SEARING HEAT Staff at the Ghazipur crematorium in Delhi cart in fresh logs as funeral pyres burn all around them
Bodies are lined up for the final rites before being consigned to the flames at the Hari Nagar crematorium in Delhi on May 2
SAY YOUR PRAYERS
A relative consoles a Covid infected girl as she lies gasping for air at the Indirapuram gurudwara in Ghaziabad, UP. The gurudwara provides free oxygen to those who don’t have access to it.
A relative carries a patient as another lugs an oxygen cylinder at a gurudwara in Ghaziabad, UP. The Sikh temple has put up tents where free oxygen is supplied to struggling Covid patients
Massed pyres and serpentine queues of shrouded bodies. Gasping, terrified men and women pleading to be accepted as patients. The broken and bereaved mourning their dead. In New Delhi today, as in any Indian metro, the roads are silent, the bazaars are shuttered. But approach any hospital and you’ll rediscover the familiar clamour of the Indian street, rising to a crescendo in the once hushed ICUs—now rent with the shouts and moans of the desperate and the dying. Of course most of us are hunkered in our homes, carpeing our diems and visiting such scenes through our screens when we’re not fielding calls and text messages from family and friends, or friends of friends, pleading for a hospital bed, an oxygen cylinder, Remdesivir, more oxygen. Expressing our sympathies on Facebook and WhatsApp.
The second wave of Covid-19 is still cresting but by now we have all been touched by its terrors, and all too many of us by its sorrows—and the dismal realisation that we are in the midst of a recurring nightmare, a tragedy foretold. We have bitter memories of the days when we were lulled by bromides of idiocy—remember the one about Indians’ superhuman immunity? Remember clanging steel utensils? Remember telling the world that India had beaten Covid-19?
That was in January, and in the four months between that moment of monumental hubris and today’s 380,000 new infections and 4,000 daily deaths lies a chronicle of missed opportunities. This despite the central government having a phalanx of empowered groups and task forces comprising top officials and experts for Covid management (see accompanying graphic). It was a time for action, for prioritising the obvious: doctors, hospital beds, Covid medicines and vaccines, oxygen, viral research and Centre-state coordination. You could say the Indian state is Covid’s biggest victim but that would be a stretch.
The fact is that the state and those who run it have failed us—in a once-in-a-lifetime Himalayan Blunder kind of way. However, it still exists, with all its branches quite intact and we must rely on it to rise to the challenge of quelling the current surge and preventing a threatened third wave of Covid-19 infections. That’s a process that should begin by taking stock of just where and how it failed.
In the following pages, we expose the sorry tale of neglect, apathy and failure of our political leadership. The institutional collapse and bureaucratic cowardice that facilitated super-spreader religious festivals and the political carnival of an eight-phase election campaign even as the second wave of a pandemic was breaking. The narcissism that enabled our leadership to ignore the warnings of expert groups. Their inability to form bipartisan alliances between the Centre and the states in the middle of a national calamity. Now that some of the loudest voices in the land have gone quiet, the government’s silence over the anguished and angry questions being raised over its management of Covid’s second wave can be deafening. Our reports offer some answers to these questions and suggestions from experts on how to find a way out of this continuing tragedy of errors. Most of all, we need action from the government—and fast.
MAPPING THE VIRUS A health worker at the genome sequencing laboratory set up at Delhi’s IGI airport
1. WARNINGS BY EXPERTS WENT UNHEEDED
GENOME SEQUENCING WAS NOT PRIORITISED EVEN AFTER CONCERNS WERE ARTICULATED ABOUT MUTANTS CAUSING A SECOND WAVE
FOREWARNED IS FOREARMED. This maxim holds good for all nations trying to combat the waves of Covid-19 that threaten the world today. Yet the Narendra Modi government, which had acted with alacrity during the first wave, was surprisingly complacent, not keeping track of mutations of the virus that could trigger a second wave of infections—as it did in the US and the UK and is now doing in India. When the first wave raged, barring two institutes, the Delhi-based Institute of Genomics and Integrative Biology (IGIB) and the Centre for Cellular and Molecular Biology (CCMB) in Hyderabad, there was no coordinated national effort to sequence Covid samples to detect the most dominant variants and to ascertain if any threatening mutations had occurred.
