New Delhi: One year ago, India lived through a lockdown trailer by observing a day-long ‘Janata curfew’ and came out in the evening in droves to bang thalis, wishing “corona” away. For the first 75 districts (including Delhi), it is also the first anniversary of lockdown — the rest of the country was shuttered from 25 March.
Looking at how these 12 months have changed our understanding of the SARS-CoV-2 virus and the Covid-19 pandemic, ThePrint lists 12 lessons this past year has taught us.
1. Testing key to controlling disease
It was on 22 March 2020, in the wake of the World Health Organization (WHO) laying down its “test test test” credo for controlling the pandemic that India’s Secretary, Health Research, Dr Balram Bhargava retorted that India was dealing with the pandemic with its own formula of “isolate isolate isolate”.
“There will be no indiscriminate testing. Isolation, Isolation, isolation,” he said.
A year on, the wheel has turned a full circle with both Dr Bhargava and NITI Aayog member (health) Dr V.K. Paul now issuing frequent public appeals to come forward and get themselves tested as a “social obligation”.
“One of the very important lessons we have learnt is that when we unnecessarily keep restricting ourselves, like we did in case of testing, without realising the capacity of the system — we crossed 10 lakh tests a day — you end up creating a doubt that persists for a long time,” says C.K. Mishra, former secretary, Ministry of Environment and Forests, who headed the empowered group on testing, hospital services, etc., till his superannuation in May.
“As a government, we should not overcentralise. More than our ability to make available beds, tests, vaccines devices etc, what is important is our ability to do a consolidated campaign to convince people.”
2. Ventilators are overrated
Early on, the clamour was about how India’s 40,000-50,000-odd ventilators, most of them in the private sector, would not be enough for a population of 1.3 billion and everyone —from start-ups manufacturing solar panel cleaning robots to car manufacturers — jumped onto the ventilators bandwagon. But it was probably somewhere around June when Delhi was in the middle of its first wave that the sheen began to wear off, largely because of vulnerability of patients on ventilators to other respiratory infections.
“In Delhi, we saw the death rates come down dramatically once doctors overcame that initial propensity to put people on ventilators,” says a senior official who had seen the situation up close.
3. Steroids work better than repurposed drugs, therapies
In March last year, the biggest therapeutic hope was touted to be a repurposed drug, remdesivir, that started life as a “wonder” drug costing $1,000-2,000 outside India for a full course. Later on, it was revised to a little over Rs 2,000 in India.
There was much excitement also about plasma therapy — that is an option to passively kickstart the immune system by introducing neutralising antibodies from one Covid survivor to a patient. But after several conflicting studies, both about remdesivir and plasma therapy, the star is now a low-cost drug that has been around for years — dexamethasone.
Steroids such as dexamethasone that cost about Rs 10 for a strip of 30 tablets can ensure that Covid patients do not get into what is known as a cytokine storm, which occurs when the body’s own immune system goes into an overdrive, often turning fatal.
“We have learnt what works and what doesn’t work and that has given physicians more confidence in treating patients. Given at the right time and the right dosage and in the right way, steroids work, blood thinners work and oxygen works. But all patients do not need steroids. It can make your blood sugar go haywire so it is a trade-off you are doing,” says Dr Anjan Trikha, professor, Department of Anaesthesiology, Critical Care and Pain Medicine, AIIMS.
“A lot of the antivirals that were talked of in the beginning do not work. Plasma and remdesivir work if you give it at the right time, at the right stage of disease. We have also learnt the importance of supportive treatments such as antibiotics, Vitamin C and Zinc,” Dr Trikha added.
He further said that another important learning has been that people with cancer, chronic kidney/liver failure etc., tend to do badly if they get the disease, so it is important that such people are taken extra care of.
4. Oxygen saves lives
It was some time in April that the Government of India first started making appeals to people who had tested positive to come forward and seek help at the first sign of breathlessness. Oxymeters became a must-have and the emphasis was on putting patients on oxygen early.
As AIIMS director Dr Randeep Guleria had explained during a Covid briefing on 18 April, “Putting people on oxygen early minimises the damage because of disruption of oxygen supply to the brain.”
Former health secretary Preeti Sudan, who retired last July, says, “We learnt very quickly that oxygen is the best treatment. That is why our case fatality ratio is so good. There is also faith in the system now, so people are coming to the hospital. Earlier they were not coming. That (oxygen) has been the biggest lesson of the pandemic in terms of treatment.”
5. No substitute for masks, hand hygiene
In the early days of the lockdown, India’s policy was to “save the masks for those that need them the most”. So much so, when some MPs wore it to Rajya Sabha, House chairman Venkaiah Naidu threatened to throw them out. From there on, the appeal to adhere to Covid-appropriate behaviour (read masks, hand hygiene social distancing) is a part of every government communication on the pandemic.
