Antibody tests will make a difference

In a conversation with Jagdish Rattanani, Dr. T Jacob John says many factors have contributed to Mumbai being the Corona capital of India. Apart from improving health infrastructure, he says a strategic plan of action to mitigate suffering is urgently required

JR: So one thing that is coming up is in Mumbai. I just saw a PDF list of the places under quarantine and so many a large majority of the city somewhere or the other there is a containment zone. So we were wondering and I want to ask you when the number of containment zones is very large, does it make sense to do containment zones or to treat the whole area as a containment zone?                                                                                  

The core concept of containment had time when it was valuable. That time is long past. Now this is a respiratory transmitted agent. And that you cannot stop it in the track except when the people who are infected are extremely few in number. Once the numbers grow into large number you’re thinking has to shift to health care approach.

Okay, but then they said there will be problem. What do you do with thickly populated areas, where you cannot control the respiratory transmission, you are stuck there. So a judicious application of containment is still valid. For example in Vellore city, in my own city, there are two what do you call, wards, of one large area under strict containment that is no entry and exit from that community, so that there are few people are infected in both places. So to contain the infection from not getting out, in other words, this is in forest fire fighting, you create fire lanes that is the whole area around the fire is cleared so that the  fire cannot jump from where it is to the outside area where the trees are. That is what is being done now.  I think….. it has to continue to certain extent. It is….it is again the strategy to flatten the curve, not to eliminate infection. Infection cannot be eliminated it will come; but then you can slow down by these very heroic measures of containment in such pockets. And that will also up to a point until there are too many pockets.                        

JR: which is what I suspect is happening in Mumbai.

Yeah, once that happens, you have to then take the entire population, and Wuhan like. And let….. let the infection evolve inside that blocked area. But then you must remember there are vulnerable people and older people, you have to protect them. You can't simply  let them just die because you want to protect the people outside the containment area. That is inhuman, inhuman. So, you have to balance whatever you do with Human rights.                                                                                                 

JR: But also it will have to be a stricter lockdown I guess in a place like Mumbai?

Pardon

JR: Mumbai we'll have to see a stricter and a longer lockdown in this case?

Yes, Mumbai will have to go through some very careful strategy planning and that is where universal mask will make a difference. And antibody testing with IgG will make a difference. That I'm trying to prove to my Rotary friends, trying to make Biocon rush with IgG antibody tests. The thing is, it (Biocon) does make it and then quality checks it and then get it approved all that will take say minimum of two weeks. But it can be done, okay. Once you have it, so it is a multi-prong strategy of containment. Treating everybody who falls ill in an outside the containment area hospital, dedicated for COVID and the family cannot stay with them.

So you have to have extra care for their welfare, safety, psychological support physical support, food etc. etc. At the same time all senior citizens and people with diabetes etc. need to have a full consultation with their own doctors. If they have it, if they don't have them, make arrangements for their own consultation so that they stay within the blocked, area cordoned off area for all their other medical requirements.

Then, if they have suspicion… no, symptoms of COVID again, I'm telling you very, very strongly that the symptoms of COVID; you have to have fever, you have to have cough. These are the two major things. And if you have loss of smell or loss of taste, this is COVID suspected.  You don't need to have breathing difficulty. If you have breathing difficulties, it is moderate or severe  COVID. If not, it is mild COVID. You judiciously say that all cases of  COVID we will test. And when you say that everyone must be tested and if they're positive and turning severe, they should be shifted to hospitals and their family members then tested.         

So it's a…. it's a labour intensive program if you want to go the whole hog.  Expecting that the blocking will somehow kill the virus within that blocked area, the price will be heavy, the senior citizen and the vulnerable people will have to be taken care of, despite, many of them may die, that should not be allowed. It is a judicious mix of public health and health care has to be defined, easily said and again I am telling you the problem is all these were, ……we had enough and more time to go through this in our minds, everything is created twice once in the mind then on the ground. Now, Maharashtra also becomes  little bit of a political problem, parties are different, it is animosity and therefore, that may be made use of…… God forbid, hopefully, we are mature enough not to play political games when the house is on fire. And full collaboration cooperation must be necessary.

