Dr V Ramana Dhara is a professor at the Indian Institute of Public Health in Hyderabad. He trained for the most part in the United States of America, and worked at America’s Center for Disease Control in America for ten years. With a background in environmental and occupational health, at the CDC, Dhara gained exposure to organising responses for many of the outbreaks around the world, such as swine flu and Ebola. He has been following the COVID-19 outbreak closely, as it has spread around the world and begun affecting Indian life. As of 20 March, India had confirmed 563 cases of COVID-19, but Dhara, among others, fears that these optimistically low numbers are the result of an egregious lack of testing. He spoke to Lewis Page, a Luce scholar at The Caravan, about the hurdles India will soon face, and what can be done to surmount them.
Lewis Page: What is the current status of tests for COVID-19 in India? How are the tests being conducted, and who specifically is being tested?
V Ramana Dhara: The government has developed criteria for who needs to be tested. Currently, they are only testing people with foreign travel, people who were exposed to a known case of COVID, or people who have symptoms of acute respiratory illness which cannot be explained by any other diagnosis. [On 20 March, the Indian Council of Medical Research had also stated that “asymptomatic direct and high-risk contact” of a confirmed case will be tested between five and 14 days of the contact, and so will symptomatic health-care workers.]
This is a good start, but the WHO has recommended “test, test, test, test”—as widely as possible. Initially, the Indian Council of Medical Research said that a test-intensive strategy was not best for India, for reasons best known to themselves. There was some speculation in the media that if testing turned out to be positive, there would be anxiety and panic. But it’s also a fact that the testing facilities may not have been adequate for the scale of the testing required. But now, a whole range of public-health experts have critiqued that strategy, and said that you do need to test widely, because you want to know what the burden of disease is in the country. You may test the people from abroad—a certain fraction tests positive, and then you may quarantine them. But then some of their family members will also get infected. From what we are seeing around the world, this virus seems to be attacking people in clusters, and spreading rapidly from there.
Right now, the only armamentarium we have against this disease is prevention methods. We don’t have a vaccine yet, and will not have one likely for the next eighteen months. We don’t have a drug yet, though there have been some trials with [the antibiotic] azithromycin and [the malaria medicince] hydroxychloroquine. But at this point in time, the only strategies we have are prevention, and to test widely so that we know how and where to most effectively apply prevention methods. It is only with a comprehensive testing strategy that we will really know what the number of cases is, and what the spectrum and the pattern of cases in the country are.
LP: If someone were to have mild symptoms of COVID-19, what would you recommend they do? Are there ways for people to get tested?
VRD: At this point, it does not look like that, for most people. The local dean of a medical college here in Hyderabad, who is well-known in government circles, said he developed upper respiratory symptoms and he wanted to get himself tested for COVID. Eventually he did get tested, but he had to go through several hoops and obstacles before he got there. And he had to pull a lot of levers. But for the ordinary person with mild symptoms, this cannot happen. The testing labs will go through the criteria for these people.
The other kind of testing that the ICMR needs to do is to test widely to see if we are moving from phase two to phase three. We know that we already have local transmission. But so far, the ICMR has said that the testing has not showed that we have community transmission. However, they have not tested widely. You need to have a pattern of testing all over the country. You need to develop the sample sizes to be done all over the country. You need to test a lot, but it does not look like the government has the capacity to do this widespread testing on a random sampling basis, to determine whether we have moved into stage-three transmission [also referred to as community transmission] or not. However, based on the experience of other countries, we are aware that we may be moving into the stage-three transmission. And that’s why they are taking these preventative measures, these national lockdowns. While they have not tested widely and while they are saying that we do not have community transmission, from a practical perspective they are moving to be proactive in breaking the cycle of transmission.
LP: Can you explain the concept “community transmission”?
VRD: Well, first we have to understand the difference between stage-one, stage-two, stage-three, and stage-four transmission. Stage one is people coming in from abroad. Stage two is what we are seeing now, local transmission—from father to son, for example. Community means it is much more widespread. And stage four is epidemic. So, the definition of stage three really depends on the population density in a certain place and the movement of people in that place. And you can only determine that if you do a systematic, random sample of the population in that community.
Let’s take the example of a particular district—say you have 10 million people in that district. Then you will do what is called a sample-size estimation. You say, these are the number of samples in this particular district that I am going to test. And you take a random sample—that means each person in the population has an equal opportunity of being tested. And if the number of samples turn positive beyond a certain fraction we say, yes, we now have community transfer.
The government initially said that there were [a few thousand] tests being done around the country. [As of 22 March, fewer than 17,000 people had been tested, according to the Financial Times.] For a country of 1.3 billion, that’s nothing. That’s probably not even adequate for a district. But in the absence of that widespread testing, one cannot tell whether there is community transmission. The ICMR has said that we have not moved into stage three, but they are well aware of that fact that it might well already be ongoing, so they are taking these preventative steps to try to break the cycle of transmission. But I think the awareness seems to be increasing that you have to test widely.
