2020-2022: A chronicle of the pandemic - Down To Earth Magazine - (2024)

Crowd of unrecognizable business people wearing surgical mask for prevent coronavirus outbreak in rush hour working day on March 18, 2020 at Bangkok transportation; Photo: IStock
COVID-19

“Co” for corona, “vi” for virus, “d” for disease, and “19” for the year 2019

I“had only seen these real life ethical dramas in sci-fi movies. It is so overwhelming when a group of 15-20 patients, all with oxygen saturations ranging from 30 per cent to 40 per cent (the normal level is 95-100 per cent), arrive at the same time and require ventilator support.

Whom should we give it to? Should it be on a first-come- first-served basis? When I did this the first time, I had to deny a ventilator to a 30-year-old against a 73-year-old. The senior person passed away within a few hours. The younger one, too, died later. I wondered if I should have given a chance to the 30-year-old. But who am I to choose; everybody has an equal right to live. I will always feel guilty that I couldn’t save either of them.”

—A doctor

See also: DTE coverage on Covid-19 Pandemic
Two healthcare workers hug and support each other; Photo: Istock
Chinese frontline health worker tired sitting on floor during Pandemic;
Photo: Istock

India’s index COVID-19 patient was a Thrissur resident studying medicine at Wuhan University

Zero Hour

On January 23, 2020, a 20-year-old Indian medical student escaped from the city of Wuhan in China. For her, the 4,500-km journey back home to Thrissur, Kerala, felt like a victorious march away from a new coronavirus, still not officially named but referred to as 2019-nCoV. The World Health Organization formally named the virus SARS-CoV-2 and the disease COVID-19, some 18 days later. Before heading back to India, the student travelled from Wuhan to another Chinese city, Kunming, by train. Being in the fourth year of her medical course, she could sense the evolving health crisis by recognising several cases of people with respiratory symptoms similar to the victims of COVID-19, already surging in the region.

She found them at the railway station as well as on the train. She did not remember if she came in close contact with any of them. Maintaining safe distances from other people and keeping oneself in isolation were just starting to gain the status of a medical prescription against this novel coronavirus. She still preferred to somehow leave China.

Landing in her home state of Kerala, referred to as “God’s own country”, she must have felt far away from the virus; India had remained free of the disease till then. Till January 26, she did not show any symptoms of COVID-19. She assumed that she was now completely safe. Then, on the morning of January 27, she developed a sore throat and had bouts of dry cough. These were similar to what she had noticed in people at the railway station and on the train.

She understood exactly how dreaded these otherwise normal ailments were if one happened to be in China. On January 27, she reported to doctors at the Emergency Department of Thrissur’s General Hospital, following the local authority’s advice to do so in case of any symptoms associated with COVID-19.

Her travel history made the doctors rush to begin a barely established protocol of informing all the higher-ups and putting her through all the tests prescribed at that point of time. Doctors in fact did not have any specific instruction to look for specific symptoms; just a broad guideline to look for “flu/cold”-like symptoms among people returning from China.

Doctors found her “afebrile”–without fever. Her pulse rate was 82 per minute; blood pressure 130/80 mmHg; temperature 98.5oF; and her blood oxygen saturation level was at 96 per cent while breathing ambient air. All parameters were normal, except for the fact that she had just returned from Wuhan and had subsequently developed a sore throat and bouts of dry cough.

An isolation room in the hospital, kept ready in anticipation of COVID-19 patients, had its first visitor. An oropharyngeal swab was collected from her and sent immediately to the National Institute of Virology, Pune, which is part of the Indian Council of Medical Research. Over the next few days, doctors also sent her blood, urine and stool samples for testing. On January 29, she was diagnosed positive for the novel coronavirus and became India’s first case of COVID-19.

Nearly a year and a half later, she again tested positive for COVID-19 on July 13, 2021. “She is re-infected with COVID-19. Her RT-PCR is positive, antigen is negative. She is asymptomatic,” K J Reena, District Medical Officer of Thrissur told the media. She was detected with the re-infection when she went for an RT-PCR test to travel to Delhi and had already taken one dose of the vaccine.

At a time when India had lost over 0.4 million people to the pandemic, her experience with the virus raises as many questions as fears. Do the antibodies fizzle out after a few months of infection? Will a mutant virus make our body’s acquired immunity from earlier infection ineffective? Will vaccines be effective against new variants? Does this also mean there would be more and more reinfections?

See also: DTE coverage on Covid-19 Pandemic
COVID-19 showed that the world was unprepared to tackle a pandemic situation; Photo: Vikas Choudhary/ Centre for Science and Environment (CSE)
Onset

The virus was not new to scientists. It belongs to a large family of viruses that had taken the world by storm earlier

AThe Lunar New Year break was uncomfortably long and quiet for almost 50 million people in China. Since January 23, 2020, authorities had locked down some 13 cities, including Wuhan in the province of Hubei, the epicentre of the coronavirus outbreak. Public transport, including trains and flights, were suspended in this city of 11 million people. Residents were allowed to leave their houses only to buy essential items like food. At some places, police deployed drones to ensure people stayed indoors. Travel restrictions and quarantine measures left streets, parks and shopping centres deserted in a dozen other cities, including Chibi, Zhejiang, Huangshi, Xiantao, Enshi, Qianjiang and Xiannning.

The country’s largest metropolis, Shangahi, resembled a ghost city. But travel restrictions and lockdowns were of little help to contain the spread of the virus.

On January 31, the School of Public Health at University of Hong Kong published a paper in The Lancet that said infections might have spilled over to other cities even before the lockdown was enforced and “the epidemic had spread exponentially in multiple major cities of China”. “Travel restrictions and lockdowns often only delay transmission, not stop it,” said Nathan Grubaugh, a virologist at the Yale School of Public Health, USA. An ancient Chinese proverb says “Never do anything that you want to remain a secret”. And that’s exactly what the Chinese did.

On December 30, 2019, Li Wenliang, a doctor in Wuhan, is believed to have first disclosed about the virus to his medical school alumni group on the popular Chinese messaging app WeChat. The same day, the city’s municipal health commission informed medical institutions about the patients, but warned them not to release treatment information to the public. Though on December 31, Wuhan’s health authorities announced the outbreak and alerted the World Health Organization (WHO), Li was reprimanded by the police for “spreading rumours online” and “severely disrupting social order”. The whistleblower succumbed to the virus a week later.

It had now become clear that the Chinese authorities had kept information under wraps for too long. A mathematical model developed by the Johns Hopkins University, USA, to gauge the spread of the virus, estimated that 58,000 people would have been infected in China by January 31, 2020. Though the Chinese government data put the figure at 11,791, it was difficult to believe given the government’s track record.

New, but familiar enemy

The virus was not new to scientists. It belongs to a large family of viruses that had taken the world by storm earlier. In November 2002, a strain of coronavirus, named the Severe Acute Respiratory Syndrome (SARS), was first isolated from patients in southern China suffering from pneumonia-like symptoms. Then too, China had kept the illness a secret for months. SARS spread across 24 countries, killing 800 people and infecting another 8,000 before it was contained in July 2003. A decade later, another strain of coronavirus, the Middle East Respiratory Syndrome (MERS), emerged in Saudi Arabia. It spread to 27 countries killing 912 people and infecting 2,400 before it was contained in 2014. But COVID-19 is scarier and has befuddled the global medical fraternity for many reasons.

For instance, when epidemiologists prepared a preliminary estimation of the epidemic potential of COVID-19, they found that the basic reproduction number, or R0, of COVID-19 was 2.6. That meant a person infected with COVID-19 could infect 2.6 more susceptible people. In comparison, SARS had an R0 of 2; MERS had 1. But as more and more studies poured in—some 50 scientific studies were published on COVID-19 in just the first 20 days of the outbreak—the value appeared to have exceeded WHO’s estimate that ranged between 1.4 and 2.5. A study published in journal medRxiv on January 29, 2020, in fact, said the R0 for COVID-19 could climb up to 4.08. (According to an analysis by journal Nature by the end of 2020, “scientists published well over 100,000 articles about the coronavirus pandemic”.)

A probable reason for this exponential spread is that we live in a highly interconnected world. A lot has changed since last major outbreaks of SARS and MERS. Today, it takes less than 36 hours for one to travel to any part of the world. Consider Hubei. Its mobility is unmatched—it has a robust rail and bus service and waterways systems. Air travel connects it to 55 cities within the country and 23 international cities. Wuhan alone hosts 23 universities and colleges that attract students from across the globe. India’s first confirmed case of COVID-19, a 20-year-old girl from Kerala, was a medical student in Wuhan. She just escaped the city’s lockdown and reported symptoms of infections two days later. Since travel ensures the virus a smooth transmission from person to person, the lunar year festivities enabled it to spread faster.

Yet in the initial months, scientists were unable to decipher the exact nature of the virus. “The global medical fraternity is ‘shadow boxing’ as the basics are still unknown,” said WHO director general Tedros Adhanom Ghebreyesus. Meanwhile, Chinese authorities identified the source of COVID-19 to the Hunan seafood market, where game meat, including live foxes, crocodiles, wolf puppies, porcupines and camel meat are sold. This market could have provided vital clues to helpless researchers to identify the real source of the virus. But local authorities quickly cleaned the market and shut it down. “Municipalities should have included a few scientists in their team,” said Xiaowei Jiang of the Xi’an Jiaotong-Liverpool University, China. In fact, China allowed a team from WHO to visit the Wuhan market only in January, 2021—one year after the outbreak.

Scientists who had studied the genome sequence of the virus—isolated from blood samples of the initial 41 patients who contracted the virus—said bats could be the host of the virus. On February 7, 2020, state news agency Xinhua published a study that said genome sequences of viruses in pangolins was 99 per cent identical to those in coronavirus patients. The study thus suggested that pangolins could be the intermediate host for COVID-19.

Even as it hid the news from the world, China presented a snapshot of what was to come. It built a 1,000-bed hospital in a record 10 days, which was a first-of-its-kind intervention for any past outbreaks. The government also announced a financial package of 1 billion Yuan (US $143 million) to Hubei to deal with the crisis. However, the magnitude of the outbreak tested China’s health infrastructure. “There’s severe shortage of medical supplies not just in Wuhan, but also in surrounding cities,” said Wang Xiaodong, governor of Hubei.

Other countries pressed the panic button and struggled to implement containment measures. First, Russia and Singapore shut its borders with China. Then, USA and Australia imposed travel restrictions. Soon, many other nations imposed partial bans. India cancelled visas of those travelling from China, except for Indians, and advised citizens to not visit China. Though there was no safety protocol in place, the advisory was used to assess the pathogen’s virulence, said an Indian health ministry official. By February 7, 2020, as many 1,275 flights coming from China, Hong Kong and Thailand carrying 0.13 million passengers had been screened, the government claimed.

On any given day, more than 10,000 flights operate globally, and this explains how interconnectivity accelerated this spread. “During the Ebola epidemic in 2014, models estimated that without travel restrictions, 7.17 infected passengers per month would have departed from highly-affected countries like Liberia, Sierra Leone and Guinea to various destinations around the globe,” said Pierrot Derjany and his colleagues from Embry Riddle Aeronautical University, USA.

Meanwhile, Chinese scientists at the Wuhan Institute of Virology were testing antiviral drugs, which could suppress the activity of the virus, and not necessarily kill it. Globally, various groups of scientists started working to develop a vaccine. “A pandemic is an epidemic occurring worldwide, or over a wide area, crossing international boundaries and unusually affecting a large number of people,” according to WHO. But even as the number of infected rapidly rose, WHO was singing a different tune.

Disease “X”

The past four pandemics were caused by the influenza (flu) virus, and therefore, the medical discourse was only on flu pandemics. In fact, WHO was caught napping when it alerted the world in early 2020: “A pandemic of a new, highly infectious, airborne virus—most likely a strain of influenza— to which most people lack immunity is inevitable. It is not a matter of “if ” another pandemic will strike, but “when” it will strike,” it had said. In 2018, who released a list of 10 diseases that could cause epidemics, and all were viral in nature. Besides the usual suspects such as Zika, Ebola and SARS (triggered by a coronavirus), the list also had a Disease X, to be caused by an unknown pathogen. There is now a growing consensus that COVID-19 is Disease X.

“This outbreak (COVID-19) is rapidly becoming the first true pandemic challenge that fits the Disease X category,” wrote Marion Koopmans, head, viroscience department, Erasmus University Medical Centre in the Netherlands in journal Cell. Peter Daszak, who was part of the WHO team that made the 2018 list, wrote in the New York Times that they had postulated Disease X would originate in animals, emerge at a place where economic development drives people and wildlife together, and go viral. The group predicted that the disease would be confused with other diseases during the initial stages and would spread quickly due to travel and trade. It would have a mortality rate higher than the seasonal flu and would spread as easily. It would shake the financial markets even before it became pandemic. “In a nutshell, COVID-19 is Disease X,” he wrote. This flies in the face of WHO’s predictions that the next pandemic would be that of influenza. The pandemic is a rude reminder that the world needs to better understand and manage epidemics.

“Our understanding of infectious diseases has improved. But we do not fully understand all aspects regarding the emergence of epidemics,” said Suresh V Kuchipudi, clinical professor and associate director, Animal Diagnostic Lab, Department of Veterinary and Biomedical Sciences, Pennsylvania State University, USA. He, however, pointed at the similarity among the past few epidemics. “RNA viruses have caused all the recent major outbreaks, including COVID-19,” he said. Due to their inherent nature to mutate and evolve, RNA viruses are more likely to cause future epidemics. WHO tracked 1,483 epidemic events in 172 countries between 2011 and 2018. Nearly 60 per cent of the recent epidemics were zoonotic, of which 72 per cent originated in wildlife. Besides COVID-19, WHO reported nine disease outbreaks in the first 79 days of 2020.

Some scientists did flag alerts about a zoonotic pandemic. Though they did not know when and where the next pandemic would surface, they were certain this pandemic would paralyse the world. “The next pandemic will be a zoonotic disease,” said Jonathan Epstein, vice-president of Science and Outreach at EcoHealth Alliance, a science- based non-profit in New York. Zoonotic diseases are caused by infections that spread from animals to humans. There were scientific posts on the web too. EcoHealth Alliance said waterfowls would host the flu pandemic, while bats and rodents would be the source for a coronavirus pandemic.

“Over the last 15 years, we’ve found dozens of novel SARS- related coronaviruses in bats in China and other parts of the world. Our research has shown that people in China hunt bats that are known to carry viruses linked to SARS and other novel corona viruses. Those exposed to these host animals earlier may have developed antibodies against these viruses, which means they’ve been exposed to them and can spread the disease,” said Epstein. It remains a coincidence that China is the country of origin of three of last four pandemics. “While we can’t predict from where the next influenza pandemic is going to emerge, there are certain places that need particular attention. And, China is the place of all of them,” said Dennis Carrol, former director of emerging threats division of United States Agency for International Development, in a Netflix series, Pandemic. Nobody expected a new coronavirus to strike, and with such magnitude. Earlier outbreaks—SARS in 2003 and MERS in 2012—were also caused by coronaviruses, but were not declared pandemics.

On March 11, 2020, WHO declared the outbreak a pandemic. The road to declaring COVID-19 a pandemic was bumpy. On January 23, 2020 WHO called a meeting to declare a global health emergency. But it did not declare it and waited for a week for Ghebreyesus to return from China. By this time, COVID-19 cases increased 10 times and the virus spread to 18 countries. WHO even denied human-to-human transmission of the virus till mid- January, 2020. Studies later said such a spread started in December 2019. Till as late as February 2020, WHO kept rebuking nations for imposing travel and trade restrictions on China. When countries began evacuating their citizens from Wuhan, WHO said it did not favour this step. By now, the UN body was completely cornered as countries refused to listen to it. A desperate WHO said it would invoke International Health Regulations and demand explanation from the countries for ignoring it.

Despite warnings from global health experts, WHO officials lived in denial till mid-February and kept deflecting the debate between “containment” and “mitigation”. Containment means a phase when the virus can be contained or the chain of transmission controlled. Mitigation is the stage when it is accepted that the virus can no longer be controlled and efforts should be made to mitigate its impact. WHO kept saying it was pointless to declare COVID-19 a pandemic since containment was possible. However, when it had to finally make that declaration, the UN body started advising nations not to go into the binary of containment and mitigation! It was widely speculated that WHO delayed the pandemic declaration under pressure from China. WHO had also been making flip-flops on the issue of masks. For long, it said healthy persons need not wear them.

Hours before the US Centers for Disease Control and Prevention advised that everyone should wear masks, WHO said it would support countries’ decision. But the next day, WHO issued a fresh guideline reverting to its previous position. “We may commit mistakes. We are human beings, after all, and not angels,” Ghebreyesus said on April 8, 2020, in his first admission of serious oversights in his response to the pandemic. “We will do an after-action review once the pandemic ends to learn lessons for future.”

On May 18, 2020, as many as 58 countries, including 27 members of the European Union, India, UK, Australia, Indonesia, Russia, New Zealand, Canada, South Korea and others presented in the 74th World Health Assembly a draft resolution demanding evaluation of WHO’s role. It demanded initiation “at the earliest appropriate moment to review experience gained and lessons learned from the WHO-coordinated international health response to COVID-19”. These countries demanded a probe into “the actions of the WHO” and “their timelines pertain to the COVID-19 pandemic” as part of the overall evaluation. The resolution said timelines were to be evaluated regarding “recommendations the WHO made to improve global pandemic prevention, preparedness, and response capacity”. The resolution also said that the functioning of the International Health Regulation (IHR) must be reviewed. IHR is an international agreement between 196 member states and the body, as per which the countries have agreed to work together for global health security. Through IHR, every member state is supposed to build capacities to detect, assess and report public health events in its respective jurisdiction.

The toll COVID-19 is the third new human coronavirus of the century, and its characteristics are not in line with this family of virus. Coronaviruses were supposed to have evolved in humans to widen their spread; not to kill us, but just sicken. That was not happening this time. COVID-19 had already infected 188 million people – over 4 million people succumbing to it – across the world and in all the continents by mid-July 2021. The total death toll was equivalent to the number of people killed in all of the world’s wars since 1982. USA, with the highest death toll at 606,000, accounted for 15 per cent of the global death toll. USA was followed by Brazil, where 520,000 people had died due to the disease. India had the third-highest death toll at 405,028.

COVID-19 showed that the world was unprepared to tackle a pandemic situation. “National health security is fundamentally weak around the world. No country is fully prepared for epidemics or pandemics, and every country has important gaps to address,” warned the Global Health Security (GHS) Index report prepared by the Johns Hopkins University and the Nuclear Threat Initiative. There were certain parameters upon which countries were ranked. On a scale of 100, almost all countries scored only 40.2. Less than 7 per cent countries scored better in terms of prevention of pandemic. Worse, only 5 per cent countries had a rapid response strategy, said the report.

A British Medical Journal paper on global preparedness published in 2019 highlighted the most prepared countries were concentrated in Europe and North America, while the least prepared countries were clustered in Central and West Africa and Southeast Asia. But COVID-19 had become a great leveller. It attacked both rich and poor countries.

Since the world was sure the next pandemic would be a flu pandemic, the trajectory of scientific research was only centred around developing the universal flu vaccine—the one which would give protection against existing and future strains of flu.

“Seasonal influenza vaccines protect only against the existing strains of H1N1, H3N2 and two influenza B viruses. The next generation vaccine will provide protection against more than these four viruses and hopefully against other circulating strains and also the future ones that may emerge,” said Jennifer Gordon, influenza vaccines program officer with US’ National Institutes of Health. So the focus was only on developing a flu vaccine. There were several corporate candidates geared to produce a universal flu vaccine—many were under clinical trials and one even reached the last phase, the human trial, as animal studies had shown positive results.

As screening and detection became aggressive worldwide, new epicentres or secondary hotspots emerged in hydra-like splits, from Europe, West Asia and Southeast Asia, and to Africa. This meant the world had to mount an even bigger and more expansive containment and surveillance to catch each suspect and then scan all those who were in touch with this individual. The virus had emerged as the powerful demolisher of the globalised world, where we all thought the world was with us for everything. One after another, COVID-19 tested the crumbling health infrastructure in the developed world. Their weaknesses and failures got globalised as affected people took the virus to other countries. Developing countries are dense in settlement and population. This made containment and detection less effective. This allowed transmission in multiple chains, almost like an uncontrolled atomic chain reaction.

The world unable to contain the spread hoped that it became a general community infection, like any other cold and flu. It was argued that in such a scenario the community would develop immunity and thus developing the capacity to fight. But, it also meant that the fatality from COVID-19 would be in thousands till we reached this level of infection. “What is important is the timescale: whether it is in a matter of 6-9 months which will completely overwhelm many health systems, or over many years which will allow health systems to cope adequately,” said Teo Yik-Ying, dean, Saw Swee Hock School of Public Health, National University of Singapore. Are we going to experience the same? If we believe epidemiologists, we would have soon a regular COVID-19 season, and we would have to pay heavily in terms of human costs.

Dec 24, 2020, Hong Kong: Cleaners put on protective clothing and prepare to clean up places where patients with suspected pneumonia have visited; Photo: Istock
Migrant workers being ‘sanitised’; Photo: Vikas Choudhary/ Centre for Science and Environment (CSE)
The lockdown in India kept workers from working and consumers from consuming. This effectively killed the demand and supply at the same time; Photo: Vikas Choudhary/ Centre for Science and Environment (CSE)
In containment

When everybody is somebody’s economic interest, the shutdown to contain the pandemic led to unimaginable livelihood crisis

By April, 2020 the COVID-19 pandemic had metamorphosed into everybody’s crisis. Unlike the Spanish Flu pandemic of 1919-20 which was spread by World War I soldiers, COVID-19 was being transmitted by ordinary citizens of a globalised world. That distinction made COVID-19 extremely hazardous, both in terms of health and economic costs.

For the first time in human history, the entire world had stopped travelling. The pandemic forced countries that account for two-thirds of the planet’s output and income to embrace containment policies, suggested the Centre for Economic Policy Research, a London-based association of over 1,300 economists engaged in research. This was extreme as the modern economy thrives on mobility as everybody is somebody’s economic interest or investment. “This pandemic was not just a health crisis. For vast swathes of the globe, the pandemic would leave deep, deep scars,” said Achim Steiner of the United Nations Development Programme (UNDP). “We risked a massive reversal of gains made over the last two decades, and an entire generation lost, if not in lives then in rights, opportunities and dignity.”

Nearly 95 per cent of nations registered a drop in per capita gross domestic product (GDP). For more than half of the countries, per capita GDP between 2019 and 2020 had reduced by over $500. In June 2021, nearly 18 months after the pandemic struck the world, the International Labour Organization estimated that global unemployment would be at 205 million in 2022, surpassing the 2019 level of 187 million. The jobs shortfall induced by the pandemic was 75 million in 2021 and was expected to be 23 million in 2022. Guy Ryder, director- general of ILO said: “It’s been 15 months since WHO declared COVID-19 to be a global pandemic and it’s not just been a public health crisis, it’s also been an employment and a human crisis as well.” The economic loss precipitated further because an estimated 55 per cent of the world’s population did not have access to social protection.

The lockdown in India kept workers from working and consumers from consuming. This effectively killed the demand and supply at the same time. The economy ceased to exist. Yet, global lockdown was the only prescription. Countries needed to flatten the epidemiological curve (the rate of COVID-19 spread) to disrupt transmission. And the faster they tried to flatten the curve; restrictions and resultant economic paralysis became widespread. The world could stop the spread of the virus only by embracing economic stagnation. As Pierre-Olivier Gourinchas, a visiting professor at Princeton University, said, “Flattening the infection curve inevitably steepened the macroeconomic recession curve.”

Lockdown declared

From the day – March 24, 2020 – national lockdown was imposed in India, disturbing images of mass exodus of migrant workers from urban centres appeared. From Kerala to Bihar; Delhi to Kashmir; and, Andhra Pradesh to Odisha, millions of workers headed to their villages. It was not due to the fear of COVID-19, but the unbearable burden of surviving without money, food or work that triggered the mass exodus.

About 87 per cent of India’s workforce was in the informal sector; and, some 125 cities/ towns reported outmigration. What was worse is that even after completing the arduous journey to their villages, the migrant poor continued to face an uncertain future.

That’s because the rural economy was already badly hit. Take the case of Dhaniram Sahu, who was not aware of the word “virus” or the concept of social distancing. “Now almost everybody was talking about coronavirus and how to stay protected,” said Sahu from Shankardah village in Chhattisgarh’s Dhamtari district. Just like scientists and epidemiologists worldwide, Sahu did not understand much about the virus. But on March 24, 2020, he came face to face with its ferocity. That morning, along with some 1,500 daily wage labourers, he was waiting at Ghadi Chowk in Dhamtari town to be hired by rice millers, shopkeepers, builders or well-to-do families. Suddenly, the group was approached by police and local officials who asked them to go back and not to venture out of their villages for the next three weeks.

“They informed us that the government has announced a nationwide lockdown to contain the coronavirus. Most of us did not know how to react,” he recalled. Sahu was the sole breadwinner of his family of five and the menial job would have earned him 150-200, sufficient to buy rice, pulses and vegetables for two days. A week later, he received two months of free ration in advance. “It was a package of 70 kg rice, 2 kg sugar and 4 packets of salt,” said Sahu, wondering how to now arrange daal (lentil) and vegetables for his children.

The situation was no different for people in nearby Gond tribal villages like Khadadah, who earned a living by working under the Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA) and selling forest produce, such as tamarind and mahua and lac, for a living. Dhamtari is, in fact, the largest producer and market of lac in Asia. But since the lockdown, MGNREGA works stopped; lac processing centres and markets remained shut.

“Mahua is in full bloom. We have also made some baskets,” said Samari Bai, who belonged to Kamari, a particularly vulnerable tribal group. “But since the broker has stopped coming to our village and haats (weekly markets) are shut, we did not getting cash to buy vegetables or oil,” she said. Haats are the lifeline of tribal economy, explained Dilawar Rokadiya, a local forest goods trader. Now that they were unable to sell, they stopped going to the forest for collecting. The pandemic hit the country at a crucial time— from February till April-end, farms and forests yield crops that ensure critical flow of cash and confidence in rural households. Though the government had exempted farmers, farm activities and food supply from the lockdown rules, the country’s agrarian economy was the biggest collateral damage in this battle against the novel coronavirus due to reasons as obvious as the fear of contagion to fast-spreading rumours and the greatest exodus India had seen since partition.

Consider wheat and pulses. These are the two most preferred rabi (winter) crops. In Madhya Pradesh, Praveen Parmar, a farmer from Bilkisganj village in Sehore district, said god had been kind to him this crop cycle. But he was in distress because of the government’s poor planning. Despite the region being hit by unseasonal rains and hails, Parmar harvested an impressive 50,000 kg of wheat from 8 hectares (ha).

