People are reluctant to get tested

Dr. T Jacob John talks to Jagdish Rattanani about partisan politics between centre and states, rising instances of central dominance and the way ahead for exiting lockdown


JR- Hi, can you talk? Yeah.

I read your piece that went very well.

JR- Yeah. Thank you. Yeah, I was very, very disturbed by what was happening.


JR- So the report said that in West Bengal, the government knew the team has come after the landed there. So, it's very…

And Didi is saying that they are not giving test kits in adequate numbers. That may or may not be true but then some verification could be done

JR- But, in the  midst of a war, a centre is a bigger authority and power can say tell me what you want just stop this. So they will….. they should withdraw all, you know, all their cadres from, you know, doing the kind of politicking that has been happening in Maharashtra certainly. First it started with the three sadhus who were killed, trying to communalise it. There is no communal angle to it.                                                                                        

It turns out to be no Muslim was involved…                               

JR- No, no, no. No Muslims involved. This is the BJP. The Chief Minister says the home minister of India called him to ask… anyway.

that you know, that may be OK,  if you hit my relative I will ask…… But the point is what is the role of the federal ministry of health or the central government? Their role should be seamlessly working with the state to fight against Coronavirus. If you say….they say you do your work we are coming and supervise, we are coming and checking. We will investigate and give you how many marks out of 10 we will decide. That’s not that's not right. You have to say what do you need?  How are you doing? We know Bombay has problems because of housing situation okay. We go to West Bengal, we know your problem because you are one of the highest population density areas and you have cholera and now this problem….. So, how can we work together, this should be the proper way

What is the role of the federal ministry of health or the central government? Their role should be seamlessly working with the state to fight against Coronavirus

JR- Correct, correct                                                                                        

Statesman like…you know…adult like; ask what their needs are and then respond to that

JR- correct, at that time when…….lives are been lost

Now, the fact that they're doing this kind of thing reinforces in my mind, their false sense of confidence that India's trajectory is going to be extremely different from that of US or our country has hidden strengths. That is their expectation and every little thing that comes out of the government, statement like curve is arithmetic progression and not exponential progression, is said by somebody who does not understand mathematics at all. If you think it is exponential increments, you have to put it on a logarithmic graph paper then it will look linear.

If you don't do that all curves have got to be linear. See, a curve only can go vertically up when the numbers are increasing. You cannot make the curve turn to the left. So that is, so therefore, the curve can only go up and the angle of the curve will predict the shape of the curve. The angle is 45 degrees, you know where the peak will be. If the angle  is 60 degrees. you know the sequence. The downslope of curve will be  mirror Iage of upslope. So, the angle is the most important thing and the angle if you put the daily thing I have not done it, it is just like a bell shaped curve.  

So, the trying to justify the action and trying to see success by this kind of argument is reinforcing their sense of security saying that everything is going to be okay. We are going to have a different trajectory. Therefore, our Prime Minister will get huge credit. Even Bill Gates is giving him credit. Now, Bill Gates I told you the other day has a different bias.  . When Modi became Prime Minister Bill Gates was almost thrown out of India. Melinda Gates was working in Bihar, she was thrown out. So, the first opportunity Bill Gates got, he gave an award to Modi in the USA that was kind of building bridges. So, today, if Bill Gates praises Modi, it is…he knows which side of the bread butter is, if he must come back to India with any credibility……with any respectable acceptance in India, he has to humor Modi.    

Bill Gates also needs his own self-interest to be protected. So he has to give an award and he has to praise Prime Minister Modi

So, I think Bill Gate is a human being, he also is biased. He also needs his own self-interest to be protected. So he has to, he has to give an award and he has to praise Prime Minister Modi

JR- He says he has to work with the government if there is any impact at all possible in a large country, so I guess that is an inevitable thing for him to do.                    

Yeah, exactly. Without such relationship…. he cannot work without the government today, in today's atmosphere.

JR- Even earlier, earlier I thought if you have to in the health sector, if you want to really do large surveys on intervention, then government support and government collaboration is what is important.

Not 15 years ago. UNICEF could do anything and get away with it. Gates Foundation could do anything and get away with it. And the UNICEF gave Vitamin A  doses, in extraordinarily large doses and children died of that.

JR- Oh, okay. I didn’t know that                                                                  

During the time when the government of India recommendations for dose were much lower. UNICEF got away with it. So, I mean, there were hardly any check measure or control. But the pendulum has swung this way now it is….everything is scrutinized, controlled and to the point that it's shooting through our own feet. Not good for us ….

For every COVID patient there are four asymptomatic people

Anyway, so, the government is saying that the graph, increment is arithmetic proportion. Increment can only be arithmetic proportion…all increments are arithmetic proportion. If 2 becomes 4 and 4 becomes 8, that is exponential growth and that will also be caught in a linear graph. The only thing is angle of the graph will be more vertical. Anyway, so that's neither here nor there. This is the time when states and centre have to work together seamlessly. So this is oneupmanship by the Centre with West Bengal.                                                                         

I think I wrote that to you, right? Yes.

JR- correct, you did…

JJ- And yeah, that’s now good.

