A year on, mind the gaps in the pandemic response

India needs to revisit its disease control strategy to ensure a more robust and humane response in similar crises

January 30, 2021 marked one year since India detected its first case of COVID-19 — a student in Kerala who had returned from Wuhan, China.

Analysing the country’s response to the novel coronavirus pandemic so far reveals a mixed bag of successes and failures along with a host of unknowns looming ahead, that urgently need to be addressed to both limit damage due to the pandemic and get back to the path of economic and social recovery.

Till date the country has recorded 1,07,90,183 cases and 1,54,703 deaths due to COVID-19 — the second largest in the world in terms of cases, after the United States, and fourth in terms of deaths.

India versus the world

Official statistics show that India has fared better on rates of infections and deaths than many higher income countries. For example, India’s case fatality ratio on February 3 stood at 1.4% compared to 2.8% in the United Kingdom or 3.1% in South Africa, while India’s deaths per million is 112, compared to 1,362 in the United States, 1,486 in Italy, or 1,831 in Belgium.

However, it has not done so well compared to countries of similar income and demography in South Asia. While India’s case fatalities ratio was lower than Bangladesh (1.5%) and Pakistan (2.1%) it was but significantly higher than Bhutan (0.1%), Nepal (0.7%), the Maldives (0.3%) and Sri Lanka (0.5%). Deaths due to COVID-19 per million population in Bangladesh was 50, Pakistan was 54 and Sri Lanka was just 16, lower than in India.

India’s initial response was marked by political commitment at the highest level, with several steps taken early in screening international travellers, restricting inbound traffic from severely affected countries, and preparing quarantine facilities for those testing positive. However, like with many other countries, India too has not been able to figure out till now what the best way to open its borders to normal travellers is while keeping out those carrying COVID-19 infection, particularly the new more virulent strains.

 

Lockdown and after

India was also among the few countries to announce a stringent nationwide lockdown much before it had a significant number of cases. The U.K. and the U.S. hesitated to impose a lockdown, costing many lives due to their late response. However, the Indian lockdown was imposed at very short notice without stating the strategy or specific objectives.

To begin with, there was no evidence-based justification provided for such a sudden imposition of the lockdown without any lead time, nor was its purpose clearly communicated to the public. Was the lockdown meant to eliminate the epidemic through contact treatment, isolation and case management? Was the valuable time gained to be used to strengthen the health system and prepare for the expected rise in cases?

Ultimately when India ended up lifting the lockdown, cases were already rising rapidly with confirmed cases per million people going further from 200 on June 9, 2020 to 7,454 on January 1, 2021.

Unfortunately, the lockdown was also marked by excessive dependence on security forces to ensure enforcement of physical distancing measures and quarantine-related restrictions. An unintended offshoot of the lockdown was the large-scale exodus of migrants and families forced to walk hundreds of kilometres back to their homes in the countryside. Dozens died in the exodus, with many in horrific road accidents. There were also deaths due to lack of sufficient food, drinking water and the sheer stress of travelling. Their plight highlighted the lack of a social safety-net for poor Indians both from before as well as during the pandemic.

State-level ownership

In terms of lessons learnt, there are many. First, in the context of the country’s federal structure, no public health response can be successful without ownership at the state level. The lack of consultation with State governments saw many of them implementing COVID-19 response policies hesitantly without much initiative or innovation. This experience has however not prompted any rethink of the top-down approach towards States at the national level.

Second, in all epidemic responses, generation and use of strategic information plays a crucial role. Given India’s global reputation as a software superpower, the pandemic would have been an ideal staging ground for fast-tracking plans to create an integrated digital health information system to improve the efficiency and transparency of the COVID-19 response. The Integrated Disease Surveillance Programme (IDSP), India’s national disease surveillance framework, was not visible throughout the response. While the Indian Council of Medical Research (ICMR) carried out selective sero-surveillance studies in metropolitan areas, these surveys were limited in coverage and periodicity. It is therefore still a matter of guesswork as to what percentage of India’s population have been infected with the virus — an indicator of herd immunity.

Civil society’s role

The response was also marked by a lack of involvement of civil society organisations as partners with state agencies. On earlier occasions such as polio eradication and AIDS response, civil society played an important preventive and promotional role in bringing the infections under control. It goes to the credit of many civil society organisations that they voluntarily stepped into the response and played a meaningful role in providing social support and lobbying with funding organisations such as the Global Fund for AIDS, Tuberculosis and Malaria (GFATM) to provide social support to affected families.

 

As India joins the select group of vaccine-producing countries, there is light at the end of the tunnel. With health-care workers, frontline workers, people above 50 and those with underlying health conditions covered by the vaccination programme launched in mid-January 2021, it can be expected that the epidemic would slow down. However, here again the end game strategy for the vaccination programme remains unclear, raising questions about whether its benefits will be sustainable in the long term.

Divide widened

Another critical unknown in India’s COVID-19 response is over its plans to revive the economy and restore livelihoods of millions of people, who are today in danger of starvation and for whom even basic health care has become unaffordable. The pandemic period has exacerbated existing social inequalities and the poor face a ‘lost decade’ ahead, a challenge which needs to be addressed on priority.

There is an urgent need to examine all these critical gaps in the response to the pandemic, whether they occurred through acts of omission or commission. Without such an open inquiry and widespread debate, India will miss yet another chance to learn the right lessons and ensure a more robust, well-thought out and humane response to similar crises in future.

J.V.R. Prasada Rao is a former Health Secretary, Government of India. Amartya Chowdhury is Research Assistant, H.P. Ghosh Research Centre, Bandhan-Konnagar, Kolkata