Between March 15 and 17, 2020, he was in urgent need of cash and sold 20,000 kg of wheat at a nearby mandi for 1,750 per 100 kg. Though the state guarantees 1,925 as the minimum support price for 100 kg of wheat, the government had not begun procurement by then. “The government should have procured food grains before announcing the lockdown,” said Parmar, adding that farmers in his village were struggling to find space for storing wheat. “We stand to face huge losses if the food grain gets spoiled,” he said ruefully. To alleviate the pressure on farmers, West Bengal on April 7, 2020, lifted restrictions on flower trade during the lockdown. But the decision did not bring much cheer to Ganesh Maiti from Mahatpur village in Purbo Medinipur district, who said the damage was already done. Around March and April, there is usually a surge in the demand of flowers, particularly marigold, because of festivals like Navratri. People also prefer organising marriage ceremonies and social gatherings during the months due to pleasant weather, Maiti explained. “But this time, there was almost no demand for flowers. If left intact, flowers can damage productivity of plants. So, we had to pluck and feed tonnes of flowers to our cattle,” said the 30-year-old. He estimated to have incurred a loss of 15,000 in just two weeks.

Industry associations said flower is a major cash crop in districts like Howrah, Nadia, North and South 24 Parganas and Purbo Medinipur, which accounted for 12 per cent of the country’s flower production. “Losses were to the tune of `8-10 crore as the market had begun to slow down as early as in mid-March when governments had issued advisories against public gatherings,” said Narayan Chandra Nayak, general secretary of the Bengal Flower Growers and Traders Association. Even if restrictions were eased, Nayak said the market might recover by just 20 per cent as very few vehicles were available for transportation. Meeranand Manna, a grower in Paschim Medinipur, said, “The situation is not likely to improve as long as scientists find a cure for the coronavirus and the ban on gatherings is lifted.”

Yogesh Rayate from Kadakmalegaon village in Maharashtra’s Nashik district understood the inevitability of lockdown. “Yet, I feel more worried than ever before,” said the 39-year-old farmer. His village on the Sahyadri hills is known for producing grapes. Rayate owns a 2-ha vineyard and grows vegetables on the 8-ha farm next to it. On March 15, 2020, just as he had finished picking the berries and had neatly packed those in crates, he heard the government had restricted activities across Nashik over the coronavirus scare till March 31. “The traders we were expecting that day to pick up the 10,000 kg of grapes did not turn up. After a week long wait, I emptied the crates and spread the berries in the sun to turn them into raisins. This was a loss of `30-40 lakh for my export-quality grapes.” Just as he was planning to recover some of his losses by selling cabbage and cauliflower after March 31, 2020, the Centre on March 24, 2020, extended the lockdown.

“The timing was brutal. The next day we celebrated gudi padwa (a spring-time festival that marks the traditional New Year for Marathi Hindus and reaping of rabi crops) by staying indoors,” he said. Two days later, the government exempted mandis, procurement agencies, farm operations and farm workers from the lockdown rules. But Rayate was offered just 2-3 for a kg for cabbage and cauliflower by traders, citing a slump in demand and travel restrictions.

A few days later, he hired a rotavator and ran it over the standing crop, worth 1.5 lakh. With no income, Rayate said he had no clue how to repay the crop loan of 18 lakh. Shankar Darekar, state president of the National Farmers’ Workers Federation, said the lockdown dealt a huge blow to grape farmers who had lost 30-40 per cent of their crop due to unseasonal rain and hail storms between January and March. Rayate, however, wonders if his losses due to coronavirus-lockdown would be covered under crop insurance that covers losses due to natural calamity.

In West Bengal, which was determined to ramp up onion production to meet domestic demand, witnessed a bumper crop for the sixth consecutive year. But the red bulbs lay scattered across the fields in one of its major productions zones of Hooghly district. Bikas Molik, a resident of Balagarh block, explained the reasons. Onion is labour-intensive. It needs to be manually planted, harvested, cured and then stacked in storage houses. At least 10 labourers work on a bigha of onion farm throughout the season. The lockdown was announced, just as they had begun harvesting. As a result, thousands of labourers left for their homes in Murshidabad and Bardhaman districts.

Subrata Karmakar, a resident of Basna village in Hooghly, said most onions in his village were yet to be harvested. “If the bulbs are not taken out in the next 15 to 20 days, they will start rotting, while we won’t be able to prepare the field for the next crop.” The exodus of labourers from Hooghly had also hit potato farmers, though the crop was harvested as early as in February, 2020, and sent to cold storage facilities. “Potato bags are hand stacked. In the absence of labourers, removing and transporting those bags became difficult,” said Karamkar. The region was staring at an impending an artificial potato shortage.

The absence of labourers had also halted activities in the country’s 8,000 pulsed mills. Industry estimates showed 0.24 million labourers work at these mills. Their exodus was now directly hitting farmers who were unsuccessfully trying to obtain minimum support price for their produce for last three years and suffered a crop loss this year due to unseasonal rains and hail storms. The Dal Mill Association said unseasonal rains might have reduced the country’s pulse production by 10 per cent to about 21 million tonnes.

Uncertainty also loomed large over Punjab and Haryana that expected a bumper wheat harvest in 2020. Punjab had announced it would begin procurement on April 15, 2020, and Haryana a little later. The procurement season was also extended till mid-June. Every year, about 1.5 million seasonal labourers travel from Uttar Pradesh and Bihar to these states to join the harvesting and procurement process. This did not happen this time. It was also a testing time for tea plantations in the Nilgiris region of Tamil Nadu and Idukki in Kerala.

“Our factories incurred losses as the export demand for processed tea powder reduced,” said B K Ajith, secretary of the Association of Planters of Kerala (APK). Some 55 per cent of tea produced for export from the Nilgiris and Idukki did not find buyers, he said. While the lockdown compounded their woes, tea estate workers said they needed to keep plucking the tea leaves on time, or else the plants would have to be pruned and they would then have to wait for a few more months to revive the yield. As per Coonoor- based United Planters Association of South India, tea estates in the region incurred losses to the tune of 250 crore due to the lockdown. Kochi-based Spices Board said cardamom farmers across south India had suffered losses to the tune of 210 crore. Nearly 80 per cent of cardamom trade happens through auctions involving international agencies and cartels. Now auctions had stopped and retail sales reached a standstill. While black pepper farmers in Kerala’s Wayanad and Karnataka’s Kodagu incurred losses of 80 crore, the natural rubber sector suffered a loss of 350 crore.

During these disruptive times, rumours were also making the rounds. In Panipat district of Haryana, a 2-ha sprawling poultry farm was silent like never before since early February. Just two months back, it had housed more than 200,000 broiler chickens. Bittu Dhandha, owner of the farm and also the secretary of National Poultry Federation of India, said, “We used to supply over 5,000 broiler chicken to Delhi every day. But in early February, 2020, we received messages that chicken, meat and eggs can cause coronavirus. At that time, only Kerala had reported three positive cases. “Though we did not take the message seriously, our consumers did,” he said, adding that one can fight diseases, but not rumours against the protein-rich diet.

The demand for his broiler chicken started dipping immediately and became zero by the third week of February. He sold some at 15-20 and distributed the rest for free before shutting the farm. In Punjab, poultry farmers culled more than 20 million birds as the supply chain of feed took a hit. On March 30, 2020, the Centre in its letter to states clarified that chicken and eggs are safe to consume. “It was a much delayed reaction,” Dhandha said. He had incurred a loss of 1 crore and was not able to restart the business.

The lockdown also impacted the country’s 73 million dairy farmers, most of whom depend on one or two cattle. Milk procurement centres in villages either shut shop or reduced procurement due to less demand. “Some 10-15 per cent of the total milk produced across the country used to go to restaurants, commercial offices and hotels which had shut down due to the lockdown,” said R S Sodhi, managing director of Amul, a cooperative dairy giant. “Even if milk reached processing units, they struggled to run at full capacity due to lack of labourers,” he said. While Amul claimed it had reduced its procurement, Rajasthan Cooperative Dairy Federation Ltd had reduced its collection by one-fourth. In states like Uttar Pradesh, private dairies had reduced procurement by 50 per cent. “There was a sharp dip in the demand of pasteurising milk,” said Jay Agarwal, managing director, Gyan Dairy, Uttar Pradesh.

In their attempt to stay afloat, farmers in Punjab had stopped providing expensive feeds to cows to save on expenses. On March 31, 2020, milkmen of Karnataka’s Belagavi district poured 1,500 litres of milk into an irrigation canal as they had no way to sell it. Ramanan Laxminarayan, director of the Center for Disease Dynamics, Economics and Policy, USA, put it succinctly when he said that the pandemic had completely disrupted the rural economy because of the lockdown.
COVID-19 emerged as the biggest cause of death in India (earlier, it was ischemic heart disease) in merely nine weeks preceding April 26, estimated the Institute for Health Metrics and Evaluation (IHME) at the University of Washington; Photo: Vikas Choudhary/ Centre for Science and Environment (CSE)
The Second Wave

“COVID-19 may run out of people to infect pretty soon”

Sudhir Mahajan, a resident of Bhajanpura in northeast Delhi, lost his parents and younger brother to COVID-19 in just 100 hours. “My parents died due to lack of oxygen, without even entering a hospital. While I was arranging for their cremation, my neighbour called me to inform that my brother was having trouble breathing,” he said. “It took me almost a day to get him admitted to the Lok Nayak Jai Prakash Narayan Hospital, while volunteers outside the hospital provided him oxygen support. Just hours after his admission, the doctors declared him dead. He was just 29 years old,” said Mahajan. All the deaths took place between April 19 and April 22, 2021 he said, as he waited for the last rites of his brother at a makeshift cremation ground on the banks of the Yamuna on April 24.

“First you wait for hospital admission, then for treatment, then for oxygen and, in case of death, for cremation,” Mahajan said. “I was told to leave the body at the crematorium with my name and phone number. I waited for two days. When nobody called, I decided to come to the crematorium and wait. I have been here for almost 10 hours. If we can’t get oxygen, what else can we expect?”

The whole of April, 2021 Delhi gasped for oxygen. As COVID-19 cases soared, so did the number of people seeking hospitalisation. Doctors said that unlike in 2020, the COVID-19 patients in the second wave had severe bloating of lungs, which could be due to the new virulent SARS-cov-2 strains. The mutant strains seemed to cause lung inflammation on the very first day of infection, and by the third day, the body’s immune system triggered what is called a cytokine storm. Cytokines are proteins deployed by the immune system to kill the body’s own cells and tissues.

The cytokine storm results in lung inflammation, severe damage to lungs and ultimately leads to hypoxia, a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level. At this stage medical oxygen (contains at least 82 per cent pure oxygen, as per the World Health Organization) is vital to help the patient keep breathing.

Ajoy Sarkar, a critical care expert at Peerless Hospital, Kolkata, said the second wave was different from the first in many ways. “Infectivity is extremely high which has led to such a high spike compared to the first wave. The virus also seems to be invading the lungs much quickly compared to earlier, pushing up the oxygen requirement.” Agreed Arup Haldar, a pulmonologist based in Kolkata. “Compared to earlier, the number of critical oxygen dependent patients is much more in hospitals,” he said.

All trudged to the hospitals, gasping

Patients with such conditions thronged hospitals in Delhi by the thousands everyday throughout April, with the number of new cases shooting up from 3,548 on April 5 to 28,395 on April 20, as per the Center for Systems Science and Engineering at Johns Hopkins University in USA.

By the second week of April, hospitals started reporting shortage of beds and oxygen. Hospital after hospital went public with SoS calls for oxygen supply. Eventually, the Delhi High Court and the Supreme Court of India took note of the emergency situation in the capital city, which had more people dying due to oxygen support than other COVID-related complication.

On May 1, a Saturday, the Supreme Court ordered the Union government to ensure supply of oxygen to the city hospitals within two days. The Delhi High Court passed a similar order the same day: “Enough is enough. No one is asking for more than allocated. If you can’t supply the allocation today, we will see your explanation on Monday (May 3).”

The High Court had ordered the Centre to supply 700 tonnes of oxygen per day to Delhi. The Centre allotted 590 tonnes of oxygen per day while the Delhi government had asked for 970 tonnes. The Delhi High Court on May 3 initiated contempt proceedings against the Centre for failing to comply with its as well as the Supreme Court’s directions to supply oxygen to the capital. The Centre moved the apex court, which stayed the order on May 5 but asked for an explanation. The Centre responded saying it had released 730 tonnes of oxygen to Delhi that day.

Ironically, on August 18, 2020, the Solicitor General of India told the Supreme Court that “there was no requirement of special plan” for the situation. According to a calculation by Milind Sohoni of IIT-Bombay and independent researcher Alakhya Deshmukh, India should have planned for five deaths per million people a day, while all medical emergencies and essential supplies like oxygen at that point of time were based on two deaths per million a day—the mortality rate witnessed during the first wave.

With this planning, we would have known that “the national capacity of 7,000 tonnes per day of oxygen was not adequate and urgent measures were required,” the researchers said. In May 2021 India’s estimated demand of oxygen stood at 4,000 tonnes per day. On May 2, at least 15 states reported 10-50 per cent deficit supply. Throughout the last two weeks of April and in the first week of May, crematoriums in the National Capital Region were overwhelmed with the constant arrival of bodies. Additional spaces were carved and platforms built for funerals in Delhi; the government allowed cremations on pavements in Ghaziabad, Uttar Pradesh; while at Dwarka, in southwest Delhi, a cremation ground for dogs was opened up for human use. Multiple bodies were cremated together to reduce the queue. At most crematoriums, bodies were burnt at undesignated spots, with the protective clothing on. Sights of half- burnt bodies were quite common.

“I have never seen a war, but the situation in Delhi must be similar to it,” said Rishab Gupta, a student at Delhi University and member of a volunteer group that had been helping COVID-19 families with basic facilities. “I never imagined that in a health emergency, I would be more involved in organising cremations than arranging medicine,” he said. Like Rishab, the world watched the lethal second wave of the pandemic in India with disbelief and shock.

Between April 26 and May 2, 2021 India recorded the highest number of new cases of COVID-19 in the world—2.6 million—with 23,800 deaths. This was the second consecutive week India held this unfortunate record. In the week before, there were 2.25 million new cases. By comparison, USA— the most COVID-19-affected country—recorded 1.77 million new cases at its worst outbreak in January 4-10, 2021. On May 11, India had more new COVID-19 cases than the rest of the world put together.

A grim milestone

COVID-19 emerged as the biggest cause of death in India (earlier, it was ischemic heart disease) in merely nine weeks preceding April 26, estimated the Institute for Health Metrics and Evaluation (IHME) at the University of Washington, USA. On February 22, it was the 26th main cause of death, accounting for an average 180 deaths per day. By April 26, it was causing an average 4,800 deaths a day. The death toll from COVID-19 in India will be 0.96 million by August 1, 2021, according to the latest projection by IHME.

With an estimated global toll of over 5 million, India would account for nearly a fifth of the total deaths. There were many more COVID-19 cases in India than the Government of India had declared, said Christopher J L Murray, professor at IHME, in a statement on the analysis on April 27, 2021. “Our analysis of seroprevalence surveys shows that the infection detection rate is below 5 per cent— maybe even around 3-4 per cent. This means that the number of cases that are being detected needs to be multiplied by 20 or more to get the number of infections that are occurring in India. The number of infections right now is extraordinarily large,” Murray said. “Our latest projections show that the number of infections driven by the surge in India (and perhaps also driven by the surges in Bangladesh and Pakistan) will be reaching 15 million a day globally,” he added.

Murray argued that infection in India was so high that “COVID-19 may run out of people to infect pretty soon”. This meant after mid-May transmission in India would start declining, estimated the report. IHME projected India’s daily death toll at 13,050 by May 15.

April turned out to be the cruelest month for India in the 15 months of the pandemic. The country recorded an unprecedented 6.6 million new cases, with 46,000 deaths, according to the World Health Organization. On the last day of the month, India became the only country to record over 400,000 new cases in a single day, suggesting that the onslaught was unlikely to ebb anytime soon. By the last week of April, the countrywide demand for medical oxygen went up by eight-fold—from 700 tonnes a day to over 6,000 tonnes a day.

Uttar Pradesh, given its poor health infrastructure and high population density, became a veritable COVID-19 hell in the pandemic’s second wave. Some 12,238 people succumbed to the disease as of April 30, 2021, while 1.2 million tested positive, making it India’s fourth worst-affected state. Hospitals had run out of oxygen and beds, and crematoriums were falling short of space. While the situation went out of control, the chief minister kept claiming the numbers were not “significant”, there was “no scarcity of oxygen”.

The government also promised “free cremation for COVID-19-related deaths”. Between April 19 and May 3, the oxygen demand in the state increased by over 300 per cent. Of the state’s 0.28 million active cases on May 5, a huge 82 per cent were in home isolation, and, as health officials said, might be needing hospitalisation if not properly treated. That added on to the already collapsing health system. Giridhar R Babu, professor and head of life course epidemiology at Public Health Foundation of India, a public-private initiative, said, “In Uttar Pradesh and Bihar, the health infrastructure is poor and human resources to provide critical care at the field level are not enough. Owing to the chronic weakness in the health systems of these states, it is unrealistic to expect them to perform better than metropolitan cities during such a health crisis.”

On May 5, the Allahabad High Court directed the district magistrates of Lucknow and Meerut to verify news of COVID-19 patients dying due to oxygen shortage and observed: “Death of COVID patients just for non-supplying of oxygen to the hospitals is a criminal act and not less than genocide.”

Doctors were in a dilemma, as resources were scarce. “I had only seen these real life ethical dramas in sci-fi movies. It is so overwhelming when a group of 15-20 patients, all with oxygen saturations ranging from 30 per cent to 40 per cent (the normal level is 95-100 per cent), arrive at the same time and require ventilator support.

Whom should we give it to? Should it be on a first-come-first-served basis? When I did this the first time, I had to deny a ventilator to a 30-year-old against a 73-year-old. The senior person passed away within a few hours. The younger one, too, died later. I wondered if I should have given a chance to the 30-year-old. But who am I to choose; everybody has an equal right to live. I will always feel guilty that I couldn’t save either of them,” vented Vivek Gundappa, deputy medical superintendent and assistant professor of pulmonology at Rajarajeswari Medical College and Hospital, Bengaluru, one of India’s worst impacted metropolitan cities.

Wave after wave

There is no definitive way to pronounce the arrival of a second wave in a pandemic. Still the pertinent question for India was: why did the country look so hapless in face of the second wave? There are reasons for us to ask this question. Across the world, countries were reporting a second wave deadlier than the first one. The Spanish Flu in the last century and even other recent pandemics, like the 2002 SARS outbreak and 2009 H1N1 influenza, showed these scourges could have multiple waves. What was, then, the hurry for India to bestow upon herself congratulatory superlatives of having fought off the disease? There has been a distinct difference between the approach of the scientific community and the political leadership, particularly the prime minister and his cabinet, who had been declaring India’s success in curbing the pandemic.

India, thus, entered 2021 with the bravado of having tamed the once-in-a-century pandemic. In September 2020, new cases had peaked at 93,000 a day before the curve started to flatten. In mid- February, 2021, India was registering some 12,000 cases a day, which was much less than what rich countries in Europe were reporting.

Soon, the call for lockdown was replaced by “unlockdown” and the country almost returned to its pre-COVID-19 level of activities. Complacency set in. Many states dismantled the emergency COVID-19 treatment facilities that were put in place in March-July 2020. Madhya Pradesh created 40,000 extra beds for COVID-19 patients last year.

By April 2021, at least 50 per cent of them were dismantled, as per the Union health ministry data. Similarly, Uttar Pradesh had set up 503 COVID-19 hospitals, with 0.15 million beds, but by February, 2021, just 83 hospitals with 17,000 beds were functional. People continued to report symptoms and got cured as well. Testing came down as a result of complacency. Even amid a second surge, Haryana, Punjab, Puduch*erry, Goa, Himachal Pradesh, Rajasthan, Assam, Andhra Pradesh, Telangana and Jharkhand decreased the number of ICU beds. Haryana and Punjab, where cases were still rising, reduced ICU beds by 79 and 70 per cent respectively in the past one year, according to health ministry data presented in Rajya Sabha on February 2, 2021. These states had also reduced the number of ventilators by 73 and 78 per cent respectively. While 26 states, including Maharashtra, had strengthened their critical care infrastructure by adding ventilators, the number had reduced in nine states, showed the data. Overall, India had added 10,461 ventilators since April 2020.

The first assurance that India was winning the battle came in October 2020 from the COVID-19 IndiaNationalSupermodelCommittee,a 10-member panel appointed by the Department of Science and Technology. In its study titled “Progression of the Covid-19 Pandemic in India: Prognosis and Lockdown Impacts”, the committee said without the stringent national lockdown imposed in March 2020, we would have hit a peak load of over 14 million cases in June 2020—the month when restrictions were withdrawn gradually. “No fresh lockdowns should be imposed on district or state level to contain the spread of COVID-19 unless there is an imminent danger of healthcare facilities being overwhelmed,” committee chairperson and professor at the Indian Institute of Technology (IIT) Hyderabad M Vidyasagar told the media on October 18, 2020, based on the supermodel, “Susceptible, Asymptomatic, Infected, Removed (SAIR)”. “If all protocols are followed, the pandemic can be controlled by early next year with minimal active symptomatic infections by the end of February,” said Vidyasagar. “The peak of active coronavirus cases came in late September (2020) at around 1 million, and by this time, India was far better equipped to handle the pandemic in terms of diagnostics and vital equipment inventories. In short, the lockdown flattened the curve.”

The same day, V K Paul, member of the NITI Aayog and head of the National Expert Group on Vaccine Administration, while reiterating that the spread of the pandemic had “stabilised” in most of the states, cautioned of a second wave in the winter months. He cited examples of European countries that were witnessing second waves with the onset of winter. Like Vidyasagar, he also warned that without COVID-19-appropriate behaviour during the “festival season and winter months” the disease could pose a challenge.

On January 28, 2021, while speaking at the Davos Dialogue of the World Economic Forum, Prime Minister Narendra Modi declared that naysayers had been proved wrong. “I remember what many reputed experts and top institutions in the world said in February-March-April last year (2020). It was predicted that India would be the most affected country from corona all over the world. It was said that there would be a tsunami of corona infections in India…In a country which is home to 18 per cent of the world population, that country has saved humanity from a big disaster by containing corona effectively,” he claimed.

On February 26, 2021, Manindra Agrawal, deputy director, IIT-Kanpur, and part of the COVID-19 India National Supermodel committee, told media that a second wave was unlikely despite a surge in cases weeks before his forecast. The “supermodel” forecast said that there would be up to 11.5 million total cases by April 2021 (all cases since March 2020), or 30,000 to 50,000 new cases a week till April 2021. At that time, Maharashtra was reporting the highest number of cases. Agarwal claimed that as per the model, 60 per cent of the population was already infected, thus, reaching herd immunity.

On February 4, 2021, Balram Bhargava, director general of the Indian Council of Medical Research, told media that only 21 per cent of population was infected, based on its third national serological survey conducted from December 17, 2020 to January 8, 2021. While these multiple forecasts churned out conflicting messages, the month saw the forecast by “supermodel” SUTRA going wrong. In October 2020, this model said that there would be just 40,000 active infections by February, 2021. The actual number was four times higher.

On March 8, 2021 speaking at a meeting of Delhi Medical Association, Union health minister Harsh Vardhan declared (he was removed from the Union Council of Ministers in a reshuffle in July, 2021): “We are in the endgame of the COVID-19 pandemic in India.” While he was speaking, his officials were collating data that would contradict his claim. For the week ending March 12, the seven-day average of new COVID-19 cases across India rose by 67 per cent from the lows seen after the end of the first wave of the pandemic. Seventeen of India’s 20 most populated states reported 20 per cent more new cases from their troughs.

Again, on March 30, 2021 the health minister, while releasing a status report on India’s battle against the pandemic, said: “This is a historical moment for all of us. On 30th January we had our first case and today, after one year and two months, we have chased more than 1.2 crore [12 million] COVID-19 cases.” He termed India’s experience as an “exceptional opportunity”, adding, “We have fared better than many countries.”

The same day, NITI Aayog member V K Paul went public saying the “situation was going from bad to worse” and that the virus almost “penetrated our defences”. Two days later, scientists working on another government-backed model for charting the trajectory of COVID-19, using SUTRA (Susceptible, Undetected, Tested-positive, and Removed Approach) predicted that India’s second wave would peak by the third week of the same month at 100,000 cases a day. A month later, the scientists admitted that the model predictions were incorrect, primarily because of the nature of the virus that had been changing very rapidly.

By then, India had launched one of its most expansive global relief operations. The country’s oxygen export increased by 734 per cent in January. It also exported around 193 million doses of vaccines. “We kept warning that the pandemic was not over but no one was listening,” said Rakesh Mishra, senior principal scientist and director of the Hyderabad-based Center for Cellular and Molecular Biology. Mishra was investigating whether the variant B.1.617, found first in India, was behind the second wave in the country. He was the scientist who went public with information that shows the government was informed of a deadly wave in early March 2020.

Reality hits home

From mid-April, India’s daily cases were above 0.2 million. This was the time when almost all states reported an increase in cases. An acute shortage of oxygen and hospital beds overwhelmed the country. On April 20, Modi addressed the nation: “The country is today fighting a very big battle against COVID-19. The situation had improved for a while, but the second COVID-19 wave has come like a storm.” His acknowledgement of a crisis that had been brewing for over six months was of little use.

It was a national emergency-like situation, said the Supreme Court two days after Modi’s address. Soon after Modi’s acknowledgement of the deadly second wave, heads of the government’s top institutes hinted that the second wave in India might have been driven by its variants—the UK variant, South African variant, Brazilian variant and the “Indian” variant—which was speculated since September, 2020. At a webinar on April 23, 2021, Sujeet Singh, director of the National Centre for Disease Control, said that the UK variant might be driving the surge in Delhi.

“In the second week of March, it was found in 28 per cent of the samples. In the last week of March, it was found in 50 per cent samples,” he said. The Indian variant’s prevalence in Delhi is also on the rise, he added. “The surge in Delhi is clearly due to the variants,” he said. Punjab’s surge had been driven by the UK variant, while in the case of Maharashtra, the “Indian variant” is the key factor, he said. T Jacob John, a virologist and professor at Christian Medical College, Vellore, said, around mid-March, 2021 when the number of cases increased, no one had the idea that the second wave was caused by a new variant of coronavirus. The spreading strain was assumed to be the dominant variant (D164G). “We thought the Centre has been regularly monitoring the spread of the UK variant (originated in September 2020), the South African variant (October 2020), and the Brazilian variant (November 2020), which have a higher transmission potential.”

“However, we were completely wrong. The fast- spreading B.1.617 (double mutant) was already present in India,” said John. In December 2020, the government assigned the genomic analysis consortium Indian SARS-cov-2 Consortium on Genomics, comprising 10 public health institutions and laboratories across India, to test 5 per cent of all the samples tested positive. The consortium had not given a report.

Super-spreaders and the politics

India is a diverse and big geography that can have simultaneous outbreak of multiple COVID-19 variants, warned experts many times. A new variant always leads to faster spread. It means, there could have been multiple outbreaks in the country, each requiring a customised strategy to curtail. That did not happen because we did not acknowledge the outbreak. State after state opened up while allowing super-spreader events like religious festivals and election rallies.

The Election Commission on February 26, 2021 declared state elections spanning over two months. “We laid the red carpet for the variants through events like the Kumbh Mela, assuming there was no virus around us. Even when we knew of the problem, there was a delay in the government to contain the spread, leading to unimaginable circ*mstances,” said John.

