 For more videos on people's struggles, please subscribe to our YouTube channel. Hello everyone and welcome to the new issue of People's Health Dispatch. Today we are going to touch upon a very important point, something that we have covered before also in our bulletin, which is about the diagnostics of COVID-19. We all know the kind of inequality that exists and there has been a lot of noise about vaccine inequity. But diagnostics inequity is as big an issue and is as rampant across the world in the context of COVID. And if we see that Israel and Australia countries, rich countries are able to diagnose 10 people per thousand population of this, while the poorer nations such as Democratic Republic of Fango and Uganda and others, they can't test even one person per 10,000. And so what are the reasons that such inequality exists and what can we do about it? And what is the science of diagnostics which can inform us as to how to go about a more rational way of investing in diagnostics and making these tests available for everyone? When we talk about track, test and treat strategy to contain the pandemic, testing becomes a very important part. Today I have with me Dr. Satyajit Rath. Most of our audience is already quite familiar with him. We have had him before with us and he is a scientist and also somebody who has been very close to people, science movements and health movement. So we will be talking to him today. Welcome Satyajit and thanks again for joining us today. So shortly I would just like to begin by asking, what is the importance of diagnostics? And I'm asking this because about vaccines and therapeutics, there is a fair amount of understanding and we talk about it more often. But diagnosis is as important. So if we can shed some light from a public health point of view also it will be great. So let's start with diagnosing COVID-19 or the virus SARS-CoV-2 infection. And there are two layers to the significance of accurately and sensitively identifying if somebody is infected with SARS-CoV-2 virus and therefore has COVID-19 illness, whether it's a symptomatic mild morbidity or severe. At the individual level, it's important for people to know because the symptoms, particularly the initial symptoms, everybody knows a cough, fever perhaps, body ache, sometimes loss of the sense of smell and taste. These are all very general. So it's not as if symptoms alone tell you if you have this particular virus or not. At the individual level, why is it important for you to know whether you have this particular virus or not? Number one, for people with comorbidities, for elderly people, for people with substantial obesity, for people with substantial diabetes, high blood pressure, there is the possibility of developing severe illness a few days down the road. And it's important to know whether what you have is COVID infection or not. Secondly, it's also possible that you may not develop severe COVID-19 illness, but what you may develop is long COVID. And in order to know whether what you have eventually is long COVID or not, it's important to have had viral, virus diagnosis early on in illness. Thirdly, now that overall antiviral pills have become available, one that Merck has done the final development on, one that Pfizer has done development on, those medicines can be taken oral. And therefore, at least in principle, if you are diagnosed early to have the virus, you can start the medicine and we can talk about whether medicines are actually accessible or not separately. But at least in principle, you can start medication and you can reduce your chances of getting severe illness and you can help your community by remaining transmission capable for a much shorter period of time. That's at the individual level. At the community level, it's important for us to be able to track how much infection with the virus is happening and in order for us to be able to track it so that we can identify clusters and outbreaks, we can build precisely directed containment measures, we can design precisely targeted vaccination, drug treatment, hospital critical care related efforts to specific communities to specific neighborhoods. It's important to be able to track the virus. So from both a community point of view and from an individual point of view, it's absolutely critical for diagnostic testing to be able to detect footprints of the virus for the COVID pandemic. So this brings us to another important question which is about the kind of diagnostics, the science of diagnostics, because we all know we have been told constantly that RT-PCR is the golden standard for diagnosing COVID. But at the same time, it is a very laboratory based testing that can be done, a unique state of the art laboratory for that. And therefore it cannot be scaled up. And that brings us to then talking about rapid diagnostic testing. But can you explain more? And do you think the way we have gone about testing in the past two years was the only way to do the science of it? And there was no other way out. Okay. So in the first place, rather than talking about RT-PCR versus rapid tests, let's talk about what the crucial difference between two major methodological categories, method categories. One method category detects the RNA of the virus, the genetic code of the virus. The other major detection category detects viral protein. Now, virus particles come as little packages with an outside that is protein and the genetic code packaged inside. So you'd say you're either detecting the genetic code, which is RNA, or you're detecting the packaging, which is the protein. What's the difference? There is a major difference. The major difference is when you detect a protein, or when you detect the genetic code, you're trying to detect with very high sensitivity and with very high accuracy. Sensitivity means that you're detecting really, really small numbers of virus particles in the, in the phlegm, in the snot, in whatever, in, in fluids, body fluids. Specificity, accuracy means that you're actually detecting only this virus and not some other related virus. Both protein detection and genetic code detection is pretty specific. It's pretty accurate for SARS-CoV-2. There are, there are reservations that will come to the minute. But as far as sensitivity is concerned, here's the problem. How many particles can I detect if I'm using protein detection? And in, in order to detect protein, I need something that recognizes protein. We use antibodies for this. That's why it's, they are called rapid antigen testing because they bind to antibodies. The rapid antigen tests, antibody