 Hello and welcome to NewsClick on this episode of Watching COVID with Dr. Satyajit Ragh. Sadeed, we have been talking about this issue now for 2-3 weeks, the way the COVID-19 curve is rising steeply. At the moment, we do not really see in overall terms too much of a flattening of the curve, though there seems to be some slowing down, particularly as big states like Maharashtra seems to have slowed, flattened, and some of the cities are starting to show also reduction in numbers. But if you see the smaller states or the other states, the position is not a small state, it's the biggest one, you will see the numbers are still going up quite steeply. So what do you think is a prediction, though I know that prediction in pandemic is really not a feasible proposition. But what do you think the near-term 2-3 weeks scenario looks like? So let me take the privilege of age and be repetitive. I keep saying that we should not be thinking of waves with their uniformity and predictability. We should be thinking about this as a series of local outbreaks, each of which has its own dynamics. So what we have been seeing is a convergence or a coalescence of these outbreaks all across the country as we have locked down and reduced interactions in response to the growing numbers. Inevitably, the rate of spread of many of these outbreaks is going down. But our response has not been uniform across the country, clearly. In some places, heavily affected places, heavily policed places since we keep converting this into a law and order problem, we have reduced interactions. But in other places, we have not. So what we currently have is the sum total of outbreaks which are dampening down because we have physically distanced ourselves. But in other places, smaller outbreaks, but many outbreaks which are still growing. And that sum is going to be what is going to be represented by a flattening. And it's slowly as more and more outbreaks die down and fewer and fewer outbreaks come up that we will begin to see the descending out. So this is a point that all of us need to keep in mind. The sheer noisy complexity of the landscape. Secondly, all of that said, it's quite clear that in the major areas contributing large growth in case numbers, there seems to be a leveling off. And if that pattern continues, then what we are likely to see over the next two or three weeks is a tapering off and a plateauing and a long slow decline. But clearly, the decline, none of us should be expecting to be as precipitated decline as the increase was. Typically, that's not how pandemic outbreaks behave. That's not how our experience has been in last year's major increase in case loads. None of us should be expecting this to be a short, sharp quick crisis. This is going to be a long, hot summer. You know, it's interesting because a lot of the epidemiologists tend to talk about the symmetric bell curve as if that's what it is. And we've been talking about it, that people get mistaken by their own models and start believing that's a reality. In fact, when you talk about the R0, R, all of these numbers, they are really artifacts of your models, then effectively a prediction of what's happening on the ground. So I think some of those issues are there. And what you point to me, why do you see a much lower decline is because a few urban centers can create a steep rise. But when the fall takes place, it's taking place across much larger, smaller towns, communities, dispersed communities and so on, because that's where it spreads next. And therefore, you see a much slower decline. But the rise is sharp because you see it really densely populated urban areas. This time the Maharashtra in the cities and Delhi, of course, in the cities. Punjab, of course, is a bit of an outline, but again, cities went up very fast there too. So while Punjab, Maharashtra seems to be slowing down, and you can see that, Delhi not as yet, maybe some slowing down because you see the positivity ratio now, infections to test seems to be coming down a bit, and there has been a long down. So you expect that you can see other reasons that we have discussed, the Kumbh and the elections, of course, also create a much more of a spread. Of course, we can't really quantify it in terms of figures, but Handoor figures are now coming out. The number of people who have been there who are already infected, according to the government statistics itself seems to show, yes, of course, all of this is going to have an effect. But the fact that it comes down more slowly is something we have to expect. And maybe what you said, a long, hot summer, that we are really going to see lockdowns over a much larger area as the summer proceeds. Well, clearly, I mean, only hours ago, Karnataka has announced a full 14-day statewide lockdown. So this, our tendency to be complacent until a point at which public health responsible, careful, graduated measures are no longer possible. And draconian conversion to a law and order perspective is the only thing remaining. Has come to the fore again and again and again. This has been the critical issue of treating it right from the beginning as initially a centralized emergency law and order issue. And then now, in fact, the central government is saying, we'll help the states. Now, they sort of, they seem to have thrown up their hands and said, we will help the states after initially saying that we have won this great victory under the leadership of the prime minister over COVID-19. And somebody, I think also said, I think it was a meeting who said the Nobel Prize-winning research and what the Nobel Prize-winning research was, was not explained to us, fortunately. But of course, now you see that it was a precursor, curtain raiser to the real crisis we are having today. So on this matter, Prabir, I should say something from the point of view of those of my friends who do modeling. Responsible, and this is for all our viewers and listeners. Responsible modellers are completely aware of the limitations that we've been discussing. And from the point of view of responsible modellers, no projections, they do not like the word predictions, I think correctly, they tend to say projections. And they point out that the projections from models begin to lose reliability day by day by day into the projection. So that beyond a week or two, those projections are really fuzzy. And this and responsible modellers point this out all the time. And I think that they, we, all of us hope and wish that both political leadership and people at large would take this into consideration rather than relying on models as though they are certainties of predictions into the far future. Yeah, after two to three weeks, they become like horoscopes. I'm joking, but that's the way one should really look at it. And anybody who has any serious modeling exercise, of course, that leaves out certain