We need to understand our own ethnic genome better: Albright's Mehul Mehta

In an interview, Mehta tells Anjuli Bhargava that picking up mutations before a spike in numbers is crucial and genomics is the future of medicine

Physician and Chief Medical Officer at the Albright Stonebridge (founded by former US secretary Madeleine Albright) group in Boston, Dr Mehul Mehta’s work over the last 23 years has spanned over 33 countries, developing new hospitals, reforming existing healthcare delivery systems, building medical educational institutions and establishing research ecosystems  and entities. He’s carried out this work through leadership positions at Harvard Medical International and at Mass General-Brigham Health International.

Through the pandemic, Dr Mehta has steadily done his bit to counter the “pandemic of misinformation”, through a regular COVID update with groups of around 50-100 participants in India, going back to April 2020 and now coming close to the 40th session under the aegis of his school (Cathedral, Mumbai) and over 55 globally.. He’s also done talks with groups of IIM-Ahmedabad alumni, the Harvard Alumni Association in India and the Young President’s organisations (YPO) India. 

He spoke to Anjuli Bhargava over Zoom for over 90 minutes on the pandemic, why it is essential to get vaccinated and where India needs to go with its genomics study and research for the future. Excerpts from a chat :

What to your mind could we have done differently to reduce infections and deaths ?

The numbers in India were rising till September and then suddenly there has been a dramatic drop. Experts thought that by December, the numbers would start moving up again but that hasn’t happened and we are still seeing a fall. There are a number of possible interesting reasons for that which I will elaborate on later.

When the pandemic hit, it was a novel pathogen and it took till January (2020) to understand what it’s full genomics was. We realised that it was the 7th coronavirus that had been pathological to humans, that was transmitted through the air (not water-borne). We had had MERS and SARS - both coronaviruses - 

and we had known that the same known virus in a new form could attack us again. When we first got SARs, people said it’s a once in a lifetime event but then we got MERs after that. So it clearly wasn’t.

I think countries reacted to this with inadequate pandemic preparedness. We were caught napping but not unaware. The fact that we expected a pandemic and not a world war was obvious and known to anyone in the field and some outside of it. In 2018, Harvard Global Health Institute held a pandemic week. Bill Gates spoke of a pandemic in some detail at his TedTalk in 2015. The world knew it faced a very real possibility, even if it could not pinpoint exactly when and how it would afflict us or how deadly it might be. So the SARS countries that  had been burnt in the past  had run preparedness programmes. South Korea had run a sort of fire drill just a couple of months prior to the global pandemic. Mock runs had been conducted so they coped far better.

Second thing is that we could only prevent the spread once we knew how it was spreading. So there was a lag that led to an exponential rise in infections and a pandemic as global travel exacerbated the situation. Countries who had past experience isolated people, did contact tracing and so on till they figured what exactly they were dealing with. Second, the virus and its spread was not homogenous. It would not infect everyone. It had a heterogenous spread. Some people would be infected and others not. In fact 20 per cent are infecting 80 per cent of the population. But almost  every country had its own seminal super spreading event - like in North Italy it was a soccer game.

In India, the strict lockdown helped although there were consequences which are making themselves felt even today. Migrant worker movement and a couple of super spreader events in Delhi worsened the situation. At that stage, contact tracing and testing became critical. You were running blind if you didn’t test. Our testing was inadequate and remains so. Countries like Germany, South Korea, Taiwan, Singapore, China all ramped up testing and did better than the laggards like the US and even India. India could have done better with testing and contact tracing.  

Once you knew what you were dealing with, public health mandates became critical. Like social distancing, masking became important. Here India was fortunate. Governments can mandate anything but if behaviour does not follow, there is no way out. In the US, we had a double whammy so to speak : it was neither mandated nor did people obey quietly when such measures were suggested. It's like saying we have vaccines but that does not mean we are vaccinated. You have to reach the last mile. So countries who took to wearing masks and following some basic rules  did well.

So countries that had seen similar outbreaks in the past did better, as did those who followed the public health measures mandated. Once countries began to reopen, this too determined how they performed. Countries with phased, controlled, measured opening did better. Authoritarian approaches as adopted by China - and not possible in democracies - also managed to control the virus better. It’s interesting that the way the virus got controlled is also contextualised to the way the country is structured. 

So, are we out of the woods in India now ?

It depends. The pandemic is a dynamic between the pathogen’s ability to infect and kill and the population’s resilience to get infected. If the latter is high the infections and deaths are lower. This is where the enigma of India lies. First, India has a younger population and is hence more resilient, unlike countries with an older population. Second and this is a generalisation, India seems to have a stronger innate immunity since it’s population  is exposed to many pathogens. There exists a stronger immune system to combat a new pathogen. Third, this particular virus has a cousin called the cold coronavirus - which causes some of the regular colds - which has given some more immunity. 

