Over the past few weeks, the coronavirus pandemic has taught us four things about ourselves.

This is the concluding segment of a four-part explainer on the coronavirus outbreak. Read parts 1, 2 and 3.

Over the past few weeks, the coronavirus pandemic has taught us four things about ourselves.

1. Governments are capable of strong, quick action.

2. The world remains unequal, with widening inequality.

3. The world has changed; China has changed.

4. Size does not matter. Time and communication does.

Strong, quick action

In January, China put 10+million people under lockdown. At that time, the world said, China is the only one who can do it.

The New York Times, on 22 January 2020, wrote:

“Scale of China’s Wuhan Shutdown Is Believed to Be Without Precedent.”

“In sealing off a city of 11 million people, China is trying to halt a coronavirus outbreak using a tactic with a complicated history of ethical concerns.”

The same NYT, reported a day later that China was ‘essentially penning in more than 35 million residents’, bringing to mind lambs held for slaughter. It was thought that draconian lockdowns were the province of undemocratic countries.

Less than 50 days later, decidedly democratic Italy followed suit, trying to lock down its 60 million citizens in a bid to control the virus. And when that failed, calling the army in to enforce movement restrictions. Liberty, it seems, is not a given.

The Times headline on 15 March, showed how much mental space we had covered in 60 days.

“Spain, on Lockdown, Weighs Liberties Against Containing coronavirus .”

“Empty streets. Shuttered stores. Spain has joined the number of countries struggling to balance public health with freedoms especially prized in a relatively young democracy.”

California – the heart of liberalism in America – went into lockdown mode in the middle of March. There were reports that the police department was using drones to enforce the ban, and convey information to the homeless. If you don’t have a home, where do you stay locked down? New York and Illinois soon followed, asking over 70 million Americans to stay put in their homes. Within days, Britain, which had initially trumped down for herd immunity, changed tack, and locked down. By midnight on 24 March, India’s 1.3 billion were under lockdown for 21 days. There were exceptions, but this scale of lockdown is unprecedented anywhere, ever.

We need no further proof that governments can take quick, strong action, when they perceive the need to be important. We are less than a month into lockdowns in some countries, and a day into lockdown mode in India. How long can we sustain it? These are uncharted waters, and, honestly, I have no clue. Look to the slums – that may be the place unable to bear the strain, and may break first.
The lockdown is predicated on the existence of a vaccine. There is a global race to create a vaccine, with an American vaccine and a Chinese vaccine in Phase I clinical trials. Best estimates say a good candidate is about a year away. In the meantime, as the Northern Hemisphere heads into summer, the Southern Hemisphere is heading into winter, helping the virus spread.

Widening Inequality

This lockdown impacts different groups differently

Gainers – Some 24-7 news channels, WhatsApp, Netflix, medical equipment/mask and other protective equipment/test-kit manufacturers (some of these are providing material/services at subsidised rates, and those cannot be considered gainers), short sellers.

Less impacted – Many information-age companies can work from home. There is a disruption, sure, but work does get done, there is saving of office power bills and transportation expenses, and revenue can be billed (sometimes). The well-to-do are losing money on the stock markets, and in profit, yes. But, this group can afford to take up ‘pursuits’, and enjoy the fresh air.

Impacted – Most of India. Retail. Manufacturing. Cinema. Schools. Religious services. The operators of these outfits are almost certainly looking at a loss this month, or maybe even this quarter. Highly leveraged players within each segment will face survival risk. Workers in this group have some job and wage security, for some time.

Wiped Out – The informal sector, including daily wage earners, beggars. Many of them operate on days. The money lender is not renowned for his forbearance. One other group, that may not elicit much sympathy, is the imprisoned community. Do we set them free or let them be?

One additional point: Most people in India do not get piped water at home. If last year’s data holds good, people, women, wait in lines to collect water. How will lockdown work here? As with climate change, this lockdown too, seems to be increasing inequality.

China

Wuhan is a prosperous Chinese city of 11 million. One reason for how the virus spread across national borders is when tourists from Wuhan visited other countries. China is now buying, not just selling – it’s harder to keep people buying one’s wares and services out. Some of you might remember the Will Smith movie, Independence Day, when America gloriously takes the lead against the aliens invading Earth. America has been too busy to playing catch-up to the virus at home to have much time to help others. They did, however, extend aid to Pakistan.

China did extend aid — officially and unofficially. There were planes of medical supplies and expertise to Italy. Then there was Jack Ma, who has been acting as China’s Unofficial-Ambassador-at-Large, donating and shipping out millions of masks to Africa, Latin America, Europe and South Asia. Interestingly, when pretty much every other country in South Asia was covered, India, reportedly, was not. He tweeted, ‘Go Asia! We will donate emergency supplies (1.8M masks, 210K test kits, 36K protective suits, plus ventilators & thermometers) to Afghanistan, Bangladesh, Cambodia, Laos, Maldives, Mongolia, Myanmar, Nepal, Pakistan & Sri Lanka. Delivering fast is not easy, but we'll get it done!’. Ironically, the Ali Baba foundation tweeted, ‘Through a donation of 500,000 testing kits and 1 million masks, we join hands with Americans in these difficult times.’

Jet Li was saving Will Smith from the aliens! This is an interesting dynamic to watch in the coming days.

