Dr Lahariya is a medical doctor, epidemiologist, vaccines and health systems expert based in New Delhi. He has more than 17 years of experience in outbreak, epidemics and pandemics and one of the Indian experts involved in the 2009, H1N1 pandemic preparedness and response. He is the co-author of 'Till We Win: India's Fight Against The COVID-19 Pandemic".
1. The second Covid wave has taken the country by storm and led to a near-collapse of the healthcare system in many states, the starkest case being that of the national capital. Who do you think the buck stops with?
A: The health systems challenges faced during the COVID-19 pandemic were widely acknowledged. The health systems weaknesses were fully detailed in a situation analysis document released as part of India’s third national health policy in March 2017. However, the type of effort which should have been made since then and till now is suboptimal. The NHP 2017 proposed to increase government funding for health to 2.5% of GDP by 2025, from 1.15% in 2015-16. Five years since then, the country is not on track to achieve the target it set for itself. We know, government funding for health and a well-functioning health system are essential to minimize the impact of any health emergency including epidemic and pandemic. We also know that health systems can not be strengthened overnight. And that is why experts have always kept repeating for the last two decades to invest in health services. India has landed in this situation because the successive elected governments, both national and state levels, and elected leaders did not follow up on the policies they approved and promises they made. The buck stops with governments and elected leaders at all levels. I believe it will change only when citizens start holding the elected leaders accountable for health services in their areas and when health will become an agenda which will determine their voting decision, in every single election.
2. How and why did we miss anticipating such a massive wave of infections?
A: There was no reason to believe, if anyone did, that India would not face a second wave of COVID-19 pandemic. The search for answers in universal BCG vaccination and high rate of underlying infection and thus heightened immune system quickly transcended to a narrative of ‘Indian exceptionalism’. What was forgotten the viruses do not respect boundaries and on any other ground. We know that 1918 -20 influenza pandemic four waves over a period of two years and the second wave was the one which was most severe and caused the highest mortality, in nearly all parts of the world. In the last year nearly every country, except China, has faced a second or third wave. All those should have alerted us to prepare for the next wave. It is clear that those signals were not fully followed. Much of the Indian response to the first wave was doing what was needed to tackle the COVID-19 such as ventilator beds, PPE, and improved testing. Though there were many discussions on strengthening health systems, I am not sure if it was actually done. If only the promises made to strengthen the health system, made by both union and state governments, would have been followed, India's handling of the second wave would have been very different.
3. In your estimation what could be the level of undercounting of deaths which are largely due to lack of access to adequate and timely treatment, rather than the disease itself—in India in the second wave thus far?
A: It is very likely that deaths due to COVID-19 in India are being undercounted, as of now. This is not going to be a problem in India but also in all countries with poor registration of deaths. The rush at crematoriums and burial grounds clearly show the excess deaths. This situation at crematoriums is not in just one city or state but across many states of India. What it points to is the excess deaths in India than the pre-pandemic period. The confirmed COVID-19 deaths would not have increased this rush. We know that there is increased mortality and many of rural India and even cities are not being tested for COVID-19. Those deaths are not counted as confirmed deaths. It is not possible to predict at this stage whether those number Whether that number would be two or four folds is not possible to say. However, India has a relatively better performing death registration system, where nearly 70% of all deaths are registered. Therefore, I am sure that in the time ahead, we will definitely get a clear picture of this in the time ahead. However, for me more important is that India needs to revise the approach to certification of COVID-19 deaths and need to make it broad-based. India also needs to increase testing and treatment services in rural parts, to ensure the timely identification and case management, which would help in reducing the deaths.
4. At one point of time, many epidemiologists believed that at least the metropolitan cities may have seen the worst of the Covid pandemic already last year. Do you think the high seroprevalence in these cities, as shown in the serosurvey, lulled policy makers and people into a false sense of security?