protagonists of modeling, world over, who think models are the reality. Know this very well. As you said, this is nonlinear phenomena. This is really human network phenomena. And this is not prone to the kind of homogeneous models we tend to build for countries and for 1.3 billion people building this kind of model is really something which at least the DST supermodellers should have been more careful about because they seem to have set the expectation that all is going to be hunky dory after February. And therefore, almost all the steps that earlier the government had been considering. And one of the key issues is really oxygen. And this is something again, we have discussed and you have said this in our previous discussions, that what we really want to prevent is the number of cases, serious cases overwhelming the health system. And that's the key target. If we can maintain that, then the number of deaths will be much lower, we'll be able to tide over the epidemic. But if that doesn't take place, all the things go out of hand, which we want what we're seeing now, then of course the key crisis, you don't have oxygen beds, you don't have ICU beds, you don't have ventilators. And that's when the death really goes up. And from what the senior person in Gangaram has said, that for the first day yesterday's statement, for the first time, we are able to give oxygen at full pressure, which means that we have been giving oxygen at partial pressures. Is that what you're supposed to be? And what's the consequences of providing not full pressure oxygen? So let me say two things about oxygen and the related issues that have come up. Firstly, despite the fact that we have been critical of the DST supermodel, so-called, what the current reports emanating are underlining is that by and large, the technical advice that the government has been getting has been pretty good. The government got the advice that it should be planning the so-called plan B reports that we are seeing, that it should be planning for large numbers of simultaneous cases. And one of the major limitations and components that needed to be planned for was oxygen, as you point out. So these things, it's not as if the government was not given this advice. It's much more than that the government in sheer hubris and complacency seems to have not exactly ignored, but as you point out, put this advice and implementation on the back burner, so to say. And that's clearly a contribution to our present state of affairs. Secondly, the point I want to make is that a lack of hospitals, a lack of beds, a lack of oxygen does not manifest in dramatic, spectacular falling off the cliff fashion. And it does not do so because health workers struggle to provide within their means for as many patients as they can, as best as they can, which is how what we are seeing underline becomes the norm. Three, four people hooked with makeshift apparatus to a single oxygen cylinder desperately lying in corridors waiting for beds. It's not that they are simply dying in rickshaws, although clearly we also have that happening. But that's not the only thing happening. There is a whole spectrum of suboptimal care happening. And that spectrum of suboptimality is the result of individual healthcare workers, not just physicians, all across the healthcare workers trying to do their best under awful conditions to provide for as many people as possible. As a result, you have low pressure oxygen being provided. And all of this is resulting not in two groups of people getting good care and people getting no care, but a whole range of people getting suboptimal care. And at each point in this suboptimality, we are going to have an increased possibility of illness, prolonged illness, and death becoming possible. So this is one major issue that we need to keep in mind. The second is that as a result of this, what we have is oxygen being provided to people in a variety of locations in hospitals at a variety of pressures. And we should keep in mind that oxygen is a gas. So patients are struggling to breathe in what they are being provided. But it's also going out into the environment with the result that hospitals are in a situation where in various parts of the hospital, there is a lot of oxygen in the air in the environment. And Praveer, you would know this much better than me. But what the outcomes of a spark in air conditioning or in the electrical system elsewhere would have as consequences, depending on ambient oxygen concentrations, and what the likelihoods of fire have been, because we are seeing repeatedly, not simply in India, but across the world, hospital fires in COVID hospitals. It is a big one with the Baghdad fire. But it is true that we have seen in the past few days reports of the fires in a number of hospitals. And though the authorities are being blamed, and I'm sure they should have taken better care, that's true. But nevertheless, it's also the unsafe conditions that you have a very large number of patients. You haven't never faced such a situation. You do not really train your people across the board. You may train them in the ICUs, how to take care of such conditions, but not in the general wards and such large scale use of oxygen, as we are seeing now, even including the corridors, as you said. But in this particular issue, the really, from what you have been telling us earlier as well, that apart from steroids, corticosteroids, oxygen is really the only medicine that is effective at this stage. And it allows the body to fight the infection. And that's the key failure and the moment that we are seeing, that we just don't, we have a collapsing oxygen infrastructure with rising numbers. And as it spreads across to other states as well, this crisis is going to compound more if it continues in the same trajectory. And we are not able to quickly harness our resources to augment the sources of oxygen. So let me, I agree, but let me underline another resource in critical health care that we keep overlooking and forgetting. And I think that it is to our collective shame. Here are two issues that we have learned, for example, over the past year. Last year in March and April, the global hospital health care delivery community, and I'm using this phrase rather than simply saying doctors, because this is not simply physicians, but it's nurses, it's paramedical, ancillary, auxiliary, staff, the entire apparatus of health care, the human apparatus of health care, learned that early ventilator dependence was actually not a good thing for COVID-19 patients. That high pressure oxygen through cannulation rather than intubated invasive procedures was a much better thing to do. And that's something we've learned. Let me point out something else we've learned. We've learned that intensive nursing care was important, that turning people over regularly so that they could be