based tests can be amplified, but only to a certain extent. So the detection sensitivity of protein detection methods is less than the detection sensitivity of genetic code detection methods because the genetic code can be amplified to a much larger extent. And therefore, because the amplification capacities of protein detection versus RNA detection are quite different, RNA detection is more sensitive than protein detection. So if you and I had the choice, which one would we prefer, given that both of them are equally accurately specific, but one is more sensitive than the other, we would say we want the more sensitive one. The more sensitive one, which is the genetic code detection one depends currently for 80 plus percent of the diagnostics market on the, as you pointed out, the RT-PCR. The trouble with the RT-PCR is that it is dependent on the polymerase chain reaction and that particular piece of a biochemical process depends on very rapid heating and very rapid cooling scores of times 20, 25, 30, 35, 40 times in very quick succession in sort of one minute intervals. In order to do that, you need an electronically controlled rapid heating, rapid cooling block. That's why the instrument is called a thermal cycle, essentially a rapid quick heating, quick cooling, quick heating, quick cooling element. So the real question is, this instrument has to be available. All the electronic paraphernalia with computerized control has to be available and that's what you meant when you said that a, at least a secondary, if not a tertiary level laboratory resource has to be available for this testing, which means that decentralized point of care, scarce resource, community-based testing is simply possible for the RT-PCR. Can I build an antibody-based test that is available as point of care? Absolutely yes. A large number of lateral flow-based antigen testing, rapid antigen testing is that kind of testing. So here's the distinction. The antigen testing is available as point of care, but is not terribly sensitive. The RT-PCR is very sensitive, but is not available as decentralized community-based point of care testing. The really crucial question to ask is, is this a gap that cannot be bridged? And that's clearly not the case. Why am I saying this? Empirical evidence says that it is not the case. So let me give two quick examples from here, from India, where the genetic code of the virus, the RNA, can be identified using molecular biochemical technologies that do not require this rapid heating and cooling and therefore can actually be designed to provide a very much decentralized close to point of care test. One of those was developed, we're talking about 2020, was developed by a government of India funded institution in Delhi called the Institute for Genomics and Integrative Biology, IGIP. They called it Pelluda for a variety of reasons that we will not get into that are India specific cultural reasons. And that test is a test that doesn't depend on high-end instrumentation at its implementation. Exactly similarly at the other end of India, Intramandram in Kerala, again a government of India funded institution called the Sri Chitra Tirunal Institute of Medical Science and Technology developed yet another technology that again does not depend on rapid heating and cooling that identifies the RNA code of the virus with high sensitivity. And again that test was also supposed to have been transferred to the private market and to have become widely available. The crucial question to ask is who was manufacturing these, who was selling these, who was buying these. Are these technologies which are far more people friendly, which have been developed in people funded taxpayer money funded public science institutions? Why is the structure of the pandemic response configured in such a fashion that these have not become huge, large scale manufactured and prominently available? Why is it that RTPCRs more than a year after these technologies were transferred to manufacturing units? Why is it that RTPCRs are still the tests of choice? That's the crucial issue. I agree and wow I mean this sounds like something which could have been done like better testing with more specificity from the beginning or at least since the since late 2020 and we have not been able to do it. But that is a question that why would you say that is the case because we know the kind of work that was being done at the level of WHO, WHO brought out guidelines after guidelines where there was, we just know about RTPCR base testing. There has hardly been any discussion and even in ACTA, the ACT accelerator which is, which we were told in April 2020 that it is going to solve all inequities that can come up, which was quite anticipated during COVID-19, but it has completely failed. In ACTA, the one thing that we notice is there are different pillars and the diagnostic pillar has been able to attract funding only something like 8 to 10% of the total funding for the vaccine pillar. So clearly there is a problem in terms of focus, maybe also in terms of wanting to even diagnose the common population or the poorer population. Do you think so too? Well, let me put it slightly differently. Let me put it in terms of the perspective through which the global response to the COVID pandemic, but with particular reference to the global South, but not simply to the global South, also to marginalized communities in the global North has been configured and that entire configuration has been one of top-down decision-making and not simply top-down decision-making. It has an element of charity in it, which means that the great philanthropies, the foundations that shall not be named, which are major non-state actors in configuring these decisions, all of them tend to think in terms of the current structure where profit-making companies, biotech, pharma, instrument, company sectors, which all intersect with each other. Remember that diagnostic tests are not made necessarily by pharma companies alone, they're also made by other companies, but they are all part of an integrated sector, which is also integrated with health manufacturing, health instrumentation-related manufacturing technologies. And it's that complexly and seamlessly configured for-profit sector, which is taken as a given by both state and non-state funders when they are thinking about delivering what I'm calling charity to the global South. And therefore, what the way that this is configured is inevitably to say, we're going to have to deliver tests in large numbers. We are inevitably, we are going to deliver, of