That continues to this day even as India has administered over 4.5 crore doses of vaccines. This is primarily because neither of the two vaccines are sterilising vaccines, that is they may not actually prevent people from contracting the disease. They, however, ensure that the severity of the disease is controlled.
6. Indian scientists triumph
Both vaccines currently part of the national programme are manufactured in India. While Covishield was developed by researchers at Oxford University, Covaxin has been developed indigenously as a collaboration between scientists of the National Institute of Virology in Pune and pharmaceutical company Bharat Biotech.
The fact that one of the handful of licensed Covid-19 vaccines in the world is of completely Indian provenance is a matter of great pride, often highlighted by the Government of India in various fora.
7. Lockdown does not break ‘chain of transmission’
The first goal that India set right after the announcement of the countrywide lockdown on 25 March was to break the chain of transmission. However, given the fact that India scaled all Covid peaks — highest cases, highest deaths, highest test positivity rate etc — after June when lockdown had been lifted shows that the initial ambitious goal was not met.
What did happen, though, is that in the extra time the lockdown gave us, we not only managed to upgrade our healthcare infrastructure but also learnt to clinically manage the disease better. Both ended up making our case fatality ratio look far better than the global numbers.
8. Night curfews, weekend lockdowns do not work
The original architect of night curfews was the Government of India, much to the chagrin of some of its own advisors who were left wondering about the public health/Covid management utility of such a move. After June, when the matter of controlling the disease was left to the wisdom of the local administrations, many states started weekend lockdowns. Some like West Bengal even did a roster of lockdown days in which the days were apparently selected randomly.
Prime Minister Narendra Modi had urged states to reconsider short lockdowns in September 2020 during an interaction with chief ministers.
Now that the country is in the throes of a second wave with Maharashtra continuing to be a problem state, Union Health Secretary Rajesh Bhushan, in his letter to the state last week, wrote: “Measures such as night curfews, weekend lockdowns etc. have very limited impact on containing or suppressing the transmission.”
9. Cities the most vulnerable
At the start of the pandemic, there were fears about what would happen if the disease was to spread to rural areas, given the severe health infrastructure limitations. In fact, during off the record conversations, officials cited that fear as one of the reasons why lockdown was announced suddenly without giving migrant workers the time to return to their villages. However, the two focal points of the pandemic have been the two biggest cities in the country — Delhi and Mumbai — and cities, in general, have been the worst-hit.
While this is partly because of the crowding in cities — the virus loves crowds — it is also a fact that contact-tracing in cities is a difficult proposition as there are no ground level workers in the urban setup, similar to ASHAs in villages.
“We have basically learnt that it is completely futile to draw up all-India prescriptions. That is playing out even now when there are demands that the vaccination policy be changed in Maharashtra,” Mishra says.
10. ‘Long’ Covid
A lot of the initial fear associated with Covid was because of the unpredictability of the outcomes.
At a webinar, Dr Anthony Fauci, chief of the National Institute of Allergy and Infectious Diseases, US, said: “I have never seen an infection where you have such a broad range. Twenty to 49 per cent of people have no symptoms, some are mildly ill for a fortnight and then have post-viral syndrome, still others need hospitalisation, oxygen support, ICU care, and even die.”
But now one of the more dreaded things about the disease is not just the immediate symptoms but the residual ones that can last for months. These include fatigue to gallbladder stones or heart problems. The recommended post-Covid investigations now include a full blood count, kidney and liver function tests, a C-reactive protein test, and an exercise tolerance test (recording level of breathlessness, heart rate, and oxygen saturation).
11. Young people spread the most, suffer the least
Covid is a disease that can be lethal for the elderly. But, as WHO said and as India’s own experience shows, it is the younger who are often asymptomatic and are spreading the disease simply because they do not know they have it. They were also the first to get back to work when lockdown was lifted.
This is also the reason why experts are now saying that instead of the highly restrictive vaccination policy covering only senior citizens and those between 45-59 with specified comorbidities, this is the age group that should be targeted.
12. India an enigma
While the virulence of the pandemic has been less in South Asia than in Europe or the Americas, there are still many things about the India experience that are not fully understood.
Unlike many other South Asian countries with prior experience of SARS where mask usage has been there from even before Covid, India’s mask compliance levels are abysmal. How, despite that, India has survived several religious festivals, a few elections (in Bihar, Kerala) and testing frauds (in Bihar) remains a question that baffles epidemiologists.
There are many theories — including the protection offered by the BCG vaccine, which is a part of the Universal Immunisation Programme, the low average age, the hygiene hypothesis that says that because of high levels of exposure to pathogens, our immune systems are better primed to take on unknown ones — to explain the low death rates in India.
A clear answer is yet awaited.
(Edited by Manasa Mohan)
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