We, The Makers Of This Calvary

It was last October that Nobel laureate Joseph Stiglitz described India as the “poster child of what not to do” in handling the Covid-­ind­uced crisis, slotting the country with the US and Brazil. Six months ago, the economist’s sharp tone could perhaps have been brushed aside, given that things were actually looking up. The epidemic, at least, was heading the other way—down. But now, it would seem prophetic—a textbook case of how things can go horribly wrong just when they were going swimmingly well.

Or were they? And, where did this tidal wave come from and what were the signals we missed? Even as distress of an extreme variety unfolds all around us, the fact that it can happen—anywhere on the planet—is the sobering reality to anyone watching from afar. “It’s a fragile situation globally,” was how the WHO’s COVID-19 technical lead Maria Van Kerkhove put it this week. Yes, other countries have seen the steep epicurve that’s currently playing out in India—a near-vertical climb all of April—but not of this scale. You don’t need a graph to tell you that.

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The worst-case scenarios are projecting 8-10 lakh rep­orted cases and 5,000 deaths daily by a mid-May peak. If anything makes that grim situation even grimmer, it’s the way COVID-19 operates—in that the testing net won’t cover all infections even at today’s pace of 17 lakh tests a day. Going by past serosurveys, the Seattle-based Institute for Health Metrics and Evaluation (IHME) suggests that current case numbers need to be multiplied by 20 to get the actual number of infections. That range is vastly lower than the guesstimates around this time last year because testing has increased—but the sheer numbers it hints at aren’t. “Even if the peak is reached in May, it will take a while for the cases and deaths to come down to a level where we can have confidence in resuming normal life,” epidemiologist Prof Bhramar Mukherjee of the University of Michigan tweeted last week. Many states have resorted to the only speed-breaker option left—local lockdowns.

Indeed, a ray of hope streamed in from Maharashtra this week where the curve has been dropping for a few days, even if slightly. But witness the images from another part of the country—on April 27, as the world watched in disbelief at distressing visuals of patients dropping dead outside hospitals gasping for oxygen, scores of devotees were taking the last shahi snan at the Kumbh Mela. “Do we need more explanation for the virus surge in tsunami proportions?” asks epidemiologist Jayaprakash Muliyil, who chairs the scientific advisory committee at the National Institute of Epidemiology. “Over 25 lakh people gathering at one place…we don’t have calculations for this kind of situation. And then you wonder why Delhi is scrambling for oxygen.” As for the other ongoing super-spreader event—elections—the Madras High Court’s exasperation at the Election Commission said it all: that the EC’s officers should probably be “booked for murder” with the way they handled the polls. The EC, of course, is a sort of proxy there.

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Many factors contributed to that original question: if India was reporting less than 10,000 daily cases in mid-February, how did this come to pass? Foremost among them being a disregard for Covid-appropriate beh­aviour, everyone being smug in the belief that the battle had been won. Many warning signals were ignored, says K. Srinath Reddy, president of the Public Health Foundation of India (PHFI). “I have been sounding alarm bells since January that we should be careful at least till April. As a country, we prematurely declared that the pandemic was over. We bel­ieved all those models that said there won’t be any second wave. The country was in a hurry to get back to rebuilding the economy,” says Reddy. In fact, in January at the World Economic Forum in Davos, Prime Minister Narendra Modi spoke about how the country fought the virus and proved the predictions of two million deaths by some experts wrong.

