Police officers patrol a desolate Gateway of India monument, Mumbai, April 5, 2021. Photo: Reuters/Niharika Kulkarni/File Photo
If you were to believe irresistible mathematical models from different groups, India will witness unprecedented growth in cases, much more than what it saw in the first wave. Even with a conservative estimate of a 100,000 cases each day in the entire country, we will require 5,000-10,000 beds every day for critical care and the corresponding oxygen supply (assuming 5-10% would require hospitalisation). At this rate, cases will accumulate faster and will cause the health system to collapse.
I must caution that nobody would want to see or dare even to mention such a scenario. I am not an alarmist but belong to a well-meaning public health community that always strives to be prepared for the worst while at the same time hoping that the surge will miraculously disappear. We know that even with a shorter peak, the country struggled to meet critical care, primarily due to the skewed distribution of advanced care.
If the second wave is speeding up the way it is now, what are the policy options before the country?
Over the last few months, the country eased out completely from previous restrictions, with all sectors encouraging borders to reopen. But as of April 2, the Maharashtra government had announced a weekend lockdown and night curfew. Whether this has been done to induce a sense of urgency among the people and to promote COVID-19-appropriate behaviour or with the intention to slow the transmission of the novel coronavirus, with several other states contemplating lockdowns we need to ask ourselves why are we here and what the alternatives could be.
First, the best opportunity to fight India’s COVID-19 epidemic is gone. The basic principle in infectious disease control is to attack the enemy (virus) when it is weak (low transmission season).
To stress this, I wrote on February 5, 2021, that with cases rapidly declining, India needs the 3Cs: coverage of vaccines, containment efforts to limit the spread and continued genetic sequencing. But many states have faltered on all three fronts.
India had a good chance of surviving the first wave with distinct advantages, especially its low mortality rate. To sustain the gains, the country should have enforced strict containment measures, including concurrent monitoring of genome sequences with epidemiological investigations and efforts to curtail the transmission.
There was undoubtedly a sense of indifference to the COVID-19 response in people’s minds. We have already lost some valuable time to respond appropriately to several issues, including scaling up vaccination by making it more straightforward and expanding our basket of choices. What took many months to peak in last year is happening over a few weeks this year. In fact, with 23 states being in the initial part of the ascending phase, the second waves’ peaks will be much higher this time.
So there is not much time available to plan to save lives as the dramatic ascent continues. We should not delay any further in responding to the second wave.
We should have had a plan by now for a graded distribution of beds for critical care, when needed, ready to be deployed in a short time. If we don’t implement strict active efforts now, the decision-makers will resort to lockdowns – which will essentially be lazy policy options to make up for the inordinate delays.
Much of what we use to manage this pandemic are war terminologies. Some of these phrases are “fight”, “deploy”, “prepare” and “launch”. Continuing with this trend, the right word to describe the current situation is to deploy battle-ready infrastructure and human resources in each state to take on the virus while it attacks the vast population of the country.
A nationwide lockdown at this stage would be akin to using nuclear weapons, which are to be used only as the last resort and whose use will be detrimental to almost every walk of life and sector. The lockdown was a necessity in 2020 mainly because the virus was new and the response was not defined, and there was a pressing need to step up human resources and infrastructure.
But this time, we have better clinical management protocols, defined mechanisms vis-à-vis COVID-19 containment measures and the advantage of vaccines. There is no need to impose a nationwide lockdown if prompt and timely actions are taken now.
Indeed, the real threat is to overestimate our ability and underestimate the virus. Unfortunately, the current approach appears to be ‘business as usual’ with no strict compliance to COVID-19-appropriate behaviour. Changing this strategy could be pivotal in terms of reducing the adverse impact (the number of cases).
More and more sectors are seeking exemptions from following the required regulations in preventing super-spreader events. For example, Karnataka recently introduced a series of measures to prevent close contacts among crowds within closed spaces by regulating cinema theatres, gyms, schools, colleges etc. The cinema industry is mighty and has successfully garnered public support to continue with 100% occupancy in theatres, done by exerting pressure on the government. Once they were successful in getting exemptions, the association of gym owners and in fact all other groups sought the same measures.
So there appears to be a competition of sorts in seeking incongruous exemptions from following COVID-19-appropriate behaviours. But as a nation, our first step should be to transform this competition into more meaningful behaviour. Since December 2020, we have only been artificially inducing a conducive environment to promote fast spread in close spaces. We need exactly the opposite action: to ensure that there is positive reinforcement in a mostly competitive manner to enforce appropriate behaviours. The alternative weapons of choice are relatively complex to implement.
The government should in effect follow three As to ace the fight against the second wave.
First, acknowledge that the second wave is real and the role of variants by scientific inquiry.
Second, adopt a revised control strategy with strict prevention of crowds of all sorts in every possible way. This will also include a revised communication strategy to ensure everyone wears masks everywhere. We may not follow traffic rules but we listened to the honourable Prime Minister Narendra Modi when he asked us to stay home for a few months. We need similar messages from the prime minister and other political leaders to motivate people to maintain appropriate behaviour.
Third, accelerate containment efforts and the pace of the vaccination.
If all three As are integrated and comprehensively scaled up, we won’t need a lockdown.
I was among a few people who had said that a lockdown would help reduce the speed of the virus’s transmission and allow us to ramp up healthcare infrastructure and the required resources to fight the pandemic. But despite these epidemiological advantages, the lockdown had disastrous consequences for vulnerable people. Today, ignoring the necessary three As, and not deploying a revised COVID-19 control strategy, can’t become an excuse to impose a lockdown.
If these measures are not taken, the number of cases will continue to rise and many lives will be lost. Poor people are at higher risk of death because they can’t access and/or afford advanced care to save their lives.
In summary, we are doomed if there is no action and if there is a lockdown. Failure to act decisively now will have a doubly deadly impact on the millions of impoverished persons in India.
Giridhara R. Babu is a professor and head of lifecourse epidemiology at the Indian Institute of Public Health, PHFI, Bengaluru.