As India grapples with a massive second wave, Chandrika Bahadur, chair of the Regional Task Force of the Lancet Commission, speaks to The Hindu on why this happened and the way ahead ….
India is undergoing a very severe second wave of COVID-19, something that could have been anticipated. What in your view went wrong in terms of anticipation and capacity building?
India prepared reasonably well for the pandemic in its early stages. The lockdown gave the medical system time to expand infrastructure, train staff, and build capacity to absorb patients. The rationale for lockdowns across the world in March-April 2020 was to “flatten the curve”. It meant taking actions that would bring down the number of cases that needed hospitalisation and treatment enough that they would not breach the limits of the medical capacity of the country. This preparation allowed the country to manage the first wave in 2020, while keeping overall mortality rates relatively low (apart from brief periods of stress in the larger cities).
The number of new cases began to decline nationwide after September (despite localised spikes in some places), and by January 2021, there was a dramatic reduction in hospital utilisation rates. Vaccinations began in January, and this led to the expectation that India would be able to vaccinate its frontline health workers, and the most vulnerable segments of the population by the summer, so even if a second wave hit, it would not be severe, and the country would be better equipped to handle it.
Three factors belied this expectation: first, the dedicated volunteer networks, special COVID-19 facilities, and emergency measures that the administration and health system had taken, were scaled back and in some cases wound down, just as cases were beginning to rise. Second, the vaccination campaign was slower to roll out, largely because of a lower sense of urgency. And third, we didn’t invest enough resources to study the emergence of new variants quickly enough.
All these factors were predicated on the assumption that the worst was behind us. So, when the wave began, from a preparedness point of view, we were, in some ways more unprepared than we were towards the end of last year.
Was there enough research being done on why we saw a major dip in the months of January and early February? Did that make the government and people complacent?
There was research, but there was no overarching compelling explanation for why recorded numbers dipped so rapidly and so much at the start of the year. The last sero-survey carried out by the Indian Council of Medical Research (ICMR) showed exposure rates of 1 in 5 amongst the respondents sampled, but with wide variations across urban and rural, and within urban between different categories of populations. So, the prevailing popular theory of “herd immunity” was not really backed by evidence. The falling numbers coincided with a continued opening of the economy; new cases didn’t rise despite increased mobility, reinforcing the sense of confidence. The lack of a compelling explanation for the fall, in my view, led to the willingness of many people to believe that the worst was behind us.
When the Lancet Commission on COVID-19 India Task Force was convened in January, several Task Force members expressed their grave concerns that the prevailing optimism was misplaced, and that a second wave was imminent. Unfortunately, those fears have been completely validated.
What is harder to understand is why corrective action was not taken at the beginning of this wave when numbers started to rise in Maharashtra and Punjab. There were enough indications that the situation was going to get difficult. And even if no one predicted the intensity of the wave, the fact that it was happening should have immediately triggered actions to limit large gatherings and reinforce safe behaviour. None of that happened till it was too late and we are seeing the consequences play out.
We are being told that new mutants of the virus are more infectious than the last time around. How much of the current situation, just in terms of spread, can be laid at the door of the mutations?
It is too early to answer this question precisely. The Lancet Commission Task Force has recommended that the Indian SARS-COV-2 Genomics Consortium (INSACOG), led by the National Centre for Disease Control (NCDC), set up in December 2020, be supported so it can achieve its goal of testing 5% of all cases every month on a continuous basis. We also recommend that in the short term, labs are equipped with TaqPath test kits to identify the B.1.1.7 and other variants. Right now, we are a long way from systematically gathering and analysing this information.
What public health interventions, do you think, need to be made urgently for the mitigation of some of the appalling shortages in medical resources we see?
In the short-term, the immediate priority is to save lives. Enough has been said on the shortages that hospitals face immediately, in terms of beds, logistics around the supplies of oxygen, and availability of drugs. The more fundamental issue is of a structure that supports patients at home and helps triage patients effectively, so that only the most critical go to hospital, and those that need to, get the help they need. Mumbai has done that well, and we are seeing the results in terms of hospitalisation rates, and overall management of the pandemic. Reducing movement and activity (through voluntary or imposed closures) is necessary step right now — to break the chain of transmission and stabilise the numbers. In April, we saw the rise of new cases growing at the rate of nearly 7%. This has to be brought down urgently.
Scaling up of vaccinations is also key as a medium-term strategy to boost protection and reduce the severity of illness and eventually (hopefully) transmission rates. The supply constraints that the vaccine manufacturers are facing right now could not have come at a worse time, given the intensity of the wave. We need to ramp up production and distribution urgently. Finally, our health care staff: doctors, nurses, attendants, administrators and ambulance drivers are under enormous stress and strain. Supplementing them with senior residents and medical students, retraining, counselling and supporting them: these are all steps that need to be planned for immediately.
Is the second wave it? Or are more waves and troughs anticipated?
I don’t believe anyone expects this wave to be the last. But the intensity of the next wave will depend on how well we learn the lessons from this one. If we can ramp vaccinations by an order of magnitude over the next few months, prepare our primary care system to effectively supervise home care and triage patients, ensure a steady supply of the inputs that hospitals need to effectively treat patients, and if we can collectively practise COVID-safe behaviours moving forward, the subsequent waves we face can be managed.