Most public health experts reckon public gestures by the political class gave a false sense of security to a citizenry only too keen to drop their guard. By end-February, the Election Commission had announced elections to five states—the Covid surge in Maharashtra became evident from mid-March, but that didn’t stop the mammoth election rallies, even when new virus mutants were being inv­estigated for faster transmission. “We knew this virus is going to be around after the first wave. We knew we had to have beds and oxygen. One year’s hard work has gone down the drain,” says virologist V. Ravi of the National Institute of Mental Health and Neurosciences, who is on a COVID-19 technical advisory panel in Karnataka. “And who is being put to maximum stress? The health infrastructure and healthcare professionals. Everybody else is happily doing what they want to do.” The Opposition concurs on the point of government abdication. Congress MP Adoor Prakash, a member of the parliamentary standing committee on health and family welfare, talks of a policy paralysis. “The country is out of breath now. But we had flagged these issues in November 2020 itself, suggesting that the Centre accelerate oxygen production and increase hospital beds.” The sequence is important. The ‘double mutant’ was first detected back in October. The COVID-19 National Task Force (NTF) met in December to discuss evidence-based modifications in testing, treatment and surveillance strategies after reports emerged of the British variant washing up on Indian shores. It’s another matter that the NTF has been rendered a toothless body, meeting “only intermittently” even as the second wave was rearing its head. Mutating authorities are one thing; what about mutations in the virus itself? What it called for was aggressive genome sequencing to map the trends first. Though a genomics network of 10 labs was set up in January to ramp up sequencing, it was choked of funds, the way lakhs of patients are now thirsting for oxygen. “We should be doing 10 to 20 times what we are doing right now. We need to expand genome sequencing right away. For that, the scientists need resources,” says Ramanan Lakshminarayan, director, Center for Disease Dynamics, Economics and Policy.

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The spectre of failure now is in some contrast to the ­situation last year. Look back on those early gains. When the pandemic first pervaded the Indian landmass last March, the response to it was mounted on a war footing. No less. Recall the initial crippling shortage of N95 masks—and how from less than a handful of suppliers, the country swung to production surpluses by June. Or how ventilators—whose supply was until then ruled by imports—came to be manufactured locally in huge numbers. All this even when the first COVID-19 wave hadn’t yet peaked. “This time around, nobody was expecting such a huge surge despite the fact that some of us have been warning from November that the second wave will be worse,” says Dr Ravi.

What could be worse than what we are witnessing now? Bodies piling up outside crematoriums. A tsunami of desperate cries for help on social media. Social actors trying to meet the desperate shortage of oxygen and medicines that State inaction left India with. Page after page of obituaries in local newspapers. Widespread talk of disregard for data, even its manipulation—Haryana CM M.L. Khattar offered a real chestnut here when he said on camera: “Why must we count the dead? They will not come back to life.” And that policy paralysis—Adoor Prakash talks of the bane of “unilateral decision-making, from last year’s lockdown onw­ards”, and cites how a Health Standing Committee session on April 9 was postponed. And lastly, international opprobrium for a government that’s responding with a predictably thin skin, writing indignant letters to foreign newspapers, banning tweets that show it in a bad light, even filing cases against those who issued public appeals for oxygen simply because that belied their wafer-thin claims of normalcy.

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What could be worse? Well, there could be a third wave later this year. Dr Ravi certainly reckons so. And Bhramar Mukherjee’s projection of a mid-May peak, with 8-10 lakh cases daily, is only the crest of the present one. What will happen if this form-shifting, flux-ridden salad bowl of mutant Covid viruses moves like a swarm of locusts into the hinterland where there’s no healthcare at all, into India’s vast landscape of congested small towns and qasbas? What happens if the present nightmare is multiplied ten-fold? That’s the scenario India must thwart at all costs.

The one weapon we have is vaccination: that rollout needs to be hastened to cover as many people as possible any which way, on a super-urgent basis. Britain, for ins­tance, does meticulous surge planning: it anticipates a surge in August, and has covered all the bases possible so as to master the ball, especially through a calibrated—and, free—vaccination (see Dr Ajay Vora interview on the elements of Britain’s planning). Dr Ravi sounds a note of dire warning on India’s potential winter apocalypse: “All those who cannot receive the vaccine by November will be the susceptible pool, if we continue what we are doing now.” Muliyil feels the deaths can be prevented only if the government targets more people above 60 years of age. “There wasn’t enough vaccine to give all the people above 45 years. Now they want to give it to younger people,” he says. “This is not sensible because the mortality difference between these groups is huge. The little vaccine we have should have been sensibly used.” India has opened the door for vaccines available globally, which should see more supply coming in. It’s another matter that policies on vaccine procurement, supplies and cost have triggered a separate debate. Cost, especially, has touched a real raw nerve—with allegations of doom profiteering flying against the private manufacturers and a seemingly facilitating government. In India, as elsewhere, life and death are political. They are also economic. And everyone’s alr­eady paying the cost. That cost must not escalate.

