'History Shows India Must Be Open To Best Science & Tech To Fight Pandemic'

Edited excerpts:

First, have we learnt the right lessons or any lessons from the first set of pandemics going back decades, if not centuries, in India?

The quick answer, because of the massive crisis that we've all collectively just gone through, would obviously be 'no' given that we had a first wave. We know from history that pandemics do come in waves. We should have been much more prepared--so we definitely did take the eye off the ball. In that sense, we definitely did not learn from history. I think the larger problem is that until the WHO [World Health Organization] announced this as a pandemic in March 2020, most Indians had never really heard of a pandemic. Even SARS and the stuff that happened in the last 20 years happened somewhere else, it didn't affect India. That's why I wrote this book because India was completely knocked out for nearly a century, and especially those last 50 years from 1870 to 1920, with life expectancy rates falling and death rates, which were already high, increasing. This was a deadly period in Indian history with cholera, plague and then eventually the 1918 influenza pandemic. These really wiped out a lot of Indians.

That particular juncture led to very important improvements in science and technology. And that's why we say in the last 100 years, the big learning over that time is that we are no longer dying at 20; our average life expectancy is 70. It's taken 100 years for the next big pandemic to arrive so the sense of collective memory has definitely been lost. Take, for example, the classic policy error of last year, where history had a lot of lessons to offer. We had a migration crisis where we saw people walk back home and history tells us that there were ways to anticipate what would happen when you enforce a national lockdown. Because the British actually had to face the same tradeoffs, policy choices back then, especially when the plague arrived--do we shut down the trains or not? How hard should the lockdown be? These debates are not new. They are of course new for our generation.

But I think there's been some learning from last year to this as well--we have not seen a migration crisis this year despite major lockdowns. Yes, migrant workers are suffering, but it's simply not the same as last year. That's because we've kept the transport systems alive at a meagre level, but they're alive so that people do not have to walk back home. That is a learning which could have happened last year from 100 years ago but did not. But this year we have one less crisis because last year we had two.

On vaccination, what is the lesson from the past that informs our present?

Like I point out in the book, the Haffkine Institute, which is now by the way being roped in to start production [of vaccines], apparently in eight months, was like the Serum Institute 100 years back. It was the vaccine-producing star of India and in 1931 the annual report mentions that there [would be] a riot if you pressed for vaccination--basically vaccine hesitancy. Now there is a riot if the vaccine supplies run out. And this tells you how this mindset shifts. It takes time, but it's very important for this shift to happen. Now how do you get over vaccine hesitancy, which is such a big issue even 100 years later? In a country like India, [what would work] is very good, concentrated public communication, and demonstration effects--where influencers, panchayat leaders, politicians, film makers take the vaccination shot and tell others that this is the right thing to do. The second thing is what history tells us--that we have to be very careful with adverse events. The vaccination drive during the plague was set back by a few years precisely because of a certain accident in which Haffkine himself was implicated though he was later cleared of the charges.

If there's such a huge demand for [Covid] vaccines, we have to be very careful with the protocols and the safety procedures. We have to take it for granted that there will unfortunately be some adverse events. Now, how you deal with the fallout of those adverse events is very important because it can very quickly become public relations disasters. In that case, you're getting more vaccine hesitancy at a time when you want more people to take vaccines. I think this is clearly something that we should learn from history--have a good strategy on how to deal with adverse events.

The third is, of course, vaccine manufacturers--we need to get safe vaccines from as many manufacturers as possible, and spread our bets widely. You can't just pick one or two manufacturers given the demand-supply constraint and so you need to go all out. During the [earlier] pandemics, the British invited the best scientists of the world to come [to India]. They came to Bombay and they all tested [their vaccines]. So you have Haffkine's vaccine but also Alexandre Yersin after whom the plague bacteria is now named. So we have to be open to the best science and technology the world has to offer in order to get over [the pandemic].

You're suggesting we focus on communication because you're likely to see adverse effects and if you don't manage those, you will only see vaccine hesitancy rising. And this will become a bigger challenge than the one you began with.