LP: What immediate measures would need to be put in place to conduct widespread testing for COVID-19 in India?
RVD: All of this is under process right now—they are trying to certify all these test kits, they are trying to certify the labs. They have to increase the number of labs. There was only one testing center in Hyderabad, for the whole state, which is completely inadequate. Now they have instituted more testing centers. [On 25 March, the ICMR released a list of 27 private labs that were certified to test for COVID-19. It certified four labs in Telangana.]
But given the large populations, given the difficulty in transportation, and given the fact that poor people cannot easily travel from one place to another, it will be very difficult. Say someone falls sick; not only will it be difficult to transfer that person to a testing facility, but that person may not even have the wherewithal or the finances to move to that testing center. That’s why you need a lot more testing centers. You need to pull in the private sector, you need to pull in private labs . Whatever public-health infrastructure is present should have to put the testing centers in place. I think the government is aware of all of this, they want to do it, but they are playing catch-up. But when you try to play catch-up with a disease that is knocking you off your feet, that is very hard.
LP: What do you think the major limiting factors for implementing widespread testing will be? The actual test kits, the mobilisation, the staffing, or infrastructure?
VRD: All of the above. It is resources, it is finances, it is staffing, it is public-versus-private-sector model, and the fact that the public-sector infrastructure is not well-developed enough to be able to do this.
LP: How do you think that this division between the public sector and the private sector will play out in India? Do you think the private sector will be called upon by the government to provide emergency services?
VRD: The government needs to use whatever structures are available to it to combat this crisis. If it is the private sector, they have to use the private sector. They will have to get them involved, because their public-health infrastructure is weak.
As you are aware, the models that have been published are predicting a huge epidemic, between 300 to 500 million infected, possibly by July. Now again, there’s a range there. We don’t know how this is going to evolve. It may mutate, it may become weaker—it’s a novel virus, we don’t know how it’s going to respond. The strains in Italy and China have already shown some difference. If it plays out as an epidemic in India, we don’t know how severe or how mild this disease will be. We do know by current statistics that 80 percent [of those infected] will have mild infections. But that’s from the data from other countries. Perhaps most of us living in this country will be infected in one way or another. And most of us recover, but many will not. Because of the numbers involved, even a small fraction of cases will mean a large, large number of deaths.
LP: From your experience with the CDC, how do you think this crisis will play out differently in India than it has in the US?
VRD: The CDC had more established protocols about how to deal with these kinds of outbreaks. However, the public health infrastructure in the United States is also quite varied, depending on the state you’re in, the county, and the local health agency. There is wide variation in quality of healthcare in the United States. There is a lot of reliance on the private sector. And though you do have a public-health infrastructure, there is variation between states and between countries and between local areas.
In India, we have invested even less in the public-health infrastructure. There are systems in place, but they have not been well-funded, and they have not been well-used. And India is a huge country with a huge population, so, as I said, it’s like playing catch up. You’ve suddenly been hit with this epidemic, and now you are trying to scramble to use this public-health infrastructure which is not funded. Also, because the public-health infrastructure is not a very efficient structure, people don’t use it that much. A lot of these people—even relatively poor people—seem to want to go to the private sector, rather than the public-health sector, because they probably don’t have adequate confidence in the system. So, this is a lesson to the government. They have to use a lot more funds, and increase the public-health infrastructure.
LP: Do you think the recent lockdown measures put in place by the government will have a significant effect on slowing the spread of the virus?
VRD: In theory, they do, and in practice, the smaller countries that implement these measures recently have seen good results. But India is such a huge country, and even though the kind of travel from foreign countries into India is not as great as it is in the United States or Italy or other countries, the fact is that the cases have already arrived here. And within India there is a lot of domestic travel—from state to state, city to city. And this is how it’s going to spread. The volume of the population makes this very difficult in India, but it is very important that we put all the measures in place that we can to slow the movement of people.
LP: What would you say to individuals who are wondering what they should do during this crisis?
VRD: They should follow the guidelines of the lockdown. They should stay at home. I know it’s hard, it can be depressing for some people. But it must be done. As of this moment, it’s primarily the prevention methods that we have. So, wash your hands frequently. Keep your one-meter distance from people, and don’t go to public gatherings. This is the best thing we can do right now.
For asymptomatic people, stay at home. If you have symptoms, then contact your local health department. This has been widely publicised in the local press. If you have these symptoms, please call up the numbers. They can put you through the questionnaire. And do what you can to get assessed, get screened. That has to be done.
This interview has been edited and condensed.
Correction: An earlier version of this interview stated that trials for curing COVID-19 had been conducted with the drug azithromycin. Dr Dhara later clarified that this was an incomplete reference, and that trails had been conducted with the drug hydroxycholoroquine as well. Further, “hoops” had been incorrectly transcribed as “loops,” “armamentarium” as “armor material” and “novel” as “normal.” These have been corrected. The Caravan regrets the errors.