As part of his on-going series of dialogues with globally recognised experts in the fields of economics, social sciences, healthcare and other fields on the tackling the Covid19 crisis, Shri Rahul Gandhi recently spoke to Professor Ashish Jha (PART-1), a globally recognised public health professional
Shri Rahul Gandhi interacted with Prof. Ashish Jha, Professor of Global Health, T.H. Chan School of Public Health and Director Harvard Global Health institute. Recently appointed Dean of School of Public Health, Brown University on 26th May, 2020 About Ashish K. Jha: He has been recently appointed as the
Dean of the Brown University School of Public Health. He is an American health scholar, the K.T. Li Professor of Global Health Harvard T.H. Chan School of Public Health and the Director of the Harvard Global Health Institute. His research centers around improving the quality and cost of health care, focusing on the impact of public health policy. Jha received his M.D. from Harvard Medical School in 1997 and then trained as a resident in Internal Medicine at the University of California, San Francisco. He returned to Boston to complete his fellowship in General Medicine from Brigham and Women’s Hospital and Harvard Medical School. In 2004, he completed his Master of Public Health degree at the Harvard T.H. Chan School of Public Health. He originally hails from Madhubani, Bihar, India. He was Born in Bihar in 1970 and moved originally to Toronto, Canada in 1979. He moved to the United States in 1983.
RAHUL GANDHI : Hello.
PROF. ASHISH JHA : Hey Rahul, How are you?
RAHUL GANDHI : Nice to see you.
PROF. ASHISH JHA : Thanks for doing this. I’m looking forward to it.
RAHUL GANDHI : How are you doing?
PROF. ASHISH JHA : I’m very very good. Thank you.
RAHUL GANDHI : You are also in a sense, what a lot of young kids in India would aspire to be. Come from India, do well and become sort of leading light in the medical field. So you have traversed that journey.
PROF. ASHISH JHA : Well I’ve tried. It’s been a good journey. Even though I spend most of my time these days thinking about America and really thinking globally, India ofcourse, for all the reasons that you can appreciate, has a very important role in my mind and in my heart. Trying to be helpful to India during this most difficult of times is very important and so anything that I can do on that front …I’ve been ….
RAHUL GANDHI : What is your view on the idea of a lockdown and how does one pull oneself out of a lockdown because it is what I’m realising now and what a lot of people are saying is that it is a psychological change. When you classify the disease and then you say that we are going to have a lockdown, you change the psychology of the people, of the population, who suddenly are convinced that this is a very dangerous thing. Which it might be, but then you have to wean them off that idea and you have to do it carefully. You can’t just blow open the doors. How does one navigate this complicated space.
PROF. ASHISH JHA : There are two aspects of it, that are both worth talking about. Both the pure public health aspect of why do the lockdown and how to release it, and the psychological aspect that you have described. And they are very interrelated in a way that I think policy people have not always understood. So let’s start with the public health part of it. The reason to do the lockdown is that you are trying to slowdown the spread of the virus. So the virus is a new virus. The humanity has not seen this virus before. That means all of us are suspect. All of us are susceptible population. Left unchecked, the virus will grow exponentially. We think on average, the virus infects 3 more people. All of a sudden 3 grows to 9, 27, 81 and all of a sudden you have exponential growth in millions. And the way to stop it is to take infected people and separate them from uninfected people. Well how do you do that? You have two choices- you can do really vigorous testing, tracing and isolation. But if you can’t do that, then you have to lock everything down. Can you slow the virus down from a lockdown? Of course you can. But of course it has very substantial economic repercussions. Most of which, many people have much more expertise than I do on economic issues. But it clearly has them. The other thing I always ask about the lockdown is, what are you using that time to do? How do you prepare for releasing the lockdown? Lockdown buys you time, but lockdown is not the goal unto itself. You want to use that time to prepare a really fabulous testing, tracing, isolation infrastructure. You want to use that time to communicate with people.. now I will get into the psychological issues. That life will be very different when lockdown ends. This is not about like going back to what life was like last May or June. That life over the next 6-12-18 months is going to look very different. And it’s really about planning all of that out. So it’s not just communication, but really thinking through, what will public transportation look like? Who will go back to work? What will schools do? There is a lot of work you want to be doing during the lockdown. And the last point I’ll make on this is around the psychological issues. There is a very clear signal that you send to people when you lock down. We’ve had a lot of outbreaks in India, elsewhere. We’ve never had to do a national lockdown. So you are saying to people that this is different. This is much more serious and is potentially much more devastating if we don’t do this. So now when you open up the economy, you have to create a certain level of confidence. Because the economy resides on confidence. Because if people are scared, they will not engage in economic activity. So you have to create some amount of confidence. It is a complicated thing. I haven’t seen any country in the world do it brilliantly. But everybody is kind of making their way through this.