There is one more. Two coronavirus epidemics, the SARS epidemic in 2002/2003 and this one, began in earnest in China – both probably from a wet market. Both of these epidemics are caused by RNA viruses. There are about 180 known types of RNA viruses which infect humans, with about two new species added every year. Most RNA viruses are zoonotic – i.e., they came from an animal host. This just means one thing; epidemics like these will recur. The Chinese preference for fresh exotic meat may carry too high a price for the world, in many ways.

Size does not matter, time and clear communication does.

The economic damage from this virus, and from the lockdowns to prevent the virus spread, will be vast. The UN estimated a $1 trillion blow. Stock markets reportedly lost $26 trillion from their February peak. These are big numbers, and every government stands ready to throw fiscal rectitude to the winds when stimulating their economies.

However.

Climate change is a far bigger threat economically, over time. It is expected to shave off trillions from the world’s GDP by 2050, while extreme events cost just the US $312.7 billion in 2017 and $91 billion in 2018. In 2019, weather-related disasters, a fingerprint of a warming climate, cost the world $229 billion in damages alone. In half a decade, using the UN estimate, a warming climate will easily cost the world more in dollars and lives than COVID-19 . Yet, governments have not taken action. Worse, many act in the opposite direction, with the IMF estimating that the subsidies for fossil fuels extends to $5.2 trillion in 2017.

Let’s leave morals and compassion aside – hard to do, since hundreds of millions are affected today. But leave them aside. On economics alone, discounting costs, depending, of course, on the discount rate, acting on climate change makes sense. Yet we haven’t. While we have taken expensive, draconian action to limit the spread of a virus with an average fatality rate of < 1.5 percent for people aged less than 60. Given low testing levels, and the fact that the disease is asymptomatic in so many people, the fatality rate could be even lower.

Why is that?

One possibility is that the slow burn of climate change is psychologically different from the quick blow of the virus. Think of the proverbial frogs in the pot of water set to boil. Time matters.

Another possibility is that there is a clear villain, who everyone hates – the SARS-CoV-2 – in this pandemic. There is overwhelming evidence than burning fossil fuels are the villain in climate change. But not everyone hates them.

Yet another possibility is that the people leading the cry for action are doctors, who are comfortable making clear and compelling disease trajectory predictions, with fatality rates, based on limited data. Compare that with the hedged, unclear calls-for-action in climate change. Enough said.

The writer is the founder of the Sundaram Climate Institute, cleantech angel investor and author of The Climate Solution — India's Climate Crisis and What We Can Do About It published by Hachette. Follow her work on her website; on Twitter; or write to her at cc@climaction.net.

India’s handling of the crisis until now, barring testing, has been hard to fault. By aggressively acting, the hope is for the spread of coronavirus to be curtailed.

This is part 3 of an explainer on the coronavirus pandemic. In part 2, how effectively will policies of travel restrictions and social distancing control the spread?

Usually I go to Shakespeare for inspiration, but this time, it was Stephen King, who perfectly captures what we are feeling.

We are fearful. In the past few months, globally, over 15,000 people have died while trying to combat COVID-19 .

Meanwhile, “CDC estimates that so far this season there have been at least 38 million flu illnesses, 3,90,000 hospitalisations and 23,000 deaths from flu.”

23,000 deaths in one country, in one season, despite the isolation and the flu vaccine.

This may be an unpopular question to ask now, but are we responding appropriately to the SARS-CoV-2, aka the coronavirus ?

And then there is Italy.

Yes, the situation in Italy is tragic and horrifying.

But India is not Italy.

What are the differences?

The age profile is probably the critical difference between India and Italy. One in every five Italians is over 65. Only about one in twenty Indians is over 65. This is meaningful, while America’s experience shows that people in their 30s and 40s are in the ICU because of COVID-19 , the population group most at risk for hospitalisations, ICU admissions and death, remains above 65 years of age.

The average temperature in Italy is in the early teens now. Last I checked, Lombardy was at 11°C. The temperature in Indian metros is double that, and in Tamil Nadu, three times that. Ambient temperature always plays a role in infections. It appears to do so in Dengue transmission, and may play a role here. That is why the seasonal flu gives way to the poxes and diarrhoea as summer rolls along. It is part of the seasonal cadence of infection. This could be one explanation of why colder countries are affected more, and warmer countries less. But we cannot be complacent – cases are rising, and other RNA virus pandemics have raged through summer months.

India does not have Italy’s (especially Northern Italy’s) medical infrastructure. Ours would fall to a lighter blow.

There are similarities too. We also love our Nani’s and our Paati’s, and we tend to be packed quite closely together.

To repeat, we cannot be complacent.

India’s handling of the crisis until now, barring testing, has been hard to fault. The hammer has been falling quite hard (recommended reading: The Hammer and the Dance). The travel restrictions, bringing back stranded overseas Indians back, even the Janata Curfew. Shutting down schools, cinema theatres, postponing exams. The article refers to the hammer as aggressive complete lockdown measures for weeks followed by a dance, with testing and tracking, until a vaccine is developed. By aggressively acting, the hope is for the spread to be curtailed (see figure)

Coronavirus Outbreak Aggressive testing containment in small pockets what India really needs to combat COVID19" width="825" height="292" />

The hammer fell harder as the number of cases ramped up. 75 districts, where a case of COVID-19 has been reported, have been shut down – meaning only essential services are allowed to function. Passenger trains, including metros and suburban trains, have been suspended. Moreover, interstate travel has been suspended, with the goal that travellers from metros don’t take the virus to rural India where the medical infrastructure cannot take the shock. As I write, Tamil Nadu, with nine confirmed cases in a 1,30,000+ square area, has announced Section 144.

