While nations across the world struggle to contain the fallout of the human toll and economic consequences of the COVID-19 pandemic, public health experts such as Dr. Ashish Jha, K.T. Li Professor of Global Health at Harvard T.H. Chan School of Public Health, and the Director of the Harvard Global Health Institute, have been at the forefront of research and public policy guidance to public and private institutions dealing with the crisis. He shared insights into epidemiological basis of the pandemic and what policy solutions hold out hope for the future in India.

You have argued that to measure the true impact of the coronavirus in India, we need to look beyond the official fatalities record of the government. Why do you believe this?

First of all, the key metrics that we want to sort relate to how many people have been infected and how many people have died. Both of those are driven a lot by how carefully you look. If you have a lot of mild infections happening, and you are not testing extensively, you are going to miss those. Therefore, you might find that you have a very high case fatality rate because you are only testing the sick patients and finding very sick people. Alternatively, if you do not have a very good surveillance system for deaths, if every death is not thoroughly investigated, you might find that a lot of people die. You do not know why they are dying. You may think that your case fatality rate is really low, because you are missing a lot of COVID-19 deaths. Understanding both how many people have been infected with and have died of this virus in India is a tricky business. You cannot just look at the official statistics.

Is there any chance in India that the accuracy of recording deaths and causes of deaths is reasonably high and the estimated fatality rate is in the correct ballpark?

The global fatality rate is about 1%, maybe a little less. When all is said and done, that will be the fatality rate in India. I actually expect that in India it will be lower than 1%, because India has a relatively younger population. But I am not particularly interested in fatality rate — I am interested in fatalities.

Right now, the statistics suggest that around 20,000 people have died of this virus in India. That, to me, is very low. It is possible that we are doing a good job in India of ascertaining all the deaths, but I would not be surprised if we are missing a lot. The reason is that when I look at the U.S., U.K. and Western Europe, all of those countries have a lot more deaths than they have officially recorded. If high-income countries with very good surveillance systems are missing anywhere from 30%-70% of deaths from the coronavirus, why would I not expect that India would also be missing a similar proportion of deaths? I also think that the current estimate of 7,00,000 people having been infected is almost surely a very substantial underestimate.

Is the government justified in conserving test kits and surveillance system resources over time, hence limiting testing to the numbers that we see?

There is no limit to how much testing a country can do if it makes investments in reagents and other supplies. It can do very large numbers of tests. India has done about ten million tests so far. The U.S. has done about 40 million, Russia has done about 20 million. Why is India’s capacity less than Russia’s in terms of the ability to do testing? I just think it is a priority issue. If India decided tomorrow that it was going to invest substantial financial and intellectual resources into ramping up testing, I know nothing about India that makes me think it cannot do it, that it does not have the capacity.

Is the theory of herd immunity our only hope until a vaccine arrives? Could either or both of these halt the pandemic in its tracks? Please explain how they work.

The purpose of herd immunity is that once you have 60%-70% of the population immune to the disease, then the virus cannot spread anymore, it slows down, and it does not completely extinguish but it becomes a much smaller problem. How do you get to 60%-70% immunity? The best way to do it is through a vaccine. If you do not have a vaccine — and this is what people usually refer to as herd immunity — what if you just let the infection run? 60%-70% of India’s population will have to get infected — the idea of nearly a billion people getting infected. If you take a 1% fatality rate, that is 10 million people dying, and tens of millions of people getting very sick, hospitals completely overwhelmed over the next year. That is a disaster. So, herd immunity is the policy of complete and utter failure. With millions of people dying and hundreds of people getting very sick, the economy will be completely destroyed.

India has had among the most stringent lockdowns across the world. Would you argue that that has had a substantial impact?

Remember, the entire strategy here is to protect people until a vaccine becomes available. I believe a vaccine will be available for India sometime in 2021 and my hope is that it will be in the first half of 2021. But there is a lot of uncertainty. Let us assume that it is in July 2021. We have about a year to go until that vaccine becomes available. But lockdowns only buy you time. You cannot be locked down for a year, it is just not possible economically and socially. The key is to use that lockdown to substantially ramp up testing, communicate to the people of India what will happen when the lockdown ends, how our behaviour must change, put in those policies, and ramp up hospital capacity. Then, when you unlock, you will be better able to handle what will surely be a surge of cases, as we are seeing in India right now.

When do you see the viral spread peaking in India and then coming down, and, accordingly, what advice would you give to the Indian government?

What policymakers in India must understand is that the pandemic is still quite early in India. What will cause the peak and the decreasing of cases? Right now, less than 1% of the Indian population has been infected. What we have seen in other places is that left unchecked, that number will grow exponentially until we hit 60%-70% infection, which is a billion people.

Of course, it is not going to be left unchecked, and I do not expect that that is going to happen. There are things that India can do to really reduce the spread of this virus and slow down that growth. Increasingly, we have good evidence around mask-wearing. People should be wearing masks outside, and indoors in any public space. Second, we have got to go after hotspots. Every time you detect an outbreak, you need to follow the testing, tracing, isolation strategy. That has worked in lots of places in India — in Kerala, and in Dharavi in Mumbai. There is no reason for me to think that that cannot be a really critical public health strategy. Third, for the next year ahead, no large gatherings.

If India does all of that — the masks, the testing, getting rid of large gatherings — then I think India has a pretty good shot at keeping the virus from getting into exponential growth.