RAHUL GANDHI : I was speaking to some migrant labourers who were making this journey home, and I have spoken to quite a few of them. A lot of them say that the really frightening thing for them is the uncertainty. They live on minimum wage, they live on a daily wage. And they say, look we don’t know what is going to happen tomorrow. That is the real problem for us. How does one think about opening this lockdown in a way medically, so that you minimise this type of uncertainty, so you don’t have an accident with this second lockdown. What are the things medically you need to think about?
RAHUL GANDHI : What about the strategy of testing? Yes you have to test a lot, is there a particular method to testing or are there certain areas we test? How do we think about testing as a strategy?
PROF. ASHISH JHA : South Korea, Taiwan, Hong Kong, actually the East Asian countries have done a very very good job of this. But certainly in Western Europe and US, people are still trying to come up with what is the right testing strategy. My general approach on this has been that- In generic terms, you should be testing anybody with any kind of symptoms. You won’t pick up everyone, because there are people without symptoms. We think that about 20% have no symptoms throughout their entire disease, and another 20-25% people spread the disease before they have any symptoms. So you should be testing everybody with symptoms. Then you should have a strategy for surveillance of high risk areas and then you have to sort of think of our high risk areas. That is where you really have to customise it to individuals. Atleast here, we talk a lot about homes for elderly people or hospitals. My feeling is that anybody who gets admitted to a hospital for almost any reason in an area with any kind of outbreak should be tested. Mostly because if you miss an asymptomatic person who comes in with a heart attack, broken leg. But they are asymptomatic and are spreading. They could spread it to 30 healthcare workers, 70 patients and that could be a disaster. You need an aggressive testing strategy in high risk areas in homes for elderly people etc. And then if you can, you want to be doing more community level surveillance. Just to make sure that you are not missing undetected cases. It is really a combination of all of that and it depends on how much testing capacity you have.
RAHUL GANDHI : Indian has got a unique aspect to it. I don’t know if the US and other countries have, we have a large young population that is diabetic, that has heart disease, hypertension. Then you have poor people who work in polluted areas, they have lung diseases. So we have this cohort of young people who are also vulnerable.
PROF. ASHISH JHA : We know that the biggest risk factor for having a bad outcome from getting very sick or dying is age. And that is one advantage that India has, compared to Western Europe, America or even East Asia. India has a younger population. Why is it that we are finding more and more, that even healthy young people, some percent of them end up getting very sick from this disease? So we should not be too cavalier even for otherwise what looks like healthy young people. And if you get into your issue of people who have lung disease, heart disease, diabetes, high blood pressure, those people are really at increased risk. Maybe not as high as a 75 year old, but definitely a lot of those people end up getting very sick and dying. We really in my mind have to protect all of those people. Which of course ends up being quite a lot of people. This is why there are some people who say that in places like India we’ll just let herd immunity happen and let hundreds of millions of people get infected. I think that is a terrible idea. The reason it is a terrible idea is that it will lead to millions and millions of people dying, including a lot of young people with this condition. We have to take a strategy that tries to protect everybody, particularly older people and younger people with chronic disease.
