A Personal and Professional Journey to India During the COVID-19 Pandemic

0:00:04.3 Narrator: Hello and welcome to Population Healthy, a podcast from the University of Michigan School of Public Health. This episode is part of a series of special editions of our podcast, focusing on the ongoing coronavirus pandemic. In the midst of rising cases of COVID-19, University of Michigan School of Public Health Biostatistics Chair and professor, Bhramar Mukherjee, recently traveled to India to continue her critical work on the pandemic and reunite with family. On this episode, we connected with Mukherjee during her stay in India to learn more about her journey and about the differences between the pandemic response in India and in the United States.

0:00:41.5 Mukherjee: This was a personal and professional journey. For the last eight months from March to November, we have all been so anxious and worried about or loved ones and our family in particular, and I’m no exception. I've been modeling the pandemic in India every single day from my clean kitchen counter in Ann Arbor, and I really wanted to get the touch of reality of what was happening on the streets of India. What is the reality? I wanted to connect with the Indian scientific community, but most importantly, I wanted to see my parents. And so I took this trip as a tribute to my personal and professional commitment, and I do not recommend travel unless it becomes absolutely necessary.

Many times you do your work and your academic work is sort of decoupled from your day-to-day life, but in this case, what I learn from colleagues, what I learn from my work, I really applied that to protect myself in a personal situation. So that was quite unique in the circumstances that we are undergoing traveling for 17 hours to India in the middle of a pandemic with all the exposures at the airport and in the airplane, so it was a very planned, well-planned journey.

I did a lot of research about exposures in airplanes and airports and I talked to my Epidemiology colleagues and the summary that I sort of synthesized is that the airports are much more of a high risk exposure place because people gather in lines and people are breathing heavily in the security line as well as the passport control, so that's where I took most of my precautions. And then the airplane, once it takes off, due to the ventilation system, there have been really very few outbreaks from airplanes. So I constantly sanitized my hands, I wore double masks, including an N- 95 through the airport and I wore goggles, I wore a face shield, and I was in a hazmat suit. So a picture of mine became very popular dressed like an astronaut in a space suit, but I just wanted to be safe and there is no space for vanity, so that's how I traveled through the airport. And then when I got into the airplane for 17 hours, I needed to be comfortable, so I was just wearing the face shield and the double mask, and I always sanitized everywhere I sat down, I minimized my food intake, and I constantly also drank hot water with Emergen-C. For the previous weeks planning for the travel also, I really tried to boost my immune system, exercise regularly, eat healthy, take zinc, take Emergen-C. There is no proven association, but still I wanted to prevent any common cold as well.

And then when I got down, I isolated myself, I got tested once, and then being a biostatistician, I know that the false negatives of this test is quite high, so I got tested twice to reduce the false negative probability before I saw my parents. So this was really a big journey, and I actually wrote a medium article about it, which became very useful to people who are taking overseas trip in general.

0:04:07.5 Mukherjee: I have been modeling the data that was released from the government and the ministry of health and talking to people, my family, primary, but it's a completely different experience to immerse yourself in the ground reality in the streets of India because the public health measures that work in the United States, everybody has their private transportation, you have a household which you can sanitize and stay inside, those things the system and India much more porous, so your personal preventive measures change a lot, as well as your adaptation of the recommendations that you are writing about. So first of all, I think that India from late September the curve has turned the corner, just like the first peak in India came much later than the Western world and in the United States. India stands at the 9.5 million cases right now and 138,000 deaths. There is a lot lower degree of underreporting in terms of cases and deaths in India. Still with that, given the country of its size, 1.3 billion people, I would say that India has managed the pandemic so far reasonably well, and I'll give you a couple of examples which were really startling to me.