It was only on December 21, after the UK variant was recorded in England, that the Union ministry of health and family welfare (MoHFW) formed the Indian SARS-CoV-2 Genomics Consortium (INSACOG) to do so. A group of 10 labs was granted funding and came under the purview of the National Centre for Disease Control (NCDC), which reports to the MoHFW. INSACOG’s job was to track Covid variants in the country, most specifically if any of the variants causing concern in the UK, Brazil and South Africa had reached India and also track the progress of the Indian variant, B.1.617, which had been detected in October 2020 by the CCMB.
INSACOG faced big hurdles from the start. The first major problem was a May 2020 Union finance ministry order banning the import of goods valued under Rs 200 crore. Several reagents and plastics used by Indian labs come from foreign manufacturers and have no Indian substitutes. To import any of these, a lab would have to prove to officials through a market assessment that no Indian alternative exists. The reagent restriction was lifted only in January this year. The second problem was funds. INSACOG was initially allocated Rs 115 crore for a six-month period, which was to come through the department of biotechnology. But the first tranche of funds was released only on March 31, 2021, and the allocation itself was reduced to Rs 80 crore. Till then, the labs had to spend their own resources for sequencing.
The third, and the biggest, problem was getting hold of samples from the states to enable the labs to track the variants. Barring Kerala, most states were lackadaisical in their approach. Covid-19 testing labs in states must preserve positive samples from patients and it is the responsibility of state governments to transport a set number of these samples to the 10 INSACOG labs every week. The problem, an official at one of the labs revealed, was that most states had not appointed nodal officers to ensure collection and transport of the samples to the labs. Some states didn’t have cold storages to preserve the samples before and during transportation. As a result, INSACOG fell far short of its objective of sequencing around 80,000 samples by February 2021—it managed to do only 3,500.
This was one reason why it was only in March that INSACOG could determine that the B.1.617 variant, detected months ago, had been found in a high 20 per cent of samples from Maharashtra. On March 10, the group shared its findings with the NCDC, which further conveyed it to MoHFW. In a draft statement that was never released, INSACOG wrote that the mutations in the B.1.617 variant were of “high concern”. On March 24, MoHFW announced the variant’s spread but played down concerns to avoid public panic. Many experts believe this cost them dearly. “That the variant was spreading and was more contagious didn’t ring alarm bells till it was too late. People continued to gather in groups without masks and social distancing,” says Rakesh Mishra, director, CCMB.
MISSING THE ALARM BELLS
The Centre claims it had taken note of INSACOG’s warnings. Ashutosh Sharma, secretary, department of science and technology, says the B.1.617 strain was discussed in an early April meeting with 21 members of the National Task Force for Covid. The task force had been set up in April 2020 to provide scientific and technical guidance to the government and is headed by Dr V.K. Paul. Its members include Indian Council of Medical Research (ICMR) director general Dr Balram Bhargava, AIIMS director Dr Randeep Guleria and NCDC director Sujeet Kumar Singh. In that meeting, around 100,000 daily new cases were predicted, with the peak of the second wave in end-April. Yet, the experts seemed to have severely underestimated the virulence of the mutant strains. Within 20 days of the meeting, India hit 300,000 new cases a day.
ON APRIL 19, NCDC director Singh met other members of the National Task Force for Covid. The minutes of the meeting, doing the rounds of social media, purportedly had Singh saying that the lockdown should have been announced 15 days ago. A task force member who attended the early April meeting says the severity of the second wave went unnoticed. “The predictions were based on how infectious the first wave had been and the modelling of the second wave mirrored the first. That the Indian variant replaced the early strain in Maharashtra in just 1.5 months was not used to predict how rapidly the second wave would spread,” he says.
LESSONS FROM THE UK
As the B.1.617 strain is showing signs of a third mutation in West Bengal and a new variant, N440K, has come up in Andhra Pradesh, the need for quick and widespread genome sequencing has never been greater. India can learn from the UK’s research consortium—COG-UK. The group was created as soon as the pandemic began in March 2020. It has been allocated £32 million (Rs 329 crore), about four times what was given in India. In the first wave itself, the group found out that Covid in the UK came from France and Spain, not Italy or China. To find out if certain viral variants are linked with more severe diseases, COG-UK is linking its viral genome sequences with NHS (National Health Service) patient data and a human genome sequencing project being carried out with Genomics England. Their work is so precise that in Addenbrooke’s Hospital in Cambridge, the group identified that an outbreak in the area was due to a bus transporting dialysis patients.
