The scourge of COVID has wreaked havoc on the contemporary world. More than 17 crore people have been infected around the world till date, with more than 37 lakh people succumbing to the dreaded pandemic. India has seen 2.84 crore people being infected, with 3.38 lakh casualties till date. While Biden and the US administration is still delving on the question of whether the pandemic originated from lab-leak in Wuhan, the key point is to strategize and fight the pandemic to the best of our abilities. Prime Minister Narendra Modi announced a 21-day lockdown on 24 March 2020, along with announcing ₹15,000 crore stimulus for healthcare spending for boosting healthcare resources such as PPE kits, isolation wards, hospitals, ventilators and beds. By February 2021, COVID case counts had gone down and experts said that the country may not face a second wave. Demand for ventilators and hospital facilities had gone down, and healthcare workers were pleasantly surprised by India’s good fortune. How did we go from this rosy picture to the grim one it acquired by April 2021? Corpses piled up in makeshift crematoriums and dead bodies were found floating in the River Ganga, an oxygen crisis emerged and hospital beds became scarce, black-marketing over medical equipments reared its head. The second wave came like a squall, destructive and more deadly than the first wave. For this analysis and essay, I got the privilege of interacting and working with Ms. Xinxin Zhang, a friend from my Cambridge days, who lived in Wuhan and closely saw the steps being undertaken by the Chinese government to contain the pandemic. Regardless of the claims of their government, I will bank upon the word of my friend here to try to see how China has been able to reach a good position. Whether that is actually the reported 7-day average of only 20 cases today is a different story! While there may be people who will be apprehensive about these figures, it will be insightful to compare and see the strategies taken up by the two Asian giants, how they were similar and where they were different, and finally: what India got right and what it could have done better in its fight against COVID.
Wuhan Roadmap and the Chinese Response
The Chinese government (rather China’s first biosafety level 4 laboratory – the Wuhan Institute of Virology) has been blamed by many for the outbreak of the pandemic, and if proven to be the case, they must be held accountable for the same. If there is any negligence or intent involved, it will be regarded as among the worst crimes in human history. In a recent study conducted by Norwegian scientist Birger Sorensen and British Professor Angus Dalgeish, it was claimed that the COVID virus was not naturally occurring but was created by Chinese scientists in a laboratory, using forensic analysis of experiments undertaken in the laboratory between 2002 and 2019. The British Intelligence has also recently said that the lab-leak theory can be feasible with Parliamentary Under-Secretary of State for COVID-19 Vaccine Deployment Nadhim Zahawi demanding the WHO to study the origins of the virus. On the other hand, a WHO report in late March 2021 concluded that it is highly unlikely that the virus was leaked from a lab. Whether this was due to political pressures and geopolitics and the report is not accurate or the people alleging the lab-leak theory are purely conspiracy theorists cannot be resolved without a comprehensive probe and analysis. I am apprehensive about the Biden probe as well, since it seems like a convenient tool to give the appearance of concern and an investigation that shall eventually close citing lack of evidence. This essay is, however, not on that, since the time till which there isn’t definitive evidence this discussion is largely speculative. Whatever may be the reality of the origin of COVID and however distorted may be official figures of cases from China, the response from their government has been able to contain the virus significantly. Let us see what they did, to fight the pandemic.