A: We know that sero-surveillance is one of the tools in pandemic and they have their limitations. Alongside, the unknowns about the SARS CoV2 virus and COVID-19 have been far too many. Back then, there was limited clarity how long the immunity lasts after natural infection and what is the protective level of antibodies. It is also true that with every serosurvey, many started arguing that ‘herd immunity’ results in the end of the pandemic. Though, even the threshold of ‘herd immunity’ was not fully understood. And the experts at the global level were divided in their opinion. The core point that in such novel pathogens, herd immunity only through the natural infection was unlikely to be achieved. Attempting that would have had a very high human cost in the form of illness and deaths. Herd immunity through vaccination would be the right approach. However, it is not about responding to the pandemic only. The weak health systems and world still being in mid of the pandemic, should have been reasons enough to continue to work upon strengthening everything which was needed to respond to the virus and pandemic. However, in my opinion, it is the traditional low priority given to health, which resulted in a lull and false sense of security. In fact, the belief that India could tackle the first wave with whatever health system it has, sort of, was taken as the system does not need anything additional.
5. Battling a fierce wave of infections, the country is also facing an acute shortage of Covid vaccines. What do you think of the country’s vaccination policy so far and would you say the government did not plan well?
A: One of the key approaches in any public health programmes has to be simplicity in design and assured provision of supply before promising delivery. That’s exactly what most countries have done. The countries have used age criteria to open the vaccination (except for health workers), the vaccination has been opened in phased manner and the availability of vaccines has been secured before started vaccinating. Nearly all countries are providing vaccines free of cost to the citizens. India had advantage of a robust universal immunization program platform, on which COVID-19 vaccination is being implemented. The way India’s COVID-19 vaccination strategy has been developed, I am not sure if it is a technical decision or political decision. Sometimes politics should be kept away from some health decisions and especially so in the pandemic. COVID-19 vaccination is one such area. I think there is still an opportunity in India to simplify the process. The vaccine supply is unlikely to increase drastically; however, if the government revisits some vaccination decisions and put a few on hold, that can streamline the vaccination drive, which is so very vital for pandemic response today.
6. Do you think a third wave of the pandemic is possible in the coming months? Going forward, what do you think could be India’s approach to the crisis?
A: We know that SARS CoV2 is unlikely to disappear and will be with humanity for years and decades to come. It is also sure that the second wave would decline in coming weeks and the epidemic curve would be flattened one more time (I think starting mid to late June 2021). However, we should also know that the number of new daily new cases is not going to be as low as we had seen in February 2021. I am also confident with increased vaccination coverage, there would be a slow but sustained downward trend. However it is very likely that with the susceptible population increasing, people dropping their guard one more time, there would be fresh waves of cases. There will be a third wave at national level, which is more likely due to surge in cases at select states. No one can say, which states would those be. Irrespective of everything, when and to what extent of third of subsequent wave of COVID-19 in India would be, will be determined by the actions taken by union and state governments, the vaccination coverage, mutations in the virus and potential immune escape, and the adherence of COVID appropriate behavior by public. See, there are so many unknowns. Therefore, how many waves India will have will be determined by our actions together but also what we learn what Indian states learn from the experience of other states.
7. Given the situation, as of now, do you support the idea of a nationwide lockdown?
A: Much of India is already under various forms of restrictions. However, there is limited value in nationwide lockdown. We know that in India there are states and districts which have a different number of daily new cases and test positivity rate. The nationwide lockdown has always been said to be a blunt instrument. A year later with better understanding of the virus and so many technical experts, there is no value in use of a blunt instrument. The approach to pandemic response to be calibrated, factoring in local epidemiology. There are international experts who have also advised for national nationwide lockdown. However, what they miss is that India is a country of 1.38 billion people and where every state has a population size equivalent to a nation in other settings. Therefore, the restriction has to be purpose-specific and not uniform. Second and most important, all the restrictions for COVID-19 should be, no matter which state or setting they are, should always be supplemented by social security measures and cash transfer for a large proportion of population, without the unnecessary burden of proof to get those benefits. The nationwide lockdown is not the right option for India in this wave.