India in a pandemic: way out of the abyss

Both, Pakistan and India, are similar in government structures and the people’s attitudes towards their governments.

To learn about government failures in India in dealing with Covid-19, we first need to identify what went wrong there. Epidemiologists consistently warned against declaring a premature victory. India had a difficult first wave which peaked mid-September 2020, while Pakistan had its first peak in June. After the first peak, Pakistan’s government started congratulating itself with self-administered awards and the Indian government followed suit even though cases were still rising. India had a difficult first wave compared to other South Asian countries, with a peak of 67 per million daily infections while Pakistan peaked with 30 and Bangladesh with 22 per million, respectively. India’s numbers kept falling until February while Pakistan already had a second wave by then. The uninterrupted five-month fall in daily cases from September 2020 to February 2021 gave India what I call a “dangerous illusion” of the virus retreating and a signal for life as “usual” to restart. Vaccination started and was seen as the final victory against the virus. Had the Indian government paid more attention to the virus’ epidemiology in other countries, it would have known that the virus was showing periodicity. Another lesson to be learned was that successive waves are bigger than initial ones. Indian epidemiologists were raising red flags but political decision-making prevailed. Big political and religious gatherings are being blamed but indoor activities as part of these outdoor activities fueled the virus transmission.

India and Pakistan started their second and third wave in February 2021. However, India is now reporting daily cases of over 200 per million, while Pakistan is under 30 per million daily cases. Bangladesh peaked at 40 and Sri Lanka is still far behind. In daily deaths, Pakistan reported 0.6 deaths per million and India reported 0.85 in their first peaks. But now India is reporting thrice the number of deaths as other regional countries once adjusted for population. Why is there such a stark difference between India and other South Asian countries?

There are multiple factors at play. However, basics of disease surveillance and outbreak response teach us to never look at just raw numbers but try to understand the full perspective. We call them caveats of disease surveillance when there is an increase in reported numbers but not an actual increase of disease. E.g., access to testing increases reported cases but does not mean disease numbers in the community have gone up. If the population is concerned about a disease, then reported numbers will rise too. But death reporting should not change. Yes, when we see the population panic, it increases pressure on hospitals causing the health system to collapse, increasing death numbers. In Wuhan, the death rate was many times higher than the Hubei province. Not because the disease was deadlier but because the health system collapsed in Wuhan. Panic drives patients toward clinical care and the clinical system in many cities cannot cope with the numbers. My suspicion is that disparity in death rates in the region is also due to the panic in India.

To come out of this abyss, the Indian government needs a new risk communication strategy which should be based on providing timely and trustworthy information with workable solutions. Some Indian public health professionals have already identified the problem and are educating the public on how to treat themselves at home and when to opt for hospitals. A real-time system of resource availability will help ease the population’s concerns. Improved health intelligence, which is beyond collection of testing numbers, should be institutionalised. This is an epic war, and we need to have the best intelligence against our enemy. We are all together in this; infectious diseases do not respect national borders!

Published in The Express Tribune, April 28^th, 2021.

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