On Tuesday evening, the chief minister of Delhi tweeted an urgent plea: Hospitals in the capital city were facing a “serious oxygen crisis,” with only a few hours of supply left, he said, urging the central government to help increase supply.
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The tweet was the latest in a barrage of social media posts which reflected the rising COVID-19 cases and overwhelmed medical facilities in cities across India. The pandemic has also hit peripheral towns and rural areas, where a shortage of testing, health care workers, and oxygen-supported beds highlight the inadequate preparedness to handle the spread of the virus.
“We’re perpetually running short of oxygen. We’ve doubled our COVID bed capacity from 200 to 400, but soon that won’t be enough,” Dr. SP Kalantri, the medical superintendent at Kasturba Gandhi Hospital in Maharashtra — one of the worst affected states — told Devex.
His hospital caters mainly to a rural population, most of whom were spared in the last wave. “We celebrated prematurely when cases went down earlier this year,” he said, “But the second wave has hit us all very badly.”
The deadly second wave in India has caught an already weak public health system unaware and unable to cope. On Wednesday, the health ministry reported 315,735 new infections nationwide — the highest number of cases reported in a single day in any country since the beginning of the pandemic.
Cases have skyrocketed over the past month — on March 14, 26,000 people were infected with the virus but just one month later, the number crossed 200,000 for the first time. So far, India has recorded over 15 million cases, and 183,000 deaths — second only to the United States, which has the highest number of cases and deaths globally.
Lax measures and false vaccine optimism
The government is being criticized for allowing events with large audiences, such as sporting events, a Hindu religious festival attended by thousands, or packed election rallies, to take place.
“Norms were flouted, and now the damage is irreversible,” Job Zachariah, the UNICEF head of the state of Chhattisgarh, told Devex. Chhattisgarh’s capital city, Raipur, hosted a cricket tournament in mid March, after which cases started rising in the state. “Can we blame it on the match? I don’t know — but almost 3 lakh [300,000] people come to the city every day, so the movement has an impact on the spread of the virus,” he said.
“Nobody is willing to admit that we have a shortage of professionals: from doctors to nurses to biomedical staff.”— Dr. SP Kalantri, medical superintendent, Kasturba Gandhi Hospital
On Feb. 28, there were only 141 new cases in the state, which is mostly rural and home to several Indigenous tribes. Within a month, that number had risen to 16,000. “What was clear from the first wave was that to save lives, we needed tertiary hospitals, which are equipped with oxygen beds and have adequate health care workers,” Zachariah said.
“But this was a lesson we did not learn — it could have been planned. It’s oxygen management that saves people from going to the ICU [intensive care unit] and needing ventilators.”
Testing capacity is also low in the state. In the first wave, the state was testing 40,000-50,000 people daily. Now, that is not enough, but Chhattisgarh doesn’t have enough RT-PCR machines and technicians to do more, Zachariah said.
UNICEF has now appealed to the private sector to help reduce the strain on the public health care system. It has asked for contributions to help procure oxygen generation plants, testing systems, personal protective equipment, and hygiene kits.
Earlier this year, when cases were falling across the country, the Lancet COVID-19 Commission’s India task force convened to chart a path forward. “The country did go into a phase of complacency,” Chandrika Bahadur, director of the SDG Academy and convener of the task force told Devex. “It was an epidemiological puzzle, and there was no definite answer for why the numbers were going down, so many believed the worst part was over.”
As cases slowed, she says, India shut down special facilities that were set up during the first wave. They’re now being re-opened, but that takes time. “The challenge,” she said, “is the speed at which the virus is spreading.”
In its report submitted this month, the task force advocated for medical and non-medical interventions, reiterated the need for ramping up the vaccination program, and recommended against strict lockdowns that will severely affect livelihoods. It also called for strengthening India’s health care system.
“India’s health care is terribly underfunded and COVID-19 has exposed that in a brutal way,” Bahadur said.
“We had almost 15 months to prepare for this — the government should have spent more resources on setting up hospitals and preparing for the worst case scenario.”— Dr. Kafeel Khan, volunteer, Doctors on Road
This brutal wave belies the sense of safety imparted when India kicked off its vaccination program, touted as the world’s largest, in January. “As soon as the vaccines arrived, health care workers thought it would give them relief. But it was like you were almost winning a cricket match, but suddenly you lost all your wickets,” Kalantri said.
Health care workers on the front lines are also dealing with burnout and the emotional fatigue that accompanies months of dealing with so much death, he said. “Usually, even if doctors are in the ICU, they have a sense of satisfaction about their work. This time, they’re fighting a losing battle.”
In his hospital, a quarter of the health care workers have contracted COVID-19. The impact of the virus on doctors and nurses is grossly underestimated, he said. “Nobody is willing to admit that we have a shortage of professionals: from doctors to nurses to biomedical staff. We’re not talking about how to increase these numbers, and how to motivate them [health care workers].”
Taking into consideration the paucity of health care workers, especially outside big cities, some doctors have taken the initiative to set up volunteer groups that travel to rural areas to conduct consultations. Dr. Kafeel Khan is a member of such a group, called Doctors on Road.
“Primary health care is in shambles — forget beds and oxygen, there is no way to get an RT-PCR test done,” he told Devex.
“We had almost 15 months to prepare for this — the government should have spent more resources on setting up hospitals and preparing for the worst case scenario. Instead, there was a false sense of victory,” Khan said.
Along with 70 other doctors, he has been traveling to remote districts in the states of Uttar Pradesh and Bihar. “Wherever we go, people are desperate and they’re clueless on how to seek treatment,” he said. “All this should have been addressed in the first few months of the pandemic.”
Lack of genomic sequencing and bungled guidelines
India’s genome sequencing efforts point to the circulation of several variants, including B.1.1.7 (the U.K. strain), B.1.351 (South African variant) and P.1 (associated with Brazil). Also in play is a new double mutant variant, B.1.617, first identified in India. As the virus mutates further, it poses a risk to an already overstretched health system and the effectiveness of the extensive vaccination program.
Experts say the testing continuum needs to incorporate robust genome surveillance systems as well to adequately fight the virus.
“Such a genomic surveillance network will become a critical part of a global genomics surveillance system that detects, tracks, and mitigates the spread of pathogens anywhere in the world,” Manisha Bhinge, the managing director for programs at The Rockefeller Foundation’s health initiative told Devex by email. India has sequenced less than 1% of its total positive samples, which impacts how health care workers understand and tackle treatment.
Added to the lack of information about variants is also misinformation and lack of clear medical guidelines and drug therapies. “The national protocol has been terribly haphazard,” Kalantri said. “This is also the failure of the medical profession and scientific bodies that we weren’t able to communicate what works and what doesn’t,” he said.
He said he still gets calls from patients to arrange for the drugs that have no clear evidence of being beneficial in the treatment of COVID-19.
“These are desperate times but we need to be honest — we need to tell people that remdesivir and plasma don’t work,” he said. He also acknowledged that in the absence of robust policy, people only have “hype and hope” to hold on to.
He’s not very convinced himself. “I see no light at the end of the tunnel,” he said.