JR- it indicates that big trouble coming. Yeah. Yeah. Okay. What is your reflection for today other than that?                                                                                        

my reflections for today is actually on two lines. One, is a plasma therapy.

JR- Yes, it's working.

We will take far greater time to build up the numbers that Italy saw

Second patient got in Max hospital. Touch wood, second patient also improved significantly. With that Kejriwal has announced, I was told by a senior ICMR officer, he called me and said, “please watch television right now Kejriwal announcing that plasma therapy is to be the norm. Okay, that means he is snubbing ICMR….I mean he is not snubbing, I am sorry I withdraw that word. He is disagreeing with the ICMR this is not the time to do….

JR- a random trial

randomized control trial in which statistically necessary, half the number of patients will be…. will not be given plasma therapy.That's what we wrote in Hindustan Times. So that is good news.

JR- Yeah.                                                                               

So activism, it is not an activism, what is it, advocacy works. Okay, that's one thought. The second thought is about the assertion made by I think the NITI Aayog person that the lockdown is working and the doubling time is increased from four days to seven days or something like some. Okay and yeah, that's even better results are expected under lockdown. So in justifying the lockdown by these kind of numbers, as if they were not sure when the lockdown was announced and this is going to happen if they knew that this is the intention of the lockdown, then one wouldn’t make too much of it or intention is working fine. But it's not working that’s why, they're trying to prove that it is working

JR- Correct                                                                             

That’s the way I feel it. And today some journalists called me and asked me, 2  journalist actually called me and asked me, what I make of these numbers 700-600 for death and 28,000 odd cases test positive…..Simplistically, you use 600 as a,d….. numerator and 28,000 as a numerator, and you divide for mortality rate; that is not valid at all.

JR- This is the fatality rate. Yes, that’s not valid at all.

Kiran Majumdar told us that there's a lot of stigma attached to it that she knows about. So people are reluctant to get tested.

It is not valid. It makes no meaning at all because the deaths are definitely COVID deaths. The tests results 28000 or something, is definitely not all COVID diagnosed patients. A vast majority is tested because of travel history and contact history. Asymptomatic majority. Okay, so asymptomatic plus some COVID patient that is the test results of 28000….. close to 30,000, I think now. Okay. So if 600 to 700 people died as we said the other day, yesterday at 10% case fatality total infected  is 60,000 to 70,000 COVID patients --not merely infected, okay, infection does not kill, COVID does. . And for every COVID patient there are four asymptomatic people. So you multiply with a factor of 4or 5…..60,000 times 4 is 240,000 plus, if 5 times then  300,000, isn’t it?       

That's a real number but we are only counting 30,000 so we cannot make head or tail out of the numbers we have. So we are again flying blind. So I'm developing the thought process that I'm going to write and I'm trying to get a good statistical person to help me and my thought processes along these lines.  That is what do you make of these numbers and…. and why is India in slower growth trajectory than Italy was, Spain was. And I have an explanation for that also, but, I'm working on it. That's where I'm looking for a collaborator to see whether that idea will work or not I will first pass it down by Sheshadri, he is a good brain, and then we will work on that. I'll tell you that tomorrow.

JR- Sure. What didn't you already say earlier conversations that it is proportional to the number of importations initially?                                             

Did I said that?! That’s the idea that is in one patient risk factor for severity, if you remove the seniority of age and comorbidity then the risk of severity depends upon the dose that you got infected with…..

We need valid, scientific, honest information to be disseminated. Rotarians are thinking about how to amplify good messages

JR- the viral load      

The viral load of infection, not the viral load of infected nostrils but the initial entry number of the virus called dose. One virus is enough to infect. Just one virus is enough to infect, not for most bacteria, bacteria you need…. if you don't have 100 typhoid bacteria are getting into the stomach, you are unlikely to get infected because body destroys the vast majority of bacteria, even viruses, if it is that place where body can destroy, not so in the nasal mucosa. So, if one virus gets deposited on the nasal mucosal surface, that fellow gets into the cell, that fellow becomes 10,000 viral particles, that fellow infects the neighbouring cells. There are 5 cells touching this cell; north, south, east and behind, they will all get infected.

And viruses 10,000 are getting into the nasal cavity. So, this 10 Cells are also getting infected. Okay, it takes, lets say a one hour, the next cycle of infection, then another hour and ..

JR- so that’s it, only 1 hour?


JR- is it one hour….?

That’s the replication time….I mean one hour is enough….I don't know exactly but we like to check. 1 hour is average of any viruses. Now, innate immunity begins to work within one hour, innate immunity is alerted with the first virus entry and the innate immunity, it is a what do you call nonspecific or its a relative immunity and the innate immunity is necessary for the active immunity to take place. So the virus grows from the nostril multiplies, it grows from 1 day, 2 day, 3 days. You then sneeze or cough and virus goes out and you keep swallowing this virus.                                          

Okay, and when you breathe in, some virus may be inhaled in, then they go to the lung. Okay, and so this takes time. I don't know how much time but I would give two or three days of time before it reaches the lungs. Another three days you have antibodies coming and therefore the antibody is capable of interacting with a limited number of infected in the body. Okay, now take the second scenario somebody gets a heavy dose of inoculum they inhale, somebody sneeze or cough and he got 1000 virus particles entering through nostril, if 1000 entering through nostril  here is also, some will be deposited on the nasal mucosa or others  will be inhaled into the lungs.

