Last New Year's Eve, I still remember the jubilation among some people shown on the local television. ‘Good Riddance 2020’, they said. They had every right to be jubilant, as 2020 spelt a difficult time for people and businesses.
COVID-19 had separated people, had taken away several freedoms that we take for granted, and sucked out money from the local economies. Everyone wanted a rosy 2021 that brings them prosperity and happiness. Little did they know of a Delta variant, or a second wave, or the nightmares that were to unravel across India’s hospitals and streets in 2021.
India is slowly emerging out of the COVID-19 second wave. Though badly bruised, the country can boast of several remarkable achievements. It has managed to deliver 1 billion vaccine doses to its people, and the deaths per million population is better than several of the High-Income Countries.
There are concerns about the quality of reporting which happened during the peak of the pandemic, but broadly the scenes of desperation due to health capacity being overwhelmed was limited to less than a couple of weeks. Since October 16, India has consistently recorded less than 15,000 COVID-19 cases a day, on most of the days. This is despite the country testing more than a million samples a day.
So, does the low number of cases, or the decreasing test-positivity rate indicate that we are nearing the end of this pandemic? The answer is not that simple.
It is interesting to discuss the future of the pandemic in the week when the cumulative mortality due to COVID-19 touched 5 million. When we look at the numbers being reported from across the world, we can see that the pandemic is far from over. Most of Europe is showing an increase in the number of cases, and the eastern part of that continent is going through a desperate situation. There are restrictions on people coming together in most of the Eastern European countries. Even Germany, where health system is robust and two-third of the population is fully vaccinated, is seeing a weekly increase of more than 70 percent in the number of confirmed COVID-19 cases and deaths.
Of course, there are explanations like onset of cold weather, the flu season, Delta variant and COVID-19 inappropriate behaviour, but the fact is that the world remains on the brink, and it's too premature to let the guard down.
This sustained level of transmission seen in parts of the world, despite high levels of vaccine coverage, shows that ‘herd immunity’ is a mirage. Kerala can be taken as an example. A study done in September showed that around 82 percent of the population had antibodies against COVID-19. In the last week of October, the state has also managed to fully vaccinate more than 50 percent of its population. In spite of this, the state is still reporting anywhere between 7,000 and 10,000 cases a day, constituting more than half of India’s total numbers. The state has the lowest case-fatality rates in India, but the second-largest number of cases after Maharashtra.
This sustained transmission is a risk factor for mutations. RNA viruses like Coronavirus are known for frequent mutations. Most of it is likely to be harmless, and the general direction tends to be towards increased transmissibility, and lower lethality. But we cannot rule out a mutation similar to what happened in the case of the Delta variant. The Delta variant, which emerged from India, had quickly spread across the world, and became the most dominant variant. Therefore, till a time when there is significant disease transmission in populations, there is always a risk of a more infectious mutant emerging.
The vast differences that we see in vaccine coverage across the world is a significant source of concern to most global health professionals. The justice issue apart, it can result in increased chances of a mutant which can have global repercussions. Most of the countries in Africa has a full vaccine coverage of less than 5 percent, while several rich countries are thinking of a third dose. The United Nations Secretary General has issued a statement on November 1, calling for greater vaccine equity. Leaders of the rich countries should realise that it is their own interest also, to vaccinate the entire world against COVID-19.
After accounting for information bias, and differences in diagnostic capacity between countries, it is evident that the countries with high levels of public investment in healthcare delivery managed to reduce the case-fatality rates, and also prevented the healthcare facilities from becoming overwhelmed by the number of cases. This shows the need to invest in health system strengthening, and providing everyone with some form of health coverage.
According to World Bank estimates, the public expenditure on health is less than 1 percent of the Gross Domestic Product in India, while Thailand spends closer to 3 percent. As a country, we need to provide better healthcare to our people and the investment needs to come from the government. If we want to soften the impact of any future pandemic, the most cost-effective way may be to ensure robust primary healthcare services for all.
COVID-19 has exposed the chinks in our armour, and demonstrated the need for countries to work together. But this pandemic is far from over. Governments should continue to share data, and learn from each other's experiences. But more importantly, principles of equity and trust should be guiding forces while we look to contain this virus.
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