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The Oximeter Reads Red

Everyone knows India is gasping for oxygen. But what’s the real situation, in infrastructural terms? Well, perversely enough, it seems India actually went from breathing normally to near-asphyxiation. Breathing is an involuntary bodily function, but at the country level, in times of a scarcity that could have been anticipated, it needed volitional will. Back in September 2020, when Covid cases had crossed the first peak and were gradually waning, the chemical and fertilisers ministry—in a gazette notification on regulating prices of liquid oxygen—pointed to an uptake in oxygen cylinders. Delivery through cylinders, it said, had “increased from 11 per cent pre-Covid to 50 per cent of current oxygen supply”. The same month, the Centre also formed a dedicated control room for oxygen supply.

The big picture first. India’s oxygen producing capacity is 7,127 metric tonnes (MT). Between April 12 and 24, as the second wave broke upon us with tsunamic suddenness, India’s medical oxygen demand nearly doubled from 3,842 MT to 6,785 MT—nearly touching that total capacity. But even that could have been met with India’s own resources. The challenge was transportation. “Most of India’s oxygen production is in the East and transporting it across India is the biggest challenge,” says Piyush Goyal, additional secretary, Ministry of Home Affairs. This involves ferrying the oxygen 1,000-2,000 km to destinations of peak demand. “Air Force planes have been dep­loyed to lift empty tankers to the oxygen-refilling states and have reduced the turn-back time from four-five days to two hours. But we can’t transport filled oxygen cylinders due to technical reasons.”

At present, India has around 1,200 oxygen cryogenic tankers for road transport—now, the government has also diverted nitrogen and argon tankers to transport oxygen. A cryogenic tanker costs around Rs 35-40 lakh, an oxygen cylinder costs around Rs 10,000, while an oxygen refill costs Rs 300-500 depending on the region. Logistics, which congealed into bottlenecks in the present crisis, has been a stated focus of the Modi government since 2016-17. Every budget has spoken about the National Logistics Policy. But a roadmap isn’t out yet, despite a separate logistics department being formed in the commerce ­ministry in 2017.

On April 24, the Centre decided to take over liquid oxygen distribution, setting a price of Rs 11,000 per tonne, allocating quotas for every state and firming up a distribution plan with oxy­gen and steel manufacturers—also as a response to open market sales where, reports say, prices were as high as Rs 18,000 per tonne.

India’s leading oxygen manufacturers include Linde India, Goyal MG Gases, National Oxygen Limited and Taiyo Nippon Sanso Corporation. Now, even steel companies, the biggest users and manufacturers of industrial liquid oxygen, have pitched in. “We are ready to compromise steel production to increase oxygen supply capacity, we believe in people-first,” says Jindal Steel and Power Limited MD V.R. Sharma. The company is providing 132 tonnes of oxygen daily from its two plants at Raigarh in Chhattisgarh and Angul in Odisha.

So the government took its eyes off a moving ball, and is now trying desperately to swat its bat to earn some runs. But even big private hospitals haven’t been proactive. They should have known what was coming. Why didn’t they inc­rease their own oxygen capacity? Set up captive plants? Well, simply because a supply of 10 litres of oxygen per minute costs a minimum of Rs 15-20 lakh of investment. A senior doctor, on condition of anonymity, concedes hospitals balked at that cost. Besides, there were practical difficulties. “You require space, manpower and quality managers to run oxygen plants. Till now, the arrangement has been that the oxygen suppliers generally instal their own tanks and sometimes even provide manpower to supply oxygen through cylinders or pipeline networks connected to the tank.” Few have thought about a more self-sufficient model, he admits.

Shouldn’t they have been, during a pandemic? Some don’t agree. “A hospital’s primary work is to provide healthcare services,” says Dr Praneet Kumar, a healthcare consultant who has helped set up several hospitals. “They can’t be channelising funds and energy for industrial work like producing liquid oxygen.” Even so, they do partner in India’s overall healthcare system, and have a role. In a recent affidavit to the Delhi High Court, the health ministry stated that 162 Pressure Swing Adsorption (PSA) plants were sanctioned under PMCares—with the arrangement that the government pays for installation, while the centralised pipeline would be set up and paid for by hospitals. But alas, complacency set in. The momentum petered out as Covid numbers seemed in control. Only 33 PSA plants have been installed so far. That’s one argument for decentralised planning (see essay by T.R. Raghunandan). Kerala set up an oxygen plant in October. Himachal Pradesh too is self-sufficient. Both now offer to supply their surplus to neighbours. The rest are choking on hot air.