The goal is the same: reduce contagion by lowering social contact, allowing hospital capacity to cope. Take Chennai, for example. As of 23/03, there were four confirmed cases in the city. Assume, worst-case, the ‘true’ number is ten times that, or 40 confirmed cases in the city. Now, let us use the reproduction number of 2.79 (this is the number the CDC came up with). This means each infected Chennaite would, in turn, infect 2.79 others. Extending this chain up to 31 March gives us,

Coronavirus Outbreak Aggressive testing containment in small pockets what India really needs to combat COVID19" width="825" height="294" />

The blue line means introducing social isolation measures, bringing the reproduction number to 1.5. Without it, Chennai may have had 14,000+ cases, with it, only 103 cases by 31 March. Chennai has 20,000 Hospital Beds, 1,200 ICU Beds, 250 of those with Ventilators (Source: Sam Mehta, Vice Chairman, Dr Mehta’s Hospitals).

Now, consider the situation, where the true number of cases is far higher, 10x, as one expert claimed. That means the true number of COVID-19 cases in Chennai on the 23 is 40. The disease spread would look like this —

Coronavirus Outbreak Aggressive testing containment in small pockets what India really needs to combat COVID19" width="825" height="291" />

Now, thanks to the CDC again, we have hospitalisation, ICU-admission and fatality rates by age group. We also have the age breakup of Chennai’s population. Putting these two together, with the data above, we get

Coronavirus Outbreak Aggressive testing containment in small pockets what India really needs to combat COVID19" width="825" height="301" />

Without lockdown, if the true number of cases was 10x what was reported, then, without lockdown, the ICU capacity would be overwhelmed, and we would have had above 1,300+ deaths more than with a lockdown in place.

Take, Mumbai, one of the epicentres of the COVID-19 epidemic in India. Mumbai had a cumulative total of 53 confirmed COVID-19 cases as of 23/03 (Source: Gayatri Nair Lobo, ATE Chandra Foundation). Projecting this forward to 31 March, we get this —

Coronavirus Outbreak Aggressive testing containment in small pockets what India really needs to combat COVID19" width="825" height="293" />

If we assume the true number of cases is 10x of 53 confirmed cases, that takes us to 530 cases as of 23/03/2020. Now, if we assume each infected person was to in turn infect 2.79 other persons, then we land up nearly two million infected persons in Mumbai by 31/03. A mind-boggling number. Most of those would still not require hospitalisation, and many will not even show symptoms. If we again assume that hospitalisation, ICU-admission and fatality rates by age group were similar to the US, then we get this —

Coronavirus Outbreak Aggressive testing containment in small pockets what India really needs to combat COVID19" width="825" height="302" />

It’s a no-brainer to take Mumbai into a lockdown.

Keep in mind for every Mumbai and Chennai, there is a Madurai with no reported cases (as of now). The logic of shutting down balancing saved lives vs shattered lives starts coming apart.

Because every action carries price tags – yes, that is plural. Each tag is paid by a different section of the population. Some people are relatively unaffected – they are well off, and can enjoy the lack of pollution and sound and traffic. Others are affected but manageably so – these are the information warriors who can work from home, using laptops.

Others have their income protected. Many corporates have come forward saying wages and jobs will be protected.

These jobs form but a few strands of India’s employment tapestry. Informal employment in India is vast – most of the workers managing your waste for you in Dharavi are informal. Many of them are migrants. Payments from the state are unlikely to reach them. Another vulnerable set is the millions of sex workers in India. “HIV can be stopped with condom use. But this [the coronavirus ] means no physical proximity – that message has gone out far and wide. Likely, very few clients will be going to them [the sex workers] now,” says Ashok Alexander, who earlier headed the Indian operations of Bill and Melinda Gates Foundation, where he helped set up the world’s largest-ever privately sponsored HIV prevention program. “Sex work in India is largely invisible. It is a consumer product that has not been recognised as a profession. Which means there is little prospect of any support reaching these women. Many of these women have children dependent on them. Life, is often is about day-to-day survival.”

That survival is in question now.

Work-from-home is a cruel joke for those who work with their hands and bodies and for daily wages. The silence so many of us applaud as the streets turn empty is the sound of hunger in other people’s homes. And for many of those, neither the forbearance of their corporates nor dole-outs from governments, will reach and help. By shutting down indiscriminately, for the thousands we are hoping to save, are we choosing death-by-a-hundred cuts for thousands of others? State after state has begun implementing Section 144, whether it makes sense in the price-tag logic. Politically, it’s a no-brainer – your next-door neighbour has declared it. You don’t lose anything if you do – not now, when the whole population is held in fear-thrall. But, if you keep society and economy open, and people die, you become rich fodder for news channels and your political opponents. Competitive federal populism.

The more important consideration is if the lockdown is effective. A Janata curfew is rendered meaningless if people come together at five to celebrate together. No, the virus does not die in 12 hours. Italy declared a lockdown on 8/9 March. But, as per accounts, the lockdown came late, and was not strict enough: one account has over 50,000 people in Italy charged for breaking quarantine rules. With this kind of flouting, lockdowns are futile, worse, counter-productive – you pay the economic price, without reaping the safety gain. The hammer was more like a Shiatsu massage, and it did not work as planned. Sure enough, Italy called in the military to enforce the lockdown less than two weeks later. What matters is effective containment – size, as in many things, was not important.

This was the belief behind Singapore and South Korea approach.