Take the case of Kerala, which remained an outstanding example of managing the pandemic and had deployed a well-thought-out strategy. Though India’s first cases of the pandemic were reported from Kerala on January 30, 2020, the state successfully flattened the curve by May, 2021 even as cases were multiplying in other states. Its deft handling of the pandemic through “delay the peak” model was recognised worldwide. There were even days when Kerala reported no cases. It took the state four months to report its first 1,000 cases. After the initial phase of success in flattening the curve, priorities of the state changed drastically. COVID-19 took a back seat in the face of two successive elections and the celebration of different festivals.

“The state seemed a little apprehensive of the possible second wave, which had by April, 2021 turned into an alarming reality. The state even failed to anticipate evolving of the genetic variations of the virus,” said V Raman Kutty, a public health expert and epidemiologist based in Thrissur. Even the state health department admitted that two successive elections—the first one to the panchayats, municipalities and city corporations in December 2020, and the second to the state assembly in April 2021— contributed immensely to the rise in cases.

As per the state health department, COVID-19 cases had risen by 255 per cent since April 14, a day when the state celebrated its harvest festival Vishu and people in large numbers engaged in shopping and festivities. “The elections and unprotected interactions in the society have created a situation in which the state failed to find a breathing period between the two waves,” added Kutty. K K Shailaja, the former health minister of Kerala, said, “Other than elections and celebration of festivals, people across the state found the post lockdown period as an occasion for what experts call revenge socialisation.”

As a result, Kerala’s situation in the second wave was similar to the rest of the country. ICU and ventilator beds earmarked for COVID-19 patients fast filled up. The pandemic, which was earlier confined to the elderly and to those with comorbidities, hit the young with little health problems. The state known for the country’s most robust public healthcare system seemed grossly unprepared for the second wave in which active cases crossed the 0.3 million mark on April 30. Kerala’s positivity rate (percentage of positive cases to total tests) was about 25 per cent and the state had lost over 5,300 lives to the virus.

In West Bengal, which had eight-phase elections and saw over 100 mega rallies, a state health ministry official conceded that the government saw signs of the second wave in the first half of March, as the cases started to rise. There was little anyone could do since the state was in election mode and the Model Code of Conduct was in place, said the official requesting anonymity. “Along with the obvious role of election, the new variants must have also played a role,” said Manas Gumta, a physician in North 24 Parganas and general secretary of the Association of Health Service Doctors, West Bengal. Subhrojyoti Bhowmick, clinical director of Peerless Hospital, Kolkata, said the spread of the contagion beyond Kolkata also hinted towards the role of elections. “Most of the areas that went to election in later phases, and hence had more meetings and rallies, are recording more cases,” said Bhowmick.

As per the West Bengal government data, 19 districts apart from Kolkata urban agglomeration contributed 56 of the state’s 216 cases (26 per cent) on February 26, 2021—the day election schedule was announced. On May 3, total number of cases had spiralled almost 81 times to reach 17,501. Districts like Birbhum and Malda that went to poll in the last phase on April 29 had two and one cases respectively on February 26, but 833 and 522 cases on May 3. “In states that have not had elections, the spurt in cases is due to the congregations of different kinds.

But in West Bengal, large congregations at the moment are mostly linked to the election,” said Giridhar R Babu, an epidemiologist associated with the non-profit initiative, Public Health Foundation of India based in Bengaluru. “We may not have the data from West Bengal or India but the analysis of the US presidential election clearly establishes the correlation between large electoral meetings or rallies, often without maintaining COVID-19 norms, and a spurt in COVID-19 cases,” said Bhowmick. “A long election is definitely contributing to the COVID-19 rise because it is maximising exposure,” said Arunava Majumdar, a former director of All India Institute of Hygiene and Public Health, Kolkata.
Between April 26 and May 2, 2021 India recorded the highest number of new cases of COVID-19 in the world—2.6 million—with 23,800 deaths; Photo: Vikas Choudhary/ Centre for Science and Environment (CSE)
Though there was no nationwide lockdown this time, all states had imposed restrictions on movements and activities; Photo: Vikas Choudhary/ Centre for Science and Environment (CSE)
In the countryside

The pandemic had never really flattened for rural India

AOn May 4, 2021, the Odisha government was thrown into a tizzy after three people of the Bonda tribe tested positive for COVID-19. That the novel coronavirus would infect this community, living in scattered hamlets in inaccessible forests, was beyond anybody’s speculation. Identified by Census 2011 as one of India’s 75 Particularly Vulnerable Tribal Groups, the Bondas are estimated to have arrived in the region some 60,000 years ago during the early human migration from Africa and have traditionally led a secluded lifestyle, residing atop forested hills in Malkangiri, the southernmost district of the state. Other than the occasional visit to local haats (weekly rural markets) to sell their produce or barter it for minimal household essentials, their interaction with the outside world is extremely restricted.

Officials suspected that the Bondas at Mudulipada village contracted the disease at a nearby market in neighbouring Andhra Pradesh, which they visited since all haats in their own region had been shut as part of lockdown measures. The government sealed Malkangiri’s borders with Andhra Pradesh and the local administration restricted access to Bonda hamlets. Though the infected persons were admitted to specialised hospitals in the district, the number of infected Bondas increased to 12 over a week.

COVID-19 breaching the hills of the Bondas marked the most worrying phase of the second wave, which had already made India the pandemic’s global hotspot. In this phase, the virus pervaded the country much beyond urban agglomerations, sweeping across areas that are home to arguably the world’s largest rural population of over half-a-billion. May 2021 was the most tragic month for the country. Between May 1 and 26, India recorded 8.2 million new COVID-19 cases—highest in a month since the first case was reported from Kerala in January 2020. In those 26 days, 103,382 people succumbed to the illness—this was more than double the lives the country lost in April and over a third of the country’s total death count of 315,235 recorded since the outbreak of the pandemic.

A Down To Earth analysis showed in those 26 days, India accounted for every other new COVID-19 case and every third death due to the infection recorded globally. What escaped everyone’s notice was that every second new case and death reported from India in May was from rural districts. This meant every fourth case reported in the world that month was from rural India.

The pandemic’s shift from urban to rural areas had, in fact, begun in April, 2021. That was the month when rural districts (where at least 60 per cent of the population live in rural areas) for the first time reported 3.1 million new cases, up from 0.4 million cases the month before. This was a little lower (by 0.6 million) than the number of cases that overwhelmed health systems and the sentiments of most people in urban districts. The number of deaths due to COVID-19, which stood at 5,600 in March, saw a significant increase to match the urban death toll of 24,000 in April.

The numbers kept growing, and in May, outpaced those in urban districts. Rural districts accounted for 53 per cent of new cases and recorded 52 per cent of COVID-19 deaths. This was a deviation from the overall trend from March 2020 to April 2021, when urban districts accounted for 52 per cent of new cases and 54 per cent of deaths.

The pandemic’s shift from urban to rural areas was evident in states worst-hit during the second wave. Rural districts in Maharashtra, for the first time in May, 2021 recorded more cases (61 per cent of the total new cases) than their urban counterparts; the state’s rural share in April was 42 per cent. In Karnataka, the share of rural districts in May stood at 49 per cent, up from 32 per cent in April. In Uttar Pradesh, rural districts accounted for 68 per cent of the new cases in May, up from 57 per cent, and in West Bengal, the figures rose to 48 per cent in May from 43 per cent in April. The daily case count on the government dash board had, however, been on a downward trend since May 8—the last date when the country recorded over 400,000 cases in a day.

Health infrastructure in rural India is substantially weaker than that in cities. Over 65 per cent of India lives in rural districts, as per the World Bank, yet only 37 per cent of beds in government hospitals are in rural India said the Union Ministry of Health and Family Welfare’s National Health Profile 2019. Lack of awareness, hesitation to get tested and reluctance to take treatment made the rural population more susceptible to COVID-19. Owing to limited testing and delayed results, the official COVID-19 numbers, especially in rural districts, were likely to be misleadingly low.

Nuapada, a rural district of Odisha and one of India’s poorest, offered a snapshot of the havoc that the pandemic could wreak in such areas. The biggest problem here was shortage of oxygen, which led to deaths. Duryodhan Majhi, a member of the Silva Gram Panchayat in the district, had COVID-19 and died on April 24 when the supply ran out at the district COVID-19 hospital, says his brother Sadhuram.

Dolley Hota, a resident of Bhubaneswar, sent a letter to the chief district medical officer (CDMO) of Nuapada after her father Janmejaya Joshi died at Khariar’s COVID hospital on April 24. She claimed her father died due to oxygen shortage. “The situation in the COVID hospital at Nuapada was good during the first wave of the pandemic. But the situation now is bad,” said a local journalist, requesting anonymity. “There are no timely visits by staff. Patients have to run to the emergency section frequently to complain of their problems,” said the journalist whose wife died of COVID-19 in the hospital. Kali Prasad Behera, CDMO, Nuapada, told that there was no question of negligence at the hospital, nor was there a shortage of oxygen, and that the hospital was getting 250 cylinders every day.

The number of daily new COVID-19 positive cases in the district as well as the percentage had not shown any decline in recent weeks. This indicated the spread had not just continued but the demand for hospitalisation was also increasing. The total number of positive cases from March 1 to April 25 was 5,399, which was 10.16 per cent of the total people tested. The number of people found positive in the district on April 25 was 300, which was about 30 per cent of the total 1,003 people tested. Deaths due to COVID-19 in Nuapada had also significantly increased in April, at an average of five deaths daily. Nuapada had already witnessed 87 deaths in the second wave of COVID-19, with the number rising by four to six deaths every day.

Still, most people in the villages of the district were shy of testing. Radheshyam Behera of Sargimunda village said most people in his village had COVID-19 symptoms. Hence, he requested the CDMO to depute a team to conduct antigen tests. “When a team reached the village the next day, only three families volunteered for testing. Six of the 20 people tested were found COVID-19 positive,” Radheshyam said. For most people in the villages, COVID-19 carried a stigma that led to restrictions on the use of village commons, especially the water sources.

Rural areas in India’s relatively more developed states had similar stories. Take the case of Gujarat, where Prime Minister Narendra Modi served as chief minister for over a decade. The state’s 18,000 villages spread over 33 districts faced a severe shortage of doctors and medical personnel, oxygen supply, beds and other life-saving equipment, said senior government officials on condition of anonymity. Many districts in Gujarat have a single community or healthcare centre for some 10 villages. Some of these centres did not even have facilities for rapid antigen tests. People’s reluctance to follow COVID-19 guidelines and social distancing norms as well as “vaccine hesitancy” made the situation worse.

Mehsana district in north Gujarat had the highest caseload among the rural districts of the state. It was the home district of Gujarat’s health minister, Nitin Patel. Chandrakant Parmar from the prosperous Kherva village in Mehsana informed there were more than 80 deaths in March and April, 2021. The village that lies on the state highway between Gandhinagar and Mehsana, had a population of 15,000 and was reportedly seeing three to four deaths daily after the infection numbers surged in April.

The village had a primary healthcare centre with a staff of 25 to 30 people, including a doctor, 10 to 15 nurses and paramedics. But it lacked intensive care units, CT- scans, sonography and oxygen cylinders. The village sarpanch did arrange for a 200-bed quarantine centre, but a lot of people were still quarantined at home. Kherva also received patients from some 15 neighbouring villages. The administration converted the Ganpat University in the village into an isolation centre.

COVID-19 testing and vaccination were free but village residents were hesitant. Kherva had about 500 COVID-19 patients, said the sarpanch of the village. Another affected village was Khanpur in Patan district in north Gujarat. The village was inhabited by 800 families and had seen three deaths. Dev Desai, a resident of Khanpur said people in the village died within three to four days after getting fever.

A new curve

The pandemic had never really flattened for rural India. With the second wave making inroads into the hinterlands, experts foresaw a vicious cycle for the country’s over-half-a-billion rural residents. Rural Indians—mostly an informal workforce and poor by any accepted definition—had been living with irregular jobs as the pandemic continues to ravage the world for over a year. The second wave, with more cases of infection in rural India, aggravated this economic crisis.

Expenditure on health might also go up as cases rise, draining people’s income or savings. According to the Centre for Monitoring Indian Economy (CMIE), an independent research firm, job losses and unemployment were reported from rural areas, unlike in 2020 in the first wave of the pandemic. CMIE’s data indicated the national unemployment rate neared the level seen in June 2020, the highest in recent memory that arose from the nationwide lockdown and restrictions to curb the spread of COVID-19. For the week ending May 16, 2021unemployment for urban areas was 14.71 per cent, while that for rural areas was 14.34 per cent. “The pandemic has slowed down the labour participation rate to 39.9 per cent from an average of 42.7 per cent in 2019-20,” stated the Reserve Bank of India in its monthly bulletin for May, 2021.

This high level of unemployment, particularly in rural areas, is referred to as the tipping point. “In 2017-18, the unemployment rate was at a 45-year high. COVID-19 has magnified this problem,” said Santosh Mehrotra, visiting professor, Centre for Development, University of Bath, UK, and former economics professor, Jawaharlal Nehru University, Delhi. The second wave, as various estimates showed, had hit the unorganised sector the most. “Unlike the first wave, rural supply chains will be impacted because farmers and cultivators are also infected,” said Mehrotra.

Though there was no nationwide lockdown this time, all states had imposed restrictions on movements and activities. The stringency of lockdowns, unlike last year, varied from state to state and from district to district. Similarly, the easing of restrictions also depended on individual states. Agriculture, which employs over 50 per cent of Indians and was the only sector to clock a positive growth of 3.6 per cent at constant prices in 2020-21 during the first wave of COVID-19, could be severely impacted because of the second wave. Dependence on agriculture is still very high as it engages about 60 per cent of the rural workforce, but contributes only about one-fourth of rural households’ income, indicating an abysmally low income for those dependent on agriculture.

“The magnitude of the problem in rural India is huge, but policy response to it has been very low. We are still struggling with oxygen and critical care breakdown in urban India. The salaried job loss in rural India will have a cascading impact on several sectors,” Sunil Kumar Sinha, principal economist of Indian Ratings and Research, a Fitch Group company, was quoted saying by the media.

The impact on the rural economy might even drain the overall economy. India Ratings and Research (IND- RA), a credit rating agency, said the economic impact of the second wave would be harder due to loss of demand in rural India, which was not likely to pick up again soon. Rural consumption was a boon for the economy during the first wave of the pandemic for it remained largely unaffected till early 2021. But with a positivity rate of over 10 per cent in more than half the country’s districts, the expenditure pattern of rural households could take a turn for the worse, even if agricultural output and income remain the same.

There may be a tendency to suppress discretionary spending due to the fear of impending disease, said Abhirup Bhunia, an international development consultant. “A downward force on consumption and demand in rural areas this year (2021) will hit us. Rural demand saved us in 2020. A health crisis of this measure will put pressure on out-of-pocket expenses for many families,” he said.

The share of government in the expenditure on health in India was only 27.1 per cent; a large share of 62.4 per cent was borne by households. “So people are going to try and save more and cut down on consumption. High out-of-pocket expenditure will put them in a debt situation,” he said. This debt could be more damaging than other types of household debt.

“As these expenses generally occur during an illness, it limits one’s ability to work, leading to depletion of household savings and unanticipated economic shocks,” said IND-RA. These out-of-pocket expenses could push millions of people below the poverty line. There could be a 10 per cent increase in rural poverty compared to what it was a decade ago, estimated Mehrotra. He said: “As much as 26 per cent of the rural population was living under poverty in 2012; we are likely to see a 10 per cent increase this year (2021).

When poverty increases at this rate, aggregate demand in the economy collapses. When that happens, the organised sector is impacted.” He said the organised sector might be doing well, but going forward as poverty increased and wages collapsed, aggregate demand here, too, would remain extremely tepid. This might mean investments would not revive and GDP growth would not get anywhere close to even 5 per cent for the next three to four years (2022-2025). Pravakar Sahoo, professor, Institute of Economic Growth (IEG), an autonomous body under the Union government, said the money in circulation or that with public in May, 2021was around 29 trillion.

“This is 50 per cent higher than the money that was with the public before demonetisation,” he said. Why the demand for money high when jobs and incomes have been lost? Sahoo said these were distressed withdrawals. “People are now withdrawing money. They have lost their income and are now relying on their savings to survive. It’s a bad sign. The consumption level will go down further.”

Behind the curve

SARS-CoV-2 virus, which is behind the ongoing pandemic, does not differentiate between rural and urban areas. It just looks for susceptible people, who still do not have the immunity against it. Since rural India remained largely unscathed during the first wave of the pandemic, the virus has found many susceptible victims there during its second wave.

Owing to the nature of the virus, its spread was inevitable. The problem emanates from the fact that the rural areas are ill equipped to deal with diseases even in best of times. More than 65 per cent of the country’s population lives in rural districts, according to World Bank data. Yet, hospitals in rural areas have just 37 per cent of the beds available in all government hospitals across the country, admitted the National Health Profile of India for 2019, a report prepared by the Central Bureau of Health Intelligence.

A parliamentary committee report on “Management of COVID-19 Pandemic and Related Issues”, presented to the chairperson of the Rajya Sabha on December 21, 2020, indicated the possibility of the disease reaching rural areas. It had advised the government to ensure testing infrastructure and upgraded health infrastructure in remote and rural areas. Earlier, on November 21, 2020 another Parliamentary committee report, “Outbreak of Pandemic COVID-19 and its Management”, submitted to Rajya Sabha highlighted the poor state of primary healthcare in rural areas and recommended that the government increase its spending under the National Rural Health Mission to strengthen the delivery of healthcare services in rural areas during the pandemic.

It was only in May, 2021 that some action was visible at the central level. On May 16, the Union Ministry of Health and Family Welfare released a standard operating procedure (SoP) on “COVID-19 Containment and Management in Peri-urban, Rural and Tribal areas”.

The SoP outlined the preparations needed in rural areas and detailed the efforts states needed to take for surveillance, screening, isolation and referral of patients. It proposed a three-tier structure—COVID-19 care centres to manage mild and asymptomatic cases; dedicated COVID health centres to manage moderate cases; and dedicated COVID hospitals to manage severe cases. Implementing the SoP should not have been difficult as India already has a three-tier healthcare system in place—primary, secondary and tertiary. Then where did it falter?

Ritu Priya, professor at the Centre of Social Medicine and Community Health, Jawaharlal Nehru University, Delhi, pointed out that a healthcare system that didn’t work in normal times was not likely to work during a pandemic and under pressure. Besides, the sop document didn’t reflect any sense of urgency by the Union health ministry for rural India. It began with the line “COVID-19 outbreak in the country is still predominantly an urban phenomenon”, she said. The SoP document also noted that 80-85 per cent of the people affected by COVID-19 didn’t need specialised care and could be quarantined at home or at a COVID care centre. However, ensuring treatment to the remaining 15- 20 per cent of COVID-19 infected persons requires major upgradation in healthcare infrastructure— community health centres, sub-district and district hospitals and transport facilities—in rural areas.

This was unthinkable for a health system that had been strapped for funds for decades now. India’s public health expenditure (a sum of Central and state spending) had remained between 1.2 per cent and 1.8 per cent of GDP between 2008- 09 and 2019-21. This was quite low when compared with other countries such as China (3.2 per cent), US (8.5 per cent) and Germany (9.4 per cent).

The National Health Mission, which envisaged achievement of universal access to equitable, affordable and quality healthcare services, received about 50 per cent of the budgetary allocation for health. Worse, the allocations for the rural component (National Rural Health Mission) had decreased by 3 per cent since 2020.

Since 2014, the government’s focus had in fact shifted to providing healthcare by roping in the private sector. The National Health Policy (2017) also envisaged providing healthcare in collaboration with the private sector. The Pradhan Mantri Jan Arogya Yojana (PM-JAY), a component of the Union government’s flagship scheme Ayushman Bharat, is an insurance-based scheme which has seen the highest increase in allocation for 2020- 21 at 100 per cent ( 6,400 crore over the revised estimates of 3,200 crore in 2019-20). The futility of this dependence on private healthcare providers via government-funded insurance schemes had become apparent during the pandemic. The private sector was not active in rural areas, and even the hospitals present refused to provide care to COVID patients during the pandemic. Even state-level insurance schemes did not perform well.

Chhattisgarh, for instance, has a universal healthcare scheme, the Khoobchand Baghel Swasthya Sahayata Yojana. During the pandemic, this scheme should have come to the rescue of each COVID-19 infected person, whether in rural or in urban areas. But private hospitals refused to implement it. Instead, several of them found newer ways to overcharge patients by providing plasma therapy and other unscientific and unproven therapies that did no good to patients, said Sulakshana Nandi, National Joint Convener of Jan Swasthya Abhiyan (JSA) and co-chair of People’s Health Movement, a global network.

The government did not demand services from the private sector though it could have legally done so under the Epidemic Diseases Act, 1897 (just the way Kerala had done). Experiences of the poor showed provision of an insurance card were not the same as effective access to free and quality care. Instead of learning from this failure of the private sector to provide any help during the pandemic, NITI Aayog, India’s premier think tank, brought out a report “Investment Opportunities in India’s Healthcare Sector”, on March 31, 2021, with a focus on private healthcare.

“Going forward, the Centre and NITI Aayog should abandon all plans for healthcare privatisations, such as PM-JAY and handing over district hospitals to private medical colleges, and instead invest all money and efforts into strengthening the public health system at all levels,” said Nandi. The major reason public healthcare had failed to perform during the pandemic is the deficiency in infrastructure—both in terms of physical structures and human resources. As of 2018, India faced a shortage of 2,188 community health centres (CHCs), 6,430 primarily health centres (PHCs) and 32,900 sub-centres.

The existing ones, too, do not have adequate infrastructure and are poorly equipped. According to an analysis by World Bank, in 2017 India had only 0.5 beds per 1,000 people, far below the global average of 2.9 beds. Small wonder, the rural healthcare infrastructure was stretched to the limit during the pandemic. “In some tribal areas of Maharashtra, not a single oxygen bed is available in the entire block. People here had to travel long distances to access medical facilities, without any assurance of a bed.

More often than not, their health condition deteriorates on the way to the health facility,” said Abhay Shukla, co-convenor, JSA. The isolation centres which had worked well in the first wave were not revived in the second wave.

“In rural areas, it is important to have institutional isolation centres to ensure adherence to COVID-appropriate behaviour,” said Shukla. According to him, it was easy to bolster health infrastructure during such times of crisis. Potentially, each rural school could be converted to an isolation centre, which could then be monitored by ASHAs and ANMs. This was a public health measure that had to be implemented and supervised with direction from the top authorities. Similarly, each taluka in the state had a 30-bed hospital, some of which could easily be converted to oxygen beds.
As awareness on the pandemic spread, so did innovations. In Chhattisgarh, many rural residents used leaf masks for protection. This was also because face masks were hard to find and most poor Indians could not afford them.
Photo: Prakash Thakur
Most viruses are made up of either a single RNA or DNA strand which stores its genes. But flu virus has eight RNA strands, which mean it infects hosts easily and they replicate quickly in them; Photo: Vikas Choudhary/ Centre for Science and Environment (CSE)
Female doctor holding mouth cotton swab test or PCR for Covid 19; Photo: Istock

The world of Viruses

There is an urgent need to understand viruses and the ways they operate

What do we know about viruses, the smallest, simplest biological entity, that has brought the most evolved species on the planet to its knees? This may appear as a philosophical question. But if virus is non- living, what does it gain by being virulent? There is no clear answer to it. But virulence is probably not the agenda of a virus. Because for these tiny invaders, a dead host is a dead end.

It disrupts cell function in its desperation to replicate. This makes us sick. In response to infection, the immune system springs into action. White blood cells, antibodies, and other mechanisms go on an overdrive to rid the body of the foreign invader. These cause fever, rash, headache and fatigue. A disease occurs when the immune system loses ground to the virus, and the latter manages to establish itself in the cells for replication.

The replication process typically begins when a virus infects its host by attaching to the host cell and penetrating the cell wall or membrane. The virus’ genome is then uncoated from the protein and hijacks the host cell’s machinery, forcing it to replicate the viral genome and produce viral proteins to make new capsids (the protein shell of a virus). The new viruses then burst out of the host cell during a process called lysis, which kills the host cell. Some viruses take a portion of the host’s membrane during the lysis process to form an envelope around the capsid. Following viral replication, the new viruses then go on to infect new hosts.

Most of the time body’s immune system (more on this later) is capable enough to get rid of viruses. Problem arises when the virus cheats or attacks the immune system to gain access to a cell and takes control over it. These are the ones capable of causing outbreaks and, sometimes, pandemics. So what are the mechanisms employed by some of the notorious viruses?

Take for instance, COVID-19. It is good at disrupting cellular programming. A typical virus replaces less than 1 per cent of the genetic material in the cells it infects. But COVID-19 replaces about 60 per cent of the RNA – “one of the three major biological macromolecules that are essential for all known forms of life along with DNA and proteins” – in an infected cell. Among other things, the virus also rewires the alarm system that cells use to warn others about infection.

Usually, as part of what is known as the “innate” immune response—so called because it is genetically hardwired, and not tailored to a specific pathogen—a cell sends out two kinds of signals. One signal, carried by molecules called interferons, which travel to neighbouring cells, telling them to build defences that slow viral spread. Another signal, transmitted through molecules called cytokines, gets a message to the circulatory system’s epithelial lining. The white blood cells summoned by this second signal do not just eat invaders and infected cells; they also gather up their dismembered protein parts. Elsewhere in the immune system, these fragments are used to create virus-specific antibodies, as part of a sophisticated “adaptive” response that can take six or seven days to develop. Mostly, viruses that create outbreaks or debilitating diseases are successful because they shut down both of these signalling programmes.

But COVID-19 is different as it seems to block only one of those two arms. It inhibits the interferon response but does nothing about the cytokines; it evades the local defenses, but allows the cells it infects to call for reinforcements. White blood cells are powerful weapons and are meant to be used selectively. Once they arrive on an inflammatory tide, they leave behind a trail of destruction. With COVID-19, inflammation distends the lungs and debris fills them like a fog.

These findings were published in the journal Cell in May, 2020. In the article, the researchers argued that this imbalanced immune response gives rise to an autoimmune disorder-of-sorts—which ranges from blood clots, strange swelling in children and cytokine storms—among those who develop severe cases of COVID-19. Individuals with COVID-19 face the same challenge as nations during the pandemic: if they can’t contain small sites of infection early—so that a targeted response can root them out—they end up mounting interventions so large that the shock inflicts its own damage.

The other such notorious virus is HIV, or the human immunodeficiency virus, that causes acquired immunodeficiency syndrome (AIDS). HIV appears to have jumped to humans early in the 20th century from a type of chimpanzee in West Africa—most likely when humans hunted these animals for meat and came into contact with their infected blood. The virus slowly spread across Africa and later to other parts of the world. As of 2019 close to 38 million people worldwide were infected with HIV; a total of 32 million have died since the outbreak began.

Unlike most other viruses, HIV attacks the immune system, destroying a type of white blood cell (T cells) that the immune system needs to fight disease. The HIV virus then takes over its cell machinery to create more viral particles. These particles then further infect other cells of the immune system, including T cells, and restart the process of hijacking the cell machinery.

What makes HIV jump to other species from their natural host is the fact that the virus is evolved to dodge its natural host’s tetherin—a protein that tethers newly made viruses to stop their release from the cell. Interestingly, of the four strains of HIV— Group M, N O and P—which made the jump from their primate host to humans at various points in time, only M was able to evolve an evasive mechanism to escape tetherin. It is therefore the most successful of all the HIV strains and is responsible for 90 per cent of the infections. However, what has made ridding the human host of the HIV virus so difficult, despite the use of antiviral drugs, is the ability of the virus to form reservoirs in immune cells that can remain undetected. Studies have found that these reservoirs do not diminish even after 14 years of uninterrupted treatment.

