The puzzling case of India’s Covid tally

Dr. T Jacob John talks to Jagdish Rattanani about plasma therapy trials, faulty Chinese kits,  lack of cohesive strategy between Centre and States on epidemic control and healthcare

Two papers finished and submitted. One is Ramanan Lakshminaryanan was invited by Indian paediatrics editorial on this concept of herd immunity. And so he asked me if I would help, So I helped. So, we submitted the paper today.

JR- where is it going, to..?

To Indian Pediatrics, the official journal of Indian Academy of Paediatrics. And Prathap and I have sent another paper to Hindu in terms of….. I mentioned yesterday, district by district, lockdown lifting and what it should….how district should plan, social mobilization and unless all actors put their acts together, it'll be chaos to maintain low infection rate, business, manufacturing units, agriculture, education institutions, everybody should be on one page in terms of infection control while social contacts increase……so that is the gist of our paper.                                                            

And if paper is accepted in Hindu and immediately we will alert our district or the neighbouring district and get all the manufacturing group to sit down together and make a uniform protocol. People are making their own protocols, each institution is making its own protocol. We are now proposing a generic protocols and to have a task force for each district. So that kind of idea. So these two papers are gone today.             

JR- What  is your reflections for today?

Today, I read the good news that in max hospital, one 49 or 50 year old man was on ventilator and not recovering and then given plasma therapy and showing improvement, immediately, dramatic. That's in other words, I expect…. suspect that they are emboldened to give the plasma therapy against the wishes of the ICMR, which wants a study done before the policy made. But giving plasma is any doctor’s right. Once you're registered as a doctor, it's your right to give plasma. So that is a line I took in the in the Hindustan Times. So I would expect or suspect that our paper emboldened, strengthen the hands of the people who tried it.

JR- Yes. Even in even in Mumbai, the municipal commissioner has gone on record to say that they are getting much more plasma machines and they will try it out.            

Okay, they will find out, right. Yeah, okay. Okay. That's good. That is trying out, meaning; you begin with the worst patient. That's what the max hospital did. And if, if the first one was a failure, god I mean nobody would try it again, we are fortunate that the first one was a success. Therefore, people will try more and more and the study can go on, let the study also be planned but then there'll be a problem for the study. The control who's not going to get plasma. Their families will protest. So I think we have thrown the monkey wrench into the study. I suspect but it's all good.

JR- very true, very true                                                                                  

Okay, second thought that I have is Mamta Banerjee saying that she's not getting enough test kits. May be true may not be true

JR- Or the kits are not working well or something like that.

That is a Chinese skit. To be frank we should be shameless to go and get Chinese kits instead of making in India…… make in India slogan. And you go and buy substandard Chinese kit, from a company that is not listed by the Chinese government. Yeah, anyway let them worry about that. So, the thought that I have is about India’s  health management. Epidemic management is the job of central government by Indian constitutional division of…. jobs between centre and state, centre is in charge of epidemic control, state in-charge of health care.

So, what happened when the COVID story broke out in China and other countries, Kerala took a leadership quite apart from any directive from Central government, which is actually flouting the constitutional stipulation that that is the Central government's responsibility, that is testing, quarantining, preventing further spread is all epidemic control. Whereas diagnosis treatment is state responsibility…  health care. But Kerala government went ahead and they did it right and thereafter other states are doing independently, whatever they want, and they are making use of this central facility of an NIV for testing. So samples from within the State are sent to  NIV and NIV has to test. So the roles have been reversed a bit and that is good. Mamta Banerjee’s complaint is that centre is not giving enough kits for West Bengal, which may be a political game. I will not know whether it's true or not true. However, my point is the division of epidemic control by the central government and healthcare by the state government is not working well.

JR: It has not worked clearly in this case                                                                  

Yeah. And in the past also when I went for lychee investigation in Bihar, there was a little a bit of a muscle flexing from the central government saying that, who are you to investigate it? It's our right to investigate. There was posturing. Okay. So what Bihar government did was constitutionally not right. To have their own independent investigator when the central government was actually investigating it from 1995 to 2012. And then I went there in 2013. That is a big joke.