They got an early start. Tested aggressively, and adopted different types of ‘hammers’ for different levels of exposure: positive cases, even cases without a single symptom, were held in hospitals, while those with exposure were asked to maintain strict home quarantine. The home quarantine included SMSs several times a day, which would verify location, and by spot checks. Singapore also ensured that business could stay open while following certain precautions: Each person entering a shop would have their temperature tested, and would note down their ID number, which helped in contact tracing. Any ‘cheating’ would be punished. For this approach to work, we need to start early (so all cases are caught), be disciplined (if only half the shops complied with the order, this wouldn’t work) and test aggressively.

In other words, Singapore and South Korea are following the needle approach — pin-pointed, intense action — rather than a broader hammer. And it appears to be working. Japan, where the outbreak appears to have been controlled, seems even more sanguine. A Japanese Health Ministry official was quoted as saying, “We don’t see a need to use all of our testing capacity, just because we have it. Neither do we think it’s necessary to test people just because they’re worried.”

What does this mean for India?

India (except perhaps Kerala) may have missed the early boat. On discipline, we have people actively flouting controls, with not enough punishment. And we have been held to not fare so well on testing. Most importantly, we do not have the capacity to ensure the curbs are held long enough.

Coronavirus Outbreak Aggressive testing containment in small pockets what India really needs to combat COVID19" width="825" height="428" />

Testing can be expensive. Two-part testing – with a cheaper screening test and a more expensive confirmatory test. The ICMR has recommended that the two tests should not cost more than Rs 4,500, with an appeal that they be free. Apart from availability, where the private labs will add capacity, there is accuracy. PCR’s need specialised technicians to run (yours truly has run PCR tests two decades ago, and know, from painful personal experience that they can be prone to error), there can be< contamination in sample collection leading to further error.

Then there are bottlenecks.

Dr Prabu Thiruppathy, Kois, a global healthcare investment firm (that has invested in molecular diagnostics across the world), says “The testing kits (PCR) need to be certified to be of acceptable accuracy by National institute of virology. Then these can be shipped and deployed at labs. However, protocol changes over the weekend mean that tests now need to be US FDA or European CE approved. A big problem is that the reagents seem to be still imported, although Indian companies make the final product in the country. Moreover, Gloves and masks are already in massive shortage across Indian hospitals.” Meaning there is a risk of contamination to the technicians collecting and testing the sample, is elevated.

One additional option is the just-approved testing in Cepheid machines, which require minimal human intervention and boast of a quick turnaround in a hospital setting.

What appears to balance out the need to overwhelm our health services, while not strangling the informal sector, is aggressive testing and containment in small pockets, with the help of private testing and, this is key, the army. We may not be able to do this effectively across 80 districts, but we can try to do this effectively in smaller pockets, where the number of cases is very high, relatively speaking. Maximise the safety bang for the economic buck. What India really needs, to use a term from another context, is a surgical strike – pointed, intense, effective. The hammer may cause more harm than the virus itself.

The writer is the founder of the Sundaram Climate Institute, cleantech angel investor and author of The Climate Solution — India's Climate Crisis and What We Can Do About It published by Hachette. Follow her work on her website; on Twitter; or write to her at cc@climaction.net.

In the second of a four-part explainer on the coronavirus pandemic, Mridula Ramesh writes: if we spread to Stage 4, where we have epidemic local transmission of COVID-19, hospital capacities would soon be overwhelmed, which may leave millions dead. Which is why policy action has been aimed at ‘flattening the curve’ or spreading out the infection trajectory to allow hospitals to cope.

This is part 2 of an explainer on the coronavirus pandemic. In part 1, where did it come from? How does it spread? Who and how does it kill? What might stop it?,

What are the implications of this on policy?

Pray for summer, obviously. But, what else?

Any policy has to be mindful of the virus, and of the capacity of the country.

Let us compare the treatment capability of different countries affected with India’s. This is data from the WHO, accessed through the World Bank.

Clearly, if we spread to Stage 4, where we have epidemic local transmission of COVID-19 , hospital capacities would soon be overwhelmed, which may leave millions dead. Which is why policy action has been aimed at ‘flattening the curve’ or spreading out the infection trajectory to allow hospitals to cope.

What has/can be done to prevent this?

The virus originated outside India. India reported its first confirmed COVID-19 case on 30 January 2020. Predictably, Kerala was the state who confirmed the case, given their excellent medical tracking abilities. The patient was a student who had been studying in Wuhan and returned to her home in Thrissur. In an interview, she is reported to have said,

“We left Wuhan by train to Kunming, took the flight to Kolkata and then to Kochi on 24 January. I had a phone message from the Indian embassy to report to the nearest medical hospital on arrival at Kochi airport, which I did. They took our temperatures and again there was no sign of any infection… I arrived in my village in Thrissur, I was careful to impose self-quarantine at home…On 27 January, I had a sore throat and cough for the first time and I immediately alerted the authorities and was asked to go the General Hospital in Thrissur. When I went there, I still did not have temperature and they started me on antibiotics… The result came in positive on 30 January, nearly a week after I left Wuhan.”

There were hundreds of Indian students studying in Wuhan. While others were later evacuated by the Indian government and quarantined, the first wave that came on their own presented a wider infection risk. While states like Kerala, with an excellent medical system, tracked and monitored the cases, what about those who returned to states with creakier infrastructure?

Within days of the first positive case being announced, the Indian government had announced a travel advisory, asking citizens to refrain from travelling to China, and saying anyone with a travel history to China from 15 January could be quarantined. They also stopped/cancelled visa facilities for Chinese nationals.