Scientists say genome sequencing can pick up outbreaks at least two weeks faster than any other surveillance, by ascertaining if cases in an area are linked. Say, if all five cases are related, it is possible that there is active transmission, which means a containment zone should be created immediately.
India has already built up its capacity to do this work. At CCMB, sequencing to identify a variant can now be done in 24 hours. But many of the labs assigned to do this work are not receiving samples from states fast enough to draw a conclusive picture of variants and their spread. Some states, like Goa, are setting up their own sequencing facilities. Rapid surveillance of Covid variants followed by immediate policy action on points of concern is the only way to prevent a repeat of April 2021 and stem the damage a third wave may cause. —Sonali Acharjee
WHAT NEEDS TO BE DONE
1 Inject funds to expand genome sequencing capacity. The UK’s genome sequencing body got £32 mn (Rs 329 crore), four times what INSACOG got in India
2 Make samples available quickly. All labs are under-utilised because not enough samples are being sent by states
3 Resolve the raw materials crisis. Many labs still cannot import the raw materials needed, and they have no Indian alternatives
2. NOT AUGMENTING THE MEDICAL WORKFORCE
A DIRE SHORTAGE OF HEALTH PROFESSIONALS HAS CRIPPLED INDIA’S FIGHT AGAINST COVID. THERE IS NEED FOR RADICAL SOLUTIONS
THE DISTRICT HOSPITAL IN Bihar’s Gopalganj district received three ventilators from the Centre in September last year. These were among the 60,000-odd ventilators the government had procured, for nearly Rs 2,000 crore, in response to the Covid pandemic; roughly 17,000 of them were dispatched to the states. But this April, when some patients at the Gopalganj district hospital needed to be put on ventilator, the life-saving devices could not be used due to a manpower crisis—the support of an anaesthetist was not available.
The unfortunate incident highlights the ill-preparedness of the nation’s medical infrastructure at the time of a raging pandemic. Indeed, there is a massive shortage of beds, ICUs, ventilators, oxygen and life-saving drugs. But as renowned cardiologist Dr Devi Prasad Shetty, chairman and executive director of Narayana Health, says, beds don’t treat patients—doctors do.
India’s response to Covid has been crippled by an acute shortage of medical staff—doctors, nurses, paramedics, technicians. For the record, the country has 37.6 health workers for every 10,000 people. The WHO (World Health Organization) benchmark is a minimum 44.5.
At 562, India has the highest number of medical colleges in the world. Not surprisingly then, we have the second highest number of doctors globally. But given our 1.3 billion population, the doctor-patient ratio is abysmal—nine doctors per 10,000 people, as against 42 in Germany, 28 in the UK and 26 in the US. Comparisons with China are starker. For its 1.4 billion people, China has 3.61 million doctors, nearly thrice that of India. Similarly, though India has around 3.2 million nurses and produces 335,000 nursing professionals every year through 5,085 institutes, there are only 15 nurses for every 10,000 individuals. The UK has 150, Germany 132, the US 85 and China 23.
The Centre, since 2014, has been pursuing an ambitious plan to set up 157 medical colleges in three phases at an estimated Rs 24,735 crore and raise 15,700 additional medical graduates every year. Work is also on to establish 22 institutes on the lines of AIIMS (All India Institute of Medical Sciences). But mega infrastructure takes time to build—only 46 of the 157 medical colleges and six of the 22 AIIMS are operational. Other central measures to beef up the medical workforce included increasing the number of MBBS seats from an average 150 to 250 per institute, relaxing the teacher-student ratio norms and age limit for appointing teachers, and making it mandatory for medical colleges to start postgraduate courses within three years of recognition.
47 PER CENT
No. of Indian districts that do not have even a single medical college
TO FIGHT COVID, the government claims to have appointed nearly 265,000 health professionals on contractual basis in the states, including 11,921 general physicians, 3,789 specialists, 73,619 nurses, 81,978 auxiliary nurse midwives and 44,314 paramedics. Defence minister Rajnath Singh has asked governors to work with chief ministers to devise plans to rope in doctors and nurses who retired from the armed forces for the fight against Covid. State governments launched recruitment drives, but with limited success. Bihar advertised for 9,000 nurses but could fill only around 5,000 posts. The Delhi government asked fourth- and fifth-year MBBS students, interns and BDS doctors to join Covid duty on a daily honorarium of Rs 1,000-Rs 2,000.
