The latest trend of rising COVID-19cases in India, which has once again made the country one of the hotbeds of the pandemic, can only be described as an explosion. By mid-April, India accounted for nearly a quarter of new COVID-19 cases worldwide. The grim situation has once again exposed the inadequacy and inefficiency of the Union government’s strategy to contain the pandemic.
The ‘opportunity’ provided by the five-month let-up in the spread, between mid-September 2020 and the first week of February 2021, was used by the government neither to reduce the chances of a second wave or hold down its scale.
As a result, the number of fresh positive cases is rapidly soaring all over the country and there is a chaotic scramble to find or expand the facilities to deal with these cases. Testing facilities are stretched, hospital beds are inadequate, and essential medicines are in short supply in several places, making it clear that no plan and preparation or proper surveillance mechanism was in place.
It was on April 2 that the government decided to augment the medical oxygen supplies of the 12 high-burden States of Maharashtra, Madhya Pradesh, Gujarat, Uttar Pradesh, Delhi, Chhattisgarh, Karnataka, Kerala, Tamil Nadu, Punjab, Haryana and Rajasthan. While Maharashtra had a demand exceeding production capacity, Madhya Pradesh did not have any production capacity at all.
There was enough and more worldwide experience to anticipate the emergence of a second wave sooner or later. The wave itself began in February slowly and steadily, marking a reversal of the declining trend in cases in the previous five months, which should have altered the authorities to face the challenge. The real surge started only in the second week of March 2021. Also read: Role of T-cells in immune response against the coronavirus
From 78,395 confirmed cases across India in the week ending February 14, 2021, the weekly total increased steadily over the next three weeks by 13.9 per cent, 19.2 per cent and 10.1 per cent to touch the figure of 1,17,157 in the week ended March 7, 2021.
In the next five weeks, however, the numbers increased by 33.1 per cent, 67.2 per cent, 50.9 per cent and 39.6 per cent, before reaching 70.1 per cent in the week ending April 11, 2021. The weekly total of confirmed cases rose more than eightfold over this five-week period to 9,38,650 in the week ended April 11, 2021.
The daily number of confirmed cases in the first few days of the week starting April 12, 2021, indicates that the trend will show an weekly increase of 60 per cent in the coming weeks.
Blistering pace
In the course of the latest surge, India’s cumulative total of confirmed cases since the beginning of the pandemic crossed 14 million. The run from 12 million to 13 million cumulative cases took just 11 days and the next million was added in an even shorter period of six days. In the process, India once again went past Brazil to become the country with the second largest number of confirmed cases since the beginning of the pandemic.
The steep climb in number of people infected led to a single-day record of confirmed cases of over 2.35 lakh by April 16, more than double the peak level of 97,894 seen during the first wave in 2020. India became only the second country in the world after the United States to have ever crossed the 1-lakh mark in daily cases.
This surpassing of the previous peak did not happen only at the all-India level. Several States have been recording record daily counts, some exceeding the 2020 levels by a very wide margin. The few exceptions until mid-April—such as Andhra Pradesh, Odisha, Kerala and the North-Eastern States including Assam—have also seen rising numbers. Also read: Virus mutations' role in the pandemic
A similar story is playing out in the number of active cases (those currently infected). The number has also climbed from 1.36 lakh on February 11 to over 15 lakh by mid-April, and is rising every day by leaps and bounds. In 2020, the highest number of active cases was 10.2 lakh, which means that the current levels are already around 50 per cent higher.
The positivity ratio in tests, whose seven-day average had fallen as low as 1.65 per cent, has also soared to over 13 per cent, greater than the peak levels seen in July last year, with some States having even higher positivity rates. For instance, on April 16, the positivity ratio in Delhi was 20.22 per cent. According to World Health Organisation norms, a positivity rate of under five per cent is considered ideal. A high positivity ratio indicates sharply rising numbers as well as inadequacy of testing capacities. Going by the number of tests being actually done, it would seem that the nationwide testing capacity is no greater than it was in October 2020.