RAHUL GANDHI : So you don’t agree with some of these arguments, which I find very very doubtful, that the virus doesn’t operate in hot temperature that Indians are immune to the virus and we have certain vaccinations that protect us from the virus. I was sceptical about this stuff. What is your view on that?
PROF. ASHISH JHA : Let’s talk about them individually. On the issue of Indians and vaccinations- I got a BCG vaccine when I was a child and many Indians have. There is some circumstantial evidence that maybe BCG vaccine may be helpful in reducing the severity of the disease. It is not very good evidence that I would bank on. I would certainly not make policy based on that. It is a new virus, there is new testing, new studies going on and in the next couple of months, we will know much more. There are some nice randomised trials happening right now. I suspect that in the next three months, we will know much more if these vaccines will play a major role. I am personally sceptical that the BCG vaccine will be an important mediator. I don’t know, but we’ll know soon. But there is certainly not enough evidence to make policy. On the issue of hot weather and temperature, there is some evidence again that weather makes a difference. And we think that being outside, there is less transmission than being inside. So the home with 15 people, all staying in one small room there is going to be very easy transmission. But once people are outside, and there is air and all that, that would make it a bit better. But the question that I ask people who bring up the temperature issue is, do we think it is enough that it will keep the virus under control? No one I know thinks that it is enough. May be if the average person transmitting to 3 people, maybe it will be 2.5. 20% benefit. Good I’ll take it. It is not enough to be able to get us out of this.
RAHUL GANDHI : You said something very interesting, which is very relevant for India. So you are saying that a joint family system, with old people living inside it is a complexity and a risk.
PROF. ASHISH JHA : Absolutely. And we have seen this coming out of places like New York where a lot of the people who got sick and died were older people who weren’t going out and working. But basically what we think is that the young people they were living with were going out and working, coming home and then there was inter-family transmission. So it is a very big challenge when that happens and in India of course …. Three generations living together is of course a very common way of doing things. So there is a real challenge of how do you protect older people. Especially as you open up and people go back to work.
RAHUL GANDHI : Testing will solve the problem.
PROF. ASHISH JHA : It will help a lot.
RAHUL GANDHI : If you could test at scale, you could test everybody and then you are much safer.
PROF. ASHISH JHA : Obviously testing everybody, depending on how big the population is difficult. There are strategies that you can use to augment and… there is pool testing.. there are all sorts of things you can do to test large numbers of people with limited kits. I’ve also felt that India has many advantages. One of them is a very advanced, very vibrant technology and biotechnology with a lot of capacity, lot of capability. When people have brought up testing and India’s testing capacity, my sense is that look I’m not an expert in the exact specifics of which company in India can do what. Everything I know about India and everything I know about testing, on which I do know something, makes me think I am not convinced that India could not do much more testing than it does right now. I don’t know why it couldn’t. It is obviously being moving forward, they’ve been doing 80,000-100,000 tests a day now. That is good, that is real progress from where things were. I don’t know what prevents us from doing many times that. If we can get up to that level of capacity then yes, we can test migrant workers before they get out.
RAHUL GANDHI : I’ve asked some bureaucrats why lower testing numbers. Their point is that if you push the testing numbers too high, you frighten the people much more and you build up a much more frightening narrative. Unofficially that is what they say. I think it is much more important to fight the disease, push as hard as you can on testing.
PROF. ASHISH JHA : One of the questions that I have been thinking a lot about is, how will this virus change society? What will social norms and interaction look like in India two years from now? How do you think life will feel different? I’ve been thinking a lot about this, and I’m just curious.