One virus that keeps health experts on their toes is influenza A. It is a highly contagious virus that kills half a million people globally every year. It was also responsible for history’s four deadliest pandemics and experts predict that the next one will also be caused by them. What makes this parasite deadlier than most other viruses is its ability to undergo sudden and complete mutation. This is possible due to its peculiar structure.

Most viruses are made up of either a single RNA or DNA strand which stores its genes. But flu virus has eight RNA strands, which mean it infects hosts easily and they replicate quickly in them, explained Shahid Jameel, an eminent virologist and former head of DBT/Wellcome Trust India Alliance, a biomedical research charity. On its surface, there are two protein types—HA (haemagglutinin) and NA (neuraminidase). There are 18 H proteins (H1 to H18) and 11 N proteins (N1 to N11). When influenza virus mutates, it can result in 198 subtypes of influenza A viruses (11 multiplied by 18). As per the US Centres for Disease Control and Prevention (CDC), 131 subtypes are known. Of these, only two influenza A types—H1N1 and H3N2—are in circulation.

Influenza viruses can mutate in two ways: drift and shift. Drift mutations cause small changes in the genes of influenza virus, resulting in viruses that have similar antigenic properties or are closely related to one another. This means antibodies that get created in a human being to fight one influenza virus will respond to its other close relative. Drift mutations are the reason people can get the flu more than one time. It, however, can be fixed by minor updates in the flu vaccine composition.

Shift mutation, on the other hand, is an abrupt, major change in influenza A virus, resulting in new HA and/or new HA and NA proteins that infect humans. Shift mutation can result in a new influenza A subtype in humans. One way a shift can happen is when an influenza virus from an animal population gains the ability to infect humans. Such animal-origin viruses can contain an HA or HA/NA combination that is so different from the same subtype in humans that most people do not have immunity to the “novel” virus. “Such a shift occurred in 2009, when an H1N1 virus with genes from North American Swine, Eurasian Swine, humans and birds emerged to infect people and quickly spread, causing a pandemic,” suggested CDC. When shift mutation happens, most people have little or no immunity against the new virus.

All the four pandemics before COVID-19 were precisely because of shift mutations, informed T Jacob John, virologist and former professor at the Christian Medical College, Vellore. According to John, the other challenge is that influenza A is a respiratory pathogen. “You can avoid other viruses that cause chikungunya and hepatitis C which are transmitted by mosquito bite or contaminated water,” he said. But how can you stop breathing?

What propels these much dreaded mutations? “Sea animals, mainly aquatic birds are natural reservoirs or hosts of flu virus. These viruses don’t harm them. But when they jump to human beings via any intermediary host, it mutates,” explained Lalit Kant, infectious diseases expert. WHO keeps a watch over flu outbreaks happening globally and records all mutations on a platform called Flunet, set up in 1997. In October 2020, the online platform said 172 influenza positive cases were reported and 108 were influenza A. Kant felt that climate change is abetting this transition.

“Aquatic birds are flying to such areas where they did not use to do so earlier. So the viruses are spreading to those areas which otherwise would not have gotten them,” he said.

Such frequent outbreaks of viral diseases are a worrying trend. First, because, vaccines do not work against all viruses. Then, antiviral drugs are not easy to make. The reason lies in the fact that unlike bacteria, viruses replicate inside the host cell. So, any drug that targets its replication process will end up targeting the host cell. Killing viruses is easy. Keeping host cells alive while you do it is the hard part.

Vaccines, which work by inducing the immune system to produce antibodies against a pathogen, are usually used to prevent a viral infection. Frequent outbreaks of viral diseases may also lead to antiviral drug resistance. In fact, two commonly used flu drugs—amantadine and rimantadine—have become obsolete and the world is currently left with just Tamiflu antiviral drug. Tamiflu, which stops the virus from infecting new cells and in turn stops its proliferation, would stop working eventually.

What causes antiviral resistance? There are a couple of explanations—from mutations to overuse of antiviral drugs during outbreaks. The world is witnessing misuse of antiviral drugs now due to the COVID-19, wrote Manish Kumar of Indian Institute of Technology-Gandhinagar, in a recent paper. The institute has joined a global consortium of 51 premier universities and research institutes to conduct a research study to find out if COVID-19 could survive in human waste.

He found that increase in COVID-19 genetic loading in wastewater samples concurred with corresponding increase in the number of active COVID-19 patients in the study area. He said since these drugs and their metabolites were mostly excreted in the urine and discharged into the environment which eventually reached waterbodies. This study also explained why there was drug resistance for Ebola, influenza and HIV. Vaccines too would become redundant over time and seldom help during a pandemic.

Researchers are now working on a universal vaccine for flu. Instead of the traditional vaccines that rely on the two surface proteins that change with mutations. This universal vaccine will attack a third protein, matrix that remains unchanged. Some researchers are also trying to develop vaccines that will attack the stem of H and N proteins instead of their heads for better efficacy. There are at least 12 universal flu vaccine candidates being worked upon. While some are in pre-clinical stages, a few have reached human trials. There is an urgent need to speed up the process for understanding viruses and their workings.

The Intergovernmental Science-Policy Platform on Biodiversity and Ecosystem Services (IPBES), in an extraordinary research paper released in October 2020, warned that pandemics like COVID-19 would hit us more frequently and also kill more than the current one. We are yet to identify some 1.7 million viruses that exist in mammals and birds. Out of these, 50 per cent have the potential or ability to infect humans. IPBES report analysed the contribution of human-induced environmental damages in the emergence of new diseases. “Land use change is a globally significant driver of pandemics and caused the emergence of more than 30 per cent of new diseases reported since 1960,” said the report.

“Although COVID-19 has its origins in microbes carried by animals, like all pandemics, its emergence has been entirely driven by human activities,” said the report. “Changes in the way we use land; the expansion and intensification of agriculture and unsustainable trade, production and consumption disrupt nature and increase contact between wildlife, livestock, pathogens and people. This is the path to pandemics,” said Peter Daszak, president of EcoHealth Alliance.

Origin of the pathogen

Our knowledge of viruses have not evolved much in the past 11,000 years, since these smallest and simplest biological entities carried out their first mass killing in history. That was the time when our nomadic ancestors had taken up farming and was adjusting to settled life. Rodents, that are natural carriers of several viruses, were becoming part of their immediate ecosystems due to easy availability of grains.

(It might be an evolutionary milestone for them as well.) A virus usually prefers limiting itself to the population of a particular species. But somewhere during this frequent interaction with rodents, one poxvirus crossed the species barrier and jumped to humans. It was a landmark event, but with lethal consequences.

The pox virus caused smallpox, one of the deadliest viral infections in humans. Over the subsequent years, the virus travelled with humans across the globe killing millions. Fatality was very high as we didn’t have immunity against this “novel” pathogen. In 1980, following an historic global campaign of surveillance and vaccination, the World Health Assembly declared that smallpox has been eradicated—the only infectious disease against which this distinction has been achieved—but nobody knows for sure whether the virus has ceased to exist.

Millions of years of evolution have caused spectacular changes in our life, but what remains a constant is the occurrence of diseases. And viruses cause most of them, at least the ones that kill the most. Over 150 million people have been killed by diseases caused by viruses in the last one century. Yet we did not acknowledge its existence until the late 19th century. In fact, in 1796 when Edward Jenner created the world’s first vaccine to cure smallpox, he had no idea about the existence of virus.

The world of viruses is dense and vast. Its diversity is greater than the world that we know and interact in. Viruses are omnipresent, found in air, land, sea to every species to even in every body parts. “An estimated 10 nonillion (10 to the 31st power) individual viruses exist on our planet—enough to assign one to every star in the universe 100 million times over,” wrote the National Geographic. Some believe that viruses have initially formed with RNA genome. Today, they have a variety of mix-and-matches of genetic materials. Some viruses like poliovirus, have RNA genomes, while the others like herpesvirus have DNA genomes. Some viruses have single-stranded genomes, while the others, like smallpox, have double-stranded genomes. They also replicate differently.

According to a study by scientists of the University of British Columbia, Canada, “almost all of the life in the oceans, by weight, is prokaryotic (bacteria and archaea), with viruses and protists making up roughly equal amounts of the remaining.” If one measures by biomass, giant sea creatures like whales would even not compare with those of the viruses. As the study by the British Columbia scientists projected, “There are about 200 mega tonnes of carbon in viruses in the ocean, which is equal to about 75 million blue whales. The most biomass that was ever in whales, as far as we know, was about 13 mega tonnes. These numbers are dwarfed by the carbon in prokaryotes, which is 5.2 gigatonnes.”

What we do not understand, we fear. What we fear, we judge as evil. So, are viruses really as notorious as they are being made to be? The pandemic just made us to re-search viruses, and understand better to save our lives. See also: DTE coverage on Covid-19 Pandemic
Young female microbiologist studying coronavirus; Photo: Istock

Hosts and hostages

Pathogens that trigger infectious zoonotic diseases are honing their genome and preparing for their next mutation

There Are hundreds of coronaviruses always circulating in the environment. Till early 21st century, they were mostly known to circulate among pigs, camels, bats and cats and caused mild forms of common cold in humans. They caught the attention of virologists in 2002 when one member jumped from a horseshoe bat to a human, possibly via a civet cat, and went on to cause the severe acute respiratory syndrome (SARS) among 8,500 people and killed 900.

Just like COVID-19, the symptoms were fever, sore throat, shortness of breath and pneumonia. A decade later, another coronavirus, believed to have originated from bats, but transmitted to humans via camels, caused a similar outbreak in Saudi Arabia. It was named the Middle East Respiratory Syndrome (MERS). Despite high fatality rates—9.5 per cent in the case of SARS and 34 per cent for MERS—none of these coronaviruses managed to cause large- scale outbreaks. While SARS appeared to have disappeared in 2004, MERS was largely contained, but continued to cause limited outbreaks. Call it an outcome of evolutionary strategy, COVID-19 had emerged as the most devastating pandemic since the 1918 Spanish Flu one. These are called the zoonotic diseases— pathogenic infections that transmit from animals to humans. They have triggered pandemics in past. Three of every four infectious diseases are caused by zoonosis.

The evolution of COVID-19 is no mean achievement, when compared with other thousands of pathogens that naturally get transmitted between animals and humans, but more often than not, fail to establish a disease in human populations, let alone cause epidemics. Most of these zoonotic pathogens—be it a virus, bacterium, fungus or parasites (protozoa and helminths)—are believed to be host-specific.

This means they usually restrict themselves to a limited number of species, such as bats, pigs, rats and chimpanzees, and prefer residing in them by creating a life cycle reservoir. This trait of pathogens is due to species barriers. Along with the human body’s resilience system against diseases, species barriers help us most of the times lead a life free from infections, despite the fact that we live in a pathogen-filled world.

Crossing it is not easy as these barriers are determined by the level of human exposure to pathogens—directly through faeces or body fluids like saliva, blood and urine of an infected animal, or indirectly through areas where they live in contaminated surfaces—and the ability of pathogens to infect a human and cope with the new host’s immune response. It thus requires the pathogen to undergo specific changes through mutation or genetic exchanges with the host.

However, these mutations are not always successful. Thus, a vast majority of animal-to-human spillover most likely results in a dead-end for the virus (and other pathogens), informed Abi Tamim Vanak, a disease ecologist at the Ashoka Trust for Research in Ecology and the Environment (ATREE), a Bengaluru- based research organisation. This means the pathogen does not get transmitted beyond the infected person. However, there have been instances when the pathogen managed to hop on to humans, but did not cause mortality or morbidity.

In early 2020, researchers in the Brazilian states of Tocantins and Amapa identified one Ambidensovirus in patients with symptoms similar to dengue or Zika. “Viral species in this genus have been described only in insects, shellfish and other invertebrates; never in mammals,” the researchers wrote in PLoS One in March 2020. They were, however, not sure if Ambidensovirus was responsible for the patients’ morbidity.

The US Centers for Disease Control and Prevention recognises 1,407 human pathogens; 60 per cent of whom are zoonotic. These pathogens have managed to cross species barriers and establish diseases in human population. However, most of these pathogens maintain their life cycle reservoir in an animal and infect humans when they get a chance. For instance, avian influenza virus (H5N1) caused the bird flu outbreaks in humans when people came in direct contact with infected poultry or surfaces and objects contaminated by droppings or during slaughter, de-feathering and butchering.

While WHO maintains the virus does not transmit efficiently from person-to-person, experts worry. “Animal-human interfaces where humans frequently get in contact with wild animals allow viruses to evolve and jump into humans leading to the emergence of a new virus,” said Pranav Pandit, a veterinary epidemiologist at the University of California, USA. H5N1 is considered endemic in poultry in six countries and at least 15 countries have reported human infections since 2003. It might not be long before the virus mutates to establish a life cycle reservoir in humans and spreads from person to person, infecting even those who have never come in contact with poultry. That would result in a catastrophe as H5N1 can kill 60 per cent of those infected.

Most human pathogens that have caused epidemics like measles, smallpox, tuberculosis, flu and whooping cough have actually had a low-key beginning like H5N1. Initially, they stayed relatively contained by restricting their jumps to humans from animal hosts like cattle, pigs, ducks and dogs. heir virulence increased as they eventually created a life cycle reservoir in humans.

The surge

What’s worrying is that more and more zoonotic pathogens are now establishing themselves in human populations. In the past 30 years, they have been responsible for 75 per cent of the 177 emerging or re- emerging infections that the world is now grappling with. In fact, of the 23 infectious diseases that WHO lists as “epidemic and pandemic-prone”, as many as 17 are capable of human-to-human transfer; no treatment or vaccine is available for nine of these diseases.

HIV1, which is responsible for a majority of HIV infections worldwide, is one such virus. It made the jump from African primates to humans as a result of bushmeat eating in the 1970s. Subsequently, it has established a life cycle reservoir in humans. The Ebola virus, which causes a severe haemorrhagic fever with a fatality rate of up to 90 per cent, however, shows what a virus is capable of to ensure its transmission. Since it was first detected in 1976 in Sudan and the Democratic Republic of Congo, the virus has managed to cause outbreaks without establishing a natural reservoir in humans.

It has rather mutated to develop the ability to transmit from human-to- human. This new-found ability of Ebola came to light during the 2013 outbreak when it spilled over, possibly from a bat to an 18-month-old boy in Guinea. Within months, it became a global epidemic. But COVID-19 showed how zoonotic pathogens are constantly honing their genome to expand their realm.

A study published in Antiviral Research in April, 2020, threw some light on this. Despite a genome sequence highly similar to that of other SARS-like coronaviruses, COVID-19 differed in its interaction with ACE2 (angiotensin-converting enzyme 2)—a crucial enzyme that remains attached to the outer surface of human cells in the lungs, arteries, heart, kidney and intestines. Such viruses use these cells as receptors to infect humans. Somewhere in its journey from a bat to a pangolin or a snake and finally to humans—the pathway still remains shrouded in mystery—COVID-19 went through mutations which enabled it to bind with ACE2 more efficiently, making it more successful to infect a person and ensure human-to-human transmission.

What is even more troubling is the increasing number of COVID-19 variants that have emerged in the fall of 2020—the UK variant, the South African variant, the Brazilian variant and the Vietnam variant. Scientists are still working to learn more about these variants to better understand how easily they might be transmitted. New information about the virologic, epidemiologic, and clinical characteristics of these variants is slowly beginning to emerge.

Viruses can infect all life forms, including microbes like bacteria. This is probably because this submicroscopic particle, made either of RNA or DNA as its genetic material, can replicate or produce multiple copies of itself only when inside a living host cell. Most of the jumps to humans are, however, made by RNA viruses that account for some 37 per cent of emerging infectious diseases, said a study published in ILAR Journal in 2017. In fact, some of the biggest zoonoses like chikungunya, dengue, Zika, avian influenza, Lassa fever, Ebola virus, MERS and SARS are all caused by RNA viruses.

These RNA viruses are considered of recent evolutionary origins. Their mutation rate can be 100,000 times higher than DNA viruses. “RNA viruses show remarkable ability to adapt to new environments and confront different selective pressures they encounter. This not only include the host’s immune system and defense mechanisms, but also the current artificial challenges devised by the biomedical community,” noted the ILAR Journal study. This high rate of mutation of a RNA virus is because of the way it replicates.

In DNA viruses, several proteins correct themselves if there is any faulty genome replication. But RNA viruses replicate without this proofreading process and this increases their mutation rates. But this has a downside too: any undesirable mutation can negatively impact the fitness of the virus.

Among the RNA virus group, coronaviruses overcome this tradeoff between mutation rate and incorrect replication. A study published in PLOS Pathogens in May 2010 said COVID-19 had mutated to produce an enzyme that diminished the number of mutations. “The viruses might switch the proofreading mechanisms on or off depending on the context, allowing them to rapidly adapt to new environments without losing replicative fidelity,” the study said.

Ultimately, it’s about humans and their interactions with other species—whether in the wild or in farming. It’s also about how we transgress into the habitat of wild species or “manufacture” food from domesticated animals. For instance, villages in the eastern foothills of the Western Ghats in India regularly experience outbreaks of the Kyasanur forest disease (KFD), a viral haemorrhagic fever similar to Ebola and dengue that is spread by ticks (Hemaphysalis spinigera) living on monkeys. Here, people mostly depend on forests for a living. SARS and COVID-19 outbreaks have also been linked to exposure to viruses in Chinese wet markets.

It’s not just the interface with wildlife, livestock also plays a role. In the case of Spanish flu, it is widely held that the avian influenza virus jumped from a pig on a military farm in Kansas, USA, to the first known human case. Though there are other theories about where the “jump” took place, from Europe to China, what’s clear is that the virus mutated from animals and was taken across the world by the movement of soldiers during the World War I. Ultimately, the Spanish flu killed more people than the war.

The transition in a system

So, it’s a combination of factors—movement of people, living conditions, population density and, of course, eating habits—that makes the virus more deadly in its new host. Ebola, for instance, was not new to parts of Africa even though outbreaks were reported way back in 1976. What changed between then and the outbreaks of 2013-14 was the demography in the affected countries, said Sanath Muliya, a scientist with the Wildlife Institute of India, Dehradun. Between the 1960s and early 2010s, population density increased by 223 per cent in Guinea, 178 per cent in Sierra Leone and by 275 per cent in Liberia, particularly in the urban parts that experienced high rural-to-urban migration. All major outbreaks occurred in such urbanised set-ups with high human densities, said Muliya.

A similar development in 1998-1999 in Indonesia led to the first outbreak of the Nipah virus. The virus is naturally harboured by pteropid fruit bats. But in the months before the outbreak, large-scale deforestation was going on in Indonesia for pulpwood. Palm oil industries had also prompted slash-and-burn of forests for setting up industrial plantations.

While deforestation destroyed the bat’s habitat, the haze reduced flowering and fruiting of forest trees. Reduced rainfall caused by the severe 1997-1998 El Niño conditions exacerbated the situation, resulting in mass migration of pteropid bats to Malaysia, which was experiencing an upsurge of large-scale piggeries with fruit orchards on their edges.

A combination of factors led to the spillover of a novel virus from the bat to the domestic pig and then to pig farmers. “The scope and scale of deforestation and the opening of new interfaces with forests and wildlife increase the chances of spillovers,” concluded Prashanth N S, public health expert at the Institute of Public Health, Bengaluru, adding, “The way in which we interact with our environment has increased the exposure to newer pathogens that would have otherwise not come into contact with large populations.”

Even as subsistence farmers and herders coped with zoonoses, the very nature of industrial food business has exacerbated the problem. Today, it is widely accepted that swine flu was first found in human beings in La Gloria, a little town in Mexico. It is known that a young boy suffering from fever in March 2009 became the first confirmed victim of the outbreak, which then spread from country to country. But what was quickly lost in this tragedy was the location of the ill-fated town—right next to one of Mexico’s biggest hog factories, owned by the world’s largest pig processor, Smithfield Foods.

What was also not reported is that people in the town had repeatedly protested about water pollution, terrible stench and waste against the food giant. While this fact was never followed up or uncovered, what was reported was that food majors wanted WHO to change the name of the contagion so that pork eating would not be affected.

Virologists at the US Centers for Disease Control and Prevention, however, found—based on genetic fingerprinting—that the strain of this swine flu is the same as first identified on industrial pig farms in North Carolina, the hub of industrial pig farms in USA. In 1998, when there was an outbreak of swine flu among pig herds in North Carolina, it was a triple hybrid—containing gene segments from human, bird and classical swine influenza viruses—that spread across pig herds of the integrated world.

Then it mutated further. Today, it is believed that the common flu virus infecting humans has got mixed with this hybrid, creating an altogether a new human- animal virus.

In 1997, when the world first caught avian flu (H5N1), wild migratory birds that are the natural carriers of the virus had been widely indicted for the spread, but with little evidence. It was easier to blame wild birds with no defenders in agribusiness, than birds produced in poultry factory farms. The problem stemmed from the model of growing chicken in an environment that is highly conducive for the virus. The birds are raised in tightly confined, often poorly ventilated enclosures with regular exposure to chemicals, blood and faecal matter. Diseases can spread, and spread fast, in such conditions. Since the birds also have lowered immunity because of their genetic uniformity, they are almost literally sitting ducks when a disease strikes.

But after avian flu hit Asia, the Food and Agriculture Organization (FAO) told governments that while it would be possible to tighten bio-safety in commercial poultry farms, it would be impossible to do it in non-commercial enterprises, such as backyard production systems where flocks forage outdoors.

It recommended animal production should move to larger farms where surveillance is possible. Danielle Nierenberg, who researched this sector at Washington-based World Watch Institute, reported that this prompted Vietnam in April 2005 to impose a ban on live poultry markets and asking farms to convert to factory-style methods. This is when, the need of the hour was to regulate the industrial processes of growing chicken so that the virus does not breed and does not grow.

The business needed to improve the genetic stock of birds and raise their immunity against diseases, just the way traditional backyard poultry farmers do. But instead of reforming the poultry industry, the containment of the flu ended up promoting the very industry and its practices and destroyed the livelihoods of small and marginal farmers.

Studies also show how viruses are ever-adapting and ever-expanding via new susceptible hosts and additional transmission routes. S Abdul Rahman, executive director, Commonwealth Veterinary Association believed unlike the old diseases like cholera and pneumonia, which we know how to deal with, these diseases were highly unpredictable. “With factors like climate change, zoonoses are emerging as the single-biggest threat to human health and we are not prepared, as is evident from the COVID-19 pandemic,” he said. The pathogens are honing their genome and preparing for their next mutation, and there is no doubt about it.

A study published in Nature in October 2015 said pathogens present in animals belonging to 10 biological orders, were 12 times more likely to transmit from human-to-human than those found in only one animal order. This was because the evolutionary process which equipped a virus to rapidly adapt to new hosts also made it capable of inter-species transmission. Many viruses, like Ebola, SARS and MERS, before jumping to humans were limited only to animals. When all conditions were met, they made the jump. Small wonder, most jumps have been made by RNA viruses.

The next step would be finding the right transmission route for easier, faster and effective dispersals. So far, oral, aerosols, direct contact, fomite andvectorshavebeenthefiveprimaryroutesofdisease transmission for zoonotic pathogens. These routes are crucial for determining their contagiousness, which is measured through reproduction rate (R0) or the number of secondary cases one case would produce in a susceptible population. In a way, they are responsible for taking a pathogen from the level of transmission to the level of epidemic spread. Cholera, a water-borne zoonotic bacterial disease, has a very high R0 of 9.5. By comparison, the R0 of Zika is 4.2; R0 of COVID-19 is 2.

One reason for this low R0 of COVID-19 is that the virus hitched rides on droplets, expelled from the body through coughs and sneezes. Since respiratory droplets are heavy, they cannot travel more than 1 metre. However, with studies finding that COVID-19 could travel up to 8 metres, several virologists disagreed that it was not airborne. As the jury is still out on how COVID-19 travels, the fact remains that airborne transmission is the most lethal of all routes that can make a virus most contagious.

Multiple factors determine if a pathogen is able to transmit with airborne droplets. First, an infectious person should be able to create droplets that are of appropriate size so that they can become aerosolised droplets with the help of particulate matter in the air. Then enough viable infectious doses have to remain in the air for a significant time so that either wind or air currents transmit it to other places where it can infect another susceptible person.

Once in the air, the success of the virus to remain infections depends both on the virus and the particle. Environmental factors like temperature, ultraviolet radiation, relative and absolute humidity, and air movement are important drivers influencing virus viability. Factors like temperature and humidity also impact the size of droplets which, in turn, affect the viability of virus. So far, Q fever among animals like goat, sheep and cattle, caused by zoonotic bacteria Coxiella burnetii is believed to be the only disease that is transmitted through airborne dispersal.

While it remains to be seen as to how long other pathogens can resist this temptation to go airborne, a study published in Cell in 2014 found evidence of airborne transmission of avian influenza among ferrets. The researchers discovered that the ability to go airborne only took five substitutions in the virus. See also: DTE coverage on Covid-19 Pandemic
Influenza victims crowd into an emergency hospital near Fort Riley, Kansas, US, in 1918 during the Spanish flu, the first pandemic in recorded history that lasted two years; Photo: National Museum of Health and Medicine
Photo: Vikas Choudhary/ Centre for Science and Environment (CSE)

Mystery Forever

The curious case of unidentified disease outbreaks in India

AS India was scrambling to contain the spread of COVID-19, healthcare practitioners in several rural pockets were fighting a similar battle—blindfolded. In Odisha’s tribal district of Malkangiri, panic gripped Kenduguda village after a dozen people died within three months since the end of February, 2020. They were all in the age group of 15 to 35 years and complained of acute respiratory problems, fever, swollen legs and bloated stomach. Medical officers from the district hospital, who visited the village, failed to ascertain the reason behind the deaths and said the deceased could be suffering either from chronic kidney disease, anaemia, tuberculosis or heart ailments. Around the same time, authorities of Karimganj district in Assam were thrown into confusion after six children in Bazaricherra village died one after the other. Though the reason was not known, media reports said they had infected tonsils.

A similar fear swept through Karnataka’s forested district of Dakshina Kannada in January, 2020, infamous for rare illnesses like viral haemorrhagic monkey fever or Kyasanur Forest Disease, after residents of Venoor village complained of prolonged fever with fatigue, pain in the abdomen and headache. Medical officers rushed to Venoor to investigate the illness. Though it could be cured with symptomatic treatment, the authorities could not figure out what caused the fever and whether it would strike again.

These unidentified, mysterious diseases are like terrorists with unknown motives and unpredictable moves. They can lead to epidemics creating a situation worse than COVID-19, as scientists had at least become familiar with the pathogen. India has an elaborate arrangement for early detection of such disease outbreaks under a century-old institute, now known as the National Centre for Disease Control (NCDC).

Surveillance and investigation of communicable diseases have been an integral part of NCDC’s activities for close to six decades. Since 1997—after the 1994 outbreak of pneumonic plague in Surat caught the country unprepared—it created a dedicated wing for early detection and systematic reporting of emerging (new) or re- emerging infectious diseases and for timely response. The wing was scaled up in 2012 to fulfill the World Health Organization’s (WHO’s) International Health Regulations, 2005, that requires each country to assess public health emergencies of international concern within 48 hours and report them to WHO within the next 24 hours.

