 Hello and welcome to Newsweek. We have another episode with Dr. Satyajit Rath and we'll discuss the COVID-19 issues as they're arising. Right now, of course, the news is the monoclonal antibodies, not a cocktail, but two monoclonal antibodies seem to have been given to Trump in a mixture. And Trump claims this is amazingly good, that he is almost fully recovered. And he's also pushing that it be now allowed for under emergency use provisions, which earlier he had proposed or he had advocated for hydroxychloroquine. And what else was it, apart from bleach, which of course he didn't really ask for emergency authorization, but also had plasma. He had pushed remdesivir, he had pushed plasma therapy. Do you think this monoclonal antibodies, the Regeneron variety, of course, which has given a huge boost to their stock, is actually something which is worth considering at this stage, that this is something really which has more positive elements to it, for whatever reports we are getting, and not from Mr. Trump, but from whatever other reports that are available. And it could be something which could be used. Yeah, so it's interesting in a variety of ways, this monoclonal antibody cocktail therapy, that's under trial and that Mr. Trump has gotten as a matter of compassionate usage authorization. Compassionate usage presupposes that one is feeling sorry for the ill person. So let's go one step back and remind ourselves that for a long time, not simply Mr. Trump and his fantasy bandwagon, but a lot of people across the world, including in India, were very hopeful about plasma therapy. Right. And the principle is being used in different parts of the world, including India. And in India, we had politicians exhorting people who had recovered to donate plasma and so on and so forth. Now, let me offer a little bit of arithmetic in this. The amount of plasma being given in plasma therapy was about 200 milliliters. 200 milliliters of plasma is on average about four grams of antibody protein. But keep in mind that of the total amount of antibody protein that anyone has circulating at any time, certainly no more than about 1% will be against a given target. Okay. That means amongst the antibodies, which is currently what the disease or infection will be having, only a small fraction of the total antibody, only that small fraction will be against the specific disease. So I think it's about 1%. So out of four grams, you were really talking about really 0.04 grams. Correct. So now consider that unlike plasma therapy, the monoclonal antibody therapy that Mr. Trump has gotten has a two-dose regimen, a high dose and a low dose. He, of course, being the leader of the free world got a high dose regimen. So the high dose regimen is eight grams. The low dose regimen is four grams. What this is saying is that in the low dose regimen, four grams of monoclonal antibody is injected into the individual. Now, unlike plasma therapy, here is the arithmetic. When you do plasma therapy, you are transferring 40 milligrams of antibody. When you do monoclonal antibody therapy, you're transferring four grams of SARS-CoV-2 specific antibody. That's a hundred times more. Effectively, monoclonal therapy is giving 100 times the amount of antiviral antibody as plasma therapy has been giving. Antibody that you are getting to really help your antibodies to fight the disease. Now, so effectively, the antibodies that you're getting are substituting for your antibodies. They're not actually helping your antibodies do anything. They are simply functioning to neutralize virus particles binding to target cells. And if that happens, the virus life cycle is interrupted and if the virus life cycle is interrupted, virus growth is prevented and that helps you get better. So what Regeneron, the company has done is taken not one but two monoclonal antibodies, both of which block virus particle binding to the cell surface. And the amounts that are being given are huge. Not only are the amounts huge, they are therefore being given as a slow intravenous trick. So here's the problem. What we are talking about is an extraordinarily expensive medication. Okay. Because such very large amounts have to be given. Consider the manufacturing and the supply chain difficulties that will arise for one dose to be of four grams or quite possibly eight grams. That's one problem. The second problem is, as I said, intravenous drip. So it can only be given in a hospital. The third issue is, we've been saying now for the past six months that for all viral diseases, antiviral medications have the most clinical effect early during infection. As a result, what we are saying is that the Regenkov II, which is what this medication is apparently called, although Mr. Trump seems to think that it's called Regeneron. That's a company, right? Which is the company. But this monoclonal medication, where would it be best? So let me point out to you where it would work supremely well. It would work beautifully as a prophylactic, as a preventive in people who are going to be very high risk exposed, such as first responders, such as healthcare workers, not simply physicians, healthcare workers, including physicians, nurses, nursing aides, ambulance drivers, mortuary, Hearst drivers, and so on and so forth. In them, a single injection might quite conceivably provide them with very strong protection for a couple of weeks or even up to a month. But the trouble with that is, they can't just take a shot and go to work. They have to go into hospital, get an intravenous drip. All of this, therefore, is to underline the fact that none of this, none of these are easy solutions. There are interesting technological possibilities, but there are daunting real life difficulties with all of this. None of this, of course, does the current president of the United States understand in any nuanced fashion, but nuance has never had any passing acquaintance, apparently, with Mr. Trump. Coming back to the science of it, which excludes Mr. Trump, what we can talk about is, yes, technologically, monoclonal antibodies have enormous potential, but to make it effective under the current situation as something which will stop the epidemic doesn't seem to be on, the cost is high. It's being able to provide it to large numbers of people. We just don't have the production abilities at the moment for that, not