Absolutely, and the issue of these adverse events will set us back by a huge margin. We have the example of the sterilisation campaigns during Indira Gandhi's reign in the 1970s that set back the family planning calendar, which otherwise was perfectly sensible, by decades. We are not on that timescale for this pandemic but it can be a huge setback. We know from all the available information that a hugely critical part of getting over the pandemic is the vaccination. And so if the population is not going to get vaccinated, it's quite likely that we will potentially have future waves and similar cycles again and again.

In any case, many or most vaccines have 80-90% efficacy so it's logical that some will not benefit fully or may actually see the infection breaking through.

How did vaccine hesitancy reduce during the plague pandemic? One is people started seeing the benefits [of vaccination]. At the village level, they suddenly saw that the chances of certain people who got the vaccine surviving the disease were very high. Remember, plague was a terrible disease. It was not very virulent but the case fatality rates were around 80%. Of course, the vaccine effectiveness rates were much lower than now but [the vaccines] started gaining currency back then and that's what we need to do: show people, demonstrate. The thing with the coronavirus is that the case mortality rate is very low so people have this idea that 'we won't take it [the vaccine], we will take a chance'. So we have to convey to them that the chances of surviving are much, much greater if you get the vaccine. Show examples of people not taking vaccines, and unfortunately succumbing, and [say that] things could have been different if they had taken the vaccine.

So, let's talk about the public policy response to this. In your book you also talk about how many politicians cut their teeth during pandemics, including in India. So, walk us through that and secondly, what is the link between the way politicians and those in office responded then and lessons there?

While researching this book it really struck me that all these great freedom fighters we learn about in our school textbooks… we never really understand how much of their lives revolved around pandemic management. This is a blank spot in Indian history, where the pandemics have vanished. I am based in Ahmedabad, so think of Sardar Patel. He started his public life as a member of the sanitation committee in the Ahmedabad Municipality. And then plague hit Ahmedabad big time in 1917. And Sardar Patel is on the streets trying to help people. And there are multiple plague outbreaks after that as well where he is very much in the thick of the action. You have people like Gokhale and Tilak in western India who become absolute stars because they were countering the British on the one hand but also dealing with the pandemic. I also mention in the book the whole cooperative movement in India which required a lot of solidarity and that came about in organising relief for plague and other pandemics.

So interestingly, what pandemics do is bring a lot of people out on the ground to do relief work which creates new networks, creates potential political leaders who will then, 30 years down the line, say that you know we cut our teeth in the great corona pandemic of 2021. So, just to give you a pointer, hypothetically if Sonu Sood becomes the Prime Minister of India 30 years down the line, it would be because of the pandemic. When a lot of these leaders like Patel got into [pandemic efforts], they didn't even know that India would become an independent country and he would become a home minister, but that's how it happened. Pandemic relief and coordination activities generate a new class [of leaders] who would not have otherwise taken this particular career and are pushed systematically towards it.

As for the learnings from this, I would say they are limited. That was the British state which clearly favoured protecting Britain rather than India from the diseases. But there was systematic attention paid to science and technology. Cholera was a massive epidemic for both Britain and India in the early 19th century, but by the end of the 19th century Britain had kind of completely eliminated it but India was still ravaged by it. And of course, these were British medical officers in India then. But what Britain had done was actually move on to this waterborne theory [of cholera's spread] and they were onto the cutting edge of the science on epidemics. Whereas the same British medical officers in India, who were steeped in a completely different paradigm, said stuff like cholera is not waterborne and so on. So, I think the key takeaway is that you have to pay attention to science and technology.

Take the example of Brazil: 100 years back, it did a reasonably good job against the plague pandemic. They got one of the best Brazillian scientists in the world who was at that time in France, a young guy, to Brazil and said, deal with this and this. Many of them credit the roots of the public health system to this institution that he set up. And today you know that Brazil's response has been very shoddy and that is because it has not paid sufficient attention to science and technology.

And if you look at our response last year, there was a migration crisis but I think the government had the right intentions in the sense that they did take it very seriously, the idea that the pandemic could devastate lives. They placed a huge premium on lives over livelihoods. Unfortunately, that sort of approach was not there this year. But in the second wave, I think we stepped in very late. I remember by April 17-20 things had not changed fundamentally in terms of acknowledging the crisis, when cases had already kind of surpassed the earlier waves.

