Clotting due to Covid is perhaps 100 times more than clotting caused by a vaccine: Soumya Swaminathan at Idea Exchange – The Indian Express

As former chief scientist of WHO, Dr Soumya Swaminathan was the public face of science and research during the pandemic, demystifying COVID-19. Now, as chairperson of the MS Swaminathan Research Foundation, she is closely working on the impact of climate change on every aspect of our lives, particularly health. Her biography, At The Wheel of Research, documents her journey to make science the pillar of our public health. She speaks at the Idea Exchange session, moderated by Rinku Ghosh, Senior Associate Editor:

Rinku Ghosh: There is collective anxiety over the safety of Covid vaccines, what with AstraZenecas submission in court that in rare cases, its vaccine resulted in blood clotting. Considering that the same vaccine was used as Covishield in India, what kind of risks are we looking at?

Im very worried that this is going to have a negative impact on people, their beliefs and confidence in vaccines. When a vaccine is developed, it is tested several times over for its efficacy and safety. If a vaccine or drug is new, regulatory agencies conduct a post-marketing surveillance or a phase IV study. This is to capture rare side effects which might have been missed in clinical trials. For example, clinical trials for Covid vaccines had 30,000 to 40,000 participants. But when you give it to millions of people, then there may be rare things which you can pick up. This is why pharmacovigilance or post-marketing surveillance is important. Vaccines began to be administered by December 2020 as Pfizer, Moderna and AstraZeneca were approved in different countries. By March 2021, we had already heard about these thrombotic events, or Thrombotic Thrombocytopenic Purpura (TTP). At WHO, we were looking very closely at the data, which was coming out of high-income countries with good pharmacovigilance systems. These very rare side effects were mentioned in different reports from different countries, maybe somewhere in the range of four to eight per million vaccines. Every regulatory agency, including the WHO, looked at the safety profile again, assessed the risk-benefit ratio and concluded that the benefits far outweighed the risks. If you vaccinated a million individuals, the number of lives that you would save because of Covid was much more than these side effects. That has remained the same. So there has been no major change in our knowledge about this side effect since.

Second, Covid itself damages the lungs, the cardiovascular, brain and nervous systems and triggers clotting. All of us, who have suffered from Covid, now have a higher risk, may be by two to three times, of suffering health conditions related to these systems than ever before. If you have already had other risks say diabetes or hypertension then Covid is an add-on risk. The clotting due to Covid is many times, perhaps even a hundred times, more than the clotting due to the vaccine.

The third aspect is that the case revolves around the compensation thats being claimed by people who have had these severe side effects. At WHO, when we set up COVAX (COVID-19 Vaccines Global Access), we had already thought about setting up a no-fault compensation system globally. We took an insurance policy for hundreds of millions of people worldwide in low and middle-income countries, who would be receiving different vaccines. Till the time I was at WHO, there had been no claims. Im not sure if there has been any claim in the past year.

Besides, these side effects occur within a few weeks of taking the vaccine. So people whove taken the vaccine in 2021 or 2022 need not worry today about a clotting disorder. They will not get it because of the vaccine. They could get it because of Covid or an underlying condition that got exacerbated.

Rinku Ghosh: Is communicating science to the masses a big challenge because we lack scientific temperament?

Vaccine hesitancy or anti-science is not directly linked with the level of education. Countries with high vaccine hesitancy generally have high levels of education western Europe and US. Comparatively India has very small pockets of vaccine hesitancy but those were overcome by officials talking to the communities and so on.

Science is about doing experiments repeatedly because the truth could change when somebody finds something contradictory. Thats why theres a need for constant scrutiny. Usually, its a collective effort scientists around the world working in a particular discipline will have their own arguments. But during Covid, all of this was playing out in the public domain. So the layman saw scientists arguing and disagreeing, which is a normal scientific practice, but thought they couldnt make up their mind and deduced something was wrong. The anti-vax and anti-science groups took advantage of this gap in understanding. This is the first pandemic that weve had in the social media age. There will be more infodemics and we have to teach our children to sift facts. As public health people, we need to give, not hide information.

Nobody can deny that any drug or vaccine could have side effects. Even the polio vaccine has had side effects but that hasnt stopped the polio eradication programme. As scientists, we have to communicate in a way that makes information more acceptable. We have to be willing to constantly answer the same questions. Scientists cannot be patronising.