It was later renamed Integrated Disease Surveillance Programme (IDSP) and turned into a national health programme with surveillance committees at the Centre, state as well as district levels; trained rapid response teams and other medical and paramedical staff; involvement of frontline health workers; a network of laboratories; and, IT-enabled infrastructure for the dissemination of disease surveillance data on a weekly basis.

Yet, every year, unnamed and unidentified diseases have continued to kill or sicken hundreds of people across the country. Some of them remain a mystery despite resurfacing in a particular region almost as an annual phenomenon. One such disease is the life-threatening chamki fever or encephalitis that grips Bihar’s Muzaffarpur district every summer since 1995. The fever—which impairs functioning of the brain—primarily affects children and is the cause of hundreds of deaths in this impoverished district. In 2019, the fever infected 653 children and caused 164 deaths.

So familiar are people with its symptoms that at the first sign they rush their children to the hospital. The government sets up camps for treating and investigating the illness. Occasionally, the outbreak attracts the attention of researchers who visit the area because of personal interest. But all that is available so far are a plethora of hypotheses that implicate everything—from pesticides, heat strokes, toxins in litchi fruit to undernourishment among children. In 2020, the region witnessed a mild impact of the disease—95 encephalitis cases and 12 deaths till June 30. Strangely, no one knows what has helped improve the situation.

An equally mysterious disease has been doing rounds in neighbouring Uttar Pradesh since 2005, when it resurfaced after going into hiding for 30 years. Initially, the authorities labelled it as Japanese Encephalitis (JE), a viral brain infection spread by mosquitoes, and focused on vector control and vaccination. But children continued to fall ill in Gorakhpur and neighbouring districts.

In 2007, the National Institute of Virology (NIV), Pune, found enterovirus in the patients but could not link it to the disease. The symptoms of enterovirus infections and JE were similar. The only difference was that the fever caused by enterovirus stretches up to 15 days as against JE which lasted about a week. In 2017, scrub typhus, a mite-borne disease, was held responsible for the illness even though the symptoms were atypical. Without any knowledge of the pathogen, the outbreaks rage uncontested.

A systemic failure

IDSP has been designed for early detection of disease outbreaks and diagnosis of mysterious diseases through syndromic surveillance, which is essentially monitoring people’s health on a real-time basis. The first round of surveillance activities are carried out by frontline health workers, including accredited social health activists or ASHA, village volunteers and paramedical staff, who during their routine visits to households keep a lookout for those suffering from six symptoms: fever, cough for less than two weeks, acute flaccid paralysis in adults, diarrhoea and jaundice and unusual events causing death or hospitalisation. IDSP classifies these as indicators of 22 major diseases.

They are then expected to fill up the suspected case or S-form for the patients, analyse the data to figure out if the numbers are higher than the previous records for the region and inform the district medical officer. The data is then sent to IDSP. The health workers also collect basic test samples and direct patients to doctors. At the district level, government and private hospitals along with medical colleges are expected to raise an alarm if there are “clustering of cases” from the same locality on a given day or on consecutive days. According to the IDSP manual, doctors at the outpatient department (OPD) should refer such suspected cases of a disease outbreak to the laboratory.

At the end of every week, the hospital superintendent is expected to fill up a presumptive or P-form based on the provisional diagnosis and uploads it on the IDSP website. Labs across districts also need to fill up the laboratory confirmed or L-form based on their investigation. This too is uploaded on the IDSP site.

However, IDSP no longer works the way it was conceptualised, said Rajan R Patil, epidemiologist and associate professor at the School of Public Health, SRM University, Tamil Nadu. He was involved in setting up IDSP as part of his UN assignment. “Now, the surveillance work is being done in a mechanical manner. Instead of monitoring and providing data on a real-time basis, people are filling the data after weeks and even months, and the weekly bulletin is often given retrospectively,” he said, adding that this defeats the very objective of early detection of outbreaks and averting large-scale sickness and deaths due to infectious diseases. His claims are not unfounded.

As on July 21, 2020, IDSP on its portal provided weekly alerts till March 16-22, 2020, which had inputs from only 17 states and Union Territories. The next day, it released two more alerts for the weeks of March 23-29, 2020, and March 30-April 5, 2020. While the update for March 23-29, 2020, provided consolidated data related only to COVID-19 and redirected to the Union health ministry website for more details, the last alert provided data on two outbreaks.

Down To Earth (DTE) analysed the weekly reports of IDSP for 2019 and 2020 (till March 22) and found that it had recorded 33 outbreaks of fever and another 12 outbreaksof AESduringtheperiod. Feveroutbreaks were reported from just 10 states—Karnataka, Assam, Tamil Nadu, Meghalaya, Arunachal Pradesh, Maharashtra, Uttar Pradesh, Sikkim, Telangana and Rajasthan. In most cases, the cause of fever remained unknown. DTE also found that IDSP didn’t follow all disease outbreaks.

For instance, its weekly alerts did not include the mystery outbreak in Odisha’s Malkangiri district. It also did not document the mysterious fever outbreak in Gujarat’s Surat district in September 2019 that was widely covered by the media. In the absence of an investigation by IDSP, the government doctors in Surat maintained that the outbreak was caused by dengue even though more than 25 per cent of the patients tested negative for the disease. Another trend observed by DTE was that in 12 of the 52 weeks in 2019, the alerts did not mention how many states uploaded data. In other weeks, there was a discrepancy in the number of states and UTs mentioned in the total tally and in the description list of the outbreaks.

For example, the alert for the first week of April 2019 said 35 states and UTs shared their records and 25 had outbreaks, but the description of outbreaks was available only for 15 states and UTs. This indicated a lackadaisical approach to data by an organisation that has been bringing out weekly alerts since 2007; data collection and dissemination was, in fact, one of its primary functions.

IDSP also seems to lose interest in the outbreaks after initial investigation. Most weekly reports mentioned that the disease was “under surveillance”, but there was rarely any update on this later. In its monthly alerts, IDSP provided the details of investigation for just one disease. But the last monthly alert was for September 2019. While the outbreak could have been investigated further by the state governments, as health is a state subject, information on the outcomes were not available in the public domain. DTE even tried to see if there were any published studies on disease investigations, a search in PubMed, an online database of biomedical and life sciences research literature for the term “integrated disease surveillance programme” threw up 16 results. None of them were on fever or AES outbreaks in 2019 and 2020.

The reason for IDSP’s failure may not be straightforward. Under the programme, all districts should have disease surveillance committees. However, the Parliament reply by Ashwini Kumar Choubey, Minister of State, Ministry of Health and Family Welfare, on July 9, 2019, revealed that only about half, or 380 of the 739, districts in the country had such committees in place to monitor disease trends and respond to outbreaks in early rising phase. The elaborate arrangement also gets hindered by limited diagnostic facilities, faulty collection and testing of samples, suggests a 2019 study paper published by researchers and the directors of multiple government agencies, including NCDC, NIV and the Indian Council of Medical Research.

The researchers had analysed outbreaks in 2017 and pointed out that even simple viral and bacterial infections such as dengue, JE and influenza went unidentified at times because of poor diagnostics. At least a third of fever outbreaks of unknown origin in the country go undiagnosed, they said in the paper, published in the Indian Journal of Medical Research. According to IDSP’s website, there are just 114 labs in the country. The lack of interest is also visible through the fact that the budget allocated under the scheme is seldom spent. In 11 of the 13 years—between 2004-05 and 2016-17—expenditure was lower than the allocated budget. The last expenditure information was available on the IDSP portal till October 2017.

An April 2019 study published in the Clinical Epidemiology and Global Health found that researchers or institutes seldom adhered to NCDC’s 10-step outbreak handling methodology. These are: determining the outbreak; confirming the diagnosis; defining it; searching for cases; generating a hypothesis using findings; testing the hypothesis with analytical study; drawing conclusions; comparing it with established facts; communicating the findings; and then executing preventive measures. The report, which reviewed 136 articles on outbreak handling in India between 2008 and 2016, found that all the 10 steps were followed in only 16 per cent of the outbreaks; and in some 24 per cent of the cases, proper analytical studies were conducted. In 98 per cent of the outbreaks, researchers were more interested in arriving at the conclusion without following other steps.

In 2015, a Joint Monitoring Mission set up by WHO and the Ministry of Health and Family Welfare, assessed IDSP and highlighted that it was limiting the scope of epidemiological studies of diseases by not collecting mortality data. The mission also raised concerns over the fact that IDSP looked at only 22 diseases, including malaria, dengue, chikungunya and AES that are already monitored by the National Vector Borne Disease Control Programme. They also pointed out that IDSP was not investigating zoonotic diseases despite the fact that it is just a matter of time that one of the emerging/re-emerging diseases become virulent and result in a major pandemic. Even the 2019 paper identified 43 emerging and re- emerging viral diseases that could affect India—23 of these are zoonotic in nature. One such is the Chandipura virus that has emerged as a major encephalitic pathogen in India in recent years.

The virus, spread by sandflies, had caused outbreaks in Andhra Pradesh (2004, 2005, 2007 and 2008), Gujarat (2005, 2009-12) and Vidarbha region of Maharashtra (2007, 2009-12), according to a study published in The Open Virology Journal in August 2018. Similarly, scrub typhus is now being reported from newer geographies. The disease, earlier found in Himachal Pradesh, was implicated for the mysterious fevers in Uttar Pradesh’s Gorakhpur district in 2018. Even the Nipah virus, first reported in Siliguri in 2001, had reached Kerala in 2018.

Cutaneous leishmaniasis, JE, scrub typhus and leptospirosis are spreading to a much wider area at an alarming rate in the past 68 years, wrote Ramesh C Dhiman of the National Institute of Malaria Research and Aakanksha Tiwari of Banaras Hindu University in a 2018 research paper. “Sudden outbreak of rare diseases like Kyasanur Forest Disease can be fatal due to the unavailability of strategies and policies to fight against them,” they wrote in the paper published in the journal Medical Reports and Case Studies.

They advised that India should strengthen the public health surveillance systems and provide quick medical support to control the damage caused by outbreaks. The failure of the government machinery to identify diseases has meant that individual researchers and doctors have often tried to unravel mystery outbreaks. “But in the absence of support from the government, a consensus on the cause is rarely reached,” said Vipin M Vashishtha, consultant paediatrician in Bijnor, Uttar Pradesh, who was part of the team that unraveled the mystery fever in Saharanpur district.

Between the 1980s and 2000s, there were reports of an average of 400 children dying each year in Saharanpur. In 2002, after 100 children died in two weeks in September, the Industrial Toxicology Research Centre, now renamed Indian Institute of Toxicological Research, visited the area and blamed it on a pesticide. Soon, the National Institute of Communicable Diseases (now NCDC) stepped in and said that the Japanese Encephalitis virus was killing the children.

As the deaths continued, Vashishtha and a group of independent doctors studied the patients in 2007 and found that the toxic pods of a weed, Cassia occidentalis (locally called kasondi or pamaad), was the cause of the illness. Children, especially from poor families, ingested the pods which then affected their liver, brain and muscles. They termed the illness hepatomyoencephalopathy. However, cases continued to be reported. In 2009, when 25 children died because of the illness, Vasistha claimed it was because local authorities did not spread awareness about the toxic pod.

In most outbreaks, where the disease remained unidentified, doctors even now simply treat patients for the symptoms and the local administration follows it up with sanitation and sensitisation drives. Milind M Gore, who set up National Institute of Virology (NIV)’s lab unit in Gorakhpur in 2008, said: “We would be able to solve the problem of infectious diseases in the country if we can solve the Gorakhpur puzzle.” But identifying the aetiology of a disease was not easy. “The search often leads to a wild goose chase and you need patience,” said Lalit Kant, former head of epidemiology and communicable diseases division at the Indian Council of Medical Research.

It also requires an experienced eye, explained Prabir Chatterjee, an epidemiologistwho was formerly with the State Health Resource Centre, Chhattisgarh. It was difficult to identify even a well-known disease if it is new to an area. If a patient from Gujarat with symptoms of Kala Azar visited the Christian Medical College (CMC), Vellore, in Tamil Nadu, doctors there were less likely to have encountered the disease and might classify it as a mysterious disease, Chatterjee explained.

A well-read doctor would be able to guess it, but he or she would still need help in disease confirmation and treatment. So the way to identify a mysterious disease involves a thorough clinical, biochemical, histopathological and microbiological investigations. In case the disease has caused deaths, autopsies must be performed to reach conclusions. The second stage of identification should consist of epidemiological investigations to identify risk factors, said Vashishtha. This requires the deployment of a team that includes epidemiologists, pathologists, neurologists, toxicology and public health experts and paediatricians. “Skilled and experienced people are especially important in recognising a zoonotic disease,” said Kant. The problem becomes more confounding with new and emerging diseases as there are no diagnostic tests and the doctors can diagnose on the basis of symptoms. So, for a new disease of suspected zoonotic origin, working in collaboration with a veterinarian would be ideal. “This synergy between agriculture experts and doctors helped India contain the bird flu outbreak,” he said.

Synergy is also critical; and, it came into play during the Nipah outbreak in Kerala in 2018. “We promptly recognised a serious outbreak and quickly got our act together to control an epidemic,” said George M Varghese, professor at the Department of Infectious Diseases, CMC, Vellore. Here, when an unusual infectious disease was noted by an astute clinician, the sample was sent to a reference laboratory which then quickly identified it as Nipah virus in 2018. “In all my years of work, I have not seen an outbreak handled as well in India as that of Nipah in Kerala. Education has paid dividends and people are aware,” he said.

Public health infrastructure too is much better in the state. The lesson from this success is that we need to work on public health infrastructure, he said. Unfortunately, there is a shortage of such health infrastructure as well as skilled and experienced persons in the country. Capacity building was thus one of the major recommendations made by the Joint Monitoring Mission set up by the World Health Organization (WHO) and the Union Ministry of Health and Family Welfare (MOHFW) in 2015. It had found that the government had only 407 epidemiologists as against the sanctioned posts of 703. There was a 33 per cent shortage of microbiologists and 80 per cent shortfall in veterinary doctors.

Experts have warned that the biggest challenge in the future would be the country’s inability to handle zoonotic diseases, which are usually the cause behind most mysterious diseases and are emerging with regular resurgence. Developing countries like India are at a higher risk of fevers of unknown origin than developed countries, it said, and for a reason. The country’s public health infrastructure is so weak that many times even common diseases do not get identified in time. See also: DTE coverage on Covid-19 Pandemic
Widows and orphans of porters who died of the 1897 bubonic plague at the Bombay Municipal Slaughter House, Maharashtra
Photo: Enroute Indian History
Photo: Vikas Choudhary/ Centre for Science and Environment (CSE)

Is Immunity Real?

It has taken a pandemic for us to realise how little we know of our body response to diseases

Immunity never before had this word been so brandied. It is said to have played a key role for most of the people worldwide who made it through the COVID-19. Even governments pinned their hopes on this magic word as their economies limped back into action. But this belief in “immunity” has also made it the most abused word.

In July, 2020, just after the first lockdown was eased in India, Emami Agrotech launched its Healthy & Tasty Smart Balance Oil, with a tag line “Ab banega har nivala, immunity wala”. The company based its claim on the fact that the oil contains vitamins A, C, D, E and omega 3 which could strengthen the immune system. In September, the Union Ministry of Chemicals and Fertilizers launched eight immunity-boosting products under the Pradhan Mantri Bhartiya Janaushadhi Priyojana (PMBJP), a campaign to provide medicines at affordable prices to the masses.

Fortified with several vitamins and micronutrients, these products were sold through PMBJP stores across the country. Speaking on the occasion, the then Minister of Chemicals & Fertilizers D V Sadananda Gowda said, “The launch of new nutraceuticals is significant in view of the COVID-19 pandemic. These products will help in boosting immunity of the people.” Since 2016, consumer goods company Hindustan Unilever was selling an immunity boosting hand sanitiser under its soap brand, Lifebuoy. The company claimed that the product, prepared using a patented technology, not only killed germs and viruses instantly, but also enhanced the innate immunity of the skin by boosting its “antimicrobial peptides” (small proteins that act against a wide variety of microorganisms, from bacteria to fungi). The Drug Controller General of India soon pulled up Hindustan Unilever for its claims calling it “misleading”.

The market, however, was flooded with everything from pills and ayurvedic formulations to superfoods and wellness products that claimed to boost one’s immunity during the pandemic.

In June 2020, barely four months after the first case of COVID-19 was diagnosed in India, Mumbai-based Pronto Consult analysed medical bills in eight cities and found that 92 per cent of the bills were against immunity- boosting products. The number historically was below 40 per cent, said Pronto. Industry estimates revealed that global market of immunity boosting food products was set to grow from US $16.31 billion in 2019 to some $24.02 billion in 2023.

The trend exasperated immunologists. “There is no one thing called “immunity” and it is hard to even envisage being “able to improve it”, said immunologist Satyajit Rath, visiting professor at the Indian Institutes of Science Education and Research, Pune. Even vaccine, that works by changing the immune response, acts only against one particular infection and cannot “improve immunity” in any general sense.

“I am yet to see any consistent body of evidence that any nutritional supplementation in an ordinarily healthy individual can ‘improve’ the immune response,” he said. It was irresponsible to make such claims and these should have been monitored by law, said Shashank Tripathi, assistant professor at the Centre for Infectious Disease Research, Indian Institute of Science, Bengaluru. His fear was that people might get overconfident because of such claims and expose themselves to the virus, believing that they are immune. These supplements can at best oil your engine, he said.

War-ready strategy

Their concerns stemmed from the fact that our immune system is an extremely complex biological system and it continues to confound scientists even over a century after scientists explained its workings; in 1908, the Nobel Prize in Physiology or Medicine was awarded to Ilya Ilyich Mechnikov and Paul Ehrlich for their contribution to explaining immune response. Just like a country’s military forces, the immune system’s task is to distinguish between “self ” and “non-self” and defend the body by eliminating organisms that can cause infection. For this, it depends on a variety of organs, tissues, cells and proteins spread throughout the body and are continually in action.

Broadly, it operates through its two arms: innate and adaptive. Innate immune system is the first line of defence against any incoming threat and consists of physical barriers like skin, airways and mucous layer of the digestive tract, and a cavalry of white blood cells that keeps circulating the body like a vigilant force. They are constantly on the lookout for foreign antigens, which are typically proteins on the surface of the invading bacteria or viruses. Some of its fierce personnel include phagocytes that simply swallow up the pathogens within minutes of getting alerted about an intrusion. Fever is the most common symptom of this war.

But most of the pathogens that cause serious infections in humans, particularly the ever-mutating, microscopic viruses, have evolved strategies to circumvent or suppress the innate immune responses. Besides, a weak innate response is often observed in old people and those who have underlying health problems.

For all such occasions, the innate immune system sends messengers to summon the adaptive immune system, which joins the war with its specialised forces—B cells and T cells. Over the next few days B cells tailor-make immunoglobulins (Ig), or antibodies specific for the antigen. These antibodies neutralise the pathogen by binding to its antigen and thus preventing it from attaching to host cell and entering it. For those pathogens that have already invaded the host cells, it calls upon T cells. The cytotoxic T cells—CD8+—neutralise the pathogen by directly destroying infected cells where the pathogen is multiplying, while helper T cells— CD4+—coordinate further attacks on the pathogen.

The war ends. But the cells do not drop their guard. Some of the B and T cells develop memory— which can persist for decades or even for a lifetime— and settle inside the lymphatic organs and tissues, such as spleen and thymus. These do not prevent re- infection, but remember every pathogen they have ever overcome. The next time a familiar pathogen attacks the body, they act swiftly, without the days- long delay, and in more numbers, stopping it from spreading throughout the body. Antibodies, like IgG, which becomes detectable in the blood once the immune response gains an upper hand, also continues to circulate in the bloodstream for a couple of weeks or months after the pathogen is cleared.

A healthy individual naturally possesses all cells of the immune system. But they proliferate and get trained only upon encountering a pathogen. This is how vaccination works.

It exposes an individual to a pathogen or an antigen in a controlled manner, without making them sick, and creates memory cells against it that fight the disease. “One can measure blood levels of various immune cells to determine if immunodeficiency issues exist, but a clinician cannot tell who will have a better response to an infection based on baseline measurements before a person is sick,” said Adrian Gombart, professor, Department of Biochemistry and Biophysics, Linus Pauling Institute, Oregan State University, USA. No amount of supplements can also train the cells how to fight off a pathogen. Rather, excessive consumption of supplements can make you sick, very sick.

Now, let’s analyse what happens to a person who survives an encounter with a pathogen. Does it guarantee him/her the much aspired long-term immunity? Not necessarily, say scientists. First, because pathogens, suchas viruses thatcause common cold, do not elicit a strong immune response, and thus do not leave behind much of a memory. This makes us vulnerable to re-infection. Even vaccines against such viruses require regular booster shots to maintain immunity. Viruses are also quick to mutate and this makes immune memory against them useless.

Even antibodies, which are mere proteins and thus degrade over time, do not guarantee long-term immunity. This is the reason serosurveys, or surveys to assess the presence of antibodies in a population during the current pandemic, help us to understand only the epidemiology of the disease and not to ascertain immunity developed by a person, to issue immunity passport or to assess herd immunity. This is also the reason the use of antibodies as therapy makes them unreliable. The Indian Council of Medical Research (ICMR) said that its plasma therapy study on COVID-19 patients—which works by harvesting antibodies from recovered patients and then administering it on those with acute symptoms to help them fight off the infection—did not really help.

COVID-19 has encouraged research projects on immune response like never before. Contradictory results still confused our understanding. Hope is mostly pinned on B and T cells that provide long- term immunity. First, some good news. In August, 2020, researchers from the Karolinska COVID-19 Study Group, Sweden, published a study in the journal Cell that mapped SARS-COV-2-specific T cell responses in unexposed individuals, exposed family members and those sick with COVID-19.

They found that T cells even in the sero-negative exposed family members and those with asymptomatic or mild COVID-19. The researchers said these SARS- COV-2 memory T cells could provide long-term immune protection against COVID-19. This was unexpected considering that immunity against other coronaviruses was short-lived; as per some estimates it was just about a year. Another study, published in Nature Reviews Immunology on July 29, 2020, also found a significant level of CD8+ and CD4+ T-cells in hospitalised COVID-19 patients.

But this does not seem to be universal, and over dependence on Tcells is not advised. Observations suggested that a bout of the disease leads to T cell exhaustion where the surviving T cells in COVID-19 patients were not able to function at full capacity and left the patients more vulnerable to secondary infection. A study published on May 5 in journal Frontiers in Immunology reported that COVID-19 patients with severe symptoms had lower T cell counts. Nonetheless, this understanding is important as it suggests that instead of focusing on respiratory function, it would be better to base treatment on T cell counts and their function—patients with low T cell counts should receive care urgently. The researchers also proposed that COVID-19 virus might not be attacking T cells directly but trigger a cytokine storm, which then drove down T cell numbers.

This finding was supported by research by Shiv Pillai, professor of medicine and health sciences and technology at Harvard Medical School, USA, and his team who have found COVID-19 patients with high levels of cytokines were less likely to develop long-term immunity against SARS-COV-2. Pillai’s team found that the spleen and lymph nodes of deceased COVID-19 patients showed a distinct lack of germinal centres, which are integral in developing long-term immune response. These germinal centres were activated upon infection or vaccination and encouraged B cells to mature into memory cells.

The paper, published in Cell on August 19, 2020 also showed that helper T cells needed by germinal centres to develop were absent in severely ill COVID-19 patients. “The immune response we saw was likely because of a virus that could not be controlled in early stages. We suspect similar things happen with any severe viral infection (like Ebola or a novel flu virus like swine flu) but these other diseases have not been studied properly before,” said Pillai. “What we have learnt could be applied to make vaccines produce better long-lived antibodies and we are working on that,” he added.

Genetic setting

But the fact is every research appears to have only deepened the mystery surrounding immune response. “We know a lot about the cells and system of our immunity but know very little about how they respond to a stimulus. Our immune system is one of the most complex biological systems on this planet. Millions of cells work together to counter a pathogen. Just imagine how much coordination is required.

A small break in their coordination may result in disaster,” said Rakesh Singh, associate professor at biochemistry department of the Institute of Science, Banaras Hindu University, Varanasi. “The probability of a non-specific response cannot be overruled as there is no accuracy even in a perfectly designed natural system.”

What Singh meantwas thatan immune cell primed for a specific pathogen or an antigen might provide partial protection against the second pathogen. When our immune cells are constantly exposed to various pathogens, they may acquire significant capability to cross protect. Take the example of BCG (Bacille Calmette-Guérin) vaccine used against tuberculosis. In this case, the immune cells are primed for specific bacterial antigens but they may have potential to protect from other pathogenic antigens.

There are some indications that BCG vaccine protects against COVID-19. “Protection depends on the quality of immune responses that have been developed in one’s body against a pathogen,” said Singh. Although, with the current level of knowledge it is difficult to quantify the quality of an effective immune response required for cross protection, measuring the numbers of antigen-specific memory B or T cells may help, he explained. This is substantiated by the fact that SARS- COV-2 reactive CD4+ T cells were found in 20 to 50 per cent of the blood samples, collected before the virus was discovered in 2019. The researchers reported in journal Science on August 4, 2020, that a range of pre-existing memory CD4+ T cells that could react to SARS-COV-2 and the four other common cold coronaviruses were present in the samples.

The unknowns surrounding our immune response do not end here. Have you ever tried to understand why cases of COVID-19 are low in African countries that have weak healthcare systems, crowding, lack of sanitation facilities and are poor? Researchers from the Netherlands tried to find an answer for this. They analysed the impact of early and extensive testing, lockdown stringency, demography and environmental exposure to pathogens on the incidence of the disease. They narrowed down the reason for fewer than expected cases in Africa to be constant exposures to pathogens. Unlike the much talked about link between non-communicable diseases and COVID-19, there is little research on how infectious diseases such as HIV/AIDS, tuberculosis, and other respiratory infections or those caused by helminths affect COVID-19, they said in the August 7, 2020 issue of Science.

The authors said such an exposure to microbes and parasites educated the immune system to guard against invading pathogens not only specifically but also non-specifically through “trained immunity”, which involved reprogramming of innate cells. These cells on secondary encounter with a pathogen could show a stronger response or “virtual memory” in which virtual T cells expanded in response to cytokines, rather than through antigens.

This could well be happening in India too. “Challenging day-to-day life with tuberculosis, malaria, dengue, chikungunya and many more pathogens likely made Indians more immune compared to several other nations. Hot weather and spicy, plant-based food habits might add Indians some degree of resistance to infection,” said Rajalingam Raja, director, Immunogenetics and Transplantation Laboratory, University of California San Francisco. But not everyone agrees with this theory. According to Rath, the low number of cases seen in India might simply be an accident of a late onset and inadequate diagnosis. Speculating about possible explanations for a phenomenon that may or may not be real is somewhat premature, he said. Tripathi elaborated further. “The logic that Indians have a better immune response because we live in an environment that has a lot of microbes is flawed. We are the number one country in infectious disease. We have the highest load of dengue, malaria and tuberculosis.