Lower fatality rate
The number of deaths during this second wave has been lower than the one in the first wave. This reflects the declining trend in fatality rates seen throughout the course of the pandemic. Indeed, this decline happened before the second wave and the fatality ratio has remained stable over the past one and a half months. With cases rising and the case fatality ratio remaining stable, the absolute numbers of deaths has risen sharply—from 688 in the week ended February 7, 2021, to 5,078 in the week ended April 11, 2021. However, these official figures may not capture the reality as reports are pouring in from several States about glaring discrepancies between death figures given in government bulletins and those reported by crematoriums dealing with bodies of COVID patients.
Moreover, with the ballooning number of active cases, there is a real danger of preventable deaths increasing because of hospitals reaching full capacity and short supply of essential drugs. Already there are grim reports from several cities of the health care system being overwhelmed and pharmacies selling remdesivir, an antiviral drug, at exorbitant rates.
How long will this surge last and how far will it go? It is well known that it is steeper than the first, but will that make its duration shorter? Even if the start of the first wave was counted from the second week of June, when the daily numbers were similar to what they were when the second wave began in February, it took over 100 days for the daily total to peak (in mid-September) and start coming down, during which some 4.86 million cases were added to the cumulative total. Also read: Government's vaccination drive a total mess
This time around, 3.69 million have been added in just 67 days, from February 8, 2021 to April 16, 2021, which is more than one and a half times the number added in the same number of days in the first wave.
However, there is absolutely no sign of the rate of increase easing, leave alone coming down. For any turnaround to be achieved, it must go down drastically. As long as the percentage change between a week’s total over the previous week remains above zero, the upward trajectory of cases will continue. As mentioned earlier, the change has remained in the 40-70 per cent range over the last few weeks. It would appear then that on its own the surge will not die down very soon. The worst is yet to come, it appears.
Neglect of States
The horrendous scenes witnessed during the unplanned lockdown between March and May last year are still fresh in everyone’s minds. Many migrant workers are now reported to be leaving cities and returning home in anticipation of another crisis. However, with the economy already in the doldrums and in the absence of any resource-backed plan to mitigate the economic effects of drastic measures on citizens and enterprises, State governments have actually dithered on the issue of imposing major restrictions to bring things under control immediately.
The Union Government bears the greatest responsibility for this state of affairs as it alone has the financial and fiscal muscle power to remedy the situation. However, instead of using its resources, it has been transferring the burden of depleting revenues disproportionately on to the States. Apart from lecturing State governments on the measures they need to take and issuing serial letters with “instructions”, the Central government has done precious little to support them.
On April 15, Rajasthan Chief Minister Ashok Gehlot publicly stated that the vaccine supply from the Centre was not enough. Similar refrains were heard from Kerala where vaccine wastage was reportedly “zero”, according to Rajesh Bhushan, Union Health Secretary. Clearly, if Kerala was not “wasting” vaccines, its complaint about a shortage of vaccines was genuine.
Unfortunately, elections and the desperation to grab power, hostility towards non-Bharatiya Janata Party State governments and the political imperatives of communal politics have also warped the Central government’s priorities, impeding the implementation of measures to curb the spread. For instance, there are fears that the Kumbh Mela may end up being a super-spreader event, even as BJP leaders mouth obscurantist ideas to justify the holding of the event with an enormous gathering of millions of people in the midst of a surge. Also read: Politics behind vaccine rollout in India
During a meeting with Chief Ministers, Prime Minister Narendra Modi talked about the importance of contact tracing, unmindful of the reality that on the ground this has been largely absent after the initial steps in the early phase of the pandemic.
The question that often remains unasked is: has the public health system’s capacity been expanded in such a way as to simultaneously do systematic contact tracing, provide care to those affected, supply necessary medicines and vaccines, and administer the vaccines? Without committing resources to strengthen the system, it is pointless to expect it to respond adequately to such a big outbreak.