I end this book with two words, patience and humility. And I believe these are the core personality traits you need to manage the pandemic. Patience because pandemics rarely get over in a few months, which means this is a long drawn-out game. And humility--you have to learn as you go and you should not actually celebrate the end of a pandemic. The British unfortunately also declared the end of plague in 1897 but it haunted India for 20 more years. And it's only when transmission was completely understood, and a lot of other things happened, that slowly the plague started receding.

Given the fact that pandemics last long, how do we calibrate our own expectations?

Once they discovered that cholera and plague were seasonal, it is very interesting how the Indian society coped with it. Once they understood that certain times of the year they could be hit by it they developed a resilience mechanism--they said, at such and such time of the year they will do ABCD. In those days, evacuation was a huge strategy--they would evacuate villages and towns and camp outside to kind of let the plague season pass by. Rest of the year, they sort of go full steam ahead saying that OK, this is the time to work and get the economy in order.

Unfortunately, we don't know anything about Covid's seasonality. All that still demands more research; I think the way forward is to acknowledge that one, this pandemic is not going to get over until it really gets through across the world, which means that new strains can be developing continuously. And then when you get these in-between slots when cases are falling we should ramp up because ultimately it's a big tradeoff between lives and livelihoods. Now is the time to get back that lost output, the incomes, maybe inject money [into the economy]. The lesson could be that you need a fiscal policy to inject money right now, in this breathing space, when you can actually get the economy back in order. So, this is now a new kind of a business cycle which will follow the pandemic [cycle]. And I think it is key to ride it smart.

If you have to think of one political leader in India's history who combined some of the best attributes needed in the response to the pandemic--respect for science, decisiveness and objectivity--who would that be?

I would say Sardar Patel, Tilak and Gokhale. Tilak was, of course, in the protest mode. So, he was pointing out all the bad things that the British were doing--extreme surveillance [for example]. What connects that era with this is the Epidemic Diseases Act of 1897--these leaders dealt with the same law back then. Of course, Gandhi was also involved in relief work but these three come to mind because they had responsibility. For example, you know Gokhale was heading Pune's urban setup for many years after plague began and he comes across as a very decent administrator. Between these three, I would probably pick Gokhale in terms of how he dealt with the situation--observing what was happening on the ground, [organising] relief, getting cooperatives to help and so on. So he was a much more consensus-building kind of person.

So, did we have lockdowns in those days?

There was never a national lockdown, only localised containment measures. The only time it got really serious was during the first plague and they had quarantine systems across all the railway systems and so on. But there was never something like what we saw last year.

Of course, the 2020 national lockdown has a logic to it. It can potentially stop the spread of the disease. But back then, I mean, the word was not 'lockdown'; quarantine was the operative word. They did try, for example, during the flu of 1918 to shut down places of large gatherings and so on. Certain protocols definitely were in place but, as I write in my book, there is a constant tiff between public health officials who think they can get into control if nobody is moving around vis-à-vis the business lobbies that said you can't stop our work because we're making losses. This is an eternal fight.

So what's heartening in this wave I think is that Uday Kotak said, look, we should be scaling down a bit because we need to get over this pandemic wave. That's the kind of cooperation that needs to happen. We can't be at loggerheads: one group saying lockdowns never work and public health officials saying no, we need a complete lockdown right now. The fashionable word now is graded lockdowns. Back then also, there was a lot of opposition to restrictions because it clearly affects livelihoods in such a direct way.

I think in a few months we will get a sense of which protocols may have worked and which may not have. Because each state chose its own policy on how to reduce activities, we should have some [idea] of the best practice. So for example, a simple thing like opening/closing time of offices is a huge debate. Should it be a few hours a day, the whole day or one day a week? We should have paid closer attention to it the last wave but after this wave officials are hopefully talking to each other and saying OK, what seems to have worked?

You can actually measure these things smartly--the Google mobility trends shows it quite nicely. I think governments can also invest in some data metrics. We've been focusing a lot on the Covid metrics, which is also highly questionable--the Covid cases and deaths. Because lockdown restrictions are so important, maybe it's a good idea to also invest in creating metrics--how are people moving about on the ground? If this [waves and lockdowns] is going to keep happening, then the places that are going to do well are also places that can restrict and unwind seamlessly, right? And for that you need some sort of a metric.

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