It’s terrifying, but in recent history, and after World War II, we’ve seen epidemics almost every 10 years: Asian flu, Hong Kong flu, cholera, severe acute respiratory syndrome (SARS), HIV/AIDS, swine flu, Middle East Respiratory Syndrome (MERS), Ebola and then the deadly Covid-19. Given the frequency and almost predictable return of strange new pathogens, the pandemic is clearly no black swan event and so health systems must be prepared for the next. Merely referring to them as ‘acts of God’ will not help.
The recent outbreak in Shanghai and a suspected case of a new variant in Mumbai are ominous to say the least. It is important for us to keep track of ‘interest types’ and of course ‘anxiety types’.
There are many concerns for India (and the world) and many questions to be answered. What have we learned in the last two years? Are we ready to fight the next battle against a new pathogen or a new disease? In fact, are we even ready for a new version?
Part of the answer has to do with vaccination coverage.
enough jab?
There are many vaccine skeptics who have claimed that vaccines are not the solution – that mass vaccination actually results in lethal forms and that vaccines were advanced quickly and were therefore irrelevant. However, among the vast majority of the medical community, the argument has settled. We need above 70%, preferably closer to 80%, for herd immunity to be fully vaccinated.
It is important to note that herd immunity is no guarantee against individuals becoming infected. There is no choice but to be fully immunized to be sure on an individual level. A single dose is simply not enough.
How are we doing accordingly? Worldwide, slightly less than 60% of the population is fully immunized. India has managed to fully vaccinate less than 63% of its population. With mass vaccination efforts coming to an end and the urgency is no longer clear, increasing it to 70% is too far-fetched and therefore vulnerable to another wave.
Even the percentages at a single dose are not enough. We have given a dose to less than 73% of our population, which means that about 450 million people have not received even a single dose of the Covid-19 vaccine. There is some relief in the fact that the term wide average is only 66%.
Another cause for concern is the booster dose. Booster doses are given to people who have received the vaccine but as time goes on, the protection provided by the original shot begins to diminish. This should be the case for a large proportion of the population who have taken the vaccine more than a year ago. However, here we have done very poorly. While the worldwide average for those taking a booster shot is 24%, in India, not even 2% of the population has been given a booster. This leaves a large section of the population vulnerable.
broken system
Meanwhile, India is also vulnerable as the country has not improved its health systems. Much work remains to be done.
The World Health Organization (WHO) has recommended 44.5 skilled health workers per 10,000 people. India’s health workforce is less than 11 per 10,000.
While we all know there are very few doctors in India’s system, what is worrying is also the shortage of nurses and midwives – they seem worse. The Medical Council of India says that there are about 12 lakh doctors in India and the Nursing Council of India claims that there are 23 lakh nurses and midwives. However, the government’s own Periodic Labor Force Survey data (2018-19) shows that as of now there are only 9 lakh doctors, including Ayurveda and Unani practitioners. Among nurses and midwives, about 15 lakh are missing from the labor force – we have only 8 lakh nurses working.
The reason for this discrepancy in the data? First, not all medical graduates join the workforce. Some go on to pursue further studies, while others simply leave to pursue a career. Another reason is that in a patriarchal society a large number of female medical graduates drop out due to the difficulty of juggling between career and responsibilities at home. More than 50% of students in medical colleges today are female, but only about 17% of practicing allopathic doctors are female. Finally, a large number of Indian graduates find their way into other markets, both in the developing and developed parts of the world.
During the waves of the pandemic, this shortage was a major factor – along with stockouts and a lack of hospital beds – for the massive loss of life across the country.
The WHO said last week that India accounted for more than 31% of all ‘excess deaths’ globally in the two COVID-19 years of 2020 and 2021. Around 14.9 million additional deaths were recorded globally, of which a staggering 4.74 million were in India – the highest in the world. While the Indian government disputes these numbers, the trend underscores the need to rapidly ramp up healthcare infrastructure in preparation for the next pandemic.
Even after opening the 157 medical colleges and 50 nursing colleges that the government has promised, we will fall far short of the minimum requirement in 2030.
get data
Any sign of a new threat requires a worldwide real-time monitoring and notification mechanism. Governments, everywhere and at all levels, should enable data registers and notifications that can quickly collect information and send it to a central database. Continuous tracking, tracing and monitoring is the key to identifying new strains and types.