Delhi’s woes
The situation in Delhi is a case in point. Even as the COVID storm was gathering, the BJP brought and pushed through a highly contentious Bill increasing the powers of the Lieutenant Governor over the elected State government. This was an eminently avoidable diversion at a time when all attention should have been on what was unfolding on the pandemic front, and also a hindrance to a swift response.
The national capital and one of the richest States in the country had already seen three waves of the pandemic in 2020. The last sero-survey done in the city indicated that some 56 per cent of the population had been already exposed to the virus and carried antibodies. However, this does not seem to have provided any general immunity to the population and Delhi has seen a rise in cases like never before.
The previous record of daily cases reported was 8,593. This was in November 2020, when the number of COVID patients in the city’s hospitals had also touched a record high of around 9500. These records of sorts were shattered decisively on April 14 when 17,282 new cases were reported and nearly 11,000 patients were already in hospital, as per Delhi Government data. The COVID bed capacity that existed just a few weeks before this was already inadequate and the Delhi government had to initiate emergency measures to increase the number of beds in private hospitals.
The Aam Aadmi Party government also announced a weekend curfew from April 17 and a slew of other restrictions aimed at banning public congregations. Some 14 hospitals were declared as dedicated to COVID but the order was soon revised after the authorities learnt about the condition of non-COVID patients already admitted to the hospitals. Also read: Safety concerns behind vaccine rollout
The question is: if such measures had to be taken, could they not have come earlier and in a less ad hoc manner? Will they now be adequate to check the outbreak quickly enough?
Delhi itself has also started reporting non-availability of drugs like remdesivir. This is, of course, the repeat of a story seen in other States. The Central government also acted only recently to bar the export of the drug and its intermediates, but it is not clear whether this will solve the problem. The Centre is also aware of the black marketeering of remdesivir and itolizumab.
One area where capacity cannot be ramped up quickly is the number of medical personnel available to provide care. Also, shifting of all existing physical and human resources to dealing with the pandemic will impact the health status of those suffering from other diseases and illnesses.
Vaccination and limitations
The second wave has also brought to the fore the limitations of India’s vaccination programme. Several State governments have been urging the Centre to allow people under 45 to be vaccinated, as their experience shows that that in this current outbreak, the number of younger people getting infected is large. States have also been complaining of a shortage of vaccine supply.
While it is unrealistic to expect the vaccination drive to deal with the crisis at hand, a difference in the age profiles of those being infected and those being vaccinated does indicate how far the the vaccination programme still needs to traverse.
The Central government, on the other hand, has sought to give a different spin to the reality by projecting India’s vaccination drive as being among the best in the world with statistics chosen to suit that narrative.
Contrary to the government’s claims of having rapidly ramped up vaccination and being number one giving average daily doses, the pace of vaccination in India relative to its population remains well below par. At 8.3 per 100 people, the number of vaccine doses administered in India as on April 14, 2021, was below the world average of 10.79. It is, of course, also way below the average of 58-59 seen in countries such as the United States and the United Kingdom. Also read: Hope as vaccination rollout starts
A country of India’s population can be the fastest to reach 10 crore vaccinations and yet end up being the last to cover the entire populace. The fact of the matter is that with the current rate of vaccination a reasonable coverage of the entire population is unlikely to happen happen even by the end of 2021. It is also not known whether the immunity of those vaccinated first will even last till the last group of people gets the vaccine. There is no information about the number of people who have got re-infected after vaccination and whether they are being isolated or whether their contacts are being traced. Through the first two weeks of April, after vaccination was opened up to those above the age of 45, the number of daily doses being administered averaged around 3.5 million. This is the broad picture arising from official statistics, which have some This is less than 0.4 per cent of the adult population being vaccinated in a day. The Tika Utsav announced by the Prime Minister during the April 11-14 period had no positive effect, with the number of vaccine doses administered remaining below average on most days. Even if more vaccines become available and their total supply improves over time, the public health system do not seem to have the spare capacity to do the vaccinations on a sustained basis.