It does not seem that living with a lot of microbes is protecting us from infections,” he said. This suggests that the “hygiene hypothesis”, which postulates that early and chronic exposure to pathogens can activate immune cells and induce a strong immune response to counteract inflammation, fails to fully explain why some have better immune response than others.

As the world tries to understand this, the answer could be in their genetic makeup, the lifestyle they lead or the environment they live in. Studies showed that Asian Indians have gained more genes that protect them from viral infections during evolution. “Two families of genes play in this protective function—one is KIR (killer Ig-like receptor) genes and the other is HLA (human leukocyte antigen) genes.

Indians have more KIR genes compared to the Chinese and Caucasians. These genes enable Natural Killer cells (usually classified as part of the innate immunity but also displays memory, just like the cells of adaptive immunity) and in case of COVID-19 pandemic, the Indian-specific immune genes are clearly playing a role in low spread of SARS-COV-2,” said Raja. He explained that as humans migrated from Africa to India, they gained newer genes to help them adapt to the changing environment. Those who reached coastal areas retained these genes as the environment there was variable too. On the other hand, those who reached the plains of China, where the environment is stable, lost the genes.

A similar advantage is also seen in people of African descent. In September 2014, the ImmVar Project published their initial findings in Science on how ancestry affected T cell responses. The scientists analysed blood samples from 348 healthy volunteers representing African, Asian or European ancestry, isolated the CD4+ T cells and activated them in a cell culture to model their response to antigens. They then used computational analysis to measure which genes were turned on or off in the cells from each person. They found that there is stronger activation of some genes in people of African ancestry. They observed this specifically for a type of response in T “helper 17” cells that protect from microbes that enter airways or the intestinal tract.

But observations on incidence of COVID-19 in Africa and USA negated the possibility of genes providing protection against the disease. Africans in America had been found susceptible to the disease unlike those in Africa. Armed with such results, the COVID Human Genetic Effort, an international consortium that aims to discover inborn errors of immunity, plans to study hundreds of COVID-19 patients from around the globe to understand the role of genes in the disease. This is likely to be difficult as environmental factors and diet also play important roles in the manifestation of a disease by leading to the expression of certain genes. Factors such as diet, exposure to toxins, lack of sleep, stress, lack of physical activity can regulate such expression.

Diet and immunity

It has been observed that consumption of junk food over long periods of time reprogrammed the genetic makeup of immune cells and their precursors in mice, as per a study published in Cell in January 2018. The mice fed with the Western diet—high in salt, sugar and fat—had higher number of immune cells like granulocytes and monocytes (part of the innate immune system). When the mice went back to low- fat diets, their inflammation levels went down, but the genetic reprogramming of their immune cells continued. This is called trained innate immunity.

It has been postulated that the Western diet changes the way in which genetic information is packaged. The genetic material is typically wrapped around proteins and many genes are inaccessible under natural circ*mstances. But bad food causes some of these hidden pieces of the genetic material to unwind and be expressed—called epigenetic changes. “In general, too much refined and processed carbohydrates and certain unsaturated fats are pro-inflammatory and can drive obesity. Individuals who make higher levels of certain inflammatory cytokines early in disease have a worse outcome. It is likely that diet linked to pre-existing conditions contribute to eventual cytokine storms when the virus hits hard,” said Pillai.

Several lifestyle diseases are believed to be the result of a deranged immune system. In his recent book “The 21-day Immunity Plan”, Aseem Malhotra, a cardiologist in the UK, wrote excess body fat in the abdomen that surrounds the liver, pancreas and even fat underneath the skin released too much of pro- inflammatory cytokines. He said metabolic disorders could be treated by improving immunity through consumption of good food.

A diet rich in fibre can improve immunity by improving the gut microbiota. A high-fibre diet improves gut microbiota which, in turn, increases the production of short-chain fatty acids which can then dampen the innate immune response that is typically associated with tissue damage, and also enhance the adaptive immune response that is charged with eliminating pathogens in mice. The study was published in journal Immunity in 2019. In vitro studies showed processed, simple sugars reduce white blood cell phagocytosis and possibly increased inflammatory cytokine markers in the blood. Meanwhile, complex carbohydrate fibre, such as that found in fruits and vegetables, appeared to reduce inflammation in both humans and mice.

But good food does not involve supplements, which are being promoted as immunity boosters. Studies suggested over consumption of vitamins could be detrimental. A study published in the Journal of Leukocyte Biology in 2015 said although vitamin A supplementation could have health benefits when someone was deficient, too much it shut down the body’s adaptive immunity and made the person more vulnerable to infections.

“Vitamin A supplementation should only be done with clear biological and clinical arguments,” wrote Mihai G Netea, Radboud University Medical Center in Nijmegen, the Netherlands, who was part of the study. “The interface of nutrition and immunity is an area of considerable importance, especially in an age when dietary supplements and vitamins are quite common,” noted John Wherry, deputy editor of the Journal of Leukocyte Biology in a press note issued at that time. But impact of food on immunity too is not linear.

“Balanced use of some vitamin supplements helps the immune system,” said Adrian Gombart, professor, Department of Biochemistry and Biophysics, Linus Pauling Institute, Oregon State University, USA. For example, vitamin C is important for both innate and adaptive immune systems. It accumulates in phagocytic cells like neutrophils and enhances chemotaxis (the movement of cells toward chemical signals), phagocytosis (the eating of bacterial cells), generation of oxygen-based pathogen killing activity, and ultimately killing of pathogens. It also helps macrophages clear debris from the immune response to reduce tissue damage. It enhances differentiation and proliferation of B and T cells. Vitamin D is important for the expression of genes by macrophages, involved in killing pathogens through phagocytosis. It induces the expression of antimicrobial peptides that kill bacteria. It is important for regulating T cell responses and reducing inflammation. “Junk food does not have adequate levels of the micronutrients that we are discussing,” said Gombart.

Just like food, exposure to toxins in the environment too affects the immune response. For instance, exposure to pesticide can reduce proliferation of T cells and increase cell death which, in turn, reduces adaptive immunity. Pesticides can also affect innate immunity by reducing the binding capacity of N K cells. In macrophages, pesticides can reduce cytokine production and phagocytosis. Triggers like pesticides and heavy metals are not very easy to manage. The impact of toxins on the immune system can also be gauged from a study published in the International Journal of Environmental Research and Public Health in August 2019. It says children with blood lead concentrations between 1 and 5 µg/ dL (micrograms per decilitre) had 11 per cent lower anti-measles and a 6 per cent lower anti-mumps antibody level compared to children with blood lead concentrations less than 1 µg/dL after vaccination.

Ubiquitous air pollutants are also detrimental to immunity as they stimulate pro-inflammatory responses across multiple classes of immune cell and can enhance certain T helper cells, leading to allergy and asthma which further damage the organs. Air pollutants can also dysregulate anti-viral immune responses, noted a paper published in Free Radical Biology and Medicine in May 2020. The adverse impact of toxins persists for a long time, even through generations.

There seems to be a strong association between prenatal arsenic exposure and subsequent childhood respiratory infections, as well as morbidity from respiratory diseases in adulthood through changes in innate immunity. This adverse effect would persist even if the person shifts to cleaner environment, suggests an experiment on mice that were exposed to 100 ppb (parts per billion) sodium arsenite in the uterus, and infected with H1N1 upon reaching adulthood. Assessment of lung tissue and fluid after infection showed there was more lung damage and inflammation in arsenic-exposed mice.

Similarly, maternal exposure to dioxin, a common industrial pollutant, can harm the immune system of child by altering the cellular machinery by which genes are expressed. These alterations are then passed along to subsequent generations. Researchers exposed pregnant mice to dioxin and observed that the production and function of cytotoxic T cells was impaired when the mice were infected with influenza A virus.

Our understanding of the immune system is still in a nascent stage. There is a need to speed up the pace if we want to benefit from it. New science keeps emerging every day. For example, it has been observed that vaccinated children are more resistant to COVID-19. But the impact was more pronounced in children who received adjuvants (pharmacological agent added to a vaccine to boost the immune response to produce more antibodies and longer- lasting immunity).

Researchers are now trying to find if a similar effect can be seen in elderly who have received flu vaccines with or without adjuvants. Similarly, Adam Cunningham, professor of functional immunity at the University of Birmingham, the UK, and his team found that mothers exposed to a disease before pregnancy can transfer long-lasting immunity to their children through breast milk. The study, published in Science Advances on May 29, 2019, might help design maternal vaccine strategies. See also: DTE coverage on Covid-19 Pandemic
A COVID-19 patient uses oxygen support to breathe at the Gurdwara Shri Guru Singh Sabha Indirapuram in Ghaziabad, Uttar Pradesh.; Photo: Vikas Choudhary/ Centre for Science and Environment (CSE)
Photo: Vikas Choudhary/ Centre for Science and Environment (CSE)

Vaccine Chauvinism

Inequitable distribution amid acute shortage has derailed the global vaccination drive

By july 2021, the pandemic had entered into a critical phase. There was no ebb in its march. The virus was mutating faster. Countries needed to vaccinate their people against COVID-19 as fast as possible. The virus might develop ways to escape the immunity provided by the vaccines, making the entire exercise futile. This was something that the world leaders knew much before the first COVID-19 vaccine was administered in the UK in December 2020.

The COVID-19 Vaccines Global Access or COVAX was set up in April 2020 to accelerate the development, production and equitable access to vaccines. The alliance, by the World Health Organization (WHO), GAVI and the Coalition for Epidemic Preparedness Innovations, hoped to deliver 2 billion doses that would ensure at least 20 per cent of the population in each of its 190 member countries was fully vaccinated by 2021. Yet six months later, shortages and inequitable distribution of doses threatened to derail the largest vaccination campaign the world had ever seen. For one, COVAX had been facing acute shortfall since April 2021 after the major source of its vaccine, Serum Institute of India (SII), slipped on the delivery timeline because of a surge in COVID-19 cases in India.

The alliance had received only around 30 per cent of the 252 million doses it had hoped to by June 2021. COVAX could procure only WHO-approved vaccines. The UN agency had given a nod to just six of the 17 vaccines that were being administered in different countries across the world. Of these, Covishield, manufactured by SII, was the cheapest at around US $3 a dose. The other vaccines cost anywhere between $1 and $40, as manufacturers were selling them at different prices to different countries to maximise profits. Sputnik V, developed by Russia, was the only other cheap vaccine selling at almost the same price as Covishield in at least some countries. WHO, however, was delaying its approval even though the manufacturer said it has submitted the necessary paperwork. As a result, COVAX was forced to reach out to the expensive WHO-approved manufactures. This was a drain on funds that were already in short supply.

Even if the alliance had the money, these manufacturers were not too keen on sharing their doses. WHO gave approval to the vaccine produced by Moderna on March 12, 2021. On June 2, the company, after persuasion by UNICEF, agreed to deliver 34 million doses in the last quarter of 2021. A similar delay could also be seen in the case of Johnson & Johnson, which agreed to provide 200 million vaccines more than two months after receiving WHO approval. Pfizer, which was the first company to get WHO’s nod, had supplied only 15.3 million doses to COVAX so far. While the delays by WHO in authorising new vaccines was leading to shortages, COVAX alone was to be blamed for the way it had so far distributed the vaccines.

Of the 2.42 billion vaccine doses that had been administered globally till June 14, 2021, the low- income nations had received a negligible 0.3 per cent. In contrast, high and upper-middle income nations had administered a little over 85 per cent of the vaccines and low-middle income nations accounted for the remaining 14 per cent or so, as per Our World in Data. The world faced the problem of “vaccine nationalism”. Developed countries had pre- booked a lion’s share of the vaccines. Rich countries with just 13 per cent of the world’s population had already purchased over 50 per cent of the scheduled vaccine production, said a position paper by the All- India Peoples Science Network. In fact, Oxfam said that 9 out of 10 people in poor countries will not get a vaccine before 2022.

Monica de Bolle, professor at the Johns Hopkins University, US, criticised COVAX for allocating vaccines in proportion to population sizes, which was not the best public health metric. As a result, it short- changed nations in desperate need of vaccines, while providing it to others that had comparatively fewer cases. The alliance also didn’t consider countries’ capacities to roll out massive immunisation campaigns. COVAX hoped that vaccine donations from developed countries would help it deal with the shortfall. The G7 group, a consortium of seven high-income countries including USA, Japan and the UK, on June 11, 2021 announced plans to donate 870 million vaccines to low-income countries; only half of them would be delivered by the end of the year. However, developed countries were reluctant to route their surplus vaccines through COVAX because bilateral transfers allowed them to increase their sphere of influence.

This approach of circumventing COVAX had further skewed distribution. Countries in East and South Asia had received 55.59 per cent of all pledged donations, despite having just 20.73 per cent of the confirmed cases since November 2020. In contrast, Latin America and Eastern Europe, which continued to suffer high case burdens and had struggled to secure vaccine access outside of COVAX, were receiving far fewer donated doses than necessary, read the June 4 analysis by Think Global Health, an initiative by think-tank Council on Foreign Relations and the Institute for Health Metrics and Evaluation.

Make-believe plans

UNICEF’s COVID-19 Vaccine Market Dashboard estimated that the world would have 9 billion vaccine doses by the end of 2021. This should be enough to completely inoculate more than 90 per cent of the adult population. The concern was that only 38 per cent of these promised doses would come from the 17 vaccines that were in the market that point of time. The industry seemed to have promised overambitious production numbers without actually setting its house in order. The unavailability of enough raw materials was likely to make matters worse. “We have been issuing warnings since March this year (2021) that some crucial raw materials are in short supply,” said Thomas Cueni, director general, International Federation of Pharmaceutical Manufacturers & Associations, which represents big pharmaceutical companies. The shortage of raw materials had already forced the Oswaldo Cruz Foundation and Butantan Institute in Brazil to suspend production of the AstraZeneca and CoronaVac vaccines in May, 2021. To ramp up the production of vaccines and raw materials, the developed countries and pharmaceutical companies had to break their monopolies and allow the vaccine technology to be freely shared with manufacturers around the world.

But they were not willing to do so. In October 2020, India and South Africa floated a proposal at the World Trade Organization (WTO) to suspend patents on products needed to control the pandemic, including vaccines. The proposal was on the back burner for almost eight months; finally, in June, 2021, member nations agreed to move ahead with text- based negotiations. A final call would be taken at the WTO Ministerial Conference in November 2021. COVAX could play an important role here.

On May 6, 2021 Human Rights Watch, Amnesty International, and Public Citizen demanded that COVAX publish its contracts with vaccine manufacturers. “Publishing contracts and prices while sharing intellectual property is a good way to start ensuring that vaccines are affordable and available for billions of people who desperately need them,” said Arvind Ganesan, business and human rights director at Human Rights Watch. So far, the alliance had refused to disclose the deal details citing confidentiality obligations. For long- term sustainability, COVAX would also need to align its work with other UN programmes like the COVID-19 Technology Access Pool by WHO that encourages voluntary contribution of intellectual property, technology and data to increase availability of medical products.

The alliance could also ensure compensation for people in poor countries who suffer from severe side effects after taking the vaccines. WHO had set up a programme that makes compensation available to individuals in 92 low-and middle-income countries without going to court. This is the first and only global no-fault compensation mechanism and it is funded by a small levy on each COVID-19 vaccine dose supported by the COVAX. Similar systems already exist in developed countries to protect consumers. For example, the UK has a Vaccine Damage Payments Scheme, which authorises one-time tax-free payments of up to £120,000 for individuals who have been disabled due to vaccine side-effects. The US has enacted the Countermeasures Injury Compensation Program to deal with COVID-19 vaccine injuries. Japan too has a long-established compensation scheme set up in 1979 and financed by contributions from pharmaceutical companies.

Deliveries via COVAX would also protect poor countries that were currently being bullied by vaccine manufacturers for immunity against lawsuits due to adverse effects. Pfizer was negotiating with the Indian government for such immunity in return of its vaccines. The government had not taken a decision on this as yet.

“The discussions lack transparency, the absence of which would be akin to trading away the rights of people who could be affected by serious adverse events and other acts of negligence of the pharmaceutical corporation in the future,” said Amulya Nidhi of civil society group Jan Swasthya Abhiyan, who had written to the Prime Minister advising against such agreements. He said that India also needed to develop its own no-fault compensation mechanism. Nidhi’s concerns were valid because Pfizer was infamous for its arm-twisting methods. Even before its vaccine was approved, Pfizer had asked Argentina to pass a law which would provide the company protection from lawsuits related to adverse reactions.

The country passed a law which absolved Pfizer of adverse reactions but still held the company liable for acts of negligence or malice. Unhappy, the company demanded sovereign assets to be handed over as collateral in return of vaccines. When Argentina rejected this, the company pressured the government to take international insurance to pay for potential future cases against the company. The country refused to agree to the demands and as a result, it failed to forge a deal with Pfizer till date. The company had supply agreements with nine countries in Latin America and the Caribbean:

Chile, Colombia, Costa Rica, Dominican Republic, Ecuador, Mexico, Panama, Peru, and Uruguay. The terms of those deals were unknown. The central reason why private players were getting away with blatant malpractices and shady deals, while developed countries remained mute spectators, was because the world lacked a comprehensive vaccination plan, a point highlighted by UN director general Antonio Guterres recently while he criticised the recent G7 announcement. In such a situation, COVAX had a crucial role to play, which went much beyond vaccine distribution. It was still to be seen if the alliance could work against the industry which indirectly supported it through GAVI.

Too many hurdles, still

India is the global hub of vaccine production. It was also one of the very few countries that managed to develop an indigenous vaccine in record time. By December, 2020 the country was all set with its COVID-19 operational guidelines to ensure a smooth rollout of the vaccines. The government was so confident of its ability to meet domestic demand that it allowed more than 60 million doses to be exported or donated to other countries between January and March, 2021. Yet when the devastating second wave engulfed the country in April, the vaccine drive failed. While people across the country struggled to secure vaccination slots on the national CoWin dashboard, the Centre worsened the situation by deciding to extend the vaccination net to include all adults under the age of 18 years.

Itwas decided that the additional vaccines would be procured by the state governments, which clearly failed because of the global shortage and the fact that states had never procured vaccines in the past. Some of the states even unsuccessfully tried to float global tenders to forge deals with vaccine manufacturers. When the desperation peaked, the Supreme Court had to step in to make some sense out of the chaos.

On June 7, 2021 amid criticism of the government’s confused vaccine policy, the Centre announced universal vaccination. According to the latest policy, 75 per cent of the vaccines needed would be purchased by the Centre and provided to the states. 25 per cent of the vaccines would be available to private hospitals for which they would need to pay more and would be able to charge accordingly ( 150 over the cost price). This universal rollout started from June 21, 2021.

India had the daunting task of vaccinating its entire adult population of nearly one billion by the end of 2021. This would require almost two billion doses. In the first six months, the country had managed only 0.25 billion doses. To be able to deliver the 1.75 billion more doses in the remaining half of the year, the country needed at least 250 million doses a month. However, according to a Press Information Bureau release, only 120 million doses had been sanctioned for June, suggesting that the progress remained slow. The Centre, though, was confident that the vaccine availability would shoot up in the coming months. It was relying on the SII and Bharat Biotech, the two major suppliers of vaccines in the country, to deliver 0.75 billion and 0.55 billion respectively by the year-end. The country was also hoping to import 0.16 billion Sputnik V vaccines, bringing the total to 1.5 million doses between August and December. The remaining shortfall was expected to be bridged by imports and newer vaccines (many of Indian origin).

The Centre had announced that Indian Immunologicals Limited would start producing Covaxin from September 2021 and Haffkine Institute and BIBCOL would start production of Covaxin from November 2021. While the numbers added up, past experience suggested that the country must be ready for the slips between the cup and the lips. The delivery of Sputnik V vaccine had already been delayed from June to August. The government also had the option of dose stretching to reduce the demand. Studies showed people who had been infected by the virus might remain safe by taking a single dose. The government needed to take quick decisions on such aspects to help the people.

The other side of India’s vaccination challenge was ensuring speedy delivery of the doses, especially in the most peripheral places. Under the current universal immunisation programme, the country administered some 390 million doses to newborns and pregnant mothers in a year. For COVID-19 relief, the country would need to deliver an additional 250 million doses a month for the rest of 2021.

The country would need new infrastructure and more importantly skilled health personnel to deliver the extra doses. A vaccination centre needs at least five people, including a trained vaccinator. It will also have to ramp up its rate of vaccine delivery. As on June 12, 2021 the country had 42,883 vaccination centres that had delivered 3.34 million doses, or 78 doses per centre per day. T Sundararaman, global coordinator of People’s Health Movement, said rolling out COVID-19 vaccination without fixing the delivery challenges would lead to distinct problems: the vulnerable population would be left out and vaccine quality would take a hit due to limited availability of cold storage facilities and human resources. As a virus jumps from one host to another and from one environment to another, it mutates.

In the case of SARS-COV-2 virus, these mutations had resulted in variants which could extend the pandemic. Many of the mutations had occurred in the very proteins that had been used to cook up the vaccine. WHO had identified four variants of concern (mutations linked to rapid spread in human population) and four variants of interest (mutations with genetic changes that can lead to rapid spread in the future). The delta variant, which was predominant in India’s second wave, was almost 40 per cent more transmissible than the alpha variant, first reported from the UK in November 2020. The alpha variant itself was around 50 per cent more transmissible than the original virus isolated from Wuhan in December 2019.

“More infectious variants increase the percentage of population that needs to be vaccinated to achieve herd immunity. Variants that partially evade immune responses are able to cause re-infections and breakthrough infections. All this makes it harder to control the pandemic,” said Shahid Jameel, director, Trivedi School of Biosciences, Ashoka University, Sonipat, Haryana.

Public oversight

During this scramble for more and more vaccines, India’s seven public sector vaccine manufacturing institutes were sitting idle. They had ensured vaccine security for India for decades. These included the Central Research Institute (CRI) in Himachal Pradesh, BCG Vaccine Laboratory (BCGVL), Pasteur Institute of India (PII) and HLL Biotech in Tamil Nadu, Bharat Immunologicals and Biologicals Corporation Limited, Uttar Pradesh, Haffkine Bio-Pharmaceutical Corporation Limited, Maharashtra, and Human Biologicals Institute, Telangana. In 2008, the Centre cancelled the manufacturing licences of three of these public sector undertakings (PSUs)—CRI, BCGVL and PII—for not meeting good manufacturing practices under the Drugs and Cosmetics Rules 1945. The three PSUs, set up in pre-Independence India, were reopened in 2012 because of public interest petition in the Supreme Court, and castigation by two parliamentary committees on health.

In July 2019, the then Union health minister of state Ashwini Kumar Choubey said the units were in different stages of vaccine production for supplying to the country’s Universal Immunisation Programme. But the data provided by him suggested otherwise.

CRI discontinued production of tetanus toxoid in 2018-19. PII, with an installed capacity of 60 million doses per annum of combination DPT vaccine, 55 million doses per year of tetanus toxoid vaccine and 15 million doses per year of diphtheria vaccine, had not produced a single dose since 2016. BCGVL’s plant in Guindy, Tamil Nadu, had not produced a vial between 2016 and 2020, despite an installed capacity of 80 million doses of BCG vaccine a year. The first batch of 450,000 doses was only rolled out in July 2020. The Centre had assigned a new role to CRI. When the Sputnik V and AstraZeneca vaccines came to the country, it carried out safety tests on them before they were allowed to be used in a clinical trial. The PSU also provided adverse events following immunisation (AEFI) assessment services to the government.

Public health experts questioned ICMR’s decision to partner with a private firm alone for manufacturing COVAXIN. “The government can ask Bharat Biotech to transfer the technologies to PSUs and other private companies in the country through the provision of compulsory licensing,” said Malini Aisola of the All India Drug Action Network, an alliance of non-profits working towards improved access to essential medicines. With a little investment, these PSUs could enhance the production capacity of COVID-19 vaccines, said K M Gopakumar of Third World Network, an advocacy organisation. “We need political will to make this happen,” he added.

On March 17, 2021 Maharashtra’s chief minister Uddhav Thackeray at a video conferencing asked Prime Minister Narendra Modi to allow the transfer of COVAXIN technology to state-owned Haffkine Institute in Mumbai. To upgrade the institute, he had asked for funds from the Centre under the recently launched Mission COVID Suraksha. The Centre had not yet given a go-ahead.

The country also had a state-of-the-art Integrated Vaccine Complex based in Chengalpattu, Tamil Nadu that had been lying idle since its inauguration in 2016. The Centre came up with the idea of the 40-hectare complex in 2008 after the manufacturing licences of the three PSUs were cancelled. The facility was meant to be the nodal centre for manufacturing, research and supply of vaccines at affordable prices under the Universal Immunisation Programme. So far, it had not developed a single vaccine. In January 2020, Bharat Biotech offered to provide 600 crore to revive the complex. The discussions did not move forward. On January 9, 2021, just days before India’s vaccination drive began; the then Union Minister of Health and Family Welfare Harsh Vardhan visited the plant to inspect the facilities. On January 16, 2021, HLL Lifecare Limited, the PSU that was running the complex through its subsidiary HLL Biotech Ltd, issued an expression of interest from vaccine manufacturers to use the plant. “The facility has the infrastructure, trained technicians and scientists for the production of vaccine and could contribute in the production of COVAXIN,” said C S Rex Sargunam, president of the Tamil Nadu Health Development Association, a non-government organisation.

India was not the only country where the public sector had been sidelined. Stuart Blume, professor emeritus at the Faculty of Social and Behavioural Sciences in the University of Amsterdam, the Netherlands, explained that the 1980s saw the rise of neoliberal thinking and privatisation of health services. “Experts in the 1980s insisted on patents and intellectual property rights that were harmonised across the globe. This is what the pharmaceutical industry wanted too,” he said.

Now, COVID-19 had given the public sector a second chance, as countries were realising profit-driven private players might not be enough during a crisis. In Canada, efforts were underway to manufacture vaccines domestically. This realisation came when after identifying a vaccine candidate, the country realised it did not have the manufacturing capability to create its components. Similarly, Cuba had started developing its own vaccine after it failed to pre-book enough doses. The first million doses of Soberana 02 vaccine were expected to be released in late April, 2021. The country was developing three more vaccine candidates: Soberana 01, Mambisa and Abdala. China and Russia had also developed vaccines through the public sector. “In India, the public sector should be revived to its full capacity with adequate support to strengthen its inherent strengths on expertise and skilled human resource,” said Y Madhavi, researcher at the Council of Scientific and Industrial Research– National Institute of Science, Technology And Development Studies.

This might not be as straightforward as the character of the PSUs had changed over time. “The institutes we used to have can’t be reconstituted in today’s climate. A new model, a good example for the world, isn’t readily available,” Blume said. The character of immunisation had also changed in India. The country preferred combination vaccines in the Universal Immunisation Programme and the old PSUs didn’t have the necessary infrastructure for that. Most new vaccines were also under patents, making it difficult for the PSUs to make them.

Madhavi said complete dependence on private industry was a mistake. There were examples where private players had failed to deliver. In 2015, a lack of vaccines led to an outbreak of Japanese encephalitis in Uttar Pradesh. “Currently, 80 per cent of the Indian government’s need for vaccines is met by private firms in India and abroad. The prices are up to 250 per cent higher than those of the public sector, as a result pushing India’s immunisation budget up seven times in only five years,” she said. The fault line in the health sector that the crisis exposed was the absence of good policies. India had two guiding health documents and they had opposing views: The National Vaccine Policy 2011 encourages public-private partnership, but its National Health Policy 2017 focused on building more public sector manufacturing units to generate healthy competition, uninterrupted supply of quality vaccines and anti-sera. On ground, only privatisation was happening.

