COVID-19 Will Test India’s Preparedness To Tackle Health Emergency

Originating in China, COVID-19 has affected 188 countries infecting more than 340,000 and resulting into more than 14,000 deaths across the globe (Worldometer, 2020). Since the promulgation of revised International Health Regulations (IHR) 2005, COVID-19 is the sixth Public Health Emergency of International Concern (PHEIC) declared by WHO on 30, January 2020.

COVID-19 is a threat to a populous country like India with a population density of 455 people per sq. km according to the World Bank. Countries with the highest number of COVID-19 cases like Italy, Iran and China have a much lower population density of 205, 50 & 148 people per sq.Km respectively. Under the current circumstances, COVID-19 pandemic can bring about an explosion in the number of cases in India, where the concept of self-isolation and social distancing is relatively new. Unlike many western countries, majority of Indians reside in a joint family set up which makes self-isolation even more challenging.

Heath care delivery in India is compromised owing to various contributing factors like unavailability of skilled manpower and poor infrastructure leading to poor health indices. Despite economic growth, upto 400 million people still survive on less than $1.25 (PPP) per day. While the Total Health Expenditure (THE) for India is abysmally low at 3.84% of GDP, the public spending fares even worse at 1.18 % of GDP (National Health Accounts Technical Secretariat, 2018).  

Since the outbreak of the virus in China in late December last year, India has had an advance warning of almost three months to help prepare the country for this public health emergency. India can “flatten the curve” to handle the shock of overwhelming cases (Sharon Begley, 2020) only through social distancing and maintaining hand hygiene by the common populace. 

The Indian Prime Minister Narendra Modi in his first address to the nation post designating COVID-19 as apublic health emergencies of international concern (PHEIC) has appealed to all citizens to practice a day-long “Janta curfew”. 

Other measures too have been put in place to contain the spread viz. all restaurants being advised by the National Restaurants Association to remain closed until 31st March, closure of schools, prompt actions limiting travel by suspending all visas, cancelling trains and limiting other public transportation facilities, mandatory screening and quarantining all suspected incoming international passengers entering India. This Universal Health Screening has enabled screening of more than one million passengers at airports which has helped monitor the entry of coronavirus (Emma Charlton, 2020). On 22 March 2020, 80 districts with reported cases have been ordered to be under locked down until 31st March 2020.

While the proactive measures taken by the GoI are necessary and commendable, within the Indian context, there are several other factors that can exacerbate the abysmal state of health care delivery. First, the government sector in India has one bed for 1,844 patients and one doctor for every 11,082 patients (Dr Indu Bhushan, 2020). If COVID-19 spreads in India the way it did in Italy, it would overwhelm the precarious health system existing  in the country.

Second, India has a population of 1.3 billion and is the second most populous country globally with an average life expectancy of 68.7 years. Though, it has the youngest population with 41% less than 18 years of age (Central Bureau of Health Intelligence, 2019), as per UN it also qualifies as a “greying nation” with 8% of total population above 60 years of age (RGI, 2011). 

Data from China and Italy reveals that older adults are the most vulnerable and the worst affected by COVID-19. Currently, Italy ranks number one with a death rate of 9.26% and more than 59,138 reported cases (Shayanne Gal, Aylin Woodward, 2020). As cited by the New York Times, Italy has the oldest population in Europe (Rachael Rettner, 2020) which could be the probable reason for such a high death rate. 

This pandemic poses a greater threat to India as the burden of non-communicable diseases (NCDs) in India is already escalating and typically the onset of NCDs occurs a decade earlier in India as compared to developed countries (≥45 years of age) (Arokiasamy, 2018). The pre-existing NCDs in India, their early onset coupled with the high risk of elderly succumbing to this pandemic are the risk factors for mortality among elders with COVID-19. 

Third, India is often disreputable for the overuse as well as misuse of antibiotics which is a major contributing factor to the current state of antimicrobial resistance. Along with this, the easy availability and access of ‘Over-the-Counter’ drug adds to the problem of ‘self-medication’. (Nafade et al., 2019). Furthermore, COVID-19 and other viral infections cannot be addressed by antibiotics, which are usually consumed, as a part of self-medication. Thus, self-medication, reluctance to consulting a  doctor and negligible self-reporting of symptoms provide us with just the superficial estimate and not the actual extent of spread. 

India has implemented screening at airports as per directions from the Directorate General of Civil Aviation (DGCA), Government of India (GoI) which has been taking effective strides to control the spread of pandemic. Additionally, compulsory self-declaration of one’s travel history is attributed to the Bureau of Immigration’s endeavour to detect and screen passengers at the entry level. Although, initial screening is being undertaken with utmost care, the fact that the incubation period of the virus ranges from 1-14 days (WHO, 2020) suggests that most of the passengers that are potential carriers of the virus remain undetected (ET Bureau, 2020) thereby causing secondary infections.

A lock down, as has been enforced in a total of 80 districts of India, is a containment strategy which will only slow the spread of the COVID-19, while only a vaccine can prevent people from getting sick. For this to happen, isolation of the virus is the foremost step towards development of drugs, vaccines & rapid diagnostic kits. After Japan, Thailand, United States of America & China, India became the fifth country to isolate the COVID-19 virus strain (Neetu Chandra Sharma, 2020). 

With pharmaceuticals across the globe rushing to develop a vaccine, Indian companies too are trying to crack the code. Currently, three Indian vaccines makers - Serum Institute of India (SII), Zydus Cadila and Bharat Biotech - are involved in the initiative. Of the three, SII is in the pre-clinical phase in partnership with a US-based clinical-stage biotechnology company Codagenix to co-develop a live-attenuated vaccine which is likely to be available by 2022. Globally, almost 35 firms and academic institutions are competing to create a vaccine (Laura Spinney, 2020). US biotech company Moderna Therapeutics has pipped others and entered phase-1 clinical trial to test it on humans. 

Though, traditional timeline for vaccine development is 15-20 years, fast tracked human clinical trials can bring down the ibid timelines to 12-18 months (Viswanath Pilla, 2020). In any care it is highly unlikely that the vaccine for COVID19 will be ready before mid 2021. It is therefore important to keep people safe through public health measures of promoting social distancing and hand hygiene.

India has 425 confirmed cases and has documented 8 deaths with fatality rate of 1.9%, while that of Italy is 9.26%. Experts warn that these figures do not paint a true picture and the numbers are alarmingly large and under-reported. Though, India has had enough time to plan a strategy to combat COVID-19 as well as learn from other countries’ experience, political leadership and health system preparedness will play a crucial role in the weeks to come in the nation’s battle against COVID-19. 

Meenakshi Sharma is a development consultant with over 11 years of experience in Public Health. She is a Gold Medalist in Medical Microbiology and a Post Graduate from Indian Institute of Health Management and Research (IIHMR), Jaipur. She is currently pursuing Masters in Global Health Policy from the London School of Economics, UK.