Covid-19: Battling the second wave
India is in a war-like situation with a highly adaptable and unpredictable enemy. A few months ago, we thought the war was over, but have now discovered that was merely one battle — the next battle has turned out to be even more aggressive and unpredictable. So, how did we get here and where do we go now?
The first wave took us by surprise. Our health system did not hold up to the challenge of the virus. We fought as best as the country could and built a plane while learning how to fly it. Economically and socially expensive lockdowns bought time; the administrative capacity of the country focused on this one emergency; a rudimentary test-trace-isolate capability was built, as was a critical care capacity; extensive communication campaigns were rolled out motivating people to wear masks and practise social distancing. We came through it all faring better than some of the predictions. With vaccines being developed surprisingly fast, it was hoped that the pandemic would be behind us.
And then the virus outsmarted us. New strains, with higher infectiveness and virulence, surprised us in a second wave with a steep exponential rise.
From the viewpoint of the health system, we are in better shape today in some respects. A large number of health workers have been vaccinated and are at work in the private and public sector, unlike last year. Processes of quarantine, isolation, tracking and clinical capabilities are stronger today, although the infrastructure like testing, Intensive Care Units (ICU)s and oxygen is completely overloaded and overwhelmed with a far greater number of patients than it can handle.
The experience and learnings of the first wave have been organic and fragmented, without a systematic machinery that could have averted this second wave. In some ways, we are back to square one, struggling with grave shortages of infrastructure. Importantly, the second wave may not be the end, as the virus mutates further. So, the burning question is — where can we go from here?
Global experience shows the value of building a responsive system to manage infectious disease outbreaks in an ongoing manner. There are at least three strands to this.
The first is doubling down on surveillance and epidemiological research. An early warning signal in January and February, which tracked variants and disease trends real-time, could have given timely warning to change population behaviours and strengthen care capacity.
The second is a transparent, continuously reinforced, and enforced protocol of citizen behaviour based on virus risk levels as done by countries such as South Korea and Vietnam. This would have led to adherence to social distancing before reaching the need for lockdowns, as has emerged now through outrightly irresponsible super-spreader events and diluted vigilance over preventive behaviours.
And the third is the ability to scale up infrastructure capacity (ICUs, ambulances, oxygen and testing) for peak load, through the government paying for additional capacity, advance commitments, and establishing public-private partnerships. This could have ensured, for example, that the 150-plus oxygen generation plants planned eight months back, were now up and running.
Vaccines are a critical defence system against Covid-19 waves. The current rate of vaccination in India, 2.6 million doses a day on average in the week ending April 22, one of the highest in the world, has covered less than 9% of the population with one dose. This is a run rate grossly insufficient against this second wave, even as the vaccination rate per day in the past week is less than the 3.3 million doses per day rate in the week ending April 15. India should aim to cover at least 50% of population in the next four months to reduce risk of future waves, translating into at least 10 million doses a day. This will require unprecedented efforts.
First, reduce the constraint on supply. Currently supply from local manufacturers is about 70 million doses a month. The government is removing key bottlenecks through liberalising procurement, advance commitments, and transparency in allocation. However, the supply gap is large and time is of the essence. Aggressive advance commitments by the Centre/states to manufacturers to secure supply may be required. While autonomy to states is welcome, differential fiscal and capacity contexts should not result in inequities across states.
Second, ensure bottom-up local-demand generation, driven by local committees and leaders. Community ownership of vaccination can be a game-changer as seen with polio, and local governments can play a strong role here.
Most importantly, India can gain from increased attention to the institutional capacity needed. India has many capable institutions, deeply engaged in the response, but the response till date has been fragmented. In contrast, focused infectious diseases institutions have led to coordinated and more effective Covid responses in other countries such as Germany, South Korea, Vietnam. Pandemic response planning, epidemiology and research capabilities, deep technical knowledge and coordination mechanism with local public health institution were housed in the Robert Koch Institute in Germany. Some countries which had a poorer response last year, have revamped their infectious disease institutions, such as the United Kingdom (UK), which established the new UK Health Security Agency on April 1, 2021, to lead future infectious disease responses.
India needs a dedicated and empowered institution, technically and politically, for future Covid-19 waves and for other pandemics.
Amrita Agarwal is a health systems researcher
Sandhya Venkateswaran is fellow, Lancet Citizen’s Commission for Reimagining India’s Health System
The views expressed are personal