there’s probably a few companies which would all be in that situation. So I wouldn’t look into short-term perturbations of the last week as indicative in any way of India sort of not wanting to play that role of providing drugs and vaccines to the world.

AYRES: Tom, did you have a follow up or should we go to the next question?

Maybe we’ll go to the next question. Todd (sp).

OPERATOR: Thank you. We’ll take our next question from Marshall Bouton with Chicago Council on Global Affairs.

Q: Thank you, Dr. Laxminarayan.

This is for the end of the hour allotted, I wanted to ask you to look ahead. So at least my lay reading of combined sort of opinion of epidemiologists and people like Bill Gates and others, who are all cautioning that—at least in the United States—we can’t really think of anything—returning to anything approaching normalcy or normality until the latter half of 2021, at the earliest. And that projection is, of course, entangled with the expectations of when we might get a vaccine produced at scale for global distribution. And apparently a key possibility for that is what J&J is working on in terms of the antibodies. So could you share with us your thinking at this point, recognizing all the uncertainties you’ve described so well, for what might be the timetable in India?

LAXMINARAYAN: Yeah. I think if you want to ask, again, disease modelers, and I’m sure deeply informed by those as well, a big unknown for us how rapidly the disease is transmitting amongst asymptomatics. We had—you know, this again comes down—

OPERATOR: Sorry. We lost our speaker. Please remain on the line just one moment.

AYRES: Oh, so sorry that happened. One of the risks of moving a roundtable discussion to conference call.

Q: You could tell that’s a vote for not anytime soon, I guess.

AYRES: I mean, I think we’ve all got to worry about everywhere. But the challenge in India is just so enormous. We’re obviously—hold on. This call is—

LAXMINARAYAN: Should I continue?

AYRES: Oh, yes, please. Terrific. We lost you! Please continue.

LAXMINARAYAN: Sorry. I don’t know what happened there.

So I think a big—as I was saying—a big question is how fast the population is getting exposed in a very quiet way, and through the sort of asymptomatic, which is probably likely amongst the younger population, especially the five to fifty year old population, which, you know, has maybe less severe symptoms. So I think we’ll know a lot more on this as more of these serologies have been conducted, because that will enable us to parameterize these models to be a lot better.

And what we should all hope for, whether in the U.S. or in India, is that we hope to have a lot of asymptomatics, and a lot of population exposure—(inaudible)—conversion, you know, and relatively few cases and deaths. And if we can keep one up and one down, then that’s what we would hope for. If we do these serological studies and find that actually not many have been exposed, but we still have in terms of huge costs in terms of cases and deaths, that would just be bad news for us and them. That’s when I would look as an end of 2021 kind of a scenario—or whenever the vaccine arrives, whichever comes first.

So there’s still a lot of unknowns with respect to the disease. And again, the temperature and humidity, which I fully admit we have no evidence to suggest that it will slow down because of heat or humidity, but, you know, one could hope. Respiratory viruses do have a habit of sort of, you know, showing some seasonality. And so I think we’ve known the virus really only since, you know, mid-January, which is really extremely short. Just about three and a half months. And I suspect that in another month, or few months from now, we will know far more in terms of how it behaves. And maybe it’s not going to be as bad as it seems, right?

AYRES: We’re almost to the end of our time. And I’m going to try to ask a very quick question in our last two minutes. Dr. Laxminarayan, when we think about a kind of rolling opening, or we’re seeing now some of the press and some of the debate in India is about how to open up, how to kind of phase an opening and end the lockdown in a way that won’t create more transmission, but will allow the economy to restart. The question that that raises for me is, cities are the economic engine. And they’re also the spaces of population density. How do you envision a kind of gradual opening that will allow the economy to restart? Because the economic piece is so important.

LAXMINARAYAN: That’s a great question. In India’s context, remember that over half of the population really depends on agriculture. So in terms of—the tradeoff is not lives versus the economy in India, like it is in the U.S. It’s really lives versus lives. We definitely don’t want to have mass deaths from hunger and starvation and from rural impoverishment, at the cost of protecting people wherever they might be against COVID. That would be a terrible mistake. So I think that opening up rural India to the extent possible by providing the health care support and the testing will enable that part of the population to get moving, because the density is not going to be as great as in urban India, would be probably the priority.

And then for urban India—which, again, I think that part of India will take—you know, in India, it’s a difference between India and Bharat. Bharat is the Hindi word for India. And Bharat is the rural India and India is the urban India. And it will be urban India that will see transmission and so forth. And the India part of India is actually—will take a hit economically. I think the projection is that will be a 2.5 percent growth rate. I think that’s pretty optimistic given what I’ve seen around in terms of the stress in the corporate sector. So that part will take a hit. But that’s the part, just by virtue of the fact that—(inaudible)—has density and even transmission will have to bear the brunt of lockdown that’s more periodic to slow down and put some brakes on the virus every now and then. But, you know, for me personally, I think the bigger concern is we shouldn’t—we shouldn’t cause people to go hungry and starve to death because we can’t save other lives because of COVID, and that’s a major, major concern for many people in India right now.

AYRES: They’re just terribly difficult choices. I can just—yeah. This is something that we’ve really never seen before—(inaudible).

We’re at the end of our time. It is 12:31 our time. And in case people weren’t aware, Dr. Laxminarayan is participating from New Delhi. So it’s gotten quite late over there for him. Can I thank Dr. Laxminarayan and my colleague Tom Bollyky for participating today and making us all a lot smarter about what’s happening in India with this coronavirus pandemic, the vulnerabilities, and India’s response. Thanks so much. And thanks to all the participants for joining us today. And I hope to keep continuing the roundtable series either by conference call or by video conference. Thank you, and everyone stay safe and healthy.

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