Italy also received its first COVID-19 courtesy Wuhan — in this case a Chinese couple who arrived from Wuhan on 23 January, and travelling through Italy. The Italian government sealed off the hotel, and suspended flights. Interestingly, on 31 January, the BBC reported the chief of the WHO, Tedros Adhanom Ghebreyesus, as saying, ‘there was no reason to limit trade or travel to China’.

Travel within India had not slowed. I was at a set of meetings in Delhi in early February. In the airport, only a handful of us were wearing masks. The pharmacy in the Delhi airport was still selling hand sanitisers at the regular price, though they did try to push the more expensive one first. The virus also spreads through the oral-faecal route. Given that so much of India’s drinking water is contaminated, this is of particular concern. If you want to look at it another way, this might help facilitate herd immunity.

For a while it seemed the virus might be contained. China had battened down the hatches, and was weathering the COVID-storm. The number of new cases globally was slowing down. The world heaved a sigh of relief. US President Donald Trump tweeted ‘The coronavirus is very much under control in the USA. … Stock market starting to look very good to me’

Meanwhile, in Italy, Iran and South Korea, the next phase of the epidemic was beginning.

In early March, the Indian government issued another travel advisory asking Indian citizens to refrain from travelling to Italy, Iran, South Korea and Japan, and suspending visas for citizens of those countries. In addition, all returning travellers would have to get a certificate of being COVID-free and self-declare that they were well. All travellers would be screened at the airport. Travel within India was still going on, but with some fear.

All around the world, travel restrictions were going up, and countries were sealing their borders. Even the Islamic State (ISIS) warned its terrorists not to enter Europe!

By 10 March, internal travel started to slow down, as the number of positive cases many of those either immediately returning from abroad or their family members/persons in close contact, began to ratchet upward.

There is a nifty little dashboard on COVID-19 timelines, which I would encourage you to check out. By taking the data from this dashboard week wise in March, I came up with this:

Clearly, the virus was being transmitted locally, through contacts with those that returned from foreign countries – Italy, the UK and the Middle East (Saudi Arabia, Iran and the UAE). The latest case, reported in Tamil Nadu, was different. This was 20-year old man who travelled by train from Delhi to Tamil Nadu, and as far as is known now, had not travelled abroad or come into contact with any foreign-returned person. Was this community transmission? It is far too early to say, especially given the low level of testing in India.

On 18 March, India banned passengers from Europe, the UK, Turkey, Afghanistan, Malaysia and the Philippines from entering the country. Furthermore, passengers who had travelled from COVID-19 hotspots, including Italy, from 15 February, would be quarantined for 14 days.

Passengers from UAE, Qatar, Oman and Kuwait would be placed under compulsory quarantine.

From the night of 22 March, India will shut off from the world. No commercial aircraft from a foreign country will be allowed to land in any Indian airport.

If implemented well, this could have a good effect. However, there are, how shall I put this politely, morons in our midst.

The Bengaluru newlywed techie’s wife’s story appears to have shades of grey, so let us leave that be. There is also the case of the Bengali bureaucrat’s son. Or the case of B-town singer, with some reporting that she hid in the bathroom to escape airport screening. It is confirmed that she was at parties with Members of Parliaments and senior politicians, putting the leadership of the country at risk. All three claim they were asymptomatic when they passed through airport screening.

The problem with self-declarations, even if people are truthful, and airport screenings is this: a significant number (between 17-30 percent) of people infected with the SARS-CoV-2 are asymptomatic. They have no fever, no cough, no sore throat. But they are infectious. They pass through every screen, and go on to infect those who may be less fortunate.

Imperfect as travel restrictions are, they are effective, and may have very well prevented from a full blown epidemic in India until now, when the temperatures are rising.

However, at the other end of the spectrum we have outright mal-intent. One example of this, are the kids partying in the beaches of Florida, who, on TV, say they don’t care about the coronavirus . Then there are those in India, who with full comprehension, of risks, take them anyway. Which is why we come to social distancing. Since anyone can have it, better to play it safe. The Prime Minister’s address to the nation on the 19 March said as much.

Most countries are focussing on prevention, which in turn focusses on minimising the virus load transmitted from one person to another. At the centre of this effort is social distancing. In social distancing, we keep away from others, preferably at greater than one-metre distances, for as long as we can. The hope here is that by doing so we break the chain of spread of the virus.

Is it safe though? Is it realistic?

The virus is a tableau of unfairness. Those who brought it to India have enough money to travel by plane outside the country. This is a tiny fraction of India’s full population, many of whom have not travelled far away from their place of birth. Much of India is employed outside the formal sector, with their hands, where work-from-home is a cruel joke. Shutdowns affect those who, for no fault of their own, are impacted. I’m not saying shutdowns are a bad idea, but they come with a cost on those who cannot bear it.

Importantly, is social distancing realistic?

I recently walked through a part of Dharavi, one of the largest slums in Asia, which is a popular destination in the ‘poverty-tourism’ circuit. Houses, 8 feet by 5 feet, hold entire families while being stacked next and atop of other such houses. I was told that 70 percent, more than two-thirds, of Dharavi’s one million population relieves themselves in community toilets. During our walk, we did walk past two of these community toilets. They looked reasonably well maintained and had lines of men waiting, face down, lota in hand, for their turn.

Can we really believe that social-distancing is anything but a forlorn hope?