The first is that it is easier to get tested in Delhi and Kolkata, easier than Michigan. So I got tested four or five times in the last four weeks without any problem, there's a wonderful home collection protocol, and you can get the results within 24 hours through your WhatsApp or your text. Also the connection of the private labs with the government seems very, very nimble. That afternoon itself, you get a note from the government. So this public-private partnership in scaling up testing and making it accessible is remarkable. And I'm seeing a lot of like testing camps in neighborhoods, free testing for people, household help, cab drivers, this is wonderful to build this network. And there’s buy in from community and religious leaders who are telling their community members that this is important, you need to get tested, you need to protect yourself. And then there’s adherence to masks. On the streets of Delhi, I saw a very high degree of adherence to masks and this is the street vendors, the shop owners, the common people on the street, everybody pretty much had face covering. It is remarkable how they understand the magnitude of the severity of the crisis.

0:06:51.6 Mukherjee: So I have to applaud the health officials throughout the hierarchy to send this consistent message that this is really serious and at every level, you need to protect yourself as best as you can. In rural areas in India, you have to rely on community health workers. In the slums, in the highly densely populated areas, you have to have buy-in from community leaders and the religious needs because people listen to them. So I think that this is a very interest tragedy, not to just talk-down messaging, but also at every level to secure buy-in to the state governments, to the district level officials, to the community leaders, and I think that that is something which has been quite effective in India in terms of communicating to the grass-root level worker and to the layperson. It's a nation which consists of many nations with different languages, different literacy levels, and not everybody has a smartphone, not everybody watches television. So this messaging going around, when I was in Delhi actually, there were canvassers and public announcements saying that you must wear your mask, this is a deadly disease, or every time you call someone, actually, there is a message from the government that says please take COVID seriously, please help people, do not stigmatize if you encounter a COVID patient. 

So all of this is very strong messaging that we still need to take this seriously even after nine months, and you know, often we forget to give these accolades to low resource countries in terms of leadership, in terms of pandemic preparedness. You have to think that in March, India did not have anything, but starting with the National lockdown, they really scaled up testing and also treatment and care of COVID patients. So I think that there is a degree of seriousness at every level that I have seen about the disease.

0:08:50.9 Narrator: At the time of the release of this episode, COVID-19 vaccines have been approved in the United States, United Kingdom and several other countries. Similar to the US, India faces challenges as it prepares to distribute vaccines to its sizable population.

0:09:06.0 Mukherjee: I think that the happiest note that can happen in 2020, is the news of all the three vaccines being quite promising. There's a lot of thinking going around the vaccine distribution as well in India right now, but distribution of the vaccine I think is a huge challenge. So India right now does not have a good digital infrastructure to identify people who are at high risk, who have comorbidities, even the aid structure is not always tabulated through census. So it’ll be a challenge, and again, you have to tap into communities in order to vaccinate because we're not going to be able to vaccinate 1.3 billion people or even half of them overnight. So we have to come up with the hierarchical strategy of prioritization and that discussion is going on in every country, not just in India, that who should be vaccinated first, the heath care workers, the essential workers, the first responders, but then people above age 50, people with comorbidities. And then we have to decide how to vaccinate the coronavirus survivors, right? And we have to watch out for the vaccine because we have efficacy data, we have limited safety data, so what are the long-term side effects? So setting up vaccinated cohorts and long-term studies will be very important for India.

Also, long-term side effects of COVID, right. So the COVID survivorship cohort is going to give us a lot of data on what were some unanticipated consequences of COVID down the road, because we have already seen a lot of people coming out in terms of heart abnormalities, neurological complications. but we have to really monitor these people who have recovered from COVID.

I think the Indian government has been really, really proactive in planning the vaccine dissemination. There are meetings all the time with the state governments and the central government, people at a grassroot level are being alerted, and I think schools are being planned to be converted into vaccination centers. Due to the storage issues with the Pfizer and the Moderna vaccine at really cold temperatures, that may not be feasible for India to distribute in the remote areas, so they are thinking more about the AstraZeneca and the Oxford vaccine, which is easier to actually distribute across the country. And also many people miss that the vaccines are not really preventing infection, they're preventing disease. So still it is worth watching that people who get vaccinated, if they get the infection, they don't manifest the disease, but whether they're infectious and transmitted to others. So I think we cannot let our guidelines down or the non-pharmaceutical interventions down unless we know that, what is the rate of infectivity for a vaccinated person. I think that it is going to take a lot of planning, but then first, we have to defeat the disease, the virus, and have to come up with the vaccination plan.