RAHUL GANDHI : So I don’t think there will be one response to this disease. Every State will have its own response to its disease. You can already see that some States are doing better than other States because of their nature, their design, their political system. I get the sense that the more decentralised States, the States that spread more power closer to the people will do better. That’s my sense. I think the large urban centers will get hurt badly. I hope that this disease will bring people together and bring them to the realisation that you can’t fight this disease as different religions, or different communities, different castes, different genders. I think in some ways there is a potential opportunity here. There is an opportunity that in fighting this disease we are able to start a conversation, we are able to understand that everybody is required to fight this disease and we are able to work together to get out of this. I think there is a potential for that. We will also have to prepare ourselves for significant pain. I do worry about our older people, I also worry about our younger people who are sort of critical for the future growth of this country. At the global level, I think the virus is operating at two levels. One it is operating at a healthcare level and two it is attacking the globalised structure. If you look at the places that are vulnerable, they are all nerve centres of globalisation. And if you look at the people who are vulnerable, they are all people who have been damaged by the food chain. Heart disease, particular types of diets, particular types of behaviour, all come from globalisation and the virus is attacking them. I’m convinced that you are going to have a new world after this virus. I also think for example, I think it is going to reshape Europe. Many people won’t like what I say… But I think Europe will have a real difficulty staying together. I think the balance of power between the US and China will change. I think we are entering… people say that 9/11 was a new chapter. This is a new book.
PROF. ASHISH JHA : Yes, I agree with that. Life will not look in anyway, five years from now, will look nothing like what it did five years ago. It’s not only hard to predict. But it is not faded. Meaning, we have a lot of influence over what life will look like in five years. And certainly a lot of traditional models in our head of who is sort of the advanced economy and who is not, it has been very interesting for me being in the United States and saying that the countries that have responded the best are South Korea, Taiwan, Hong Kong and the countries that have responded the worst are Italy, Spain, United States and the United Kingdom. Welcome to the new world order. This is not how we had always envisioned things. It will have long term repercussions and I am not sure what those are.
RAHUL GANDHI : So, tell me. Ye bhaiya batiyea, vaccine kab aayegi? Aayegi nahi aayegi?
PROF. ASHISH JHA : Do teen toh vaccines hain jisme promise hai, ek American Vaccine hai, ek Chinese Vaccine hai, Oxford ka ek jo vaccine hai; teeno promising lag raha hai. I don’t know which one will work. Ho sakta hai ki all of them, ho sakta hai ek nikal jaye. I don’t know. Lekin I am very confident ki vaccine, kahin na kahin se next year tak aa jayega aur work karega and then India has to have a plan, kyunki India ke liye, you know, kitna 50crore- 60crore vaccine jarurat padega. So you know, India has to have a plan, how do you have that much vaccination available once it becomes possible. So that’s an area where there has to be a lot of focus.
PROF. ASHISH JHA : The other thing I will say Rahul, that I think is very important is that we are entering an age of pandemics. I am confident that this is not the last large global pandemic you and I are going to see in the next 20 years.
RAHUL GANDHI : Why do you say that? Why do you say we are entering an age of pandemics? What is the structural reason?
PROF. ASHISH JHA : Yeah, so many things have happened that have made this. So, you know, we got lucky that in the 2009 H1N1 swine flu that ended up being not so bad, thought it was a global pandemic. So what’s different now, than let’s say 20years ago? You’ve actually touched on several of these. Globalization, right? So a virus that gets started somewhere spreads globally very quick. Second is big environmental changes. All of this economic growth that China and India and many other places have had, which has been wonderful for lifting people out of poverty, has also meant encroachment into, deforestation, encroachment into areas where there are more animals and most pandemics, most pandemics, most diseases that come to humans, new ones are jumps from animals to humans, right? So this virus has existed in bats but there was a small change probably in the genome and all of a sudden it became suitable for human hosts. I think that, I think climate change is going to make many of these things all the more worse and then of course the other things that have happened with economic growth is that people are eating lot more meat and so that also means more interactions between humans and animals. Put all of it together. If you look at the last 100 years you’ll see increasing frequency of these kinds of outbreaks and this one of course is the worst in a 100 years but I am confident that we are going to have more global pandemics in the upcoming years and decades. And so as we get through this one, we have to ask ourselves, how we are going to better prepare for the next one.
RAHUL GANDHI : Well thank you very very much.
PROF. ASHISH JHA : It has been my pleasure. Stay safe.