China started with extreme measures at the beginning of the breakout. It implemented an unprecedented lockdown in Wuhan and across the country for over 2 months, besides building two large-capacity hospitals dedicated to treat COVID patients in Wuhan in ten days. Their government undertook consolidated national control, with mask-wearing and temperature check being made mandatory for all public places across the nation. Places as small as a district and a block have been classified by risk levels: high-risk, medium-risk and low-risk classes. Unnecessary traveling in and out of high and medium risk areas has been strictly prohibited until the risk level change to low risk. Mandatory quarantine is required for necessary travel in and out of high and medium risk areas. There have been unified travel policies in all domestic cities and provinces during recovering phase. For instance, a negative nucleic acid testing report done within seven days has been required for any inter-city movement. They also undertook comprehensive information tracking, with measures such as Health QR code. Everyone is required to obtain a “Health code” on his/her smartphone by filling out information including his/her health conditions, personal identifications, location and travel history. A green “Health code” indicates one doesn’t experience any COVID related symptoms or was exposed to any risks thus is considered to be “safe”. A green “health code” is required for one to enter any public places or travel to another city. There are other type of smartphone tracking programs that are widely required for public space entrance and inter-city traveling such as “Travel big data” in which it records the cities one has been to in the past 14 days. The comprehensive information tracking system allows for a quick and relatively accurate detection of new cases in the public and those who maybe affected. A major area they have paid attention to is rigorous testing regulation. When a new case emerge, a mass testing of all potential affected population is required to carry out. For instance, when there are ten new cases emerged in a district, population of the entire district, the neighboring districts and even the entire city would be subject to mandatory testing. The government undertook schemes to educate the public in scientific hygiene practices. Scientific hygiene practices such as frequent and thoroughly hand-washing, use serving cutlery when eating with others are being widely promoted through modes such as public posters, mobile phones and televisions. There has been a call for rejection of non-scientific treatments and false or unofficial information related to COVID-19 in the public. Public places are being disinfected frequently, mask vendors and hand sanitizers are supplied in most public places.
There has been a major element of decentralisation that has worked wonders for China in its response to COVID. At the grassroots, the Residential Committees (RCs) played a critical role. These are not quite part of the state but rather institutions of self-governance. Such committees are instruments for the party to govern effectively and also exert political control. The RCs are supposed to implement policy, perform administrative tasks, help in mediating local disputes as well as help governmental agencies to maintain health and sanitation, public surveillance and care for the elderly. When COVID struck, after the initial confusion, the Residential Committees took the initiative and charge to respond to the problem on the ground. For instance, the 7,148 communities in Wuhan were completely closed off. Rules of entry and exit were strictly enforced by community workers. Residents were not allowed to leave and non-residents were not allowed to access the community area other than for epidemic control or essential medical needs. There volunteers assigned for different shifts at the gates of the communities, who would also check access passes. These volunteers would keep a tab on family members’ status and health condition, conduct regular temperature checks on residents at their homes as well as gather information regularly about travel history of the residents. If there was anybody in self-quarantine or was aged, the RC workers would provide home delivery of daily food. They also traced contact, visited and registered each individual, placed sick individuals under community management and transferred them to designated medical units for quarantining. These volunteers and workers were mainly college students and youth, and this model was the ‘first line of defence’ of China that was pursued across the country. The government of China supported these workers with incentivisation and support such as insurance, subsidies, publicity, provision of health equipment and other institutional support. While India has many such residental groups and committees, what lacks thereof is a centralised plan of action, which the RCs of China have. There must be clear channels to pass forward resources and authority from the central to the local bodies. Volunteers need to be utilised by local governmental organisations, which are empowered by higher authorities, to disseminate information, deliver services and promote social distancing.
The story is however not all-the-way rosy. The Chinese government formally notified WHO on 3 January 2020 that a `severe pneumonia of unknown etiology’ had been discovered in Wuhan. But for the first three weeks of the month, Chinese officials said there were only a few dozen confirmed cases and actively downplayed the risk of human transmission. From local officials to county governments, there was complacency across the board with regards to immediate actions and steps to be taken. By the time the situation in Wuhan was completely out of control, other cities that were just an hour’s drive away were entirely unprepared. Even when an Imperial College study found that there had to be about 4,000 symptomatic people in Wuhan for it to have spread as far as Bangkok and Tokyo, the complacency and negligence was visible in how a large annual legislative meeting as well as a pre-Chinese new year dinner with 40,000 families participating in the latter was held in Wuhan on 18 January 2020. The Chinese government and WHO downplayed growing concerns about whether the COVID virus could be transmitted between humans. Maria Van Kerkhove, then-acting head of the emerging diseases unit of the WHO, on 14 January 2020 said that there had been “limited human-to-human transmission” in Wuhan. Zhong Nanshan, Chinese epidemiologist and Chinese government adviser, finally confirmed in an interview with the Chinese state media on 20 January 2020 that the virus could spread between people. Externally, President Xi Jinping and his administration sought to downplay the threat that the virus posed and initially lobbied against `excessive actions’, be it an early declaration of a global health emergency or any form of a travel ban aimed at Chinese nationals. It was hypocritical of the government to change its mind on the wisdom of travel bans in late March 2020 when the virus was coming under control in China but was spreading unchecked in USA and Europe, so that foreign arrivals can be barred. When it comes to the decentralised model of China in tackling COVID, there have been reports of shortages of food items and medical supplies on the ground, along with instances where Resident Committee members suffered from deteriorating mental and physical health, burnouts and frustration. Lack of training and standard (albeit encumbering) procedures of bureaucracy hampered the response on the ground. Personally and more recently, I also do not appreciate and, in fact, highly condemn the way in which the Chinese State media and propaganda machinery have sought to use the crisis that came with the second COVID wave in India as an opportunity to undermine us. In May 2021, official accounts on Chinese platforms such as Baidu and Sina Weibo have posted messages mocking scenes of funeral pyres at cremation sites in India.
