Dr Gajendra Singh is a Medical Graduate and Public Health Specialist with 15 years of diverse experience in Health System Strengthening in Program Management (Immunization, Maternal & Child Health, Family Planning, and Reproductive Health).
Alyssa Nagrath is a young researcher engaged with organisations like UNGCNI, Foundation for Community Consensus, and UNICEF. Having been a youth delegate in interactions with ambassadors and the youngest member of the UN75 team, she brings a unique global perspective to her research.
COVID-19 response is an essential component of almost every branch of government. However, because of its unprecedented nature, it initially appeared to policymakers as a nightmare. This article attempts to examine India’s response to the pandemic based on information available in the public domain and experience gained through close collaboration with the government. It includes the government’s various efforts and steps at all levels – prevention, treatment, and COVID vaccination. The article also suggests some steps to make India’s response the best in the world.
COVID-19 has caused over 230 million infections and more than 4.5 million deaths worldwide. With 33,380,438 infections (14.7% of total) and 444,724 deaths, India ranks second (9.5% of total). These figures are sufficient to tell the story. For nearly a year, governments and societies have turned inward to combat an invisible foe, exposing competing structures, vulnerabilities, and political priorities. The question that many policymakers and subject experts are still interested in is which country handled the crisis better and how. More review is required in a large and diverse country like India.
In this article, COVID-19 responses of countries are examined from the beginning to the end of July 2021. No single country can be named the undisputed winner for the right efforts at the right time for the right people and getting the right results. India’s response to the COVID-19 pandemic was manageable until 2021 when a deadly second wave of coronavirus infections devastated the country. In the middle of April, India was responsible for more than half of the world’s daily cases, setting a new record of around 400,000 per day. The healthcare system was in shambles due to a lack of ambulances, PPE kits, hospital beds, essential medicines, oxygen cylinders, and other supplies. For most of May and June 2021, India remained the second-worst affected country.
The India Story
If we recall the initial response of India, the sequence of events was as follows:
2020:
- 30th January: First confirmed case
- 1st February: First airlift from Wuhan, China
- 27th February: Final airlift from Wuhan, China (759 Indians and 43 foreign nationals) and airlift from Japan (119 Indians and 5 foreign nationals)
- 3rd March: Total Cases – 5
- 6th March: International passenger screenings at airports
- 10th March: First airlift from Iran
- 11th March: First airlift from Italy
- 12th March: First confirmed death
- 13th March: Suspension of non-essential traveller visas
- 15th March: 100 confirmed cases
- 16th March: Passenger land border crossing suspended
- 22nd March: Final airlift from Italy (564 Indians), 14-hour curfew
- 25th March: Nationwide lockdown imposed till April 14, Case Count – 606
- 28th March: 1,000 confirmed cases
- 29th March: Final airlift from Iran (764 Indians)
The first few cases had travel histories from Wuhan, Japan, Dubai, Italy, and other places. As a result, COVID-19 cases in India were initially thought to be due to the country’s global nature and constant connections abroad, rather than transmission within the country. To contain the spread, the Ministry of Health and Family Welfare issued travel advisory restrictions, including the imposition of self-quarantine rules for all incoming international travellers for 14 days. Furthermore, travel visas for other countries were restricted until April 15. On March 16, 2020, various interventions such as social distancing were proposed to avoid/decrease the rate and extent of disease transmission in a community. Following this, a series of lockdowns were imposed.
The question here is whether all of the actions taken in the first 45 days (from the first case on January 30 to the 100th case on March 15) were sufficient to deal with the situation, or if those were standard precautions taken in previous pandemics such as SARS, Ebola, and bubonic plague, or if we missed an opportunity to combat the disease by not timely delaying air travel to India.
Actions at the Prevention Level
Till mid-March 2020, awareness about the virus gained momentum. Public health interventions focused on massive awareness generation including the implementation of strict social distancing norms, updating clinical guidelines for State Governments and local authorities, mobilisation of appropriate resources from the private sector, and the implementation of the most severe form of movement restriction (national lockdown).
On the MoH&FW website, awareness materials on “Do’s and Don’ts” were provided in all regional languages. Posters regarding social distancing, hand washing, and cough etiquette were among the resources provided. Following then, information was widely disseminated through all types of media. Efforts were stepped up at the national, State, and district levels. The Ministry of Health and Family Welfare (MoH&FW) coordinated national awareness initiatives and oversaw the uniform execution of recommendations at the State level, where States were in charge of regulating the dissemination of information for disease containment at regional/district levels. Notably, all cellular networks in the country supported the campaign by playing a “coronavirus awareness ringtone” every time a number was dialled. This ringtone teaches cough etiquette, reiterates COVID-19 symptoms, offers a helpline number for medical assistance, and cautions against discrimination against healthcare personnel and COVID-19 patients.