in beds and with nursing handling, skilled handling, they could be turned over so that they were lying on their bellies, so that their lungs could drain, then they were turned back again. See, this is the kind of hands-on skilled care that is saving lives, that has been saving lives in the pandemic this entire year. Consider just how much pressure we are putting our skilled health care personnel under when we increase the numbers that they have to deal with. We have nursing staff that are being put in charge of 15, 20, 25, 30 patients day after day, week after week. We are not just acknowledging their efforts. We are not making any efforts to enhance these numbers. See, it's one thing to talk about oxygen. You can manufacture oxygen with a delay of weeks if you do it on a phrase that I particularly dislike, war footing. How will you do this for skilled personnel availability? This is what the largest casualty of short-term crisis perspective in pandemic management has been. We have not planned for the long term. In fact, that's a very, very poignant point that you are making, that we are burning our health care staff out. We have made them face one epidemic surge, which went on to actually two or three minor surges in between. And then we are now again stressing them out under conditions which are completely unacceptable or should have been unacceptable to a public health system. And on top of that, when they fall sick, then even they do not have much recourse to medical facilities because either beds are not available or if they are, then the pressure to give it to somebody else is more. So this is a pathetic condition that we are in. We don't want to talk so much about how bad it is because that's perhaps something at this point we don't need to do. People are seeing it for themselves. But Satyajit, the last word, and I'm going to call this the last word, that the immediate issue is not vaccination. That's a slightly longer term issue as we've been discussing. This epidemic peak has to be handled by essentially people who are already exposed to infections and without vaccinating them and waiting for herd immunity, so to say. But this is the point I wanted to come to, that there was a talk about herd immunity in February. Now it's very clear we didn't have herd immunity, but we're also talking about the mutation that we see that some of them can escape the current generation of vaccines. And this again is something that we have talked about that will lead probably more and more newer kinds of vaccines as well. But do you see that this particular epidemic that we are seeing that isn't it making much more clear that herd immunity through infections is a complete mirage? Certainly herd immunity through infections of this particular virus and illness has never made a great deal of sense. Sweden, for example, has been attempting to do this although off and on in a data driven fashion and so on and so forth. And this is because the idea of herd immunity is dependent on a number that nobody knows with any certainty. For a new disease, there is no way of predicting a percentage of people who are immune reliably. But that aside, let me say something about the issue of variants. And let me say this from the point of evolutionary biology. Virus populations will have variations. As we begin globally to maintain distancing, many of these virus individual viruses in the population are going to find it hard to be transmitted successfully. Those variations that are successfully transmissible even under these distancing conditions will therefore get an advantage in surviving and propagating. This is why the world over there is a convergent evolution independently emerging across the world of variants whose common property appears to be that they are more easily transmissible. And that common property is the consequence of our common human global response of maintaining distancing. Enough of us have not yet become immune to the virus, be a similar selection pressure as yet. And therefore, the current variants are unlikely to be strongly selected to be immune escape variants. And therefore, for the moment, the issue is of easy transmissibility rather than of immune escape. However, I remind all of us that as vaccination campaigns gather steam and cover the world, what we are going to be in is a situation from the point of view of the virus where its potential targets are immune protected in certain ways. And it is at that point that we will begin to see, I suspect, variants of the virus that are selected to dodge immune protection at least a little bit enough to provide propagation. And it is at that point that we will enter what you might perhaps call the long drawn end game of the pandemic where we will be playing catch up with virus variants that are immune evasive and we are trying to provide next generation vaccines with local vaccination campaigns to deal with those. You know, Satish, I'm going to finish this with one specific example drawn from the United States. We had one State Department official who actually said that in the United States policy is to help the world. And how does it help the world? We help ourselves. And if we help ourselves and after we have finished our epidemic here, then what will happen is we can give our vaccines to other people, but we will be saving the world from actually transferring our mutant viruses elsewhere. Now, what they seem to have forgotten that this kind of protecting the world from Americans still need the Americans unprotected from the rest of the world. The only protection against SARS-CoV-2 and COVID-19 is all of us. Either we all survive together or we all sink together the world over. If there is one lesson that the pandemic ought, that we ought to be learning from the pandemic, it is this, that the idea that if I respond selfishly for myself, I am in some mystical involuntary way providing for the greater good is a fundamental error. So this is the crux of the capitalist ideology that selfishness is the best way to serve the human good. That if I am selfish, then everybody is selfish. That's the best condition for humanity. That is what this ideology that the State Department and the United States policy cutting across both the administrations of the Trump administration and the Biden administration has been saying. So I think they're essentially right in their view because they do believe that capitalism is the best condition for humanity. We'll see if the pandemic persuades them otherwise. Thank you Satyit for being with us and taking us to rather difficult terrain from what role oxygen plays to how the pandemic develops and how the immune system and the virus respond to each other. We'll continue to cover this and other issues with you and for our listeners, our viewers, do come to NewsClick, do visit our website and our YouTube channel.