Rinku Ghosh: What are the big takeaways of COVID-19 and have we internalised them enough?

I can tell you the lessons from my perspective. How many governments and people have internalised them and are acting on them is a good question. We can see the push and pull in the negotiations of a global pandemic treaty to strengthen pandemic prevention, preparedness and response. This is a once-in-a-lifetime opportunity to actually put down on paper the lessons weve learnt and what needs to be done in the future.

First, a pandemic is a global issue and needs a global effort, solidarity and cooperation on surveillance, sharing data and R&D. Second is the issue of financing for which the World Bank has set up a fund. About $ 2 billion has come in as contribution and the bank has already finished one round of grants. We have to invest in science, be it to tackle climate change or for pathogen X. The third is investing in public health. Countries which had focussed more on public health infrastructure and primary healthcare actually did much better in terms of lowering deaths than first world countries. The US is a good example where the Centers for Disease Control and Prevention (CDC) public health budget had been cut year after year. So it couldnt do very simple things like contact tracing or scaling up surveillance. In contrast, poorer countries in Africa with a strong cadre of community health workers were able to do much better. Thailand is a prime example of a Southeast Asian country with excellent primary health care services. It was the first country outside China to locate the virus, put in place containment measures and use technology like South Korea did to test almost its entire population. The fourth is countering misinformation and the fifth is strengthening frontline workers. We need to pick up outbreaks quickly and you need an empowered team at the district level that immediately goes to the hotspot, investigates, reports, collects the data and acts on it. Decentralisation of data-based decision-making is the key.

Amitabh Sinha: How did the pandemic go away, what explains the negligible numbers now?

In a majority of countries, 60-70 per cent of the population has been vaccinated. Besides, people acquired immunity through natural infection. So a large part of the world today has cell-mediated as well as antibody-based immunity. And therefore, the virus is no longer able to extract the damage that it did in the early part. But the virus is still mutating and spreading. Were still getting infected but were not falling sick because our cell immunity kicks in and protects us. May be after four or five years that immunity will wane and we will all need boosters. Or a small infection may actually be boosting our immunity. We need regular studies on our levels of immunity.

Amitabh Sinha: Although we experienced the worst pandemic, none of the political parties has mentioned healthcare in manifestoes. Your take?

WHO Director-General Dr Tedros Ghebreyesus had predicted that we would go through this cycle of panic and neglect. We would panic in the middle of something terrible and ease away when we got a little comfortable. Im afraid thats happening all over the world. Other priorities have come up now, be it conflicts, trade wars, economic issues. There is no focus on health. I was happy that this time, during the World Bank-IMF Spring Meetings, the bank president, Ajay Banga, talked about a liveable planet, a sustainable lifestyle, health and nutrition. I think from the perspective of politicians, it is more rewarding to invest in a facility, which is very visible, because you can get credit from the local population.

Preventive healthcare is completely invisible. Its about making the right policies, laws and implementing them, dealing with lobbies and doing hard work behind the scenes. We have to implement the Rules on the Clinical Establishment Act. Thats why private hospitals continue to exploit the patient. And out-of-pocket expenditure in India though it has come down from 60 per cent to 45 per cent is still extremely high. I will again quote the example of Thailand, where the government actually invested in an organisation for health promotion and disease prevention. It is funded by taxes on tobacco, alcohol, sugar and unhealthy items.

Harish Damodaran: The remit of public health has traditionally been confined to communicable diseases like TB, malaria and viral infection. Now we are seeing lifestyle or non-communicable diseases like diabetes and cardiovascular conditions affecting the poor and lower middle-classes alike. Can we bring these under the public health umbrella?

Yes, public health is not just about communicable diseases. The WHOs SDG (Sustainable Development Goal) target 3.4 aims to reduce by one third premature mortality from non-communicable diseases through prevention and treatment by 2030. These are increasing rapidly in developing countries because of unhealthy diets and air pollution. The National Institute of Nutrition (NIN) data has shown that only a small fraction of the population is actually consuming a healthy diet. Some of it can be attributed to behavioural change as a recent household expenditure survey showed that 10 per cent of household expenditure, both in urban and rural areas, is now being spent on processed and ready-to-eat foods. Thats huge. May be, it has to do with convenience but it has also got to do with believing misleading advertisements that tell you these are healthy when actually they are not. A lot of public education drives have to be done on nutrition. A lot of policy and regulatory work needs to be done. We need to focus on agriculture and ensure we produce more nutritious food rather than focus on just rice and wheat. Dietary diversity has to improve. Big changes cannot be done without government intervention, certainly with regard to air quality and pollution.

