The coronavirus situation in India offers a sobering reminder of how quickly a pandemic can escalate. With half of the world’s new confirmed Covid-19 cases from India this past week, hospital beds and oxygen are in short supply. Official estimates of mortality are staggering at 4,000 deaths, every day, but the actual numbers may be much higher. But not long ago, India felt that it had dodged the bullet; a feeling that Narendra Modi, India’s Prime Minister, gave voice to at the World Economic Forum on January 28th: "(India) has saved the world, entire humanity, from a major tragedy by effectively controlling coronavirus."
What went wrong?
While it will take months, if not years, to identify the precise triggers that set off this surge, a few things are clear. First, the relatively muted waves over the past year created a sense of exceptionalism and false security, leading to compliance fatigue among the general population. Second, the danger of this gradual movement away from mask-wearing and social distancing was exacerbated by a government that encouraged large election rallies (for instance, in West Bengal) and religious festivals. April saw massive gatherings for the Kumbh Mela seeing millions converge in one location. Third, even as India produced vaccines for the world, its own vaccination rates remained low and ultimately plummeted as vaccine shortages riled the industry. Fourth, states like Delhi were woefully unprepared for a surge of this magnitude, and worse, leadership crumbled leaving civil society and citizens to negotiate an increasingly treacherous medical landscape.
Unfortunately, Pakistan shares many of the ingredients in this deadly cocktail.
There is a belief that the low prevalence and mortality rates in the first few waves implies we must have some natural immunity. Our recent wave has started with a similar decline in compliance. With the coming of spring came large weddings and large political rallies. With Eid around the corner, there is no shortage of religious fervour and a chance that extended vacations may mean even larger gatherings of extended family.
The data are already showing that Pakistan may be headed into a similar catastrophe.
First, Pakistan’s positivity rate has remained higher than India and in February this year, its positivity rate was even higher than India’s. And while it has stabilised in recent weeks, there is no guarantee that this stability will hold. Even these numbers may understate the extent of the pandemic — India dramatically increased its testing as cases rose, but Pakistan’s testing has remained the same even as cases have increased. In India, 1.26 samples are tested daily per thousand people while only 0.2 tests are performed daily per thousand people in Pakistan.
Second, mortality rates have risen: April 27, 2021 was the worst day in terms of Covid-19 deaths, and April was the worst month since June 2020.
Third, Pakistan spends even less than its neighbour on healthcare. The country faced massive shortages of ventilators and plasma in the first wave, which was a blip compared to what India is experiencing now.
Fourth, we cannot pin our hopes on vaccines. As of May 8, 2021, 9.66% of India received at least one dose of vaccine, whereas Pakistan’s number had barely crossed 1% by the end of April. Although the only way out of this pandemic is to immunise a large fraction of our population, clearly this is not happening any time soon.
The fact of the matter is that we need to act now. But how?
First, continue testing, emphasising and subsidising mask wearing and other protective measures (Mobarak, 2021), and imposing smart lockdowns as the government has already done with markets closed in the evening. Although it is a big ask of a population that is tired and wants to celebrate, the closures of the chand raat bazars, tourism destinations, inessential businesses, educational institutes, banquet halls and any sort of large gatherings will have to continue.
Second, India’s surge pattern offers some insights on where things could go wrong. Specifically, the places that were first hit in India's surge were exactly the same as the areas that were hit in the previous surge. This is data that Pakistan has, and it should set up special monitoring cells for those districts and urban areas that have already experienced a surge. If hospitalisations and positivity rates in these areas start increasing, alarm bells should ring.
Third, the time to source and procure oxygen cylinders and concentrators is now. Although, as they should, much of the market will go to India, a fair way to proceed is to put in advance orders for mid-June by when the surge in India is expected to decline. These cylinders and concentrators must be centrally warehoused and managed by our disaster management teams. Pakistan has had considerable experience handling logistics with big disasters like the floods in Punjab and the earthquake in AJK and KP, and the same urgency combined with quiet efficiency needs to be put in place now.
Fourth, contractual arrangements with private hospitals for “surge capacity” beds need to be put in place right away. Clear guidelines and financial arrangements (for instance, markers that will force private hospitals to dedicate 20%, 50% and 80% beds must be decided on without delay) will help reduce confusion and contractual delays in case of a surge.
Fifth, the surge in India continues to hit some areas worse than others. This means that mobility —whether of doctors and equipment, or of patients, can save lives. Cross-district movement of doctors and what will be required to put this in place are policy decisions that need to be made urgently. Similarly, what vehicles can be requisitioned if a sudden increase in ambulances is required needs to be thought of.
Sixth, India is fast discovering that relying only on hospitals will not work in an out-of-control surge situation. The limiting factor, even when oxygen is available, are the human resources. There just aren’t enough doctors and nurses to handle vast patient increases in hospitals. The fact of the matter is that many patients can be managed in a field setting and training paramedical staff to provide oxygen takes less than an hour. How to set up field hospitals quickly in key rural areas so that people do not need to travel to cities (therefore decreasing the pressure on urban hospitals) is a final critical step that Pakistan can take.
Disasters become catastrophes when there is no advanced planning. India’s situation tears at our hearts and we must at this time do everything we can to help. At the same time, we have to realise that complacency on the home front can turn to catastrophe at the blink of an eye and we must be ready to deal with it.
The Analytical Angle is a monthly column where top researchers bring rigorous evidence to policy debates in Pakistan. The series is a collaboration between the Centre for Economic Research in Pakistan and Dawn.com. The views expressed are the authors’ alone.
This article was an effort of CERP's SCALE consortium which consists of Pakistani and international researchers and experts on epidemiology, public health, applied economics, statistics, public management, technology and data analytics. They have been working on a containment plan in an informed, feasible and timely manner.