Going Viral, In a Billion Ways?

This is a clinical whodunit. Is the COVID-19 virus ­acq­uiring new ninja-like skills—moving more nimbly, stealthily, and attacking at will? Can it shift form to ­become more infectious or escape antibodies? The answer can only come from continuous genomic sequencing of ­infected samples. What is that analysis telling us about the epidemic in India?

That there are a handful of variants in circulation. One of them is the B.1.617 variant, first reported in India and known better by the misnomer ‘double mutant’. This was first seen in Maharashtra, and now in Madhya Pradesh, Chhattisgarh and 14 other states—growing with a kind of radiating fury. There’s a related second variant called B.1.618, seen in samples in West Bengal. Then, the B.1.1.7 or the UK variant that’s primarily behind the spread in Punjab. Besides this, smaller numbers of the B.1.351, or the South African variant.

That scenario is still unfolding, Sujeet Kumar Singh, dir­ector, National Centre for Disease Control, said at a public webinar last week. While B.1.617 was found in proportions of over 50 per cent in many cities in Maharashtra, B.1.1.7 was catching up in Delhi. “From 28 per cent of the UK variant in the second week of March, it rose to 50 per cent in the last week. If we observe the surge in Delhi, I think it dir­ectly correlates to the type of variant.”

A bit about virus mutations. Changes to the virus’s structure take place all the time, possibly every time a virus replicates its genetic material inside the host. Indeed, the first 6,000 genomes of Indian isolates showed no less than 7,000 variants, as Rakesh Mishra, director, Centre for Cellular and Molecular Biology (CCMB), explains. “That’s how it evolves, it’s very normal.” Most mutations are random and meaningless—only the ones that accidentally end up causing trouble matter. Here again, some detail to clear the air—the Indian double and triple mutants are actually the same variant, B.1.167. The third mutation was flagged subsequently. One of its mutations was first seen in California amid a spike in cases there.

The first sequences of B.1.617 were seen in December, but cases were declining then, explains Anurag Agrawal, ­director, Institute of Genomics and Integrative Biology, at the webinar hosted by the Indian SARS-CoV-2 Genomics Consortium (INSACOG), a network of sequencing labs that India put together in December to track the virus’s spread. By end-March, B.1.617 moved from being a ‘Variant of Interest’ closer to a ‘Variant of Concern’—the latter term refers to an ability to spread faster, dodge the immune res­ponse and/or cause severe disease. It will still take a couple of weeks to get an exact fix on B.1.617—how fast it is spreading or replacing other variants. It’s much the same story world over. A strain gets tagged by the country that ­identifies it, so it doesn’t necessarily imply country of ­origin. “Today, we have an Indian strain because we ­sequenced it,” notes Agrawal.

But India’s sequencing effort needs a serious ramp-up. Till last week, we had sequenced about 15,133 genomes—compare that with over 3 lakh entries shared by the UK and US, about 8 and 1 per cent of their total Covid cases. The INSACOG has set a target of sequencing 5 per cent of ­positive cases. But given the soaring graph of new ­infections, that is going to be a near-impossible ask. More infections naturally provide more scope for mutations. That said, the SARS-CoV-2 virus is known to change more slowly than the HIV or influenza viruses. “The general trend,” as Agrawal explains, “is viruses become more ­infective through mutations, but less severe over a period of time. And that’s what will happen eventually.” The ­rationale for this, as experts say, is that the virus actually has little interest in killing its host. “In fact, if the host lives, meets many people, is totally asymptomatic and infects as many people as possible, the virus actually propagates ­better,” explains Agrawal.

The good news: early studies indicate that both Covishield and Covaxin offer protection against B.1.617. “Sequencing is essential to know if we are able to get a monster out or if we have a new variant for which none of the vaccines will give immunity,” says virologist V. Ravi. “That kind of mutant has not emerged anywhere in the world yet. But unless we keep policing, we won’t catch such a variant.”

