The failure to plan and prepare for multiple waves of COVID-19 in India has resulted in the despair and helplessness we are seeing today. Since more waves are expected, what lessons can we learn from the present in order to plan for the long term? This article speaks of the challenges and the road ahead.
Surveillance strategy
First, while it is easy to blame modellers for failing to predict waves, the reason why they are not able to do so is that clear data are unavailable. There is unreliable testing and under-reporting of cases and deaths even now. This does not instil confidence in any of the modellers to come up with realistic estimates. Under-reporting and manipulated data inputs can only provide faulty projections. The Central and State government should use real-time data by encouraging reliable reporting and initiating standardised definitions. This is the time to have a standardised definition of how many cases are expected per million population. Instead of admiring the efforts of administrations in the areas that have fewer cases, efforts should be made to detect the minimum number of cases, to instil confidence in people that the surveillance system works in the state. This can only be done through the syndromic approach of identifying suspect cases and through a reliable testing strategy which does not change when there is a surge in cases.
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Bangladesh sends second consignment of medicines to India
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Concurrent genomic sequencing in real-time in the fixed proportion of samples will give us an idea of the likelihood of the variants causing several outbreaks. If the outbreaks in Kerala, Punjab, and Maharashtra were noticed from the results of genomic sequencing, India could have advocated for local lockdowns in high-burden areas and imposed severe restrictions to stop the wide spread of the second wave. We can prevent the adversities of future waves by relying and acting on the inputs of a strong surveillance system.
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Vaccinating the population
Next, through vaccination, we can turn the story around. India can emerge as the world’s biggest exporter of vaccines in addition to helping citizens in the country. The Central government should proactively reach out to all the vaccine manufacturing firms in the west and invite them to collaborate with Indian firms under the ‘Make in India’ programme. India needs to fast-track the manufacturing of all vaccines which have been approved for use by various regulatory authorities through a single-window clearance. India can become a soft superpower if it facilitates faster manufacturing by helping the Indian industry. This is not an unrealistic ambition as the country has already proved how it can scale up testing facilities within a short period of time. At this stage, there needs to be greater impetus in stepping up manufacturing and coverage of vaccines. Not many countries in the world have the wherewithal to manufacture their own vaccines if India cannot cater to the vaccination needs of its own citizens and that of the world.
With newer variants of concern emerging, it is important to update the vaccines depending on how the virus changes. This provides a clear case and a good business opportunity for setting up manufacturing facilities in both the public and private sectors. Vaccines might be the shot in the arm for our economy. Greater financial allocations, stepping up systems to expand vaccination, applied research, enhancing effective communication, and monitoring effectiveness will solidify India’s role in the future for preventing and managing pandemics.
Since 2009, the World Health Organization has declared six public health emergencies of international concern, including COVID-19. In the near future, India has to have a system that can respond to newer pandemics in the making. We cannot build reactive systems for each wave and each pandemic. Nearly 60% of known infectious diseases and up to 75% of new or emerging infectious diseases are zoonotic in origin. Respecting the boundaries of animals and preserving the ecosystem in its natural form is important in order to prevent future pandemics. Therefore, the country needs to adopt the ‘One Health’ agenda in its entirety and ensure that environmental health and animal health are given similar priority as human health.
Robust public health workforce
The rapid spread of SARS-CoV-2 shows us the importance of timely and efficient public health responses. We can only fight better when we have a battle-ready public health workforce. Unfortunately, our health systems are collapsing. Doctors and nurses have to bear the burden mainly because of a depleted or absent public health workforce. It is an essential to hire front-line workers in public health who can engage in surveillance and contract-tracing, and mobilise people for primary healthcare services, including vaccination. The front-line public health workforce is particularly absent in urban areas, while critical care capacity (oxygenated beds, ICUs) is limited in rural areas. Irrespective of the urban-rural divide, the country needs to reconfigure the health systems to ensure that one Accredited Social Health Activist (ASHA) worker is hired for every 1,000 people, an Auxiliary Nurse Midwife (ANM) and nurse practitioner are hired for every 5,000 people and a hospital with at least 100 beds, including beds with emergency and critical care services, caters to a population of 30,000-50,000.
It is time to have plans for pandemics. We need to improve the health system and public health and regularly review plans to ensure that we prevent future disasters. For now, it is important to have enhanced surveillance to detect and contain future waves, expand vaccination, and work towards building a robust pandemic preparedness plan.
Giridhara R. Babu Professor and Head, Life Course Epidemiology at the Indian Institute of Public Health, Bengaluru