JR:Yeah, which is not there I think, I suspect.                                                            

I don't know I am sitting here, I have no idea.

JR: because the way the reports are coming out here….

oh okay, that is bad for the country. We are one nation we are all Indians first. Religion next, political parties next. Okay. So, so the thing that could not have been predicted in one and half to two months ago what might happen in Bombay, okay. That is why tomorrow in the Hindu, this social vaccine paper is coming. That social vaccine paper reads very innocuous in the sense that we are describing all the social defences that you can build public education, public awareness, behaviour modification, education, information, all these are we are describing. But intelligent people will understand that that's not the strategy of India. So, in contrast,we identify the flaws without pointing fingers.

Yeah, without pointing fingers at the government response we are saying what this social vaccine should be and how it has to be worked out. Far too late in the game to make revisions and amendments because people have got the impression that this is nothing, we are Indians, we will fight it. The virus will not bother us. Strong. we have immunity, we are strong people and the government is going in the right direction. Everything is fine. We are the best in the world. Our response to COVID is best….better than Italy better than Spain, better than Germany, UK, better than USA. That kind of message has come through. I don't know how it has come through. But my friends in my Rotary circle they are actually optimistic.

JR: All of them?                                                                                              

Most of them. One or two guys saying caution. Rest of them believes that this is a passing show. And that message is from public health point of view uncalled for unjustified and not completely honest. Even if you believe that might be the case, there are reasons why you should expect serious problems….. You could argue that protection  might be due to  cases of malaria,  BCG.  Thinking of yet another possibility why Indians might be a bit protected that I cannot share it with you because it's the two of us together and so I can't. Okay.

JR: Sure, sure

These are all kept in the back of your mind. Yeah, but public health, public health is working towards the worst case scenario. And if the worst case scenario didn't materialize, don’t worry.

JR: then no problem.                                                                                      

But if you do not expect the worst case scenario or a bad case scenario, and then if it happens, then the immediate reaction, particularly political leaders can imagine is searching for scapegoats. Then, the house is divided…….

JR: Yeah, but tell me what is your gut feeling on Mumbai? What are you feeling?

More specifically, Mumbai is going to have big trouble. Somebody asked me from Mumbai, the rich people will have to stay home, they stay put, but the lower income people who are, you know……physical distancing is a theoretical for them. We have to think of them -- life and livelihood requires interaction, social interaction. That is why I don't like the word social distancing. I always say social connectedness, physical distancing. I talked to Ramanan Lakshminarayanan and I made the point….. he said,  he completely agree. So social connectedness is a psychological requirement for everybody. Physical distancing, he said biomedical requirement for everybody.

JR: Okay

Okay, so Mumbai, you know, in a way, I feel I'm lucky I'm not in Mumbai. But that is no comfort. Mumbai was Mumbai in February, then in March, so this whole concept of evidence based approach, which you're saying, that is wait for community transmission has  not occurred yet. No, it's not yet occurred, there is no evidence. Is it inappropriate for public health?

Okay. And where are these people getting infected from?! after all it is infected from other people and so, denying community transmission and posturing that we are different and that we have many advantages which are all theoretical, but BCG is one tangible but then BCG people themselves say don't count on it. Even the NDTV had a big show with the big shot. What is his name? NDTV’s guru?

JR: Pranoy Roy

yeah. Pranoy Roy asking a number of people. There are some microbiologist. I think Cambridge somewhere…  Dr. Lalitha Ramachandran or maybe somebody else….she said yeah BCG has some indication, but then BCG doesn't protect TB itself. So, the point was don't count on BCG, if it helps, well and good. But she said something very interesting……She said there are private institutions like Christian medical college Vellore. They stand out…they are world class…their leaders are world class leaders…. But Pranoy Roy didn’t react to that.