JR- You were appointed by the state government to go in 2013?

Invited no appointment invited.

JR- 2013?

2012 December, I was invited. 2013 during the outbreak period I went and what they could not do from 1995 to 2012, how many years is that? 17 years. I took one week to sort it out

JR- 1995 to 2000?

To 2012. Okay. It took me one week to tell the Bihar government, what the problem is. And then I had to create supportive evidence which we did in 2014 and 15, while preventive modalities were given to the Bihar government;  they took action and the disease virtually disappeared until 2019 when things fell apart, for various reasons. Anyway, the point I am saying is, the epidemic investigation and control is union government’s, what do you call responsibility, and it is the National Centre for Disease Control that should be doing it. And if they goof up, then the state government has to just watch children die. It is watching children die, that the government, one of the senior medical officers took pity on the families and got government permission to invite me. And when I went there, I was fully supported by the health secretary, National Rural Health mission agency, expanded program on Immunization. They were all, you know, welcomed me with open arms and in one week it was sorted out.

JR- This is an amazing story.                                                                         

Yeah. Anyway, so I'm saying that there was a little bit of …..I use the word muscle flexing, saying that….. So then at that point, things were sorted out by a Bihar government order directly to me saying that we are appointing you to do this study, after the whole thing is done, when the muscle flexing happened, they gave me written orders.

Okay. My point is the centre state equation in health management I'm using the word health management because the epidemic detection, prevention and healthcare both are managing human health. The interface between center and state needs to be re-engineered. And this epidemic the previous things are small, small mosquito bites. This is a crocodile bite or whatever, this is a big thing. So therefore, we need to set that right…. now as it  happened, I was explaining to you, that Kerala government took its own lead. They just ignored the central government. And then various state governments began working. Delhi, even there and the central government's directive  to test people coming from foreign countries. You know who ordered it aviation, civil aviation ministry. Director General of  civil aviation is the one who passed orders. That is very interesting.

JR- yes, very interesting                                                                     

Anyway, so we need to re visit the health management scenario and re -engineer the Union Government, state government's responsibilities otherwise the…. accountability will fall between stools.

JR-very, very, very well put

Responsibilities, governments have, not with accountability, responsibilities are only voluntary…. That also you know, you can say you're responsible, but you have to be accountable too; for that, there you need reengineering.

JR- Yeah, absolutely. Yeah. So very, very interesting point.

Yeah. On the  lychee disease did you write anything after that date? Can I see, can you send me something that I could put as a reference document within that conversation?

Of course, Indian Express first carried it in 2019 – most recent.  this the lychee connection is scientifically proven by scientific papers in 2014 and 2015, 3 papers.. It was reconfirmed by an independent group of observers or Scientists and NCDC had brought CDC Atlanta into the picture. So they had an extensive investigation and they reconfirmed everything we had said and published already. We had small, small publications, three, you know bits and pieces so that all together the picture was all clear. We are publishing for the sake of Bihar government. Bihar government wanted peer reviewed scientific publications so that they can defend…. if anybody asked them questions. For that purpose, we published it in the journal Current Science…..it is poor man’s Nature, coming from Bangalore, , Indian Academy of Science’s, official publication, Okay, anyway and so 2019, 294 children died by withdrawing all the preventive recommendations applied in 2014, 2015 2016, 2017, 2018 and keeping the annual numbers below 10.

JR-Why would the government withdraw that, preventive measure?                      

I had word with health Secretary and health secretary said that it was not a deliberate withdrawal. It was by default, the district administration…. First of all, the health education staff, there were all on election duty. So they were not giving the health education that was necessary.,,,, What is the health education necessary? Give a meal to children before they go to sleep. That's all

JR- Give a meal to children …..

before they go to sleep

JR- Okay, how does that help? Sorry, I am…..

that prevents death

JR- So, how's that linked to lychee disease?

That is if you go to bed at let's say 5:30 or 6 pm these are hot months. April, May, June.