course, more tests to the global North than to the global South. We are going to try and reduce the gap, at least for appearances sake, but we are going to have to deliver quite a few tests, quite a few vaccines, quite a few everything to the global South at costs that are not high-profit costs. How can we offset the revenue loss? We can offset it by selling instruments to the global South with which these tests have to be done. And much of this is a complex spiderweb of trade-offs to try and minimize profit losses in what is an inevitable large-scale charity-driven response to the problem. And as a consequence of this, the overwhelming presence in the COVID diagnostic market still remains the certified, the familiar, the branded RDPCR tests with their affiliated technologies. Let me ask, let me add a final point to this of players and actors in this configuration. And those are the private sector healthcare delivery systems. The, I speak about Indian experiences, the private healthcare laboratories, diagnostic laboratories, which have been doing an India grade deal of diagnostic testing. And for them also, this is familiar territory, this complex web of pharma companies, diagnostic manufacturing companies, healthcare instrumentation manufacturing companies, and diagnostic laboratories on the ground at the secondary level in Townsend and so on and so forth. It's this complex web of the for-profit sector that is the dominant presence that's shaping the entirety of the response. It's no surprise that point of care tests, especially high sensitivity point of care tests have had no traction. So I think we all in India heard about failure that test so much because at one point everybody thought that is going to be the test in India because it was going to be cheap as well. And you're saying that there are other efforts also. We also know that in Malaysia as well, some similar testing has come up. Many organizations are actually calling for local production, local research, and then local production of diagnosis in primarily in the developing countries, beat Africa or Asia. There has been another strand where activists and organizations, civil society organizations have been asking the organizations or companies like CFIT to bring the price down of their test because the production cost is so low and they are just making a killing during the pandemic which is so unethical. Considering this entire landscape, what do you think should be the response of WHO ideally? We all know that WHO is the work now increasingly being determined by, as you said, philanthropies that shall not be named and other organizations, CFIT, FIND, and all of them. But what should they be doing? And I would again request you to put, shed some light as a scientist or in terms of science as to what can they look at and bring these tests into their pre-qualification the entire dossier so that others can start to use it. Well, certainly having a WHO imprimatur of approval helps credibility for any product that includes these tests. But frankly, the World Health Organization is essentially a coordinating office and it coordinates what's available and what its funders press it to coordinate. So it's no surprise that this combination of state and non-state actors that are functioning in what I'm pointing out is a configured for-profit web of the health, the industrial, and the healthcare delivery diagnostic sector is going to be focused on what they are focused on. My argument is that we in public health activism need to be demanding of our governments and we should be doing this this past year and a half. But in the era of emerging variant strains, there is still very much reason for us to be demanding much wider testing, much more agile, nimble, flexible testing, testing to be developed for sensitive yet decentralized point-of-care methodologies and for these to be taken out of the for-profit sector by using public health networks. All countries of the global south have some measure of public health networks. India's public health networks, for example, go all the way to the primary health centers, which have very basic elementary laboratories. Can we deliver reagent packages, chemical packages that allow primary health care centers to do testing at their levels? Can we make the research institutions that are publicly funded develop these? Can we use public health, public sector manufacturing facilities simply to put these packages together? Can we use in countries like India the wanted clinical epidemiological expertise in place for building a quality assurance quality control network for these entirely in the public health domain outside the for-profit network and deliver rapid nimble testing that's modified and tweaked as variants arise for large-scale tests to be available free to people everywhere on demand. That's really going to be, that's always been a crucial component that has been understated. That's always going to remain for the next few months as variants emerge and spread. That's going to remain the issue. One last point on that. Until now, we didn't even have oral antiviral drugs so that when people with 24 hours of symptoms, even if they felt battling against all the stigmatization that has happened, even if they felt like they would go get a test done, number one, tests haven't been available, but even if tests were available, what would they do with a positive test apart from self-isolation which is economically disabling for many people? Now, it is possible for us to say track, test and treat on a large scale has become feasible with oral antiviral drugs. Why are those drugs, and I come for the circle on this, why are those drugs not being manufactured under compulsory licensing in large amounts and being made available to the people? Why is that drug availability not being coupled to widespread decentralized point of care testing so that communities and individuals can be empowered to deal with their health individually and collectively in their communities? Thank you. Thank you, Satyajit. I think this was really good and not only in terms of learning about the science of diagnostics, but also understanding that how different everything is so interlinked that if you need diagnosis, you also need treatment and now that we have how important diagnosis becomes in itself. Thank you everyone for watching this and we will be bringing you more such in-depth interviews and as you know that we try to cover the political economy of health in our People's Health Dispatch and not just give you news. So keep coming back. Thank you so much.