So, we have been pioneers in bringing technology, high-tech and bringing it to  within reach of the poorest of the poor.

What I'm saying is CMC is a national resource. India’s all neurosurgeons were grandchildren, great grandchildren of CMC trained people. First generation in India was trained in CMC, nephrologists  likewise cardiothoracic surgeons. So, we have been pioneers in bringing technology, high-tech and bringing it to  within reach of the poorest of the poor.  That is CMCs philosophy. That is…it is it is a robin hood philosophy. We literally overcharge the rich and literally subsidize the poor. Okay, and the, anyway, I'm positively biased by my institution.

JR: Correct

She mentioned the CMC and anyway, so she was saying, she was pointing out the  private sector being kind of sidelined for many things in this fight. That didn't….that was not picked up by Prannoy Roy very effectively because I think he didn't want…he didn’t know how to react to naming Christian Medical College.

JR: Okay

Okay. But then the problem is, if you look at the private medical establishment in India, you can’t name many others of that type in the private sector. So I think we are stuck also. That I blame the 1980s, whoever was in power, I think….congress Prime Minister whoever….

JR: Indira Gandhi

Narshima Rao, down, Indira Gandhi, Manmohan Singh everybody. They wanted healthcare opened up for  private sector. Bright idea. Private sector would save finance and give service to a huge number of people. Good idea. And the mistake was they expected private sector to be a self -regulatory body.

JR: correct.

don’t know this is India and if you don't curb, how much profit you can make. If you don't curb, how much you can charge people for health care. If you don't establish an auditing system so that quality is absolutely assured. Quality and cost must be under government regulation and government  supervision under the watchful eye, in the case, you give a free land to the private sector you give concessions, you give excise duty exemption for procuring all the benefits that was given to the private sector. Most cases or many cases if not most cases happen to be private money making concern.                                

Okay, so that was a tactical blunder made three decades ago. Wherever, I got an opportunity, I said, there is a third model in India. The private sector, not for profit and low cost, high volume, therefore, low cost is possible…..can be built in.

JR: possible, yeah

Yeah. So that's what CMC does very much. Now, when you look at the cost per test, it may be comparable to other private hospitals. But if you look at the cost of testing per head will be only a fraction of what other people charge because we don't test unnecessarily. Okay, all tests are under one roof. Okay, when I had to have a MRI scan for….., mainly to find out anything serious, you know, when I got my appointment 2 am, 

JR: 2 am?

yeah, because the machines are working continuously. Yeah, so that means high volume. Therefore the cost is not high.

JR: So you went 2 am in the morning?

Yes

JR: But you being from CMC and the doctor…they could have given you a better time or no?

We treat everybody more or less equal. So if that is a time slot they have, that’s the time slot I use, I will not go and tell the head of the department, “Sir, I can’t come at 2 am, give me another time”. No, I don't do it. Others.. I don't think anybody does it.

JR: Okay.

I did the better thing. I got admitted the previous evening and one day before I am admitted. I go for my scan from the hospital. Go back to my bed and sleep. Then, next morning I'm in….more or less I am okay. The point is third model of private sector are not for profit. If they had encouraged this, it would have been many many many NGOs who would  have created not for profit hospitals and medical college.      

JR: But you see many of big five star hospitals are formally registered as not for profit when actually there anything but that.

Yes, that is because there is no overseeing body from the government, because the government thought they will self-regulate.

JR: correct

Okay, for quality especially, and of course charging they all thought they know that we have doctors, doctors have a reputation of being just, fair and ethical and scientific. But then I'm told by some people that a doctor is paid four lakhs per month salary, the doctor must bring at least five lakhs per month income and for that the doctor will have to make adjustments. That is where the rot begins. Okay.