0:12:13.1 Narrator: After nearly a year of work responding to the pandemic, Mukherjee has learned a great deal about the challenges the US and India still face and the gaps each will need to address before other illnesses arrive.

0:12:25.6 Mukherjee: We have learned a few important lessons from here. One is that the importance of prevention and having pandemic preparedness and a pandemic response team. Because pandemics do not happen that often it may seem like we are spending a lot of money on something that we do not need every day, but if you think about the cost that we pay if it happens once in a while and if we do not take the right precautions, and if we are not prepared, it costs a trillions and trillions of dollars. So prevention is always sort of like a silent entity, which is prior to disease. This public health principle of prevention, people do not understand. We always feel like, yes, we are going to do whatever we want, and then when we get the disease treatment is going to come to our rescue. So prevention is much more silent and working in the background, because you don't see it being manifested as a disease, but this principle of prevention being underscored throughout the world and having strong public health infrastructures in terms of contact tracing, in terms of testing, in terms of treating is so important.

The second thing I think is very important that we all learn is that our health is interconnected. Even in India, unless all the states are in a state of containment, we cannot have peace. All around the world, if the pandemic does not subside, then we cannot travel freely. It’s going to move, the virus is going to move from one country to another. So I think that the national lockdown was very controversial in India, but I think it helped in various ways. There are pros and cons. So the pros were that India did not have any capacity for testing at the time, and also how to take care of COVID patients. That part was remarkably expanded in the six weeks of the lockdown. And then I think that the national lockdown also sent a message that this is a very serious issue, and if we do not adhere to public health guidelines and non-pharmaceutical interventions, then it's going to be...we’ll need lockdown again. And we cannot afford to have that because India has many daily wage earners and loss of lives versus livelihoods, so we have to combat this whole thing together. And another gap is that this digital ID, which is also a gap in the United States, because we do not have the national health services. In terms of vaccine distribution, for example, if we had an integrated digital health ID we’d be able to identify all of these people who need the vaccine first in terms of risk stratification and risk prioritization. So I think it is underscored, some data apps for India and the government is actually proposing a digital ID for health, for health services all across the country, and so there will be some tremendous progress.

0:15:28.0 Mukherjee: Finally, I think the structural barriers and the structural inequities in health have been really, really emphasized, so we need to do better. There's absolutely no question that there are social inequalities which will percolate into health inequities, and some communities have been hit exceptionally hard, and the distribution of loss due to COVID has not been equal across social strata, across the world, and we need to work towards a better, equitable, and healthier world.

We were all very hopeful for 2020, but we realized with much humility that we do not really know much. We cannot really predict. Our scholastic crystal ball have a very limited radius, and there's so much that we do not know what's coming. So it just showed the fragility of our civilization, for our very technologically advanced civilization. Also this year has been a tremendous time for our frontline health workers and my hats off to think about doctors in 2019. I think I did not have this every day remembrance of the physicians who take care of the patients every day, and so the frontline health workers and the people who kept our system running, and I think that I did not pay so much attention and gratitude for these people who are at the core level of our society, and 2020 has given me a lot of appreciation of these people, but also science and scientists, how hard we all have worked. Because we all wanted to contribute in our ways and it was not because this was not at a time which was just about our CVs or about our own personal glory, we’re just desperate and groping to contribute. And so this passion for science and the triumph of science, this has really been inspirational. From the magnificent discoveries to these little gestures, how humanity fought with resilience, with vigilance, with collective force, and social sacrifice - that will be something that I did not impress every day. I took many things for granted, and I think that I will be a changed person when this year is over.

0:18:09.0 Narrator: This has been a special edition of Population Healthy, a podcast from the University of Michigan School of Public Health. During the ongoing coronavirus pandemic, we’ll work to bring you analysis from our community of experts to help you understand what this public health crisis means for you. To stay up-to-date in between special edition episodes, be sure to check out our website publichealth.umich.edu, subscribe to our Population Healthy newsletter at publichealth.umich.edu/news/newsletter and follow us on Twitter, Instagram, and Facebook @umichsph.