The way to move forward would be to provide a level playing field for both public and private sectors with around 50 per cent of vaccine production to remain with the public sector. All vaccines which are of national importance should be reserved for the public sector, said Madhavi. This would help in another way. The focus on COVID-19 vaccine could take away resources from the vaccines used in the Universal Immunization Programme and routine immunisation in children could be derailed. While the private was busy fighting the pandemic, PSUs could at least avert this shortage. COVID-19 clearly showed that countries, not the pharmaceutical companies, needed to play a pivotal role.

See also: DTE coverage on Covid-19 Pandemic
Free COVID-19 vaccination is being given to the people of special priority group at the initiative of the government. Burdwan Town, Purba Bardhaman District, West Bengal; May 17, 2021; Photo: iStock
As deep cracks surfaced in the global supply chain of masks, personal protection equipment (PPE), testing kits, drugs and ventilators, it triggered infighting within countries.
Photo: Vikas Choudhary/ Centre for Science and Environment (CSE)

The Big Pharma Mess

The pandemic exposed a serious fault line in the global pharmaceutical supply chain

ALL nations – rich and poor – scurried for medical supplies as the pandemic erupted. They were ready to play dirty. It’s about national security, said countries, and each wanted to reduce its dependence on foreign supplies. On March 25, 2020, for instance, when COVID-19, was spreading rapidly, the European Union included health, medical research and biotechnology as part of its “restrictive list” of foreign investment. Italy, which was then the worst affected country after China, begged EU member nations for face masks. Instead of offering help, Germany and the Czech Republic promptly banned export of masks and other protective equipments. In fact, Germany intercepted a truck, on way to Switzerland with 240,000 masks, before it left German soil. Turkey and Russia followed suit.

As deep cracks surfaced in the global supply chain of masks, personal protection equipment (PPE), testing kits, drugs and ventilators, it triggered infighting within countries. In USA, the federal government seized masks, thermometers and other essentials ordered by different states. In France, the government requisitioned all available masks for its own use. Israel deployed its intelligence agency, Mossad, to take control of all ventilators in the country. Worldwide, the demand for ventilators was increasing. Germany had 25,000 ventilators with 10,000 more on way, but the country was unwilling to share it.

NITI Aayog on April 3, 2020, estimated that India would need 27 million N95 masks, 15 million PPE, 1.6million diagnostic kits and 50,000 ventilators within two months. India was further pushed into the eye of the storm when experimental drugs like hydroxychloroquine (HCQ) became part of politics. As stocks of active pharmaceutical ingredients (APIs)—basic therapeutic chemicals that act as raw materials for producing tablets, capsules and syrups— dwindled globally, India put 13 APIs, also called bulk drugs, and their formulations on the restricted list for exports on March 3, 2020, and then banned their export on April 4.

These accounted for 10 per cent of India’s total pharma export. The anti-malarial HCQ was part of that list. But India was forced to lift the ban on humanitarian grounds. USA, in fact, threatened India with retaliation. On April 6, 2020, India’s Directorate General of Foreign Trade (DGFT) had to permit the export of APIs and formulations. Export of formulations made from paracetamol was also allowed, though DGFT continued to restrict export of the API for paracetamol. This medicine for fever was part of the arsenal to provide immediate relief to COVID-19 patients.

The pharmaceutical industry has evolved in a way that makes every country vulnerable during crisis, said Ashok Madan, executive director of Indian Drug Manufacturer Association. As every country scrambled for medical essentials, it enormously strained the global supply. At the same time, the scramble also exposed a faultline in the global supply chain, created over the years by an industry that flourished by putting profit before public health. With bulk of the production of pharmaceuticals and medical essentials occurring only in China and India, global reliance on these countries was overwhelming. Developed countries make APIs only for patented drugs. It was left to India and China to produce APIs for generic drugs.

USA imported 80 per cent of the APIs from the two countries. China is the biggest player. It provided 97 per cent of the antibiotics and over 90 per cent of vitamin C used in USA in 2019. In 2018, 95 per cent of ibuprofen, 91 per cent of hydrocortisone, 70 per cent of aceta-minophen and 40-45 per cent of heparin in USA was procured from China. Similarly, some 90 per cent of the APIs for generic medicines in the EU were sourced from India and China, revealed a paper prepared for the EU pharmaceutical committee in March, 2020. According to the UK’s Medicines and Healthcare Products Regulatory Agency, China manufactured around 40 per cent of all APIs used worldwide although the World Health Organization (WHO) put this figure at 20 per cent. The China Chamber of Commerce for Import and Export of Medicines and Health Products said the export value of Chinese APIs in 2018 was US $30.48 billion and the export volume reached 929.72 million tonnes.

The reason for Chinese supremacy in API manufacturing is because when the sector first developed in China, it was state-owned. The government strategically supported the industry by giving incentives such as cheap electricity, water and labour and no charge on land. It also established special industrial zones. “In the late 1980s, when global corporations started shifting their production base to developing countries, their interest was to get cheap labour and raw materials in an effort to maximise the benefit,” said K M Gopakumar, legal advisor and senior researcher with Third World Network, an international research and advocacy organisation. China emerged the winner and managed to kill India’s existing pharmaceutical sector.

“For example, China dumped cheap Penicillin G in India, outperforming Indian manufacturers like Hindustan Antibiotic in the public sector and Torrent Pharmaceuticals Ltd, Alembic Pharma, Southern Petrochemical Industries Corporation Ltd and J K Pharmachem in the private sector,” explained Madan of the Indian Drug Manufacturer Association.

A new chain

But the pandemic forced China to lock down its production hub in Hubei province, which hit hard its supply to the world. The region had 44 companies which were either approved by the USA Food and Drug Administration (FDA) or meet EU standards. These units were shut down on January 24, 2020. Unlike China, India was more involved in producing finished products. The country is the world’s largest provider of generic medicines, accounting for 20 per cent of global generic drug exports in volume terms. Small wonder, India is also called the “pharmacy to the world”. In a response to a Rajya Sabha question, the government said on March 13, 2020, that India exported medicines worth $14,389 million in 2018-19. Medicines were sent to more than 200 nations—from the highly-regulated North American and European markets to countries with limited drug manufacturing capacity, including most of sub-Saharan Africa, wrote researchers at the University of Oxford in F1000 Research, an open access publishing platform, in April, 2020. Indian manufacturers produced 67 per cent of worldwide pharmaceutical products for HIV/AIDS, diarrhoea, hepatitis, malaria, influenza, reproductive health, tuberculosis and neglected tropical diseases. Unfortunately, the production of a majority of these drugs was dependent on APIs sourced from China. Of the total import of APIs in India, 67.56 per cent was from China.

On March 13, 2020, when the BJP and Congress leaders Prabhakar Kore and Selja Kumari questioned in the Rajya Sabha about drug security, the then Chemicals and Fertilisers Minister D V Sadananda Gowda said that according to the Central Drugs Standard Control Organisation, the stock-in-hand of APIs would be sufficient only for two to three months. The government’s ban on export of APIs and formulations was a result of this fear.

Chinese dominance in the pharmaceutical sector has always been questioned across the world. On April 6, 2020, the US Congressional Research Service observed that COVID-19 was “drawing attention to the ways in which the US economy depends on manufacturing and supply chains based in China”.

Now, relocation of medical supply chains to the US was being planned. Japan and Australia too came up with similar strategies. In fact, in September 2019, the European Fine Chemical Group, a non-profit association of European fine chemical manufacturers, published a briefing paper asking countries to reduce their dependence on China and India. Maggie Saykali, director of Specialty Chemicals, a grouping of over 50 sectors of Europe’s fine and consumer chemicals industry, said that massive offshoring of API production and Registered Starting Materials had left the EU dependent on China and India for close to 80 per cent of its medicinal products. COVID-19 underlined the domination of the global supply chain, said Saykali. Only 28 per cent of the manufacturing facilities making APIs for the USA markets were based in that country. This was told to a US House of Representative sub-committee by Janet Woodco*ck, director, Center for Evaluation and Research, US FDA.

In her testimony, Woodco*ck quoted two papers to highlight why China and India were in advantageous positions when it came to producing APIS. Referring to a 2009 paper by the World Bank—“Exploratory Study on Active Pharmaceutical Ingredient Manufacturing for Essential Medicines”—she said if a typical Western API company had an average wage index of 100, the index was as low as 8 for a Chinese company and 10 for an Indian company.

Referring to a 2011 FDA report—“Pathway to Global Product Safety and Quality”—Woodco*ck said China and India had an advantage of low labour costs that reduced the API manufacturing costs. API manufacturing in India could reduce costs for the USA and European companies by 30 to 40 per cent. Manufacturing in China got the benefit of low electricity, coal and water costs. Chinese firms are also embedded in a network of raw materials and intermediary suppliers and, therefore, have lower shipping and transaction costs. They face fewer environmental regulations regarding buying, handling and disposing toxic chemicals, leading to lower direct costs for these firms, Woodco*ck said.

India, too, has been worried about its increasing dependence on China. In 2014, former Rajya Sabha member the late Motilal Vora raised the issue of inappropriateness of importing API from a single country in the House. The same year, National Security Advisor Ajit Doval called the rising dependence on Chinese drug makers a “national threat”. In 2013, a high-level committee to promote domestic manufacture of APIs was set up under V M Katoch, the then director general of the Indian Council of Medical Research (ICMR) and secretary of the department of health research under the Union Ministry of Health and Family Welfare. In July 2018, a parliamentary standing committee report presented to the Rajya Sabha pointed out that there was an urgent need to revive the country’s capability to produce APIS. The committee noted that China had increased the prices 1,200 per cent in just two years. This slashed the profit margin for India’s industry.

To increase self-sufficiency, the Katoch committee’s report, submitted to the Ministry of Chemicals and Fertilizers in February 2015, recommended the creation of three to six mega parks. These parks should provide free or shared water, electricity, effluent treatment plants and testing facilities to the pharmaceutical industry. The government would have to invest 750-1,000 crore for each of these parks. The committee recommended that the private manufacturers should be provided benefits like 15-year tax-free status, access to loans and foreign investment. It also pushed to revive the public sector Indian Drugs and Pharmaceuticals Limited with an infusion of 500 crore.

While this committee’s report was awaiting implementation, the government formed another task force in 2018, chaired by Mansukh Mandaviya, the then Union Minister of State for Chemicals and Fertilisers. This, too, reiterated the recommendations of Katoch committee. India had already started work to revive the industry. The department of pharmaceuticals has approved development of mega parks in Andhra Pradesh, Telangana and Himachal Pradesh and is providing assistance up to 100 crore.

The cost of cheap medicines

Manufacturers said it was not easy to cut the umbilical cord with China for supply of basic drugs. The government had to regulate drug prices to ensure people have access to cheaper medicines. This, in turn, made the pharmaceutical sector look for ways to cut prices, thus increasing their dependence on the low-cost Chinese model. Besides availability, the affordability of medicines had always been a major challenge for India. Media reports said API prices in India shot up after the pandemic. China provided 75 per cent of APIs used in the formulations of drugs in the National List of Essential Medicines (NLEM) and there could be an increase in prices of medicines in the list. In a recent interview to the national daily Financial Express, Mandaviya said increased self- sufficiency in manufacturing of critical bulk drugs would ensure the availability of essential drugs listed under NLEM at affordable prices.

The government has to mandatorily ensure that prices are low as these drugs are part of the Essential Commodities Act, 1955, which regulates the prices of essential supplies like grains, foodstuffs and medicines. The list of drugs under price control has steadily expanded from 74 in 1995 to nearly 860 in 2019. According to brokerage firm Centrum Broking, going by the wholesale price index of 2019 and 2020, the increase in prices of drugs under NLEM would not be steep. However, prices of non-NLEM drugs would increase by 10 per cent. “With China resuming supplies of raw materials, the potential disruption in manufacturing was now no longer a concern. There was inflation in select raw material supplies but the same should only have a minor impact on gross margins during the quarter,” brokerage firm Nirmal Bang said.

However, private manufacturers had not been keen to provide medicines that are under price cap. They said it does not help as the poor are still not able to afford them. “The problem is that India has been spending too little on healthcare,” writes Amir Ullah Khan, professor of economic policy at the Indian School of Business and the Nalsar University of Law, in the national daily Mint. Instead of price control, he suggested that options like trade margin rationalisation, centralised procurement, social health insurance schemes, cross subsidisation and state financing of essential drugs should be used.

India has to keep the drug costs low. But as its public spending on health has been very low, it was not going to be likely for the country to procure much if it purchased at the private sector prices. Public sector pharmaceutical companies, therefore, have become relevant as they can provide drugs at the cost price even after including the cost of pollution control.

Environmental pollution is, obviously, the most devastating byproduct of the drug-making race, but global efforts to reduce it have been tardy. In 2014, the EU issued a draft strategy to ensure that companies that supplied antibiotics to them were responsible and non-polluting. Under this, EU members could have environmental clauses in international agreements. This would have allowed EU inspectors to visit factories in Asia or Africa to ensure that they were not polluting. But the draft was diluted. The replacement passage in the new 2018 draft merely gave countries an option for “the possibility of using procurement policy to encourage greener pharmaceutical design”.

The dilution was linked to lobbying by drug companies. Voluntary declarations showed that the pharmaceutical industry spent nearly about $37 million on lobbying EU institutions in 2015. Public records showed the European Federation of Pharmaceutical Industries and Associations had over 50 meetings with the Juncker Commission in its first four-and-a-half months of office. Fortunately, the European Parliament had been demanding stricter measures again. Its environment committee unanimously backed a call to go tough on pharmaceutical pollution, including reductions in drug use, greener manufacturing and better waste management.

Developing countries, too, were formulating policies to control pharmaceutical pollution. On January 23, 2020, India released a draft Environmental Standards for Bulk Drug and Formulation (Pharmaceutical) Industry to limit the concentration of toxins in effluents released by bulk drug manufacturers. It specified maximum residues for 121 antibiotics that could be present in the treated effluent of bulk drug and formulation industry and in the outlet of the common effluent treatment plants.

The draft notification also prescribed maximum concentration for various other parameters, including heavy metals and hexavalent chromium. China, too, was trying to reduce environmental pollution. In 2002, it formulated the China Safety Production Law which controls all industries, including chemical and pharmaceutical. But the industry continued to pollute. With President Xi Jinping at the helm, it was taking action to ensure that the Chinese industry was in line with global environmental standards. Between 2016 and 2018, inspections led to the closure of 150 factories producing APIs, according to a white paper published by consultancy firm Beroe in July 2019.

In the case of antibiotics, China issued strict guidelines in its National Action Plan, 2016. It promotes green manufacturing of antibiotics and monitoring of effluents. In January 2018, China came out with an “environmental tax declaration” under which less polluting industries were eligible for tax reductions. A 25-per cent tax relief was allowed if the discharge, mainly wastewater and air pollution, was 30 per cent lower than the national or provincial standards.

If a company was able to maintain its pollution level at 50 per cent lower than the standard concentration, they could apply for a 50 per cent tax reduction. According to the Beroe white paper, China had also planned to put in measures so that polluters would face a levy of between 1.2 yuan ($0.18) and 12 yuan ($1.8) for every 0.95 kg of nitrogen oxide or sulphur dioxide they release. According to estimates, taxes up to 50 billion yuan (about $7.68 billion) would be collected annually from manufacturers.

Such stringent pollution norms would increase manufacturing costs and take away China’s competitive edge. Earlier too, diligently operating European firms went out of business because they could not compete with a non-compliant China, according to an article published in Chemical & Engineering News in 2018.

It said a strict inspection regimen could trigger a migration of business back to the West as environmental compliance would increase the cost of operating in China. India, however, had been unable to control pollution in its pharmaceutical hubs like Patancheru-Bollaram Industrial Estate in Telangana, Baddi Industrial Area in Himachal Pradesh, and Sipcot Industrial Estate in Cuddalore, Tamil Nadu. This, despite the Environment (Protection) Rules, 1986, that were in force.

India’s new pharmaceutical parks were planned in these very places. The Department of Pharmaceuticals had promised fast environmental clearances to the industry. Such quick-fix measures would be detrimental in the long- run unless strict regulations were put in place. India needed to be more cautious now. China claimed it had resumed production of APIs and said it was unlikely that there would be any shortage in India or globally. The pandemic, however, had given the world a chance to do a rethink on the pharmaceutical industry. Countries had realised that their over- dependence on one country could cause big trouble. They were trying to become self-sufficient.

India too was developing legislations and using public spending to revive the development of APIs. USA and EU were contemplating legislations to bring both APIs and Finished Dosages (FDs) back home.

But industry experts said this might not be the way to go. “It would be a knee-jerk reaction,” said Kiran Mazumdar-Shaw, chairperson and managing director of Biocon Limited, a biotechnology company based in Bengaluru. “The surge in demand caused an acute shortage of medical supplies, diagnostics and medicines which ought to point fingers to the failure of global healthcare systems to stockpile inventory as a preparedness response to any public health crisis. Once the surge in demand recedes, countries would need to manage costs and competitive market forces would favour economies of scale,” she said.

Others concurred. “We believe production of both APIs and FDs must be global, with trusted trade partners, to ensure that any type of national or international disaster does not cause a collapse of the manufacturing and the supply of pharmaceuticals,” said David Gaugh, senior vice-president, Association for Accessible Medicine, a trade association that represents manufacturers and distributors of generic prescription drugs. Industry favoured pharmaceutical parks as these would be SEZ-like structures with fiscal incentives, common utilities and common effluent treatment plants that can create economies of scale and lower operational costs. But some fear this would help only the private industry.

Y Madhavi, scientist at the National Institute of Science, Technology and Development Studies, New Delhi, said public sector was crucial in the regulation of the sector. Citing an example from 2008, she said public sector vaccine manufacturers were closed down with the assurance from private manufacturers that they would give affordable vaccines for the universal immunisation programme. This never happened (more on this in the next chapter). The industry made huge profits with trade margins that can sometimes be 4,000 per cent of the cost price. In October 2019, the Department of Pharmaceuticals proposed a maximum trade margin of 43 per cent over cost price for 10,600 non-scheduled drugs.

Gopakumar said the solution lied in increasing the capacity, both in public and private sectors. “We need a new kind of public sector that can maintain the assets the private players can operate. The government has to spend the money. The private sector will make the money and pay the government back,” he said. Whatever mix be the strategy—private versus public sector or domestic production versus import—the industry couldn’t be permitted to pollute.

This would result in a price hike. S Srinivasan, who ran a generic drug company LOCOST, said the price would not increase beyond 5 per cent if the chemicals are made in large quantities. “Much of it would be capital costs which need to be apportioned over time,” he said.

“No doubt API production is highly polluting, but new technologies must be brought and upgraded constantly to minimise the impact of pollution,” said Sakthivel Selvaraj, director of health economics, financing and policy at Public Health Foundation of India, New Delhi. He added that the additional cost due to pollution control measures would be negligible. Even if these costs were factored in, India would still have an edge both in API and the formulation business.

See also: DTE coverage on Covid-19 Pandemic
Inequitable distribution amid acute shortage derailed the global vaccination drive against COVID-19; Illustration: Ritika Bohra/CSE
The pandemic exposed the myth that everyone is in the same boat; Photo: Vikas Choudhary/ Centre for Science and Environment (CSE)
COVID-19 & SDGs
While the Sustainable Development Goals (SDGs) can help India and the world recover from the impacts of the COVID-19 pandemic, human development challenges such as poverty and undernutrition will continue to plague countries even in 2050

GOAL 1
India to have half a million women in poverty in 2050 even in the SDG push scenario

Source: State of India’s Environment 2022: In Figures/ Assessing COVID-19 impact on the Sustainable Development Goals, UNDP
GOAL 2
India likely to have almost 8% children malnourished in 2050 even through SDG push
Source: State of India’s Environment 2022: In Figures/ Assessing COVID-19 impact on the Sustainable Development Goals, UNDP
GOAL 3
In India, 10 out of 1,000 children will GOAL 2 continue to die in 2050
Source: State of India’s Environment 2022: In Figures/ Assessing COVID-19 impact on the Sustainable Development Goals, UNDP

Malnourished and the Multi-Billionaires

“The pandemic exposed the myth that everyone is in the same boat”

IIn his 56 years, Sukru Ojha, a resident of Koraput, Odisha experienced hunger more than food. “Hunger is an adaptation method for me. If I am forced to cut down on daily food intakes or on the quality of my diet, I know that I have a survival crisis,” he said. A healthy diet, as we understand or define using World Health Organization (WHO) guidelines, had always been an impossible dream for him. But switching to a meal of basic grains, irrespective of its nutritional values or his need for a balanced diet that his occupation as a manual worker demanded, was what people resorted to in crisis situations. “Good food or just food? Our choice is always the latter. We need to survive,” he reasoned. How did he manage during the COVID-19 pandemic?” “I am hungry again. I have cut down on my vegetables, eggs, and lentils.” He replied.

“Only rice… it means I am again adapting to a crisis situation,” he said, adding, “But this time, it is too long a period to endure and the future is not certain.” In November, 2020- April, 2021, he earned around 1,000 each. He had to sustain a family of four. Before that, he could earn up to 3,000 in a month.

Sukru’s adaptation method in the face of food insecurity is a common practice among the poor. First, they cut down expenditure on non-essentials, like education and festivals. Second, they cut down on vegetables, dairy and non-vegetarian foods. Third, they do away with basic accompaniments like lentils and potatoes and onions. Fourth, and the extreme measure of crisis, they just stick to a diet of foodgrains like rice and that too once a day. “I am having two meals a day currently, but only rice. I could collect a few raw mangoes. That is a luxury,” he said.

With COVID-19 resurged and the pandemic becoming wider, lockdowns and shutdowns were back. The government had already curtailed many activities, like construction that generate employment. Sukru had been making rounds of many colonies in search of daily work. “People have stopped constructing.” Rural Indians — mostly an informal workforce and poor by any accepted definition — had already lived with irregular jobs for over a year (2020). Anecdotal stories of precarious survival poured in. People were cutting back on food items; many had stopped having the basics like lentils as food inflation had spiked.

The Food and Agriculture Organization (FAO)’s latest State of Food Security and Nutrition in the World 2021 report had a grim reminder of this impact of the COVID-19 pandemic. The FAO report quoted a study done in 63 low- and middle-income countries covering a population of 3.5 billion on changes in the income of people. It had extrapolated its impact on choice of diets. The study found a significant dip in people’s affordability for healthy food due to a loss in income. The analysis suggested that the pandemic led to an additional 141 million people being unable to afford a healthy diet in the countries studied. The primary reason for this is the loss of income. But food price rise had made the situation more acute. By the end of 2020, global consumer food prices were the highest in six years. In the first four months of 2021, they continued to rise.

According to the World Health Organization (WHO), “a healthy diet contains a balanced, diverse and appropriate selection of foods eaten over a period of time” and “it protects against malnutrition in all its forms, including non-communicable diseases such as diabetes, heart disease, stroke and cancer”. In normal times, a healthy diet costs more; at the global level, the cost of a healthy diet in 2019 was $4.04 per person/ day (compare it with the international poverty line of $1.90 per day). FAO’s analysis showed that the cost of a healthy diet was 60 per cent more than a diet that just meets “requirements for essential nutrients” and almost five times as much as a diet that just meets “the minimum dietary energy needs through a starchy staple”.

In 2020, some 2.37 billion people couldn’t access adequate food in 2020; an increase of 320 million people in comparison to the 2019 figure. Or, one in three people in the world couldn’t access adequate food — read year-round access to adequate food — in 2020. Nearly 12 per cent of the global population faced severe levels of food insecurity or they ran out of food and in worst situations, must have a day without food. In one year — that is 2020 — the rise in the food insecure population was more than the combined number of the last five years. Add to that, the unaffordability of food that greatly impacted people’s food choice and access. More people in 2020 were unable to afford a healthy diet in comparison to 2019.

“The number of people unable to afford even half the cost of a healthy diet was also estimated to have risen from 43 per cent to 50 per cent,” the FAO report said. This resulted in healthy diets being out of reach of the world’s three billion people. The overall decline in food intake also increased hunger levels in 2020, making the primary Sustainable Development Goal of ending hunger by 2030 impossible now. Between 720 and 811 million people in the world endured hunger in 2020.

In comparison to 2019, there were an additional 161 million people who faced hunger. “New projections confirm that hunger will not be eradicated by 2030 unless bold actions are taken to accelerate progress, especially actions to address inequality in access to food. All other things constant, around 660 million people may still face hunger in 2030 in part due to lasting effects of the pandemic on global food security — 30 million more people than in a scenario in which the pandemic had not occurred,” said the FAO report. According to the recently released Global Food Policy Report 2021 by the International Food Policy Research Institute (IFPRI), “The impacts of rising poverty and reduced livelihoods are reflected clearly in rising levels of food insecurity and decreasing diet quality.”

“Widespread food insecurity and a shift toward consumption of low-quality diets could, in turn, have devastating consequences for health and nutrition in low- and middle-income countries, especially among women of reproductive age and young children,” said Marie Ruel, director of the Poverty, Health, and Nutrition Division, IFPRI and Inge D Brouwer, an associate professor in the Division of Human Nutrition and Health, Wageningen University & Research, the Netherlands, who had written a chapter in the report. According to the WHO, poor diet is a major reason for malnutrition, stunting and wasting among children, obesity, overweight and underweight and also diet-related non-communicable diseases. WHO estimates that poor diets are responsible for 22 per cent of all deaths among adults in the world. It was an alarm bell for the world that already has a high prevalence of undernourishment.

The pandemic generation

In 2020, India would have recorded over 25 million births—a generation born in the middle of the worst pandemic in recent times. Add to it the current generation of 350 million Indians in the age group of 0-14 years that lived through the pandemic and would carry its varied impacts through life. By 2040, these would account for roughly 46 per cent of the workforce in the country. How would they remember the pandemic? A report by the Pew Research Center said that “an individual’s age is one of the most common predictors of differences in attitudes and behaviours”.

Though there is a general definition of a “generation” as a group of people born at an interval of 15 to 25 years, we also identify a generation with reference to a big event or development. For example, in India we call those born after 1991 as the “free market” generation to mark the year when India’s economy was opened up. So, we can call the newborns and children under five years of age in 2020 as the “pandemic generation”. Undoubtedly, this generation is one of the worst victims of the pandemic. UNICEF estimated that 91 per cent of children experienced disruption in their school schedules due to the pandemic impacting their education. In case of India, this also meant that most of the children missed the food in school canteens given by the government to ensure adequate nutrition. Globally, as UNICEF data showed, some 119 million children might have missed critical healthcare and life-saving vaccinations. Surveys by the UK non-profit Save the Children pointed out that 50 per cent of children surveyed reported being “worried”; a third of them expressed a feeling of “scared”. Both indicated a state of uneasiness and lack of overall well-being.

Notwithstanding the development inequality that was pervasive in our world, the pandemic generation was born in a world healthier and wealthier than ever. Unlike us, the new generation just born would not remember enduring a pandemic of this scale. Does this mean they would be a normal generation? Would they only read about the pandemic in textbooks, just like we do about the Spanish flu pandemic of 1918- 20? Before attempting an answer, here are a few historical reminders. Scientists and researchers said that children in-utero or born during the 1918 pandemic had less educational as well as financial attainments as adults.