JR: Correct, very true, very true. Very very serious problem

Yeah. The other thing is allowing capitation fee, that too partly because politicians and such people established medical colleges and that is probably why capitation fee was charged. In the Christian Medical College, will never had capitation fee. It doesn't have capitation fee, I said we are high volume low margins, our margin per patient is low, but we have high volume and we exist as a hospital only because of the college. Okay. So, this is a teaching institution.

JR: How many seats are there?

100. You know what the annual tuition fee is, you take a guess

JR: I will guess about two lakhs

3000 rupees per annum 3000 rupees per annum

JR: Oh,

You know why? Because they call the hospital exist on behalf of the College. So, the college actually is the owner of the hospital. So, the hospital's high volume, low margin income is more than enough to subsidize medical education. Now, one of the ways we do it is that the anatomy professor and the neurosurgeon have the same salary. The salary is fixed by lecturer, assistant professor, associate professor, professor.

So, therefore, the anatomy Professor can hold his head high and be in the institution. Okay, and the students are…people asked, why are we why do you keep this 3000 for years together? The answer is very simple, we want medical students to know that they are being educated by the patient whom they serve. Not by your father's income, or your bank loan or your intended dowry that  comes when you get your degree, none of that. You are created by society and you owe everything to society. Okay.  That is a philosophy that we teach and that is what the students see, learn because the teachers practice the same simple living, not much luxury but very comfortable living, it is a Gurukul system because we are all on the campus when their practicing.

Moreover, every student is picked by some faculty member as a foster parent. So, for those students, we have been foster parents for many, many students’ generations of children. They come anytime to home. Okay, we have had a person who had very disturbed psychologically far away from home and he…..my wife handled him very well and he came out of trouble. They call us uncle and auntie they don't call us sir. Their uncle and auntie, they come home. They share meals with us. They talk about their family. They play around with our children. So, these are certain bond making, which has permanent value

JR: really, very true.                                                                                                   

Recently, Mr.Ram in the Hindu wrote to me, I mean in various, some conversations he said one of his students is in Mayo Clinic and he gave me his email id. So I looked up he is 1984 batch, I think…

JR: CMC, Vellore?

CMC Vellore, and he is in Mayo clinic, he is big shot there. So I contacted him and the conversations with him he told me, “sir don't you remember me? One day I came to eat the lunch in the same restaurant, opposite CMC that you eat regularly. I sat next to you. And we were chatting. I asked you a question.” Something, I don't know…I didn’t ask him what question…..And he said, “you listened to me and you said something to me, which I never ever forget. It is the question you ask is very clear in your mind. So you must articulate your question so that the listener should understand the spirit of your question”.

“So you  reworded the question and asked me How does that sound?” He's telling me, I don't remember the stories. And he says, those days, I was known for my research and all that. So everybody thinks that you know so much…… the kind of deify  people who do well and that kind of... so he was quite taken by the freedom with which I talked and the gentle nudging to put him in the right direction for communication. And he says he still remembers that and he was so thankful that the idea was put into his mind in that way. So what I'm trying to say when you say gurukula, it is truly Gurukula, okay. In another situation, another person could have brushed him aside there what a stupid question get a query to. 

JR: very true, spirit yes….and that he remembers it.

Yeah

JR: Why did Ram want you to contact him just to say hello or what?

No, no, I had an idea to write a book.

JR: Okay.

I told you…

JR: Yes, you told me, of course

pandemics and epidemics in independent India. So, Ram thought that he would be a good co-author. Bu he is so frightfully busy. And this is not pressing in his mind. So he politely declined.But then our conversation went in a different direction.

JR: Very, very interesting.                                                                              

But this is not the first time Let me tell you something else.

JR: Yes. So tell me. So CMC is how old now? I mean, I didn't know anything about all that you're saying? I know, CMC, but how old is the institution……

2018-19, we celebrated hundred years of medical education. Okay. The medical the MBBS started in 1949, no MBBS out of the 19……..originally, women's Medical College, started as a diploma, then converted into MBBS and only for women at the beginning and then men joined in I think in 1947 that men were allowed but before that during British time itself it became an MBBS medical doctor.