Not surprisingly, social media and other information outlets were loaded early on with false information, including support for unproven therapies by homoeopathy doctors and others. To address this, the Government issued regulations with penalties for the spread of false information, and the MoH&FW website incorporated blogs and materials to address fact checks and myth busters. To promote communication and answer queries promptly, the Government introduced the @CovidIndiaSeva platform on Twitter. Meanwhile, Gram Panchayats (local authorities in villages) were empowered to spread awareness in remote villages.
India also introduced a mobile application – Aarogya Setu – which already crossed 100 million+ downloads. It uses contact tracing to record details of all the people you may have come in contact with as you go about your normal activities. If any one of them, at a later point in time, tests positive for COVID-19, you are immediately informed, and proactive medical intervention is arranged for you.
Further, travel and lockdown restrictions were imposed. The Government issued travel advisories and imposed travel restrictions in January. Entry screenings with self-declaration forms were initiated for all travellers returning from China. The screening process was expanded in February to include seven more countries. With Italy and the Republic of Korea becoming hot spots, the Government of India issued a requirement for a COVID-19 negative certificate for all travellers returning from these countries. The implementation of this mandatory clause caused chaos among Indians returning home. Soon after WHO declared COVID-19 a pandemic, several visa restrictions were introduced by the Indian Government. Passengers with travel history were monitored for 14 days upon arrival to the country, either at home or in quarantine facilities depending on the presence of symptoms or history of high-risk exposures. Later, travel restrictions were expanded with the closure of border checkpoints of neighbouring countries. Eventually, India closed its borders on March 25, 2020.
Compared to countries like Italy, UK and USA, India was very quick to implement strict social distancing policies. With 606 cases on March 25, 2020, a nationwide curfew called the “War Against Coronavirus” was imposed to prevent the local transmission of the virus. Wearing masks was made mandatory. Only essential providers such as hospitals, grocery shops and pharmacies were allowed to stay open. The national lockdown was later extended, given the increased number of cases going beyond 10,000. This was termed Lockdown 2.0, which further underwent two more extensions. The first travel ban was implemented on extremely short notice, causing chaos among Indians returning home.
On the other hand, the sudden implementation of the national lockdown left millions of migrant workers stranded in different parts of the nation with no means of transportation to reach hometowns. As a result, millions of migrant workers started walking over 100 miles by foot, deprived of adequate water and food supplies to reach their families. The Indian Railways began operating 1600 special Shramik Trains to transport more than two million migrant workers. All migrant workers returning home had to undergo mandatory health screening and 14-day quarantine at designated quarantine centres.
Despite these interventions, infections continue to increase. The first lockdown failed to flatten the curve. Despite 68 days of lockdown in 4 phases (March 25 to May 31, 2020), cases increased from 606 to 182,143, and the number of deaths went from 10 to 5164.
Actions at the Treatment Level
COVID-19 treatment in India was late to arrive, and a lack of coordination in public policy resulted in poor outcomes, particularly in the second wave, as previously mentioned. Due to a lack of required medication, oxygen cylinders, hospital beds, PPE kits and Remdesivir injections, mortality rates increased dramatically. Mortality rates reached a stage where crematoriums were full, and bodies heaped one on top of the other. India lacked the medical resources necessary to treat COVID patients appropriately.
The second wave affected India harder than any other country, as evidenced by the fact that it now has the highest number of COVID cases and a damaged healthcare system. The healthcare system collapsed massively due to a lack of preparation by policymakers, who, although knowing that a second wave was on the way, did not take the required steps to increase supplies and suppress needless social contact such as political rallies. Despite repeated warnings about the potential of a second outbreak and the emergence of new strains, the administration gave the impression that India had defeated COVID-19 after several months of low case counts.
In addition, incidences of COVID treatment-related disorders such as Mucormycosis increased dramatically, raising concerns regarding the use of combinations of repurposed and experimental drugs as a one-size-fits-all solution. Researchers, doctors, and people have been disputing on social media whether over-prescribing medications are to blame for the increased number of illnesses among COVID patients. Steroids were also used unreasonably.
COVID-19 Vaccination
India started preparing to vaccinate its population in April 2020 by forming a Vaccine Task Force. Following this, the National Expert Group on COVID-19 Vaccine Administration (NEGVAC) was formed, and States were required to establish State-level mechanisms for the COVID-19 vaccine programme and develop cold chain points by October 2020. The Health Ministry also released a communication strategy for the vaccination programme in January 2021, focusing on concerns such as vaccine excitement and hesitation.
The COVID-19 vaccine was first provided to the priority group – healthcare and frontline workers – on January 16, 2021. From May 1, 2021, all eligible citizens above the age of 18 years were eligible for the vaccine. Registration for the vaccine was streamlined through a portal created by the Government called the CoWIN portal. Although the portal was a fantastic idea, when India launched Phase 2 of its immunisation campaign for the elderly and those with comorbidities in March, the portal was inundated with millions of people trying to book a slot. The influx caused issues with the mobile app and website, with servers going down and users unable to find and book appointments. The faults were exacerbated as vaccination became available to everyone over the age of 45, including those without comorbidities, and then to those over the age of 18. The site was overburdened, and there were insufficient slots for those who attempted to log in. The Supreme Court of India mentioned in a directive that “while Co-WIN was meant to facilitate the vaccination drive, it needs more logistical support in terms of ease of access and use. The past few weeks have revealed the system’s weaknesses, especially for use in the rural regions”.