The Modi Module and Falling to the Second Wave
After the lockdown in March, the government faced the dilemma of how to undertake a balanced approach so as to protect both lives and livelihood. Taking a page out of how the country had faced and contained previous epidemics, India focused on cluster containment as well as breaking the chain of transmission in March 2020. Virus testing was put as a primary pillar of the response by the government with 52 labs named that were capable of virus testing by 13 March 2020. On the 14th, the National Institute of Virology was able to isolate a strain of the novel Coronavirus, thereby making India the fifth country to be able to do so. On 17 March 2020, the Union Ministry of Health (Government of India) decided to allow private (pathology) laboratories to test for COVID, with the Pune-based Mylab Discovery Solutions becoming the first Indian company to have received regulatory validation for its RT-PCR test on 24 March 2020. In April 2020, the Institute of Genomics and Integrative Biology in Delhi developed a low cost paper-strip test that could detect the Coronavirus within an hour, with each test costing ₹500. On 16 April 2020, China dispatched 6,50,000 RNA extraction and rapid antibody test. In May 2020, the National Institute of Virology introduced the antibody test kit called ELISA for rapid testing, with it being able to process 90 samples in a single run of two and a half hours. By the third quarter of 2020, India had attained the highest number of daily tests in the world! In terms of ways to tackle COVID, an insight was obtained from Rajasthan, where a combination of anti Swine flue, anti-malaria and anti-HIV drugs led to the recovery of three COVID patients in March 2020. On 23 March 2020, the National Task Force for COVID-19 recommended the usage of hydroxychloroquine for treatment of COVID patients, especially high risk cases. India approved the use of the repurposed antiviral medication Favipiravir for the treatment of mild to moderate Coronavirus symptoms in June 2020, the use of Biocon’s repurposed medicine Itolizumab for treating chronic plaque psoriasis (a symptom of the disease) in July 2020, the use of Cadila Healthcare’s repurposed Peginterferon alfa-2b in April 2021 and the use of DRDO’s 2-deoxy-D-glucose, which was developed with Dr. Reddy’s Laboratories, as an adjunct or alternative therapy for treating moderate to severe cases of COVID-19, in May 2021. When it came to medical supplies, India quickly became a leader and pioneer in the production of both vaccines and medical equipments. From having negligible capacity in previous years, India started producing 2 lakh N95 masks and 2 lakh PPE kits per day in May 2020, with Indian being the world’s second largest producer of PPE body coveralls by the second half of May. Vaccine-wise, the Oxford-AstraZeneca vaccine, manufactured by the Serum Institute of India under the name Covishield, and Bharat Biotech’s vaccine Covaxin (BBV152), developed in association with the National Institute of Virology (NIV) and the Indian Council of Medical Research (ICMR), were approved for usage, with India launching its vaccination program on 16 January 2021.