JR: Okay, It is it is run by as a trust, right? Run as a trust, owned by some trustees I guess from…….

yeah ….. Society, not a trust. A charitable society, charitable education society,

JR:okay…it is owned by the Christian missionaries….is it owned by individuals or…?

the society has membership okay and membership  are mainly by the Christian Denominations of churches in India.

JR: okay, I got it……

Okay, so they actually technically own the institutions run by a executive, body, the college council, all the member organisations are represented and the executive the committee is elected by the Council of key individuals. That is how it runs

JR: And it gives its own degrees or is the university?

Madras University, now it is MGR Medical University. We never wanted to be an independent university. Because it's extremely highly nationalistic, nationalistic in the sense, not in the bad sense but very patriotic… So we don't look for any extra advantage for CMC. We join the national……We obey all the laws when it came to NEET, we said look NEET, sounds fair and just. But it is not fair and just. There are problems so we went to the Supreme Court and eventually…. I mean we're not objecting to NEET. We're objecting to the Tamil Nadu…… rural students get a bad deal with the NEET. Because they are taught in Tamil, but good students, with Tamil Nadu model was every district to have a medical college with at least hundred seats. So they were making medical colleges in every district. That is when NEET came, so Tamil students then don't have any advantage. Anyway,

JR: so you're telling me the other story when I interrupted…sorry                          

the other story was about medical students. So, teaching virology the shape of a virus is a geometrical shape, so……

JR: Always?

not always, but Coronavirus is not a geometrical shape. It's pleomorphic but poliovirus, adenovirus, measles virus, many viruses are geometric shape. So I am teaching about geometrical shape, there are all electronmicroscopic. So in a big medical conference, one big shot from a vaccine manufacturing company who is in charge of the quality control division, that’s a big division you have to ….. the vaccine has to be high quality. After the end of the talk, this guy, came and told me “Sir do you remember me”. I had difficulty in remembering him. And he told me a story. Sir one day you asked in the class football is round, but it is not made up of……. It's made up of pieces…..Each piece has a particular shape. What is the pieces’s shape? 

So, one student said it’s a hexagon, six sides. Okay, right. So I began drawing the six sided  shapes on the board. Next one, next one, next one, next one. Then I turned around, and said, hey there I have a problem….this is not beginning to become round. This is growing sideways. You know, it just expands in one dimension…..two dimensions. Yeah, there is no curving. So one guy from the back row stood up and said they are mixed with pentagons  in between.……the whole class laughed because they all thought that's a stupid answer, you know. Using hexagons and pentagons a stupid answer because one item will have only one sub unit when the laughter died out, apparently I told him his name his name doesn't matter. I told him look when the whole world laughs at you don't feel bad,  because the world laughs at people who are correct. You are, absolutely correct.   

Then I made a paper model and showed them how hexagons, the story is reverse the class said hexagon, hexagon hexagon. I drew hexagon on the on the board. And then this guy said in between pentagons will come. That is when everybody laughed. So, I then made they made everybody do a paper model. I asked them to draw. I had it all prepared. Paper ready. And the everybody had to draw a hexagon, hexagon, hexagon in between that Pentagon, that will pull the hexagon towards the center. Anyway, the point is, he remembered that one comment that one comment. He said, “Sir, that comment has made me self-confident. And I insist when I know I'm right, even the owner of the company, I tell him that this is right. There is a reason why it is right”. And he can stand up to any opposition. Once he is sure he is correct. Then he defends himself without any problem. So he says that self-confidence came to him with that one comment, when the whole class laughed at it.

JR: Yeah, that can be a turning moment. Absolutely.                                               

Yeah. And many years later, this is about two and a half decades later. He's coming and telling you that. The point I'm making is a teacher has to be careful. Yeah. You can't ….