We need action to keep the green, green and try to convert the orange, green. So we need to have district by district by district strategy planning and strategic planning means what the schools do, what will the shops do, who will run the shop, who will do the agriculture, how will the factory run. So we have to build up the district as army unit, one man, everybody on the same page like Kerala State is doing.

JR- Yeah                                                        

JJ- So you have simultaneously lung and nasal mucosa getting infected, simultaneously you have a huge problem on hand, so innate immunity is working it still takes seven days before antibody responses is bounded. By this time both lungs are infected and in another six seven days you have bad disease. That is virologically well accepted theory. Heavier the inoculum more likely serious it is, lesser the inoculum that is if you infected in spite of wearing masks and goggles. Your inoculum stage is very small, your diseases likely to be mild. This is of the human beings. Same applies to Italy and India.

If Italy got a heavy inoculum dose, that all the visitors to Lombardy, Venice, Genoa, Pisa,. Pisa tower you know…..and the Lake Como and all these kind of places…. They brought a whole number of infections and a whole number of people got infected in India, 1 from China, another from China, 3rd from China, all of them detected and the transmission chain stopped. Then we got infected from the western side, Dubai immediately picked up and curtailed, Italy immediately picked up and curtailed.  So our introductions were far fewer theoretically. And therefore, we will take far greater time to build up the numbers that Italy saw.

JR- but build up, they will for sure?                                                  

They will, with a two month time’s delay.

My guess is Italy and Spain got infected in November. Testing was not available. Testing was available in February, end of January, beginning of February. And so they found a few cases. Okay. In one month Italy's numbers shot up. India’s numbers did not shoot up. India still at the end of the month had only three cases, we went up from two to three. February 2 to March we went up two to three. Okay. Italy, I'll tell you the number, very, very interesting. Italy went up from also two because that testing was delayed, so they found two. Italy 2nd February two, India 2nd February two, India, 1st March, India three, Italy 1694 that is not exponential growth from two. It is growth from January, December, probably even November.                                                                                                     

So that is the difference between India and Italy? When did India reach that number, 1st April we have the same number as in Italy in 1st March. Okay. So by this time we are already in lockdown, 25th March we were on lockdown. Okay, so we were lucky that lockdown was announced early. And we were lucky that we had very good introduction. The dose was low. And that makes all the difference for the later progression until you come to number of 20,000, 30,000 50,000                              

Now 700 COVID deaths means 70,000 COVID disease. No no  700,000 infections…………… 70,000 COVID diseases, that means 70,000 plus 28,000 asymptomatic infection. So 28,000 plus 70,000 is one lakh. So we have one lakh we only detected 30,000 so our trajectory is probably lower than Italy because Italy had no clue what's going on. We were adequately warned, we had plenty of information that infection should be sustained by contact tracing, quarantining etc. So that’s my explanation. Okay, all right here. I now received your 4 transcriptions….                        

I had a very long conversation today, with Kiran Majumdar, Biocon, and Rotary leaders in Bangalore and Chennai, they got quite taken by my suggestion that IgG antibody will be technique to certify people who can go back to normal life activities. You know that So we call the conference call Kiran Majumdar and Rotary leaders. And we are thinking in terms of developing two things. Kiran Majumdar told us that there's a lot of stigma attached to it that she knows about. So people are reluctant to get tested.     

So we need valid, scientific, honest information to be disseminated. So we have agreed to Rotary that Rotary will take up that issue. You don't have to ask anybody's permission. You simply…..Rotarians are thinking about how to amplify good messages and I'm thinking about how, what good messages should be. The second thing that we Rotarians are beginning to think about is the lifting of the lockdown will be district by district by district. That is a decision almost taken by the PM. Red district will not be lifted, orange will not be lifted, green will be lifted. And if you lift green and make a mistake, the green will become orange and red.

That's because the lockdown was lifted. So we need action to keep the green, green and try to convert the orange, green. So we need to have district by district by district strategy planning and strategic planning means what the schools do, what will the shops do, who will run the shop, who will do the agriculture, who will do if there is the factory, how will the factory run, if one workers infects the rest of the factory, the factory is closed. So we need protocol based opening, so everybody should be on the one page, the entire district. So we have to build up the district as army unit, one man, everybody on the same page like Kerala State is doing. So we need to think about that and that can only be taught through collaboration with Rotary and the state government. We are still in the planning stage, if it comes through that is the social vaccine that we talked about a couple of days ago.                                       

And we have the same idea of the district wise social mobilization informing everybody all information getting their corporation, getting them to do the right things. That paper have gone to Hindu by the Pratap and me together and we will wait for Hindu decision.

That’s the idea.                                                                                 

JR- Yes. Yes. Yes. Good. That's good. So today you have the time to look at some of earlier conversation or tomorrow…..