Where other options do we have? Shut down, test everyone, or weather the storm and hope for herd immunity. Let us consider each of them in turn next time.

The writer is the founder of the Sundaram Climate Institute, cleantech angel investor and author of The Climate Solution — India's Climate Crisis and What We Can Do About It published by Hachette. Follow her work on her website; on Twitter; or write to her at cc@climaction.net.

In the first of this four-part explainer, Mridula Ramesh answers essential questions about the coronavirus pandemic: Where did it come from? How does it spread? Who and how does it kill? What might stop it?

In November 2002, when the first atypical pneumonia case was reported in Guangdong, China, WeChat, China’s enormously popular social messaging app, was a dream. Those three months before the WHO office in Beijing received information about a ‘strange contagious disease’ that had left 100 people dead. The three months gave the deadly SARS-Co-V virus enough time to get a foothold and set off an epidemic that, within months, infected at least 8,000 people, killing 774 before dying out in the summer of 2003.

Seventeen years later, on 30 December 2019, Li Wenliang, a young ophthalmologist, shared that "seven cases of SARS confirmed" to his WeChat group, called ‘Wuhan University Clinical 04’. Within days, the Public Security Bureau in Wuhan called him in and got him to sign a statement saying he was lying and disturbing public order. What made Li a hero was he published the statement on Weibo. In January, Li took to Weibo again, saying,

‘I started having cough symptoms on 10 January, fever on 11 January and hospitalisation on 12 January’.

On 23 January, Wuhan, the epicentre of the epidemic shut down. There were far less than 700 publicly reported, confirmed cases of COVID-19 in China at that point of time. The truth is, China or the world did not know truly how many cases there really were. The world had never seen a quarantine of that scale — Wuhan alone had a population of 11 million. There were sporadic images coming through on the internet: people dying in the corridors of hospital, hospitals being overwhelmed. Doctors dying.

In February, Li gave his final social media update,

‘Today the nucleic acid test result is positive, the dust has settled and the diagnosis has finally been confirmed.’

Within a week, he was dead, falling prey to the COVID-19 disease, that he had tried to warn the world about. It was clear that Chinese leadership, including Xi Jinping, knew about the outbreak well before the lockdown. In the transcript of a 3 February speech, Xi clearly states he had asked for the control of the pneumonia outbreak as early as 7 January. China swung into action as only China can – shutting down cities, factories, clearing land and building a 1,000-bed hospital from scratch in less than two weeks. These are measures that democracies could not, at that point, contemplate.

On 19 March, Wuhan, the initial epicentre of the COVID-19 Pandemic, declared no new case, about 3.5 months after they reported the first case. Clearly, the virus could be beat — at a price. Ironically, China has now instituted quarantines against visitors from overseas. The pandemic had almost come full circle.

Coronaviruses get their name from their spiked profile, which looks like a crown when viewed under a microscope. The SARS-CoV-2 virus, popularly called ‘The Corona Virus’, causes the COVID-19 , a respiratory infection that can be lethal for older people with pre-existing health conditions like hypertension. Humanity has periodically dealt with coronavirus infections, that tend to be, for the most part, upper respiratory tract infections. Bats are considered the natural reservoir of coronavirus es, such as this one, and the one that caused the SARS outbreak about 17 years ago. The SARS-CoV-2 virus is 96 percent identical at a whole genome level to a bat coronavirus . It is also 79.6 percent similar to the coronavirus that caused SARS, which gives us a place to start for mechanism and cure. More on that later.

While virulent WhatsApp images of bats in a soup have fed the imagination, scientists believe there was an intermediate host, most likely the pangolin. That’s because the coronavirus es isolated from smuggled pangolins were between 85-92 percent genetically identical to the coronavirus currently causing havoc in humans. Pangolins are internationally banned, but are still smuggled into China, where they are prized for their scales in traditional Chinese Medicine and for their meat. Which is why they feature in the live animal markets like the one in Huanan Seafood Wholesale Market in Wuhan. These markets are called ‘wet’ because of the spillage from aquatic tanks and the blood from the slaughtered animals. In the spattering from the slaughter, viruses can jump from animal to man.

The SARS epidemic is suspected to have started in a wet market, with civets as the assumed intermediate host. Camels were considered to be the intermediate host in the MERS epidemic. The Huanan Seafood Wholesale Market in Wuhan, which had a section with wildlife, has been the prime suspect for this pandemic. At least, that’s the theory. A Lancet paper considering the history of 41 early patients showed a significant number did not visit the wet market, and importantly, the earliest case did not. Given this Bin Cao, one of the co-authors wrote, “Now it seems clear that [the] seafood market is not the only origin of the virus,” he wrote. “But to be honest, we still do not know where the virus came from.” To be safe, China shut down the market on 1 January 2020.

Why do origins matter?

The Centre for Disease Control (CDC) in America says that three of four new infectious diseases come from animals. Knowing how and controlling for this is important to prevent future pandemics – this is something our bodies have not faced and have no immunity for. At the very least, given the global economic and human carnage, there need to be very strict slaughtering rules. China shut down wildlife trade, which many conservationists hailed as a positive step. However, there are loopholes. The ban does not cover animal use for medicinal uses or fur, leaving open the door for future animal-human jumps.

How does the virus work?

The virus particle consists of a fatty sheath in which spike proteins are embedded, and which surrounds a strand of RNA. There are other proteins provided structural integrity, but let us focus on the sheath, the spike and the RNA, because these hold the key, quite literally.