Experts say the prevailing health emergency demands radical steps and urgent hiring of medical staff by cutting down on red tape. A paper published in March by Anup Karan, additional professor at the New Delhi-based Indian Institute of Public Health, says incentives should be offered to encourage the estimated 30 per cent doctors, who are no longer a part of the workforce, to return to duty. Recruitments to public health services should be fast-tracked by relaxing norms. National-level live registers of health professionals should be maintained to ensure their quick deployment across the country as per need.
WHAT NEEDS TO BE DONE
1 Give final-year medical students provisional approval to manage Covid cases in hospitals and ICUs, at least in some vital disciplines
2 Fast-track hirings to public health services and reskill doctors and nurses who are out of the workforce
3 ‘Recognise’ and engage medical specialists with diplomas in critical specialities, such as emergency medicine
Dr Shetty suggests that the 25,000 MBBS students, who are about to finish training in medical or surgical specialties, be exempted from their final exams if they agree to work in Covid ICUs for a year. Then, a few thousand medical personnel hold diplomas in critical specialties, such as intensive care cardiology and emergency medicine, which aren’t recognised by the Medical Council of India. Giving recognition to these diplomas would add thousands of professionals to the Covid workforce, he says. Only about 35,000 of the over 130,000 doctors preparing for PG entrances will be admitted in clinical subjects. Those who fail could be offered grace marks in the exams next year provided they work in a Covid ICU now.
Dr Shetty and the National Working Group on Covid, a consortium of top doctors in the country, suggest that foreign medical graduates be allowed to work in Covid ICUs for a year and, in return, directly enrolled under the state medical councils. Nurses and paramedics who opt to work in Covid ICUs should be given grace marks while applying for PG courses as well as preference in government jobs. Nitin Pai, director of the Bengaluru-based Takshashila Institution, a public policy research centre, calls for creation of ‘chartered nurses’, who can perform routine functions of general physicians and lighten their load.
On May 2, in a meeting chaired by Prime Minister Narendra Modi, the Centre decided to act on several suggestions given by experts. While the PG entrance has been postponed by at least four months, medical interns will be put on Covid duty under the supervision of their faculty. Final-year MBBS students will help with teleconsultation and handling mild Covid cases. Medical staff completing 100 days of Covid duty will get priority in government recruitments and honoured with the PM’s Distinguished Covid National Service Samman. —Kaushik Deka
3. THE VANISHING HOSPITAL BEDS
ACROSS STATES, HEALTH INFRASTRUCTURE CREATED DURING THE FIRST WAVE WAS DISMANTLED UNDER THE DELUSION THAT THE PANDEMIC WAS OVER
LAST NOVEMBER, WHEN COVID cases in Delhi peaked to over 8,500 daily, a majority of the patients requiring hospitalisation struggled to find beds. Even temporary additional facilities set up earlier in June failed to handle the extra load of patients. The four temporary facilities included a 10,000-bed centre in Chhatarpur, run by the ITBP, with at least 1,000 oxygen beds. Similar but smaller facilities had been set up in Dhaula Kuan and at the Commonwealth Games Village.
But, in February, when daily cases dropped to below 200, the Delhi government declared victory over Covid and the four additional facilities were dismantled. Two months on, as the second Covid wave struck, Delhi witnessed an unprecedented shortage of hospital beds. Average daily cases peaked to over 25,000 and the city was gripped by an acute shortage of medical oxygen. Two major hospitals— the Rajiv Gandhi Super Speciality Hospital and the GTB Hospital—had to slash the number of Covid beds by half due to the shortage of oxygen.
It’s not just Delhi. Across states, around February, health infrastructure created during the first wave of Covid was dismantled because of the misplaced belief that the pandemic was drawing to an end. Makeshift hospitals were folded up, contractual healthcare staff let go, and little effort was made to ramp up critical equipment, such as ventilators and oxygen tankers. For instance, Uttar Pradesh claimed to have set up 503 Covid hospitals, with about 150,000 beds. By early February, it had only 83 hospitals with 17,000 Covid beds. In Pune, one of the worst-affected cities, an 800-bed hospital shut down in January.
Such premature actions left most states ill-prepared for the second wave. In April, the Jharkhand High Court had to intervene to get the Ranchi-based Rajendra Institute of Medical Sciences, the biggest government hospital in Jharkhand, to procure a high-resolution CT scan machine. In Bihar, during the first wave, district administrations had demanded that government facilities be equipped with at least 10 ventilators each. Only 10 of the state’s 38 districts now have more than five ventilators.
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