India is entering a critical phase in the efforts to contain the second wave of Covid-19, which has hit us badly in the last two months. Though many in the government would like to believe that the second wave came unheralded, it is a fact that we received several warnings over the last six months.
Besides, historical data from similar outbreaks of air borne viral illnesses show us that the spread of infection takes the form of waves — in most cases three waves. The height and breadth of the second wave is usually bigger than first or third, if a vaccine is not made available early enough.
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India seems to have grossly overestimated its capacity to vaccinate its people and we exported over 66 million doses to 95 countries. We did not have a clear roadmap in place for vaccination, and firm orders were not placed till January. This was probably a part of the ‘pandemic fatigue’ which was visible among policy circles and the public by the end of last year. As a nation, we were complacent about the public health precautions needed to prevent the second wave, and we are now suffering together.
Though many naïve observers see India as a monolith and evaluate the COVID-19 outbreak in the entire country together, we need to understand that almost every state has a vastly varying epidemic curve. It means that each state is at a different stage of outbreak and it’s quite futile to aggregate the data.
Apart from this, the healthcare capacity and the social capital available in each state is also very different from each other. Therefore, a one-size-fits-all strategy is bound to fail and we need localised, quick decision-making during an outbreak like this. As public health experts globally would vouch for, a multi-sectoral approach with a bouquet of various interventions is the best possible way out of this difficult situation. Many believe that our mortality numbers are seriously underreported and that we are well on our way to more than 1 million deaths by August.
Hope In Vaccines
The most important weapon that we have against COVID-19 is the vaccine. As the largest vaccine manufacturer in the world, the mandarins of the health ministry had probably thought that most of the facilities could be quickly repurposed for COVID-19 vaccines production — clearly that did not happen.
The Serum Institute of India (SII) has a current capacity to produce 60-70 million Covishield doses and Bharat Biotech can manufacture around 10 million doses of its Covaxin. Both these manufacturers had sought financial assistance from the government for expanding the manufacturing base, citing that the previous pricing policy did not give them enough margins to reinvest. The government has obliged them by allowing the companies to increase prices for supplies to state governments and private agencies; and gave firm advance purchase commitments from its side.
Though the transparency in pricing is questionable, considering the fact that significant public money was used in the research & development, and the vaccine is a public good, those issues can be sorted out on another day.
This largesse from the government may allow the SII and Bharat Biotech to boost their capacity to 100 million and 20 million respectively by the end of June. Besides, the news that the first batch of Russian-made Sputnik V arrived in India on May 1, is heartening. Dr Reddy’s labs has the distribution rights of 125 million doses imported from Russia and the company plans to manufacture 850 million doses in India.
Here again, the timelines are not clear and it may take a while before the actual rollout happens.
At least five other vaccines, including the locally-developed one from Zydus Cadilla, will be available in the Indian market by the end of 2021. But none of them will be useful during this second wave which has shattered people’s trust in the health system.
India has administered around 154 million vaccine doses till date, but considering a population of 1.3 billion, it is quite a small proportion. We haven’t been able to fully vaccinate the most vulnerable sections of the society, and only 2 percent of our population has received the two doses. Since we do not see a rapid increase in supply of vaccines in the near horizon, it is important for us to look at other measures more closely.
Preventing infections of such a highly contagious virus is a very difficult task for any government. As we have been told since the beginning of the pandemic, social (rather physical) distancing is the most effective method to reduce the spread of infections.
An effective testing and isolation strategy is also needed to complement ‘social distancing’ norms. We are doing around 1.5 million tests a day and that is grossly insufficient, when a large proportion of cases are asymptomatic or mildly symptomatic. Ramping up the testing capacity is possible, when India has several home grown Reverse Transcription Polymerase Chain Reaction (RT-PCR) kit manufacturers. Just that we need to incentivise more testing through smarter decision-making.
Also, we have been bombarded with information about hand-washing, sanitizers and masks to prevent COVID-19.
Test For Rural Health Infrastructure
However, the enforcement capacity available in India is so poor. Apart from a well-thought-out messaging strategy, we need to find ways to enforce the universal use of masks and hand hygiene. Even local restriction of movement and focal lockdowns in districts where test positivity rates are high, can be used as public health tools in dire scenarios. State or national lockdowns rarely yield significant benefits and the humanitarian costs may be higher than the toll taken by the disease itself.
Rapidly augmenting treatment capacity is one other important task in front of the central and state governments. When the outbreak moves from big cities to smaller towns and rural areas, the health system will surely buckle in most of the states.
As data from this outbreak shows, only a small proportion needs oxygen, intensive care or ventilator support. Most of the patients can be managed through systematic monitoring and protocol-based treatment, which need not require the fulltime supervision of medical professionals. A decentralised system of ad-hoc COVID-19 hospitals, manned by field-level healthcare workers or Accredited Social Health Activists (ASHAs) can possibly help us to tide over the crisis.
Schools, community halls and even auditoria can be easily converted to COVID-19 hospitals in small towns and rural areas. The vast army of medical, dental and nursing students can also be utilised for managing these facilities. The biggest worry is that the outbreak will be forgotten once it reaches the rural swathes of India — testing is scant, healthcare facilities are lacking, registration of deaths is poor and mainstream media may not be interested.
India needs decisive governance and lots of resources to get out of this situation. Inability to get oxygen and hospital beds, as seen in some metro cities, form just the tip of the iceberg. India’s poor investment history in strengthening healthcare systems will be tested by the present reality. We can only hope that the Centre and states will keep aside political differences; and unite to fight this pandemic using a rational approach. Otherwise, our crematoriums and burial grounds will continue to see long queues.