Let us start with the sheath: Washing one’s hands with soap breaks open the sheath. Washing thoroughly and long ensures every virus particle (hidden in crevices or under nails) is attacked.

The spike is what enables the virus to enter our cells. The virus needs to enter our cells to reproduce — it cannot do so on its own. If the spike protein is the key, what is the lock? The lock, researchers have found, is the ACE2, a protein found on the surface of many cells in the human body, especially and significantly for this pandemic, the lungs. ACE2 functions in a complex of proteins that modulate vascular functioning. Importantly, ACE2 appears to have a significant role to play in organ protection and blood pressure control, which is why persons with blood pressure, or hypertension, seem to have a rougher time during COVID-19 infections.

A key ingredient of the SARS-CoV-2 virus is the the replication-transcription complex, which is what makes more RNA copies of the virus. This is important. Human cells make RNA from DNA — they have no machinery to make RNA from RNA. This act is foreign, and as such makes a great target for anti-viral drugs.

Remdesivir is an antiviral drug developed by Gilead Biosciences, to work against Ebola, another RNA virus. In trials, this was shown to mess up viral RNA replication. The hope is this should work here too, which very limited trials show promise. However, the question also is will Remdesivir be available quickly and cheaply enough? And in the quantities required?

Other early (very small) trials showing promise include treating COVID-19 patients with a combination of anti-HIV drugs. However, there have been other trials that show that this combination of lopinavir and ritonavir, don’t really do the trick, lessening death rate by only 5.8 percent over the control group. Others say that this trial is not reflective of the efficacy, because patients had already been symptomatic for two weeks before starting treatment, and that 13 patients on the combo were stopped given the combo in the middle of the trial because of adverse events.

In this kind of a battle, every arrow in the arsenal is important, and doctors in Kasturba Hospital have been treating COVID-19 patients with the lopinavir-ritonavir combo.

Another approach is to trick the virus. This is the thinking behind APN01, a floating ACE2 if you will, made by Apieron Biologics. The hope is that APN01 will act as a honey trap for the virus, preventing from latching onto human cells. Data from a trial in China to check the effectiveness of APN01, the synthetic ACE2, is awaited.

In addition, the virus, like RNA viruses are wont to do, is mutating. One paper, summarized that there are two known strains of SARS-CoV-2, the deadlier, “L” strain, and the older, “S” Stain. China’s initial cases were primarily from the L strain, which gave way to the more docile S strain. Others point out that one mutation does not a strain make. The important point is that these mutations pose challenges to vaccine development and building immunity, depending on where they occur within the virus.

Comparisons with other large scale infections show that SARS-CoV-2 is more infectious than the seasonal flu and the 1918 Spanish Flu and about as infectious as tuberculosis.

On average, COVID-19 is far less deadly than tuberculosis. But not if one is above 65, and especially not if one suffers from diabetes, hypertension, asthma, smoking-history or heart-disease. Then, the virus can be deadly. Children and young people, the least likely to be hospitalised, can be silent carriers of the disease, or face a mild version of COVID-19 .

ACE2 expression drops of with age, and women have higher ACE2 levels. ACE2 presence is thought to prevent lung damage, especially in people with high blood pressure. Which is why the virus appears to be particularly deadly for men, in general, and older men, in particular. This group, old men, comprising much of the world’s political and business leadership, is the most susceptible to SARS-CoV-2.

How does the disease progress?

According to the WHO, there are three stages of the disease: viral replication, immune response and pulmonary damage.

Soon after exposure, the SARS-CoV-2 starts to invade our cells and reproducing in the upper respiratory tract. This is called the prodrome period, and lasts for about five days. The exposed person, during this period, does not have any symptoms such as fever or a cough. Now comes the kicker – what makes COVID-19 a pandemic. The WHO says:

‘Infected individuals produce a large quantity of virus in the upper respiratory tract during a prodrome period, are mobile, and carry on usual activities, contributing to the spread of infection.’

Then comes infection. Almost everyone (97.5 percent) infected with the SARS-CoV-2, develop symptoms with 11.5 days, which is why quarantine periods have been set for 14 days. Fever, Fatigue and a dry cough, are the most common symptoms, but the disease has a wide range of manifestation, and not every person has every symptom. A significant proportion of people remain asymptomatic.

The immune response for most infected people likely involves a host of the body’s immune responses including antibodies and Helper T-cells, at a local level, which fights the infection and then recedes. The WHO estimates that 80 percent of people recover from COVID-19 without any specialist treatment.

What happens in severe cases? One hypothesis is that it takes a while for the immune to kick in, which could allow the infection to move deeper, from the airways to the air sacs. In other cases, the viral load is so high (medical care givers), that the disease moves quicker to the air sacs than the immune system can adapt. Air sacs look like bunches of grapes with very thin walls with tubes which allow oxygen from the air to enter our red blood cells. For them to do their job, the thin walls are a must. But in a serious infection, the coronavirus attacks and damages the wall of these air sacs and the tubes. The damaged material lines the walls, making them thicker, and block the easy transmission of oxygen to the blood cells. Which leaves you breathless and with very low oxygen levels in your blood, and needing hospitalization.

Runaway cases, where the immune responses is un-tempered, lead to lung damage and death. ACE2 levels appear to be lower in cases of acute lung injury, which may be why older men are at risk.