In terms of precautions, the total lockdown of March 2021 entailed that all non-critical services and businesses were ordered closed except for pharmacies, grocery stores and hospitals, and there was a complete ban on citizens leaving their homes for non-essential purposes. The measure was so stringent and effective that the Stringency Index of the Oxford COVID-19 Government Response Tracker gave India’s response to COVID the highest score of 100 based on 11 indicators. On 16 April 2020, districts were divided into zones using a colour-coded tier system based on incidence rates, classified as a “Red” (hotspot), “Orange”, or “Green” (little to no transmission) zone, with all of India’s major cities falling into Red zones. Beginning from 20 April 2020, stores that sold farming supplies and agricultural businesses, along with cargo transport, banks, government centres distributing benefits and public works programmes, were allowed to resume operation, although Phases 3 and 4 of the lockdown extended till 31 May 2020, with small changes and relaxations. By mid-May 2021, around 18 of India’s states and union territories had some kind of state-wide and local restrictions. India had constituted various committees, advisory groups and task forces to guided the COVID response of the country, including the National Technical Advisory Group on Immunisation (NTAGI) and the Integrated Disease Surveillance Programme (IDSP). The Prime Minister and his office have led India’s COVID response, with almost 70 review meetings having been held by it between January 2020 and May 2021. The Indian military and private entities have supported the Indian government’s response during the pandemic, in myriad ways. Not only did we try to fight the battle within our country around the first wave, we also helped other countries. The Indian government provided around 66 million doses of COVID vaccines to 95 countries, of which 10.5 million doses were gifted while the others were COVAX and commercial obligations, between 20 January 2021 and late March 2021.
This benevolence was reciprocated during the second wave, when in late April 2021, international relief for COVID to India significantly increased, with countries Romania, France, Ireland, Portugal, Belgium, Germany, Luxembourg, Sweden, Singapore, Bahrain, Thailand, Saudi Arabia, Russia, Taiwan, China, Bhutan, Kenya, Bangladesh, Switzerland, Kuwait, Poland, Israel, Netherlands and UNICEF having sent all manner of support and aid. With all these steps, however, in September 2020, India was seeing almost 1,00,000 new COVID cases each day. The economy was nosediving and hospitals were packed. But within four months, the COVID cases in India dramatically declined, with there being only about 9,000 new daily cases by the end of January 2021. This sharp fall came with increased testing and prompt reporting to hospitals by COVID patients. India’s strict mask policy also helped, with PM Modi’s move to wear a ask while appearing on television sending a clear message to the masses even as he led by example. In many parts of India, such as in Mumbai, those not wearing a mask were handed tickets and fines by the police. Massive awareness building exercises have also helped. On phone calls, instead of simple ring-tones or songs-based caller-tunes, one hears government-sponsored messages warning everyone to wear masks, wash their hands and get vaccinated. A review of hundreds of scientific articles, published in PLOS One in September 2020, found that wet and warm climates seem to reduce the spread of COVID, thereby giving India an additional help, although research published in GeoHealth in December 2020 highlighted that urban India’s severe air pollution could increase COVID, both in the environment and within individuals’ bodies.
This happy story did not last long. We had the second wave in April 2021. One of the key aspects that may have led to problems was the lack of effective disease surveillance through Integrated Disease Surveillance and Response (IDSP) due to lack of manpower, funds and comprehensiveness. For instance, Integrated Disease Surveillance and Response (IDSP) does not track deaths due to COVID of those not tested or deaths outside hospitals. A number of problems have also been found with the modeling and forecasting by the National COVID-19 Supermodel Committee by various commentators, with the committee saying that they had not been able to predict the second wave accurately, in May 2021. To make matters worse, the Indian Council for Medical Research (ICMR) did not update the treatment protocol for COVID between July 2020 and April 2021. A major cause of concern nationally has been the lack of epidemiologists in various positions in the state and national decision-making bodies and strategy-making units for COVID. More specifically with regards to the recent surge, it is shocking to see reports that the National Task Force for COVID-19 did not meet in February and March 2021 despite certain members claiming a second wave was imminent. Other warnings with surges in cases in March, shortage in medical equipments particularly oxygen and an imminent second wave were brushed aside. More generally, the long-term and general issues of the Indian public health system posed a lot of problems for India’s response to the second wave. While political leadership and social cooperation saw even the Char Dham Yatra being conducted in a regulated way with only around 4.2 lakh pilgrims in 2020 as opposed to 38 lakh in 2019, there were instances where super-spreader events, mostly religious or political, took place, such as the Tablighi Jamaat congregation in Delhi in 2020, crowded election rallies organised by various parties in the run-up to the State elections in West Bengal, Tamil Nadu, Kerala and Assam and the Haridwar Kumbh Mela in 2021, although the Mela organisers have put forth a rebuttal claiming based on facts that the mega-event in Haridwar was not a super-spreader.