likely in the near future either. The cost is high. And fourth, as you pointed out, it needs hospitalization. And people who are likely to benefit most are unlikely to be able to get into a hospital to get this prophylactic, and unless you really privilege completely the healthcare system as the primary user of this, which at the moment is not likely because then, of course, Regeneron doesn't make high profits from it. And therefore, this doesn't seem to be the way the most talks about use of the monoclonal antibodies are being discussed at the moment. So let me add a political footnote to this, which is that none of what you just summarized is going to stop Regeneron's stock price from going up, and none of it is going to prevent the use of the Regeneron monoclonal antibody cocktail eventually when it is licensed, by the rich and fates. And that is emblematic of our socio-political response to the pandemic. You know, it's also interesting that all this goes, the interest goes high, there's a lot of hype, then it seems to die down. Remdesivir is not being discussed about, you know, about the discussion seems to have completely died down. We don't know whether any benefits are accruing to the people, but it's certainly true that it is, Remdesivir is certainly a high selling drug at the moment. So as you said, the stock price of the company, definitely, Williams is definitely has gone up. But in terms of does it really help? We don't seem to hear about it anymore, because we had pointed out, you had pointed out in this show that it might be useful in the early stages, but that's not the stage in which it's normally being given. And it's been given in hospitals. And that's not the stage that it really is very useful. At that stage, dexamethasone, corticosteroids are definitely much more useful, because you're facing a difference in the problems at that point of time. Coming back to our discussion, and we have been doing this for quite some time now, that COVID-19 pandemic can only be stopped with vaccines. That's really the long-term solution, if we call it a solution, to the pandemic. That yes, even if it becomes aemic, but the ravages of the pandemic as you see can be certainly controlled significantly with vaccines. Now, vaccines now has moved, of course, we haven't got vaccines as yet, but all the indications are that the vaccine candidates now going through the various trials, some of them will pass, one or two may not, but some of them will pass, and some of them seem to show significant benefits in the sense that there seems to be 50, 60, 70% prophylactic properties being exhibited. Now, do you now think that the problem will shift to how it is to be given, when it is to be given, who gets it? So, let's get a few cautions on the table about vaccines. I know we've said this earlier, but I think that one can never say this enough. In the first place, vaccines are not going to be a magic bullet solution. They are simply going to be one more instrument, one more resource in our societal, inclusive response to the pandemic. Part of this is going to be driven, as you said, by the fact that realistically, none of the first-generation vaccines is likely to show the absolute certain protection levels in excess of 95% protection that we sort of implicitly expect of vaccine-based protection. And therefore, it's always going to remain possible for vaccinated people to catch the infection, just that it will be at a 50% or more slower rate or lower rate. The second issue about vaccines is that while there are a dozen vaccines now, 11 I think is the current number, in actual protection trials for COVID-19, there are no data as yet about actual protection. Mr. Trump's Mungerilal Dreams Not Withstanding, I doubt seriously whether any credible data are going to come out before his fate is determined on the 3rd of November at the election hostings. Let's also remember that AstraZeneca's vaccine candidate had to be stopped in the trials for quite a few days because one individual who received the vaccine as a volunteer became seriously ill. And it was only after quite a few days of data examination and thinking by the Data Safety and Management Board of overseeing the vaccine trial that the trial resumed. These sorts of interruptions are the norm in large-scale trials of any medication, not simply vaccines. And to underline that, only yesterday, the Johnson and Johnson Vaccine Candidate Trial has been halted again for exactly the same reason why the Data Safety Management Board examines the matter. This is to make the point that there is a long way to go before we begin to get reliable data about any of these vaccine candidates before coming to the point of licensing any of them. What's going to happen at the end of this is going to be even more confusing and we as the larger societal conversation need to be cognizant of this because what's likely to happen is that in a span of a few weeks, more than one vaccine that provides a modest degree of protection, as you said, 60%, 70%, 75% will get licensed. And then the question will be, who has access not just to a vaccine, but who has access to which vaccine? Which vaccine should be given to whom first? Can we cross vaccines? I have taken this vaccine. Six months later, can I take the other vaccine or am I now technology locked in into one vaccine? What happens if supplies for one vaccine run out? The kind of logistical nightmare in public health that this has the potential to create has to be thought about seriously and not simply by opaque government policy-making bodies which is the current state of affairs, the world over, but also by informed citizens at large. You know, Satya, you make a very, very important point that the opaque decision-making bodies all over the world, particularly in the country. But we must also welcome and normally we have been very critical of this government which will continue to be, I'm sure, that for the first time, we have the Health Ministry talking about public health, not the Home Ministry. Till now, it wasn't a disaster management act. It was the Home Ministry which came out with all the notifications. There is now hope that actually strangely enough, even the Health Ministry might start talking about COVID-19 and we have Harsha Vardhan, Health Health Minister, have already three such deliveries to the nation. He