Kids go to sleep, having got exhausted during daytime playing. They don’t wake the child they for a meal. So that means 5:30 till next early morning 5:30 is 12 hours and if you fast for 12 hours your blood sugar will go down. When your blood sugar goes down your brain demands glucose. So, liver kicks out glucose stores in the liver to keep the blood sugar level above 70 to protect the brain, but your liver does not have sugar storage because you are malnourished, undernourished, severely undernourished. Not acute under nutrition, but chronically undernourished. Then you cannot correct the hypoglycaemia.

Then the body goes through an alternate mechanism to synthesize glucose. That's a very interesting story. What do you use as a base? Fat you burn fat to make blood sugar. That is why the ketogenic diet for weight reduction works. Have you heard about that?

JR- Yes.

Okay, that is to make you….. burn your fat. You can eat a lot of fat you can eat a lot of protein but don't take any carbohydrate. Because all the carbohydrates stored must be recycled and you begin burning your fat. Anyway, so the fatty acid conversion into glucose. That's the only thing lychee blocks okay. So if you are not on a ketogenic diet, lychee is delicious and non toxic. But if you are, if your liver storage of glucose is 0, minimal and you have prolonged fasting and you had lychee you had it, you may die. Children going into the early morning brain disease and if you don't treat it quickly then they die.

JR- Oh, I see

Yeah. The easily intervenable thing is, one evening meal or cooked meal at night. No child dies if the child has a cooked meal by about 7:30 or 8

JR- So doesn’t sleep on an empty stomach.

Exactly                                                                                                      

JR-  they eat lychees because lychees are in abundance there, is it?

Yes, Muzaffarpur district produces 85% of India's lychees production

JR- which district?

85% of India's lychees  production is in Muzaffarpur, Bihar. And so the lychee harvesting families and their children, they befriend their neighbours and all the lychees that falls to the ground as single fruits have no commercial value. It has to be in bunches…. like bunches of grape bunches of grapes like that. That is only saleable. So kids can store these lychees,  and they can eat lychees during daytime, any number you want share it with friends. And then you go to bed and then you sleep, prolong fasting we figured out it's about 10 hours of fasting or something like that.

And early in the morning children fall ill….anyway,  I figured it out. In the NCDC investigation, they brought  in an epidemiologist, an epidemiologist, look at the epidemiology and cannot make head or tail out of it. You bring another  expert, the neurology expert cannot make head or tails out of it. American neurologist is unfamiliar with under nutrition You need a good pediatrician, which was missing in Muzafarpur.

When I say good pediatrician, a pediatrician who has wide knowledge that such as …this disease mimicked two other diseases that I knew about. So therefore, it was fairly easy for me to make a clinical diagnosis. And then Google search and see how lychee might be contributing and lo and behold, Google tells you, how lychee can be related to this. So within a week, the hypothesis was made, and the links were shown. And the prolonged fasting was discovered by walking around in the lychee Gardens and talking to the families . Also visited families  who had children previously affected, affected in 2012 and earlier. And with all that it was sorted out.  But the point is that the…

JR- So how did the guideline did not work in 19, 2019.

The health workers were called for election duty. The primary health centre doctors I trained 32 of them in 2013 and 2014, they were transferred to other places and all that so new batches had come. Nobody took classes to them. Okay, then it's very easy to call an ambulance and send the kids to  medical college hospital which is 3-4-5-6 hours by by road from the rural areas and so they goofed  badly on the biomedical advice. Nobody is advising them for a full meal at night and the senior paediatrician did not follow instructions that were given by me. So altogether 294 children died.                                                             

I, in my definition, would call this homicide by neglect. If a doctor misdiagnosis and mistreat a child when the child dies, it's called medical negligence. When 200 children die, due to public health negligence and public health is government's responsibility. Government meaning problem between central government, state government and because of that problem 200 children die means 200 children were victims of homicide by neglect. That's my personal opinion. I'm not pointing fingers at anybody. That's not my point. My point is that if…… there are other instances in which I have got involved in this outbreak investigation between central and state, anyway, there are two other stories like that….but reengineering is  essential.

JR- I got the point, larger point, something broken there.

Yeah, something fractured there.                                     

