Covid: It will get worse before it gets better
There has been shocking, collective policy failure. Focus on controlling the spread of infections, taking care of the ill, vaccination, and genome sequencing now
There are four factors why the second wave has hit India with such intensity.
First, the variants. The B.1.1.7, the one from the United Kingdom (UK), is present in parts of northern India. B.1.617, sometimes known as the “double mutant”, is pervasive in many places across India. We don’t know how much more contagious B.1.617 is, but we do know that B.1.1.7 is very, very contagious. India should have seen this coming because variants were causing massive spikes in cases between December 2020 and February 2021 in the UK, Israel and Europe. It stood to reason that this global problem was going to come to India.
The second is the fact that in late-February and early March, infection numbers were rising quickly. And certainly by mid- to late-March, the rise was extremely obvious to anyone paying attention. And yet, through all of March, there was little to no action by the government. This was a collective and shocking policy failure.
Three, there was no adhering to basic public health guidelines — there were massive rallies and the Kumbh mela (one of the most disastrous super-spreading events), with no mask-wearing. Family and friends in India told me that India had beaten Covid-19. But how could India have beaten it, when no one in the world had beaten it? There was a broader mindset that, somehow, India was special and different from the rest of humanity. This was, of course, not possible.
And fourth, there is some evidence (though I don’t know how substantial it is) that the virus spreads more efficiently when humidity levels get lower. February-March months tend to be lower humidity months in some parts of India. This may have contributed, but is unlikely to have been a major factor.
India must now urgently and effectively do four sets of things.
First, we have to stop the spread of the infections. What we are seeing now are deaths from infections that happened two to three weeks ago. And if you see how much that infection number has increased, the number of people who are going to get very sick and need hospital and oxygen support will grow in the coming weeks. Stopping the spread requires three strategies.
One, stop the indoor gathering of people who are not part of the same household. That is not the same as a full lockdown. But what we need are significant public health restrictions — closing all indoor restaurants, shopping malls, offices. I would do this nationwide. There must, of course, be no crowds, no large events, no large gatherings.
Two, we have very good data now that shows wearing masks is critical. And the quality of the mask matters. We should be doing a much better job at getting high-quality masks out to the population. This does not require N95 masks, but even high-quality surgical masks can be very helpful. India must have a national mask policy that says that the moment you leave your home, you must wear a mask.
Three, scale up testing. You need to test people very early in the disease course when people have the mildest of symptoms, ideally before they even develop symptoms. This is because most of the spread of the virus happens early. Aggressive testing needs to take place in communities that have had outbreaks, so that infected people can be identified and isolated. India requires three to five times more testing than present levels. If this is not possible, then, at least, double it.
Second, the government needs to do a better job of taking care of the ill. That means setting up field hospitals, increasing oxygen supply and medicines. In the next four to six weeks, we will see a flood of patients arriving at hospitals. If it’s bad now, it’s going to get worse. A lot of effort has to go into taking care of those people and saving as many lives as possible. Here it is critical to follow scientific guidelines and not use baseless treatments such as Ivermectin. International protocols developed with top Indian doctors must be followed for how to care for sick people.
Third, focus on vaccination, which is going to take us out of this, although the benefit of the vaccinations will take some time. In terms of supplies, the Serum Institute of India (SII) is making around 75 million does a month. This is not enough. India has a legacy of vaccine-delivery programmes, but we need more supply. The problem is raw materials, which are in short supply everywhere in the world.
This is not a problem of the United States (US) stopping exports. There is a global shortage of supplies because everyone in the world is trying to make vaccines. So, the Indian government needs to work with SII to make more raw materials available. That’s going to take weeks and a lot of work. We should not invest too much hope in vaccines in the short-run; but they are critically important in the medium- to long-run.
In terms of priority, older people and health care workers must be given precedence and until those groups are widely vaccinated, I would not necessarily open it to everybody. I also worry about issues around costs, which may put the poor at the back of the line. Look at what Europe, the US or Israel has done — the central government procures vaccines (it is not the states or the private sector) and has a national programme that is free for everyone, and prioritises high-risk groups. This has worked. I find what is happening now in India very confusing. Indian vaccines must be centrally purchased, given to states for free, and given out equitably so that every state gets its fair share.
Fourth, genome sequencing is critically important — we have to track what is happening with these variants, where they are spreading, and where the disease is going next. If you do not do genomic sequencing, you are basically fighting a war without intelligence. The UK is the gold standard for genomic sequencing; it does about five to 10% of all infections; in the US, it’s about 2%. India does far less than 1%. India needs to increase genomic surveillance as much as tenfold. There are US and UK companies ready to ship genomic sequencing supplies to India today. But the Indian government must want it and be ready to use them.
The Joe Biden administration has stepped up. In my conversations with the administration, I have said that the $100 million aid is good but it needs to do more. Of course, India must want more help. I believe that the Biden administration will do more if India asks. India and the US are friends and allies and at a time of need, one friend can come to the help of the other.
May is going to be horrible in India. June is going to be hard. If we take the steps outlined here, we are going to see real progress in June, and, by July, things may be meaningfully better. But if we do these things in a half-hearted manner now, the nightmare that India is living through now will last longer.
India needs a 21st-century health care system. Currently, it has a 19th-century one with small pockets of excellence. As we get out of this crisis, I hope India will prioritise its public health and health care system. Fighting an enemy such as Covid with poor policymaking and an outdated health system is costing too many lives.
Ashish K Jha is the dean of the Brown University School of Public Health
The views expressed are personal
(As told to Kumkum Dasgupta)