While measures were taken in some of these cases, I feel more could and should have been done. In general, people seemed to have felt a sense of accomplishment and complacency prematurely after the first wave had waned. Mask usage dropped, medical stockpile preparedness for a bigger wave was underwhelming. It almost seemed like the Battles of Tarain syndrome had returned: one victory made us so complacent that we were underprepared and caught out in the next battle we faced, with the same enemy. Infections have increased over time and yet the pace of vaccinations has not caught up. India has administered a whopping 150 million doses, making it the third-highest in the world. However, the massive population of India means that only about 9% of Indians have received atleast one dose and less than 2% are completely vaccinated. A glaring problem in this is the lack of quick and strong government support to private-sector vaccine R&D and manufacturing firms by the Indian government. To give you some context, the United State invested $18 billion in this sector, through Operation Warp Speed, and placed orders for vaccines from May 2020 onwards. On the other hand, the Indian government did not makes its first official purchase of the vaccines produced in India until January 2021, with the idea seemingly being that domestically manufactured vaccines shall be made available for domestic use. This left these manufacturers cash strapped, with vaccine manufacturers like the Serum Institute being funded independently by entities such as the Bill and Melinda Gates Foundation. This was even as they had to balance sales domestically, to other low and middle income countries and also into the global vaccine distribution initiative known as COVAX. To make matters worse, these manufacturers have been unable to get raw materials easily, especially with export restrictions by major players like the United States.
The Indian government is taking increasingly more proactive steps lately. The central government recently approved advance purchase payments for Bharat Biotech and Serum Institute worth over ₹4,500 crore in advance payment. Recently, the government announced a string of measures for dependents of those who lost their lives due to COVID, among other benefits such as utilising the PM Cares to pay for education, care of children orphaned by COVID. For the first time, a pandemic has been declared a notified tragedy by the Ministry of Home Affairs of the Government of India, following the global spread of COVID, and thereby India’s Disaster Management (DM) Act has been invoked. India has faced an uphill task with its large population and dysfunctional federalism with the inability of governments across the country to prepare for the second wave and alleged lack of cooperation by state governments such as that of West Bengal under CM Mamata Banerjee. Since China has a humongous population as well, we could look at what worked therein. What we can take from China’s approach to fight COVID, particularly its steps in Wuhan, is the effective use of stricter lockdowns (high penalties even when there are violations done by people during temporary relaxations), micro-containment strategies and modular approaches to fighting COVID (with temporary hospitals, evidence-based policy making at every phase of the pandemic as well as decentralising the command chain as much as possible into local units albeit with a well-planned modular elements, centralised planning and clear-cut timelines for, as well as expectations from, units on the ground).
We need not be led by the Chinese model at all, but it is pertinent to be informed about best practices that have yielded good results elsewhere, where there has been a large population fighting COVID, ere possibly supplementing our approach with any significant actions that may help our battle against the pandemic. This time let us not show triumphalism and declare victory on the virus so quickly, even if the second wave were to wane (hopefully soon). We have to look towards short and local lockdowns in the event of future surges of the virus, even as we are some way off from herd immunity and our vaccination rate remains slow, with regards to percentage of our entire population. We must enforce regulations strictly and support and deploy research and development on vaccines as well as medical best practices to fight COVID. In all of this, we must remember that the crisis we see looming in front of us is colossal, and alongwith strict policy and regulation by the central and state governments, needs proactive steps taken by, and discipline of, civil society and citizens. The more we are disciplined, decentralised and dedicated in fighting COVID, albeit with centralised planning and strategy, more likely are we to come out of this war against the pandemic, victorious.
The future is in our hands!
Banner Courtesy: Baranagar Mission