JR- Yeah, so I wrote a piece that came in one of the papers today very late yesterday, saying that this is not the time to play politics and that piece was inspired by reports that a central team had come to Mumbai. And you must have seen in the Hindu they have given numbers of more than six lakh cases by May 15. And the shortages that will be huge of beds and oxygen and all that, and this was accompanied by some BJP people saying that the government can't control you need the army here. And it came at the same time as a central team went to West Bengal. And the West Bengal government knew that the central team has come after the landed in Kolkata. There was also sparring there. So my piece was that you can always do all the numbers give worst case scenarios but support the government to be able to work at this time. Don't do this politically. There was a lot of that I could see and the state government was also talking about it. I will send the page to you to see. There is another center state dimension was both West Bengal and Maharashtra non BJP governments.

Yeah, That's true

JR- is a very short piece. I'll send it to you to read for the sake of ..                        

Yeah. Sure sure. I will be interested in that because this is not the time to play politics.

JR- Exactly. Do what…… I'm saying give the worst scenario… I'm not saying Mumbai is doing well. They are at least trying. The commissioner is a commissioner who was worked in disasters all through his life. So you must support him if there is a short,….. you tell me what the center is giving…..don't leak numbers because it is a non-BJP government.

that is wrong and….. yeah. what can you do? And that is really sad,

JR- very very sad, very cheap, very poor level of politics…

Mumbai, Mumbai is Mumbai, no matter who governs. Over crowded, and so this is the time when.everyone has to work together as a team. okay………. today somebody sent to me a piece from guardian or New Yorker or some foreign paper saying that Modi government is fighting without the war room. Now, the war room expression I can guess where it came from. I wrote about the war room in mid March or so. Okay. The absence of the war room has been felt by foreign journalists or foreign journal looking at India for response; and at  the same time there is a rumor or some bits and pieces saying that there are…..the foreign journals are wanting India to have worse scenario and they're jealous or they're not appreciative of how well India has controlled

Okay that kind of. So anyway, so you will see, the other thing today was that the number is going up under the lockdown the gleeful explanation is that this is only arithmetic expansion not geometric exponential expansion.                                                             

JR- Who is saying that?

I think it was a ICMR somebody some I forget the name, C.K. Mishra. I think C.K.Mishra. I think he's the one who probably……I won't be sure but this is arthematic Increment or increase and not exponential increase, forgetting the fact that this is increase under lockdown. Under lockdown, you cannot have geometric or exponentially increase. And again the number game is terrible. Today the total death  number is close to 700 and 700 death, only COVID patients die, not the asymptomatic infection don't die. So 700 COVID patients mean 70,000 COVID patients the total detectable is 21,000 that don't tally. 21,000 were found infected, only 5000 only could be COVID. If 5000 are COVID, you cannot have 650 death. So numbers don’t tally, whichever way you add up, it doesn't tally.

JR- You're using a factor of what from infected to COVID                        

JJ- yeah, 80 per cents will have no symptoms, 20%, 15 to 20% would be COVID of it small proportion will be severe COVID. So, the deaths are only in severe COVID but the denominator of death cannot be severe COVID and death….. it should be COVID and death, the case fatality is calculated on number of deaths per hundred cases, symptomatic cases nobody calculates the number of deaths per hundred infections because infections are mostly asymptomatic, so, case fatality is case based. Case means disease.

So, if you take one per cent mortality of all COVID patients…. COVID can be mild, moderate, severe and life threatening. So, one per cent is not a that…… influenza had point one per cent, this has one per cent. So, if you calculate one per cent 600,means 60,000 cases of COVID and we have only detected 21,000, total infected and COVID put together and there is no division as to how many was infected detected through contact tracing. And how many was detected by testing for pneumonia? Have you ever seen any numbers that, how many pneumonia cases?

JR-No                                                                                     

at one point, they said the 2% of severe pneumonia, tested as a study by ICMR were positive. But I don't know whether that study is over. Yeah, it was over more than a week ago. But the routine testing is not happening. Okay. All right.

JR- Yep. Yep. So that is a reflection for today. Yeah, yeah.