Treatment options

Studies show (it’s early days yet) that Chloroquine, and its less-toxic version, Hydroxychloroquine, show antiviral effect in vitro, and have been known to temper immune response. If this pans out, this is great news for India, because both these molecules are widely available and cheap. One team (with a small sample) showed that Hydroxychloroquine was tremendously effective against COVID-19 when used in conjunction with another cheap, widely available drug, Azithromycin.

Another way to boost immune response and prevent acute respiratory tract infections is to take Vitamin D. In a review paper published by the BMJ, of randomised control trials involving over 10,000 participants, showed that Vitamin D supplementation did protect against acute respiratory tract infections. Again, this is cheap to do at a mass scale.

A key need is for Indian teams to start trying and sharing results to what works in an Indian context. Thus far, we have looked at what happens should one get infected. How does one prevent infection?

How does the virus spread?

The SARS-CoV-2 virus is highly contagious. Studies indicate each infected person in turn infects about 2+ people.

As the WHO puts it:

‘The disease can spread from person to person through small droplets from the nose or mouth which are spread when a person with COVID-19 coughs or exhales. These droplets land on objects and surfaces around the person. Other people then catch COVID-19 by touching these objects or surfaces, then touching their eyes, nose or mouth. People can also catch COVID-19 if they breathe in droplets from a person with COVID-19 who coughs out or exhales droplets. This is why it is important to stay more than 1 meter (3 feet) away from a person who is sick.’

The chance of any person getting infected is a function of

1. Their own susceptibility, a. Old > Young b. Men > Women c. Unhealthy (Diabetes/Hypertension/Lung impairment/Smokers) > Healthy

At every step, the virus is fighting with the body’s immune system and the native flora (the normal viruses and bacteria) of our respiratory tract for getting a foothold. Usually, the more virus (called the virus load) gets into your body, the greater likelihood of getting the virus.

The viral load, in turn, depends on a number of factors.

Assume average guy, Joe, has COVID-19 . How many people Joe infects depends on,

Closeness of contact: If Joe shakes hands with Jill, while Joe says namaste to Jack, then Jill is more likely to catch COVID-19 from Joe. Which is why kindergarten and primary classes, where children lick their fingers, dig their nose, hug other children, lick other children’s fingers etc., are great sources of spreading infection. These virus-bearing-children then come home and kiss and snuggle with their parents and vulnerable grandparents. That’s why many countries, even though children were not directly showing symptoms, shut down schools, especially primary schools.

Length of time of exposure: If people pass by Joe, without staying too long next to him, then there is less chance of them getting infected. If Susan travels on a flight with Joe for 4 hours, while Sara passes him by in the airport, Susan has a higher chance of getting infected from Joe than Sara does.

Length of virus survival outside the host: How long the virus survives on various surfaces, which itself is a function of — 1. Ambient temperature 2. Surface

Consider temperature (and humidity).

Joe coughs in a room and leaves. How long is the room ‘contagious’? At least three hours, it turns out. Of course, if there are more Joes and they cough more often, the infectiousness of the room would go up. These trials to show how long viruses were active were conducted at an ambient temperature of 21-23°C.

A new study by Jingyuan Wang and team shows the contagiousness of the SARS-CoV-2 virus is highly influenced by temperature. This relationship, where R indicates how contagious a virus is, is shown in the graph below, reproduced from their paper.

This helps explain why warmer countries such as India have been less impacted. They are not exempt, as the rising case incidence in India and other warm countries shows. Rising Indian infections could have something to do with more widespread testing, but rising cases in Singapore does speak to warm, humid weather not being an effective deterrent.

Now, let us consider surface.

Again, trials showed that the virus stays infectious on stainless steel and plastic for days, although progressively in smaller quantities. The virus does not like copper, but stays active on cardboard for up to 24 hours.

Putting all this together, how should Joe behave, if he does not want to infect others?

Joe minimises the spread of virus by covering his nose/mouth while coughing or sneezing.

When Joe goes out, Joe does not into crowded places.

Joe does not travel, especially on flights.

People around Joe wash their hands. This is not infallible. Joe touches his body, gets virus on hands. Joe then touches door knob. Virus moves to door knob. The door knob is not copper, which means anyone else touching the door knob within 24 hours can potentially get exposed.

Consider one scenario: You and Joe work in an office. Joe coughs, and a droplet containing the virus lands on your phone. You have your mask on, but you grab your phone and put it into your pocket. You then leave the room (Joe coughed!), and wash your hands meticulously for 20 seconds, and destroy the fatty sheath of every last virus on your hand. Feeling jittery, you grab your phone out of your pocket and type a WhatsApp message: ‘this jerk Joe coughed, but thank god, I had my mask on, and I washed my hands.’ You then rub your nose. Bingo, chances are you are exposed. Since you are younger than 65, chances are no serious harm done.

Italy, where the average high temperatures in February/March range between 10-15°C, with a large older population (a fifth are 65+) and a culture that cherishes intergenerational mixing (everyone loves Nonna/grandma), seems tailor-made for COVID-19 .

India, where temperatures are warmer and the people are younger, is still at risk for two reasons:

Our healthcare sector, including testing capabilities, treatment infrastructure and monitoring facilities are dwarfed by our large population. Large sections of our people live in close proximity, where spacing of 1 metre between families, is a pipe dream.

Given this, what can India do?

Part 2: How effectively will policies of travel restrictions and social distancing control the spread?

The writer is the founder of the Sundaram Climate Institute, cleantech angel investor and author of The Climate Solution — India's Climate Crisis and What We Can Do About It published by Hachette. Follow her work on her website; on Twitter; or write to her at cc@climaction.net.