That vigil must be eternal. Meanwhile, the basics on the ground don’t change, says Dr Ravi. “A zillion variants may come, but none of them will pass through the mask more ­eff­iciently than their predecessors. How we control the third wave will depend on how we behave. We have been abysmal in behaviour change communication, and communication alone is not enough.” Srinath Reddy of PHFI agrees. “We flouted every single public health rule that should have been followed,” he says. “We gave an open road for the virus to travel and variants also came in with a faster rate of ­transmission. I would say the variants are only partly ­responsible for the current crisis. They increased the rate of spread. But the spread would have happened even with the original virus.” The second waves in most countries were typically a sharp spike and fall, say epidemiologists. But, as they warn, there could be others to follow before the virus settles in and becomes a humdrum endemic thing. Yes, we need both eyes on the burning building right now. But we also need a wary third eye on the future.

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Death Climbs The Hills

From 318 active cases on March 1 to over 14,000—where did the tourism magnet lose the plot?

Sobs rend the air as bodies wrapped in plastic are loaded into vans outside the Covid wards at Shimla’s Indira Gandhi Medical College and Hospital, Himachal Pradesh’s biggest healthcare institution. Some of the bodies are of people from far-off villages, with no kin around during their last journey. The scene is no different at Dr Rajendra Prasad Medical College in Kangra district, where 10 to 12 ­people are dying of Covid every day. The district has seen more than 300 Covid deaths so far. Only 8 per cent of Covid patients in the hill state have been hospitalised, with the rest kept in home isolation. The two prime hospitals in Himachal have a combined bed capacity of 270, and as that is far short of the growing demand, CM Jai Ram Thakur of the ruling BJP recently made arrangements for 1,000 beds at a site in Dharamshala owned by the Radha Soami Trust, a religious ­organisation. “With the number of cases rising, we need more ambulances, beds with oxygen facilities, doctors and ­paramedics immediately,” says Kangra deputy commissioner Rakesh Prajapati.

The surge in Covid cases is surprising in a state where 90 per cent of the population lives in villages in the hills and ­valleys, cut off from densely populated cities like Shimla. “There is a complete collapse of governance and the decision-­making process amid misplaced priorities,” says Mukesh Agnihotri, leader of the Opposition in the Himachal assembly. “After the number of cases dropped and unlocking was announced, the CM shifted to election mode and forgot about plans to enhance bed capacity, set up makeshift ­hospitals and recruit doctors and other medical staff. That’s why Himachal was caught unprepared when the second wave hit the state.” Plans to set up oxygen plants, including one for Deen Dayal Upadhyay Hospital in the heart of Shimla, slid down the priority scale when the first wave subsided, while polls for panchayats and urban civic bodies, political rallies and Maha Shivratri celebrations contributed to the ­resurgence of Covid. In fact, the CM had invited PM Narendra Modi to the Himachal Day function on April 15 and a ‘rath yatra’ was planned to mark 50 years of the formation of the state. The plan was cancelled only after the spike in cases. Until then, the focus was on unlocking every activity, opening schools, allowing mega weddings and social or religious events, throwing open the state borders for unrestricted ­mobility…even as Covid testing facilities were reduced by ­almost 80 per cent. It will soon be peak summer, when Himachal attracts tourists in large numbers. But this year the hotels are shut and the markets deserted.

—Ashwani Sharma in Shimla

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All It Takes Is Will

Proper planning and proactive action can stop spread of the virus, as Dhule district shows

Around mid-2020, Dhule district in Maharashtra had turned into a coronavirus hotspot when local residents came in contact with Covid-positive migrant workers passing through the region on their way back home from the state during the first nationwide lockdown. The situation was, however, quickly brought under control. Cut to 2021. As the second wave of the pandemic rolled through the western state, afflicting millions and killing hundreds, Dhule once again bore the brunt of the viral ­infections. Dhule, though, is not a story of despair, but of hope. It’s also the story of a proactive administration taking control of the situation as fast as it had sunk. In Covid-ravaged Maharashtra, Dhule is the feel-good story.

Since March this year, when positivity rate was as high as 25 per cent and daily cases rising to 5,000, Dhule has turned things around—positivity is below 10 per cent and in daily numbers falling to 400-500. Officials attribute the turnaround to the administration broadening the base of people being tracked and tested by trained workers going door-to-door. Many are also coming to primary health ­centres for screening. “We are still grappling with Covid, but we are now seeing some encouraging results with the percentage of positive cases going down. We are also now in a position to help our neighbouring districts like Malegaon and Nandurbar,” says Dhule collector Sanjay Yadav. To go with the recovery rate of around 88 per cent, the administration is targeting to bring down positive cases to below five per cent.