In the Indian context, it is important to have a ready account of the dead and their causes of death. It is the lack of a data collection mechanism that embarrassed the health system in the country when the WHO came out with its estimate of more deaths. It is important to automate all registrations of births and deaths and collect this data.
Real time data will enable governments to bring in masking and distancing norms. Make it mandatory to do testing and quarantine when the danger is high.
Bill Gates stresses on the importance of three things – diagnostics, data transparency, quarantine to fight the pandemic. They argue that all of this needs to be done within 100 days to prevent the local outbreak from going overseas.
The way China controlled the spread in its early days is an example of how proactive surveillance, testing, distancing and quarantining can result in the spread of this highly contagious disease. If, like in Wuhan in 2019-20, the Covid-19 spread had been contained within 100 days, 98% of the total deaths could have been avoided.
Even after knowing the positive cases when the pandemic first came, India delayed the containment. But the country also learned that a widely spread lockdown could never be the solution. They are rigid and provide a feel-good factor only by flattening the curve for a while. The number goes up again and when it does, it becomes unbearable. The lockdown also causes huge economic hardships, reverse migration, and stockouts of essential medicines including life-saving oxygen cylinders.
Gates argues that the health gap—or the gap—access to health care between the rich and the poor should be reduced. Health systems have received heavy attention during the past two years, making it possible for states and governments to increase spending on health information systems, testing facilities and databases that contain and analyze this information.
keep the research alive
Given that the threat of new variants and new viruses is real, let’s see what is known.
Some vulnerabilities have been identified. Animal-to-human transmission is now seen as a major threat. It is estimated that 75% of new infections come from animals and there are more than 5 million animal viruses lurking around. Only 250 of them have so far made a fatal leap to the human population. Therefore, it is important to continue studying animal viruses and to quickly identify those that are at risk of infection in humans.
The research activity we saw during SARS and MERS ended as the threat subsided. This cannot happen again.
It is important for public health institutions and laboratories to collect information about various potential hazards. This should facilitate comparison of the genome sequences of the continents. Active and passive surveillance should be carried out, especially in border settlements where humans come into contact with wild animals.
A large number of researchers have now started collaborating on an academic level. There has been an increase in the number of papers written by co-authors working across borders, especially during the pandemic. Funding agencies have also ensured that teams work together across national borders. WHO has long maintained and encouraged cross-border cooperation. For example, the body’s Southeast Asia region has taken several initiatives since the mid-1990s to ensure that Nepal, Bhutan, Bangladesh and Myanmar—countries bordering India—prevent the spread of diseases across borders. Monitor, and be sure to treat all infected, whatever their type. Nationality or legal status.
The ‘End TB’ strategy, combating Kala Azar and the Global Technological Strategy for Malaria are all global efforts that have been successful in the past.
government work
Of course, governments need to work diligently on communication programs that educate the public on the need for cleanliness, distance and cleanliness. The importance of paying attention when warning and sounding alarms also needs to be emphasized.
In India, coordination among states is essential to reduce the burden on hospital beds and intensive care units (ICUs). Import and purchase orders of life-saving equipment and vaccines should be streamlined and adequate stocks kept in preparation for a possible fourth wave.
The state should provide immediate data on vaccine effectiveness, new outbreaks, the number of empty ICU beds and guide people on when to receive booster doses. Steps need to be taken to ensure that there is no stigma on getting infected and adequate care is taken for those suffering due to the large number of mental health issues.
Having said that, a fourth wave seems unlikely because the strains and variants we have seen after Delta are benign. They haven’t really threatened to raise our mortality rate. However, the virus still lurks and the battle is not over either on the medical or economic front. Therefore, responsible personal behavior should be wearing a mask and maintaining physical distance – yes, preaching is easy but it is very difficult to practice, as we have mostly seen.
As mentioned earlier in this article, we will certainly see another pandemic within the next decade and a half – if not a fourth wave of COVID-19. If we don’t improve our hospital infrastructure by then, we will only blame ourselves.
(Aamir Ullah Khan teaches Development Policy at the Indian School of Business)