JR: Yeah, absolutely true. You can break a person and make a person.

You don't ridicule anybody for any…..any mistake, somebody gets falsely judged unfairly judged. Any error or charged with any this demeanour…. misdemeanour, they got to be extremely non judgmental is an understanding anyway. I am describing CMC’s culture.

JR: It's a very eye opening thing for me. It's amazing. And the question that comes to my mind I'm sorry, I'm taking too much time. Why is it that there are not 100 CMC's in the country? Why couldn't your own CMC do first 99 others.                        

We exist and we exist on a model that was made and we are not..we know we are not the saviors of the whole population. We are here to train medical students and then send them out. But train them not only in the biomedical field, but also in the humanity field, they should see the ethics and they should also see how the rural people live. And so, faculty members take them and live in the village groups of students live in the village, interact the villagers and come back or, you know, converted into saying that look, we have now seen the real India and they said they are normal people. They are good people that intelligent people that are kind hearted people and the only thing is they don't have the opportunities that we have gotten out like us……..their attitude about poor people or the disadvantage is completely ‘ulta’ okay completely, changed, transformed 

JR: Amazing, amazing, but you have been taking people to rural settings from the beginning or is it a recent thing?

No, this started in the….In the beginning, there were doctors going to rural area in a mobile van stopping under the tree and treating people with ulcers and those kind of things. If they needed admission, very few will need admission. They were asked to come and they got admitted but the majority people have some injury or some skin disease or some tooth problem or some kind of things. So this is a token outreach program that was original thing. Then later on in the community health department some of us establish their system called COP; community orientation program. In the beginning it was based in hostels and go during daytime and come back but then one of the heads of the apartments he decided to make them stay in the, in the villages, that’s a little more…plan it very carefully.

JR: So this is which year first year, second year?

This is the second and third year when they get their community health posting. Okay.

JR: and you started in which year, you said?, roughly?

I get confused with the years but probably 40 years ago                         

JR: oh okay, amazing

and originally stay in the hostel and go but later on live in the village and they have a simple makeshift stay boys in one place, girls in another place. Their toilets, water, food everything is arranged. Faculty, stay with them. Women faculty with women students men faculty with men students and it’s a teaching learning experience. They make their own projects and they submit the projects they get it approved. They apply it in the community then they report it in the general group….. that is back home after they come back to the

JR: How many days they stay…one week or three days,

I think it's one week,

JR: okay.

Long enough to see the rural life short enough to take time off the medical thing. They have to come back and write their reports on Sundays and often senior faculty are called to listen to their presentation.                                                                                    

JR: Amazing

amazing they do. And so they learn not only to the community. They also learn how to prepare a project, how to make a report. how to present it. The whole thing is a very holistic way of and students also love it. Yeah, okay so

JR: you have given me some good good insight into CMC

Yeah, yeah, yeah. Okay all right so back to Mumbai… is bit scary yes scary

JR: Yeah , we don't know where this will end. This is only the beginning for us

Absolutely right, you know, it takes I told you it takes one case becomes 32 cases in 15 days or so. So we have our importation mostly or almost exclusively in the month of March. Very few in the month of February very very few means, the total number on March 1 was only three. All three were in Kerala also. They were all Wuhan students.                             

So something that people have not understood is that the amplification that is the what do you call amplification of the virus, putting the world at for importation, was not China, it was Europe. That information got to people quite late. They were all looking at China, China, China, then little bit of Hong Kong, little bit of South Korea, those kind of thing they're always looking. But this time Europe was exporting virus to European countries and to Asian countries. There's a funny story I heard the other day. Mongolia closed the China border with Mongolia very early on. Not a single case came from China. The first case came from a French visitor to Mongolia. So you understand the irony of it

JR:Yeah, yeah. Amazing, so the virus went around the world and come back.

So we also got most of our importation from Italy, from the US. Dubai, Dubai is also a western country for us. Okay.

JR: Yeah. Correct.

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