How the Centre bungled
Unfortunately, the political leadership does not appear to be up to that task. On April 16, Union Health Minister Harsh Vardhan, while reviewing the state of preparedness at the All India Institute of Medical Sciences (AIIMS), said: “We defeated the virus when we did not know much about it and we can do it again.” According to a release issued by his Ministry, he praised the contributions of the ‘corona warriors’ (health workers) and said: “With the fundamentals of the disease known, the task ahead would be comparatively easy.”
The Health Minister also said that in 2021, the government has had more experience, knowledge and understanding of the disease. He cautioned health care worker about not neglecting non-COVID diseases. In a bid to focus on ‘positive news’, he said: “There were 52 districts with no fresh cases in seven days, 34 districts with no fresh cases in 14 days, four districts with no fresh cases in 21 days and 44 districts with no fresh cases in 28 days.In a country with more than 740 districts, these “achievements” could hardly be described as proof of the virus being contained.
On the same day, the Health Ministry issued an advisory to all Central Ministries and public sector units under them to dedicate their hospital beds for COVID management. A similar step was taken in the first wave of the pandemic. But the situation is vastly different now. Entire families are getting infected and people are struggling to get beds in hospitals and medical oxygen in the capital region of Delhi.
After the first peak, the government had five months to put its house in order. It had enough time to suppress the virus through contact tracing but that window of opportunity was lost. The supplies of medical oxygen could have been organised earlier. The government itself had no clue about the second wave. Instead, it reacted to the surge with knee-jerk responses such as imposing curfews and placing the entire responsibility of COVID-appropriate behaviour on the public.
In early March, Frontline suggested that in view of the steady rise in the daily numbers of COVID infections, India could be well on the verge of a second wave (“Is India on the verge of a second Covid wave”, March 26, 2021).
At that time, the government did not think that the numbers were a cause for worry. In the latest weekly briefing by the Ministry, V.K. Paul, a senior NITI Aayog member who heads the National Task Force on COVID, said that people who had tested positive should consult ayurveda practitioners, consume immunity boosters such as Chyawanprash, do yoga, and drink kadha (a combination of herbs and spices). Also read: Will antibodies help in battling the virus?
When history is written, he said, it will be remembered how COVID was controlled in India, adding that it would also be written how the nation adopted these practices. On the same day, he announced that foreign vaccines would be approved through bridging of clinical trials. The government had invited three companies, Pfizer, Moderna and Johnson and Johnson, “to seek licensure to come to India as early as possible”.
The National Expert Group on Vaccine Administration for COVID-19, which is the nodal agency coordinating the COVID vaccine rollout programme in the country, recommended that vaccines that had received Emergency Use Authorisation by the U.S. Food and Drugs Administration, European Medicines Agency (EMA), the U.K.’s Medicines and Healthcare Products Regulatory Agency or Japan’s Pharmaceuticals and Medical Devices Agency or those listed in the WHO’s Emergency Use Listing may be granted emergency use approval for India with “post approval parallel bridging clinical trial” instead of local clinical trials.
According to a release, this would expand the “basket of vaccines” for domestic use and hasten the “pace and coverage of vaccination”. The first hundred beneficiaries would be assessed for safety outcomes before it would be rolled out for general immunisation. All this was in addition to the Russian vaccine Sputnik V, which had received the Drug Controller’s approval for EUA in India.
Relying only on the vaccination programme may not be the way out to stem the current surge. In fact, the surge may have adversely affected the programme itself, given the huge demand for health care personnel and entire hospitals getting converted to COVID critical care hospitals. It is important to quell the outbreak to ensure the success of the rollout programme.
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