Then, there’s interesting evidence to show that countries that have strong penetration of the BCG vaccine had lower mortality. In India, a large percentage did get the BCG vaccine. Climate - warmer and more humid - may have helped. So you have now this dance of infectivity with receptivity to get infected.

I think it's a multivariate set of factors driving things. To put it in mathematical terms, these are “chaotic”systems. If all elements that drive an avalanche are there, all you need to do is shout loudly and it’ll trigger it. So in combination all the factors I mentioned, acting in consort with each other, with regard to India have made a difference. 

But this is assuming nothing has changed with the virus. The moment the virus changes - either becomes more or less virulent - the dynamics can shift quite rapidly. So, I think we are not yet out of the woods.

If the pathogen changes, it can become more or less infectious. If India sees the S. African or Brazilian type of mutations, our numbers will rapidly rise, as has happened in those countries. Again, if we get large numbers vaccinated, we could triumph over the virus and its mutations. By doing that you can raise the resilience to such a level that no matter what happens to the pathogen, it will not have the same receptivity. Remember the faster one vaccinates, the lower the infections,  lower the viral replications and  hence mutations. Also, many of the current vaccines are showing lower but still over 50% effectiveness against the mutations. Finally, most vaccine manufacturers are already into early trials with vaccines reconfigured against the known mutations. 

Picking up mutations before a spike in numbers is very critical. Once a spike occurs then the horse is out of the barn, so to speak. This is where I worry for India. In the UK, they picked up the new mutant because of advanced genomics. We have the National Genomics Institute but for the scale of the country, we need to ramp up our surveillance and genomics capabilities. 

This is something I strongly would like to push for. Genomics is the future of medicine. We need to understand our own ethnic genome better so we can develop treatments and drugs  optimized to  work best with our diverse ethinic groups, not just  apply treatments and drug dosing  developed for other ethinic groups. Create our own national health and genomic stack and base. This needs a national push. Above all, we need a career path in research that is very very attractive for young professionals in medicine to pursue.

You are then assuming the vaccines work well...

We need to rephrase vaccine efficacy. When we talk of vaccine efficacy we talk of what percentage will be protected against COVID. The discussion needs to move to what percentage will be protected from death or serious illness due to infection and the answer then is almost 100 per cent. If you take both doses of the vaccine,   you may fall mildly ill if you get infected but be protected from severe disease and death.

It is however not a vaccine against death or all disease. That can and will happen due to a number of other unrelated causes.  But if you can convert a lethal disease to a cold, wouldn’t you ? 

People fear the vaccine because this is new, not a known animal like smallpox or BCG…they fear allergic reactions and so on...

The immune system for  vaccines works the same way. You present to the immune system a set of foreign antigens so that it can respond to them when it sees it in real life. The basic immunology of vaccines has not changed since Jenner carried out the first smallpox vaccine study using cowpox in the 1700s. Only the way we are presenting the pathogen and stimulating the immune system to respond  to the body is new. 

My big takeaway on vaccines is do the world a favour and get it. I keep telling those who worry about allergies and other reactions to look carefully at the data : serious adverse reactions are rare. They are often taking daily medication without giving it a thought or even reading what allergic reactions it could lead to..

Also, if you don’t get the vaccine, you will get coronavirus at some point. The pandemic may stop but the pathogen will not disappear. It will still infect those who are susceptible. Why not vaccinate yourself rather than risk falling severely ill at some point ? That’s the question we need to ask each other and all those who are suffering from vaccine hesitancy.

How has the vaccine been developed so quickly and how long does it normally take?

For a new pathogen, it normally takes years. We have to first figure out what it is. In the past, genomics was not developed to the level it is today. This time we knew what we were dealing with within a month or two. Then, animal models have to be developed and run experiments. These steps take years. In this case, we had the animal models since we had SARs and MERs. Viral platforms were there. Also, phases of testing were squeezed and merged. Manufacturing took place at risk - even before they knew it would work.

Second, lots of money and resources went into developing vaccines this time since the entire world was affected. Normally, the diseases that need vaccines are in smaller populations and in poorer countries. So, resources are less. Vaccines don’t make much money since it’s a public health intervention. This was different. Resources are flowing in. Some of the companies who are making vaccines are doing it at cost.  Some may make a margin on it but nobody will make a killing on it : it’s unethical.

We (the world) have heavily underinvested in public health and this has become clear. You think of national security and you think of war and oil. Have we ever considered health is national security? There is no economy if there is a pandemic : an economy is a consequence of human interaction. If human interaction is not safe and possible, what economy can you have?

The anchor for any country’s stability is the health of its citizens. If one is facing an existential crisis, nothing else matters. We have to invest more in public health. India’s investment in health as a percentage of GDP needs to go up from the present 2 per cent or so to at least double or triple that. We need to build systems that respond quickly. We have a strong pharma industry supplying generics to the world but we need to marry that with innovation in health sciences and find our own indigenous therapeutic approaches. Moreover, we are also short of highly trained, skilled staff in the sector.