As of September 26, 2021, India has administered more than one billion vaccination doses at more than 35,000 vaccination centres, second after China with 2.17 billion vaccination doses.
Way Forward
Prevention
- The majority of deaths that happened in India can be accounted due to delay in tracking and assessing if the patient has the virus. The overall journey so far has taught that strategy of timely ‘Track, Test and Treat’ is the key to combat this pandemic.
- Instead of stationary buildings and passive testing (testing those who come to the centres for this purpose), we should be focusing on targeted testing (testing those who are susceptible), which also includes random testing and mobile testing.
- Awareness campaigns on the various aspects of COVID prevention, treatment, vaccination, debunking of myths in rural areas should be undertaken by local healthcare workers and volunteers. Such workers are trusted and relatable to the local citizens and thus are likely to have a greater impact on people’s minds.
- Lockdown may give some temporary relief and time to prepare, but half-hearted efforts do not contribute to a scientific solution. Hence, lockdown should not be abrupt, repeated, and ill-planned.
Treatment
- India must draw from its experiences during the second wave and create a reserve of basic medical supplies such as PPE kits, oxygen cylinders, and so on to ensure that if in the future, a similar disease strikes, then it is equipped with the correct supplies to ensure treatment.
- Public-private partnerships can be very effective and critical at this juncture to create a contingency plan for manufacturing of health supplies on behalf of the Government if similar pandemics arise in the future
- Grassroot level approach can also be adopted wherein municipalities and RWAs can be encouraged to maintain a health resource bank funded by nominal fees contributed by members of the locality, complementing the use of a certain portion of funds allocated to such bodies. Local healthcare workers and volunteers can be mobilised for the treatment of low-intensity COVID-19 cases to reduce the burden on the formal healthcare system.
- Mapping of accessibility and availability of health essentials needs to be done. In areas where accessibility is the problem, infrastructural and storage facilities need a boost; in areas where availability is the problem, production facilities need a boost. Transparency must be maintained in this process so that citizens themselves are aware of the reasons behind the lack of health resources.
Vaccination
- At the policy level, proactive negotiations or bulk acquisition of vaccines and raw materials are required. Local manufacturing capability, on the other hand, requires a boost. Until India can stock up on foreign-made vaccinations or set up production lines, the domestically-produced Covishield and Covaxin remain the best chances.
- The existing supply chain and cold chain infrastructure need re-evaluations and modernisation, including public-private partnerships to ensure that transportation and storage of vaccines are done even in remote areas. While the storage requirements for the mRNA vaccines have been relaxed, a robust setup must be in place to ensure quality control. With an influx of vaccine stocks expected in the coming months, all States must have adequate resources for storage and distribution.
- Apprehension to vaccine apprehension must be addressed ahead of time, particularly in locations where enough and accurate information is lacking. Communication on behaviour change and community engagement must be done right away. Through continual health messaging, awareness campaigns, and confidence-building initiatives, all citizens should be informed about the severity of COVID-19 and the necessity to get the vaccine.
Although certain health policies are significantly more effective than others, no single hypothesis adequately explains the differences in national outcomes. Certain structural elements, on the other hand, appear to be more closely linked to favourable results. The COVID-19 pandemic is the most serious risk management challenge any world leader has encountered in the previous two years.
Is it possible that things could have been handled better? Was there enough information for anything like this to happen?
In actuality, given the circumstances and newness of the disease, every government tried its hardest to combat it. Arguments and debates over specific concerns and methods taken might be lengthy, but given India’s vast territory and diverse culture, the country’s management of the pandemic at all levels has proven satisfying and in the best interests of 1.39 billion people. Justices Shah and AS Bopanna from the Hon’ble Supreme Court of India also recently appreciated India’s response to the coronavirus pandemic that drew intense scrutiny over thousands of deaths due to the lack of preparedness for the second wave and shortages of essentials like medical oxygen.
“Given the size of our population, vaccine expenses, economic situation and the adverse circumstances that we faced… we took exemplary steps… No other country managed to do what India did,” the judges said.
However, there is little doubt that complacency and a lack of preparation contributed to the deadliest second wave that wreaked havoc on the healthcare system. Nonetheless, the COVID-19 pandemic is a hidden problem that we are all learning about regularly, including governments. To strengthen its COVID-19 management techniques, India needs to learn from the best practices of other countries and States within its own country. Provisions must be made to ensure that India is prepared if a similar pandemic situation happens in future.
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