has spoken to the nation three times on this issue and he has talked about one-to-one does vaccine distribution, priorities and all of this thing, saying that we are going to take care of it. Of course, as you said, we do not know who else is involved, how are the states going to be involved, who are the producers. It's also true that the government seems to be poof-poohing the argument that other punawala gave that we need 80,000 crore rupees for the vaccine. He said the amount will be much less. How the amount will be much less? We have no idea. Is it because you could use much less vaccines or is it that they have cheaper vaccine sources which you know nothing about? None of this is in the public domain, but at least we should welcome the Health Minister talking about health, right? Oh, absolutely. I, in agreement with you, I have been both surprised and pleased that the Health Minister of the country has been speaking to the country and by and large has been saying unexceptionable evidence-based, science-based things about the epidemic. This is to be welcomed. No matter what political configurations and reconfigurations lie behind it, it must be welcomed. I still have grave reservations about the fact that we have an Ayush ministry that has been issuing packages and cocktails of medications. I used the word in inverted comments that rival Mr. Trump's fantasies about, with regard to their utility in COVID-19 being suggested by the government of India. But nonetheless, by and large, I agree entirely with this. Let me say something in this somewhat unfamiliar context of saying good things about governments. And that is, I must confess that I sympathize with governmental policy-making bodies that are grappling with the issue of COVID-19 vaccine implementation strategies and policies. The sheer unknowns on the one hand of the still-emerging pandemic, on the other hand of the still-emerging vaccine scenario, both in terms of which candidates will have efficacy and in terms of what will be available, especially in a situation where 50% of vaccine doses for unproven vaccine candidates have already been pre-bought by 10% or 15% of the world's population in the global north. Which countries, European Union and United States, of course, in the chief ones. And in this situation, I must confess that I have great sympathies with any committee or advisory group that is grappling with vaccine implementation policies and strategies to suggest. So I, you know, we should be critical, we should be asking for information, but we should also give our sympathy when it is well deserved. Yes, and as you say, that there are a number of questions who gets it, when did they get it, which vaccine do they get, and how to reach it to them. This is not going to be a minor issue, reaching with the cold chain intact, being able to distribute it. These are two-shot vaccines, most of these, the two shots have to be given at a certain sequence. They're not the same for each of the vaccines. All of it is a logistical nightmare. And unfortunately, the government till date, its ability to handle complex logistical issues has been really weak, given the fact of how it implemented the lockdown, how it implemented share the ability to reach food to the people, all of that. So we'll have to still see how it works. And hopefully that the vaccines will appear and the vaccines will be delivered, even if there are failures at different levels, at least some response is now in the offing. And hopefully we will see, as Mr. Harshwantad has said by 2021, we will have 20 to 25 core people vaccinated. And that should at least reduce the spread of the pandemic or bring down the numbers, new cases numbers, at least, significantly. Well, yes, I'm by no means convinced with the optimistic projections that the Health Minister makes. But we will wait and see. As you point out, let me underline for our audience, the technical challenges involved with only two examples. One is that one of the front runner vaccines, the Moderna vaccine candidate, requires ultra low temperature storage. 70 to 80 degrees centigrade is the storage. Below zero. And it is just impossible. Minus 70 to 80. Minus 70 to 80, minus 80 degrees. It requires freezing. It's not refrigeration, it requires freezing. That's ultra low freezing temperatures. And I cannot conceive by any stretch of imagination such a vaccine to become a public health policy response to scale in India. I'm sorry, I wish I were wrong, but I cannot imagine. Satyajit's not even you and India. The same argument is being raised now with the United States and the US, as you know, the federal architecture like India. The state governments have said that we have no ability to handle this temperatures at this scale. So more evolved, more technologically developed systems are also not seem to be in a position to do it. And it also raises the question, why so much hype about Moderna if this was the problem? And there are a couple of more of the same genre which also requires similar temperatures. Yes. And the second, absolutely. And the second example I want to give is the fact that the only single dose vaccine candidate that is currently being tested for protection is the one that was halted yesterday, the Johnson and Johnson. So all the other vaccine leading so-called front runner vaccine candidates are more than one dose, by and large two doses. And that immeasurably complicates a massive, very short-term vaccination implementation program. So none of this is going to be easy. And I am therefore not anywhere near as sanguine about 2021 and our vaccination status as the health minister is, but nonetheless, he has my sympathies in this difficult time. Cautious optimism, but we need to keep our fingers crossed about how the logistics will be handled, who will it be handled for and whether it will reap the success that is being hoped or claimed for it. Thank you, Satyith, for being with us and explaining to us the rather difficult task of how do we look now at the immune system's response to the COVID-19 infection because whether it's monoclonal antibodies or vaccines, this is what we're looking at. And that, of course, is your specialization. This is all the time we have for NewsClick today. Do keep watching NewsClick and also watch our COVID-19 discussions as well as the discussions with Professor Raaz.