The official attributes the success to his team of ­administrators and medical experts, who had warned of a possible second wave and helped bolster infrastructure beforehand. Besides daily review meetings, the ­administration is ensuring prompt disbursement of ­resources to the 61 hospitals and two medical colleges in the district managing Covid cases. Teams coordinating ­oxygen and medicine supply are also active around the clock. He adds that efforts are on to ensure oxygen buffer stocks for 24 hours to prevent any supply disruption though the district has no oxygen plant.

“Monitoring, containment zone implementation and the three Ts—tracking, testing and treatment—are the reason for the success in Dhule,” says Radhakrishna Game, ­divisional commissioner, Nashik. Game oversees five ­districts out of which Dhule and Jalgaon are doing well in Covid management.

—Lola Nayar

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Footing  The Bills

For decades, India has invested little in healthcare. The results show up as a festering sore.

India, a country of 1.3 billion people. has 0.55 beds per 1,000 population, data from the National Health Profile show. There is more. The country also has 22 health workers per 1,000 people, against the WHO ­recommendation of 44. The ave­rage GDP spending on the health sector in India is a meagre 1 per cent. Ironically, even after 73 years of independence, nearly 70 per cent of expenditure on health is borne by ­patients, forcing 60 million Indians into ­poverty each year, acc­ording to Finance Commission estimates.

India Health Infra

• 0.55/1,000 0.55 beds per 1,000 peopl

• 22/1,000 22 health workers per 1,000 people, as against the WHO norm of 44:1,000

• 1:1,511 Doctor to population ratio in India is 1:1,511, as against the WHO norm of 1:1,000

• 1:670 Nurse to population ratio is 1:670, against the norm of 1:300

India is estimated to have a total of 18,99,228 hospital beds—over 60 per cent of which are in the private sector. This is much lower than in other ­countries: China’s bed density exceeds four per 1,000; Sri Lanka, the United Kingdom and the United States have around three per 1,000; and in Thailand and Brazil, hospital beds exceed two per 1,000 people.

Within India, hospital bed densities are particularly low in Bihar, Odisha, Chhattisgarh, Jharkhand, Manipur, Madhya Pradesh and Assam. Gujarat, Uttar Pradesh, Maharashtra, Andhra Pradesh, Haryana and Telangana have ­relatively low densities of public hospital beds, but this is made up by the ­availability of private beds.

Health sector experts agree that the health sector in India has been underfunded for decades. Today, 70 per cent of funding for the health sector is from states, while the Centre provides the re­m­aining. In 1992-93, health expenditure was 1.01 per cent of GDP, but reduced to 0.99 per cent in 2003-04. It came further down to 0.91 per cent in 2015-16, a year after the Modi government took over. And this year it’s around 1.26 per cent of GDP, as per the Union Budget 2021-22.

A senior government official on condition of anonymity says that the health ministry in a submission to a parliamentary ­committee had projected the demand for the five-year period from 2021-22 to 2025-26 at Rs 6.16 lakh crore. This demand has been spread over some very crucial ­aspects of the health sector, like setting up of medical colleges, NHM, post-Covid health sector reforms etc. “But where is the money and who will foot the bills?” he asks, adding that the private sector won’t come forward for public good and CSR funds alone won’t be enough.

Till September 2020, only Rs 7,822 crore was spent by India Inc and PSUs on CSR. In 2017-18, the spending was Rs 13,889 crore, which rose to Rs 18,654 crore for 2018-19. Out of this, allocation for the healthcare sector was Rs 2,210 crore,
Rs 3,216 crore and Rs 1,048 crore for the years 2017-18, 2018-19 and 2019-20, respectively.

A Niti Aayog official on condition of ­anonymity says, “The government is working on a legislation to make it ­mandatory for both private and public sector to deposit their CSR funds in a ­central government kitty, and the Centre will ­decide where to spend the money acc­ording to its priorities.” He adds that with the pandemic experience and PMCares Fund, the idea has even more support, with whispers in the government ­corridors that the legislation will have a more targeted approach.

—Jyotika Sood