My interest today is in looking at these determinants of health. Covid taught me to look upstream. We need an inter-sectoral and a holistic view of health, not a narrow one. Its a joke now that the Ministry of Health should perhaps be called the Ministry of Sickness and Disease, because its current focus is on managing a sick population. But the Ministry of Health also needs to be a steward and an advocate for good health across other ministries.

Rinku Ghosh: Recently, there was a row on added sugars in baby food and contaminants in spices. What would you say are the challenges of regulating food in India?

The primary focus of regulators in India has to be on public health and safety. For example, ban advertisements which have misleading information. Make sure that there is front of pack labelling on food, which is a simple traffic light system and has been adopted by many countries. As soon as you pick up a packet and see a red star on it, youre alerted that the package has been classified as unhealthy because it has high fat, sugar and salt. You dont even have to be literate to understand the potential dangers. Studies have shown how such labelling has helped in significantly reducing serious health outcomes like heart attacks. Strict labelling also compels the food industry into making healthier products.

As for contamination, lead poisoning is a huge public health risk in India. One of the sources is adulterated turmeric, which contains lead chromate to give it a bright yellow colour. A recent study across 10 cities showed that the average lead levels in children were far higher than the WHO cut-off. There is lead in our environment, coming from recycling batteries and paint. This is affecting the cognitive development of children. The Economist, in fact, had an article saying that if you get rid of lead, then your IQ levels improve.

Regulation and advertising are going to be important in dealing with the private sector. This is why we talk about commercial determinants of health, which are now as important as the social and environmental ones.

Anuradha Mascarenhas: How prepared are we for dengue outbreaks today? What about tuberculosis?

Dengue is the fastest-growing infection globally as the vector has adapted itself extremely well to living in cities. Genetic manipulation with Wolbachia bacteria can manipulate mosquito populations and reduce disease transmission. This has been tried in some countries. You have to breed and release a lot of mosquitoes with the Wolbachia to control dengue. A small place like Singapore probably can do it but it may be very difficult to do it across India. May be some cities could.

Were very close to eliminating diseases like filariasis and kalazar. As regards TB, the national prevalence survey indicates wide variations between states. The biggest risk factor for TB is under-nutrition with almost 50 per cent of cases being attributed to it. We have to think out of the box, use more technology and data-driven approaches. Statewise approaches will be different. In terms of financial resources, its going to require a multi-disciplinary approach.

Ankita Upadhyay: Are we doing enough to tackle air pollution, which comes at an enormous health cost?

In large parts of the country, the AQI (air quality index) is way above the WHO cut-off and even way above the Indian cut-off for PM 2.5, which is 40 g/m3. The more we learn about the health effects of air pollution, the more frightening it is. Setting up inflammatory cascades, pollution is impacting our brain, triggering early dementia. Its impacting the heart and lungs. Data shows that women exposed to pollution, particularly in the first and third trimester, have premature babies.

We do not need more data, we now need multi-sectoral action. By moving to clean energy, we can achieve net zero goals while reducing air pollution. We need to reduce the number of vehicles on the road and use public transport, cycle or walk. The Chief Technology Officer of the Transport for London told me that obesity rates in the city are much lower than those in other districts because people use public transport. In London, people are incentivised not to own cars. So if you want an apartment in the heart of London, they now have what are called ultra-low emission zones, which means you cannot own a car. You have to make a commitment to public transport, then the government has to provide it. It works both ways. In India, were still incentivising cars. We want three car parks with each apartment. In Geneva, I didnt have a car. I had a bicycle, I used to walk, take the train or bus.

Rinku Ghosh: Are you playing the violin and which is your favourite Beatles song?

No, I am not playing and have to restart practice. I listen to Hindustani music, old songs and jazz. I am a hiker and trekker and recently visited Kashmir. And my favourite Beatles song is probably Michelle.

See more here:

Clotting due to Covid is perhaps 100 times more than clotting caused by a vaccine: Soumya Swaminathan at Idea Exchange - The Indian Express