Similarly, expectant mothers, particularly those from poor families, gave birth to underweight infants during the 2008 economic recession. In 1998, El Niño caused devastating floods in Ecuador. Children born during this period were underweight and stunting continued for five to seven years. The common factor in all these after- effects of crisis-like events was the dipping economic status. So, the answer to the question is scary. We already had preliminary indicators that the pandemic generation would follow along the same lines. The recently released Human Capital Index (HCI) of the world, prepared by the World Bank, said that the adult generation of 2040 would be stunted, with a lower human capital, and the toughest development challenge for the world. HCI measured “the human capital that a child born today can expect to attain by her 18th birthday”. This included the health and education entitlements of a newborn now and how it would impact his/her future productivity. COVID-19 would not impact the health of a child or a pregnant mother like pandemics of the past. But the economic impacts of the pandemic would devastate this generation—including children in-utero—the most for the simple reason that a poor household would not spend much on health, food and education. There would be higher child mortality and stunting among those who survived. Besides, millions of children and pregnant mothers had been kept away from essential health services due to the disruption in the systems.

According to the HCI estimates, child mortality would increase by 45 per cent in 118 low-income and middle-income countries. Analysis showed that a 10 per cent increase in gross domestic product (GDP) per capita reduces infant mortality by 4.5 per cent. Looking at various estimates, most countries experienced a higher loss in GDP due to the pandemic. In October 2020, various UN agencies released the first joint estimates of stillbirths—a baby born with no signs of life at 28 weeks of pregnancy or more—in the world for 2019.

Some 0.34 million of the 1.9 million stillbirths globally in 2019 were in India, more than in any other country. India had recorded significant progress in reducing stillbirths despite the high number. But the joint report warned that the COVID-19 pandemic could increase the global number of stillbirths, including in India.

The report said that the pandemic would cause more than 200,000 stillbirths in just 12 months (during 2020-2021) in 117 low- and middle-income countries due to disruptions in healthcare services. A study published in the journal Global Health Science in July 2020 found that the food shocks triggered by lockdowns to contain COVID-19 could increase the burden of malnutrition in India. The study based its findings on the weight loss caused by inadequate diet. In a scenario of 5 per cent weight-loss, India would experience an increase of about 4,393,178 and 5,140,396 additional cases of under-weight and severe wasting respectively. The estimates were substantially high for severe under-weight and wasting as well, said the study. Bihar, Madhya Pradesh and Uttar Pradesh would be the most affected and would account for the highest share in estimated additional underweight and wasting cases among the poorest households.

All this at a time when the world had much catching up to do in reducing malnutrition and poverty. HCI clearly brought out the fact that even if the pandemic was a temporary shock, it would have crippling and long-lasting impacts on the pandemic generation. It was time the world took the problem seriously. It couldn’t afford to add to its tally of the chronically deprived.

Inequality is wider

The late microbiologist and environmentalist René Dubois famously articulated that every civilisation created its own diseases and epidemics. The COVID- 19 pandemic brought out ours: inequality. The crisis is now being popularly mentioned as the “pandemic of inequality”. Global conversations on the pandemic revolved around its impacts on hunger, poverty and inequality. Estimates and analyses showed that the pandemic impacted the poor more, whether they were in developed or developing countries.

António Guterres, secretary-general of the United Nations, while delivering the 2020 Nelson Mandela Annual Lecture, said: “The COVID-19 pandemic has played an important role in highlighting growing inequalities. It exposed the myth that everyone is in the same boat. While we are all floating on the same sea, it’s clear that some are in superyachts, while others are clinging to the drifting debris.” He highlighted that the world had ignored inequality for too long, further putting the poor at greater risk during the pandemic. This was not only the world’s first recession triggered by a pandemic, but also its “sharpest decline in per capita income” since 1870. The impacts of the global economic collapse had, indeed, trickled faster to the poor. Oxfam, a non- profit operating across the world, estimated that there were 121 million more people on the brink of starvation in the pandemic period due to mass unemployment, disruption to food production and supplies. “As many as 12,000 people could die every day from COVID-linked hunger,” declared Oxfam. “The frontline in the battle against the coronavirus is shifting from the rich world to the poor world,” said David Beasley, the executive director of the World Food Programme (WFP). Beasley declared in a press conference that the global body was running its biggest-ever humanitarian response to provide food to millions. In 2019, WFP assisted 97 million people, which was a record then.

In 2020, it assisted 138 million people by July. The pandemic precipitated a severe hunger crisis among those who were already surviving at subsistence level or with external support. According to WFP, the number of hungry in the countries where it operated would increase to 270 million by the end of 2020. This would be an increase of 82 per cent from the level immediately before the pandemic erupted. The geography of hunger, however, remained the same. The COVID- 19 pandemic impacted those areas harder that were already in crisis. Spikes in hunger were also evident in west and central Africa, that had seen a 135 per cent jump in the number of food-insecure people, as well as in southern Africa, where there had been a 90 per cent rise. This geography faced the wrath of climate change, conflicts and also lack of development aids.

In the four years before COVID-19, the population of severely food-insecure rose by 70 per cent. In the past, these people were not counted or escaped from the “severe levels of food insecurity”. They were again the victims in disproportionate degrees. “Until the day we have a medical vaccine, food is the best vaccine against chaos. Without it, we could see increased social unrest and protests, a rise in migration, deepening conflict and widespread under- nutrition among populations that were previously immune from hunger,” Beasley said.

It was the first time since 1990, when the concept of human development measurement was adopted worldwide that the human development measure came down in 2020. Inequality makes any recovery difficult for the already poor and disadvantaged. Forecasts say economic recovery would not have the desired impacts on the poor in 2021. Over time, economic growth had led to reduction in income inequality among countries. But within countries, inequality in income has, in fact, increased—by 4 per cent in Gini coefficient (a statistical measure to gauge wealth distribution) since 1990. This global increase in inequality was driven by widening inequality in China, India, Indonesia and USA. A FAO assessment showed that COVID-19 might cause an increase in each country’s Gini coefficient by 2 per cent. In this case, the number of poor would additionally increase by 35-65 per cent. In India alone, some 400 million people would slip into poverty due to the impacts of the pandemic. And these were mostly workers in informal sectors. This again showed how disproportionate the pandemic’s impacts have been.

The pandemic struck India when it recorded its lowest economic growth in over a decade. The slowing economy had disproportionately impacted the rural areas, where the country’s majority of consumers and poor reside. Even in absence of any official data, one could perceive a rise in rural poverty. Unemployment was high; consumption expenditure was constantly coming down; and public spending on development was stagnant. These three factors together dictate the wellbeing of an economy.

The Mahatma Gandhi National Rural Employment Guarantee Scheme was no more able to absorb demands for employment. Many were digging into their meager savings. With the second wave of the pandemic hitting hard, it was a situation of extreme desperation. One could argue the economy for the poor and the marginally well-off have ceased. What did this result in?

India was back in a situation to be called a “country of mass poverty” after 45 years. With this, India’s uninterrupted progress in poverty reduction since the 1970s had stalled. Last time India reported an increase in poverty was in the first quarter-century after Independence. From 1951 to 1974, the population of the poor increased from 47 to 56 per cent of the total population. In the recent years, India emerged as the country with the highest rate of poverty reduction. In 2019, the Global Multidimensional Poverty Index reported that India lifted 271 million citizens out of poverty between 2006 and 2016. Contrast this with the situation in 2020: the highest global poverty increase happened in India.

India had not counted its poor since 2011. But the United Nations estimated the number of poor in the country to be 364 million in 2019, or 28 per cent of the population. All the estimated new poor due to the pandemic was in addition to this. Also, as estimates pointed out, millions in urban areas had also slipped below the poverty line. Even the middle class had shrunk by a third, said Pew Center’s estimate. Overall, cutting across population and geographical segments, millions of Indians had either become poorer, or poor, or on the brink of becoming poor.

Was this a temporary phase? The usual belief was that with economic recovery, many would climb above the poverty line. But the question was: how? People had reduced spending or were not able to spend. They had already exhausted their savings, reducing their capacity to spend in future. Government spending was also proportionate to the crisis. This meant a perpetuation of the current economic situation. And a way out of it was not certain, like the pathway of the pandemic.

People who were not affected

The rich will only get richer, irrespective of the poor getting richer or not. The same had been established since the financial crisis of 2008. But this was the once-in-a-century pandemic period. One would get curious about the impacts of the pandemic on the world’s richest. Did they lose? The Hurun Global Rich List was out on March 3, 2021. India had added 40 new billionaires in 2020. The list ranked Mukesh Ambani as the country’s wealthiest with a net worth of $83 billion. He registered a 24 per cent growth in his wealth.

The world proudly welcomed eight billionaires a week as the pandemic rampaged across countries decimating their economies, the Hurun Rich List showed. According to Statista.com, “The world’s leading billionaires added over one trillion dollars to their collective wealth during the novel coronavirus disease (COVID-19) pandemic.”

That this bloom of the billionaires continued uninterrupted, even without an exception in a year of pandemic, was the news. This made that popular perception of “rich get richer, poor get poorer” into a stark piece of secular news. If the past was the indicator of the present, inequality in wealth had become the essential by-product of economic growth. As we had been debating the death of capitalism and the free market model, the world after the 2008 global meltdown was a pointer to this fact.

By 2018, the 10th anniversary of the 2008 crisis, non-profit Oxfam reported that the number of billionaires had nearly doubled. “Meanwhile the wealth of the poorest half of humanity, 3.8 billion people, fell by 11 per cent,” said one of its wealth distribution annual reports. More to it, the “trickle” had not been ensured as only 4 per cent of taxes came from such wealth. Rather, in some countries (like Brazil and UK), “when tax paid on incomes and tax paid on consumption (value-added tax or VAT) were both considered, the richest 10% are actually paying a lower rate of tax than the poorest 10%”. The “super rich” apparently hid $7.6 trillion from tax authorities. “There is no law of economics that says the richest should grow ever richer while people in poverty die for lack of medicine. It makes no sense to have so much wealth in so few hands, when those resources could be used to help all of humanity. Inequality is a political and a policy choice,” said Oxfam.

Former International Monetary Fund Deputy Managing Director David Lipton even blogged (though controversially) that voters across the developed and developing countries were losing “trust” in globalisation. He argued that this had the potential capacity to “tear down” the international order, read globalisation model. An honest assessment but, as one delved a bit into his argument, he said so basically from the perspective of those who have already benefited from the recession since 2008. He wrote: “This resentment will make it far harder for taxpayers’ money to be used to shore up banks during the next crisis. If a future recession harms ordinary workers and small businessmen, states will come under pressure to financially support these people as they did for the banks in 2008. This could push up public sector debt to dangerously high levels.”

One could realise how true he was. The pandemic just did that. But, as we experience now, countries were pumping in money to support the pandemic- struck citizens, even though not adequately. Public debt was surely increasing, and there was also enormous pressure on governments from the public to support. But it raised a question: if countries were supporting people just to tide over, and the economies were in shambles, how come a handful of individuals continued to remain unaffected by the downturn?

Earlier the Oxfam India said “It would take an unskilled worker 10,000 years to make what Ambani made in an hour during the pandemic and 3 years to make what Ambani made in a second.” Another wealth ranking report called “Allianz Global Wealth Report 2020” in fact titled 2020 as the “Year of the Rich”. The annual report said: “We didn’t really have to wait for the pandemic to wipe out the progress made in making the world more equal in terms of wealth distribution. 2019 widened the wealth gap between rich and poor countries again, increasing the difference in net financial assets per capita to 22 times from 19 times in 2016.” This was still well below the gap of 87 times that we had in 2000 but the trend reversal was disturbing indeed, the Allianz report said.

There was inequality in wealth. But in case of a disaster that struck all, there were surmises that the level of inequality might come down. But in reality, it had further widened. Allianz economist Patricia Pelayo Romero was quoted saying, “It is quite worrying that the gap between rich and poor countries started to widen again even before COVID-19 hit the world.” “Because the pandemic will very likely increase inequality further, being a setback not only to globalisation but also disrupting education and health services, particularly in low- income countries.”

See also: DTE coverage on Covid-19 Pandemic
Some 100 million Indian migrants lost jobs due to the lockdown; Photo: Vikas Choudhary/ Centre for Science and Environment (CSE)

Cash, On Delivery

How India mounted its largest and longest ever relief operations and discovered pitfalls in delivery of development

Without Any cash or work, how will I survive? That was the first thought of Ram Kewat, a 60-year- old daily wage labourer, when he reached his village. It was a journey of 450 km from Delhi to his village on the outskirts of Jhansi, one of Uttar Pradesh’s southernmost districts. Kewat had covered that distance on foot in just five days, walking, on average an excruciatingly tiresome 90 km a day to reach his village on March 29, 2020.

After the government announced a three-week nationwide lockdown– India’s first–to prevent the spread of COVID-19 on March 24, 2020, Kewat knew he would be out of work and food, and decided to walk to his village since there was no other mode of commute.

Upon reaching his village, he survived on food provided by a local non-profit for a week and was out of sorts when, on April 7, 2020, he received a message on his phone informing him of a 2,000 deposit in his bank account under the Pradhan Mantri Jan Dhan Yojana (PMJDY). “I had completely forgotten about this account that I had opened last year,” he said. “I didn’t receive any money in 2019. The money was a blessing,” he said. PMJDY was launched in 2014 to provide universal access to banking services. In 2019, when the government announced the Pradhan Mantri Kisan Samman Nidhi (PM-KISAN) scheme— an income support scheme for farmers—Kewat registered to receive cash support of 6,000 a year in three installments. He opened his PMJDY account using his Aadhaar number, and his mobile phone was also seeded to this account.

Kewat was one of India’s 100 million migrant workers—a number estimated by the United Nations Development Programme (UNDP)—many of whom had left cities for villages because they could no longer pursue their livelihoods. In his case, one could see the importance of the government’s ability to provide life- saving support during crises. As per a submission made by the government to the Supreme Court on March 31, 2020, over 0.6 million people who were on the roads had been stopped and provided accommodation, while over 22 million were provided ration.

There were millions others in cities and villages who needed support. Identifying them and providing them assistance was the government’s biggest challenge, especially because economy has come to a standstill due to the lockdown. As per the State Bank of India’s (SBI’s) Ecowrap research report released on April 16, 2020, almost 70 per cent of India’s economic activities had stopped. What made the situation worse then was that the states with the most number of COVID-19 cases—Maharashtra, Tamil Nadu and Delhi—were also the biggest contributors to the country’s economy. According to an HDFC Bank press release that was released in April, 2020, these three states account for 30 per cent of India’s GDP.

Similarly, the cluster of Uttar Pradesh, Rajasthan, Andhra Pradesh, Telangana and Madhya Pradesh, where COVID-19 cases were rising rapidly, accounted for 34 per cent of India’s manufacturing activity. That made resumption of economic activities difficult.

To help people tide over the lockdown, Finance Minister Nirmala Sitharaman, on March 26, 2020, announced a 1.70 lakh crore direct benefit transfer (DBT) package for 800 million, or two-thirds of India’s population under the Pradhan Mantri Garib Kalyan Yojana (PMGKY).

On May 12, 2020, Prime Minister Narendra Modi announced an economic recovery package worth 20 lakh crore. Between May 12 and May 17, 2020, Sitharaman held four press conferences and gave details of the 20 lakh crore recovery packages, including the 1.70 lakh crore. The DBT package included support in cash and kind. Under cash support, 500 was being transferred to all 200 million women with accounts under PMJDY and 2,000 to 87 million farmers under PM-KISAN. This was an advancement of two months for the first installment in the new crop cycle and the amount that Kewat received in his account. A government release on June 3, 2020, said 420 million people had been provided a financial assistance of 53, 248 crore under PMGKY.

That meant an assistance of 1,267 per person. The cash component of the relief package also included the increased wages under the Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA)—from 182 to 202 a day—for 136 million beneficiary families. The support in kind was for three months and was provided through the Public Distribution System (PDS). It included free supplies of 5 kg wheat or rice per head per month, 1 kg of preferred pulses per family per month and three refills of LPG cylinders under the Pradhan Mantri Ujjwala Yojana (PMUY). State governments, too, started sending cash to stranded migrant workers.

However, these efforts were not enough. The Ecowrap report put the total loss in income to India’s 373 million workers (self-employed, casual and regular workers) during the lockdown at around 4 lakh crore (or 2 per cent of GDP) and clearly stated that the relief package was inadequate. “We believe that to enable these sectors to grow at the same pace as they would have grown in normal times, a fiscal package of at least 3.5 lakh crore is needed. Our estimates also suggest that given a labour and capital income loss of around 3.60 lakh crore, the minimum subsistence fiscal package must be scaled up by 3 lakh crore, over and above the incremental 73,000 crore that was unleashed in the first phase,” the report stated. What this meant was that in the 1.7lakh crore packages, only 73,000 crore were fresh announcements and the rest were already budgeted for in the Union Budget 2020-21.

Arranging and delivering the benefits was a gigantic task and there were huge lapses. In a webinar organised on May 2, 2020, the Institute of Human Development (IHD), a Delhi-based non-profit, estimated that relief measures introduced in the wake of COVID-19 had reached only a third of the country’s total migrant workers. Take the case of Kamla Prasad Verma, a farmer from Uttar Pradesh’s Shravasti district. He should have received 2,000 under PM-KISAN and 500 in his mother’s Jan Dhan account, but neither amount was credited till mid- April, 2020. Same was the case with Narottam Baiga, a 45-year-old wage labourer from Madhya Pradesh’s Umaria district. His village had 107 households and all had Jan Dhan accounts, said Vrindavan Singh, a social activist who had been working in the village. But nobody had received any money.

What these cases highlighted was that the implementation of DBT was an enormous challenge for the government. Data revealed that the COVID-19 relief programme was the biggest, widest and longest of the government’s relief operations in the past 100 years. At its best, it was also the quickest. The arrival of 2,000 in Kewat’s account weeks after the government announced the scheme was testimony to the speed at which the DBT infrastructure could work. “Relief through DBT would be of utmost importance,” said Santosh Mehrotra, professor at the Centre for Informal Sector and Labour Studies, Jawaharlal Nehru University.

There were 420 schemes across the country that was delivered through DBT. Of these, 63 were “in-kind” schemes while the remaining was either cash or a mix of cash and kind schemes. But the mechanism was not always so widespread and had evolved over two decades.

The erstwhile Planning Commission made the blueprint for the cash transfer method in 2011. Mehrotra, the then director general of Planning Commission’s Institute of Applied Manpower Research, had prepared the paper titled “Introducing Conditional Cash Transfer in India”. The paper stated: “India has had a long history of untargeted or poorly targeted subsidies, which are in need of replacement, especially because the fiscal burdens of these subsidies have become increasingly unbearable after the multiple fiscal stimuli post-2008 economic crisis.”

The idea of DBT was triggered by the expensive way of delivering these schemes. To provide one rupee of development, India used to spend 3.65 in delivery in 2000, according to official estimates. The Economic Survey of 2010-11 for the first time propounded the transition to a complete DBT mode with more unconditional cash transfer schemes. In the Union budget of 2011-12, the government announced a taskforce led by entrepreneur Nandan Nilekani to explore ways and means to implement DBT, particularly for subsidies. On January 1, 2013, India, for the first time, shifted seven Centrally-sponsored schemes into DBT mode. It set up the DBT Mission under the erstwhile Planning Commission.

But the real push to DBT came during the first tenure of the National Democratic Alliance government (2014-2019). The Economic Survey of 2014-15 proposed JAM trinity—a Jan Dhan bank account, Aadhaar as the verification tool, and mobile phone as the personal operating system. This created the basis for delivering benefits of schemes under DBT. This also had to do with the prime minister’s strategy to deliver government schemes directly to the beneficiary—both for better governance and also as an electoral strategy.

In his first term, he directed DBT to 220 million people with an aim to deliver all the basics at the household level: housing, employment, subsidised foodgrain, toilet, electricity, health insurance, farm cash support and insurance. Later, he added piped water to the list as well. By July 2020, at least one of these had reached directly into the bank accounts of one of the family members.

For the past several years, DBT had become the accepted way of delivering development schemes. India delivered some 450 schemes to over 900 million people through this mode. Since 2014, the government disbursed a whopping 8.22 lakh crore— close to 60 per cent of welfare and subsidies budget of the Union government—directly to the bank accounts of the beneficiaries, as per the DBT Mission website. In 2019-20, the total transfer under DBT was 3.81 lakh crore. This was a 40-fold increase from 7,368 crore transferred in 2013—the first year of DBT rollout. The budget allocation to schemes under DBT constituted around 81 per cent of the total agriculture budget of 2020-21, which indicated the volume of direct cash transfers.

The government said DBT had not only made delivery precise, but also helped save money by stopping pilferage and administrative costs. The savings, as of June 2020, stood at 1.7 lakh crore, said the DBT Mission website—an amount same as the first COVID-19 relief package. Of the 63 “in-kind” schemes, the most prominent ones were subsidised ration (provided under PDS in 34 states and Union Territories), supplementary nutrition programme through anganwadi services, mid day meal schemes, fertiliser subsidy, Pradhan Mantri Fasal Bima Yojana (which provides insurance cover against crop failure), Ayushman Bharat and Ujjwala. Under “in-kind” schemes, the government or its agency incurred the internal expenditure to procure and provide goods to the targeted beneficiaries for free or subsidised rates.

Who is the beneficiary?

The most fundamental, and troublesome, aspect of DBT was identification of the beneficiaries. Most of the DBT schemes were managed by states, except a few like MGNREGA, PM-KISAN or PMUY, where money was transferred to the beneficiaries’ accounts directly by the Centre. For each DBT scheme, the government used a different criteria, beneficiary list and delivery channel. For example, MGNREGA had 90 million registered workers; the National Food Security Act (NFSA) had 810 million; PM-KISAN over 140 million; and, PMUY over 80 million. The problem was that during the pandemic crisis, the government randomly selected beneficiary lists to transfer benefits, which led to exclusions.

In many cases, the lists were not properly targeted or exhaustive. Take the case of PDS. In the early 1990s, India made its PDS targeted and delivered subsidised food grains to below poverty line (BPL) families. The country had its first BPL survey in 1997. After that, no such list was prepared, said Umi Daniel, director, migration and education, Aide et Action International, an international non-profit. Since there was no recent BPL list, the list of beneficiaries identified for NFSA was used for PDS. The first NFSA list was prepared in 2011-12. “It is updated every year and many transfers at the Central and state levels through JAM trinity are based on the NFSA list,” said Daniel.

ExclusionsalsomarredPM-KISAN—India’s largest cash income support scheme. Since its inception in 2019, there were glaring gaps between its identified beneficiaries and those who received support. For this scheme, the government used the number of landholding as a proxy for the number of beneficiaries.

The initial estimate of beneficiaries under the scheme was 140 million. It was later reduced to 87 million because of low registration under the scheme. These 87 million farmers were promised 2,000 as an upfront payment under PM-KISAN in the COVID-19 relief package. “India has around 140 million landholdings and these many people might have been counted as total beneficiaries. But only 87 million beneficiaries would have been able to provide updated land records.

Land records of the rest would not be complete,” said Pratap Singh Birthal, professor at the National Institute of Agricultural Economics and Policy Research, New Delhi. Also, tenant farmers were not considered for benefits and neither were people with livestock. “There is too much exclusion,” he said. “There is an urgent need to link existing databases. Unless we have a database where different components—like a beneficiary’s occupation and land profile—are available and linked to Aadhaar and bank account, it will not serve our purpose,” said Shweta Saini, senior consultant (external) at the Indian Council for Research on International Economic Relations, a non-profit policy think-tank based in Delhi. “But there has been no effort to link the lists of beneficiaries,”

said Ravi Srivastava, director, Centre for Employment Studies, Institute of Human Development, a Delhi- based non-profit. In a crisis like the pandemic, the government should have identified beneficiaries using both MGNREGA and NFSA lists, instead of targeting only Jan Dhan account holders. These lists had the highest number of beneficiaries with bank accounts, even more than those with Jan Dhan accounts.

In 2017, the Centre decided to use Socio Economic Caste Census (SECC)-2011 data, instead of the poverty line, to identify beneficiaries and to transfer funds for social schemes in rural areas. Mehrotra said the SECC database was a good starting point for bringing uniformity into these lists and for identifying beneficiaries correctly, but it required to be crosschecked on the ground because the database was old. At present, four-fifths of Indians received benefits in cash or kind. This huge volume also made implementation of DBT a daunting task and led to exclusions.

At least the agriculture sector had a list of target beneficiaries. “But there was no database for labourers in the informal sector. Identification in the informal sector in urban areas is a huge challenge and they were completely left out of any benefits,” said Saini. “There was a lot of exclusion among the urban poor, the homeless and the destitute. There were ‘seasonal’ migrants who got excluded from the state they migrated to because one would have to run around to get covered under different schemes. Often, their families also got excluded,” Srivastava added.

That’s the reason the government waived ration card as a condition to avail free foodgrains as an emergency and temporary measure. The second PMGKY package announced on May 14, 2020, included an expenditure of 3,500 crore to supply free foodgrain through the PDS network to around 80 million migrant workers who were non-card holders for two months.

Universalising PDS might have appeared to be the answer, but in many cases it was not. Take the case of Bihar. “We feel universalising PDS in rural areas and urban slums may not seem like an urgent matter since PDS coverage in Bihar is already supposed to be close to universal (84 per cent),” economist and social activist Jean Dreze wrote in his letter to the Bihar chief minister in 2016. “However, the actual coverage was barely 70 percent, becauseofpopulationincreasesince 2011, which was ignored by the Central government,” he added.

“Even if only one-third of the excluded 30 per cent consisted of households vulnerable to hunger, this would have meant that 10 per cent of the population of Bihar (about 13 million persons, based on projected 2019 population) would be exposed to hunger during the pandemic,” he wrote. In February, 2018, Jharkhand, which had been experimenting with direct cash transfer of foodgrain subsidy under PDS, witnessed protests by beneficiaries. The protestors named their agitation “Ration Bachao” or save the public distribution system. Under DBT, started on a pilot basis in October 2017 in Ranchi’s Nagri block, beneficiaries had to collect their food subsidy in cash from the bank before using it to buy rice from the ration shop at 32 per kg. Earlier, they were able to buy rice from the ration shop at 1 per kg.

In January 2018, a survey organised by civil society organisations and coordinated by Dreze was conducted in 13 randomly selected villages of Nagri to assess public view. The findings were startling. The survey found that the DBT system was a big inconvenience and that 97 per cent of PDS cardholders surveyed were opposed to it. Nearly half of intended beneficiaries had been deprived of their food rations in the preceding four months because they had to spend, on an average, around 12 hours to collect the subsidy amount and then buy food from the public distribution shop.

Banks are located on an average 5 km away from the respondents’ homes and at least 70 per cent of respondents had no way to find out if their DBT money had been credited without going to the bank. The Jan Dhan account was targeted at people without access to financial institutions and to make sure that cash transfers for various subsidies were done effectively. But there had been a lot of problems. For instance, the eligibility criterion for opening such accounts was vague which resulted in a large number of people having multiple accounts. “Jan Dhan accounts were for the rural and urban poor who do not have an account. But this could not be verified and people opened multiple accounts. They thought the government would deposit R15 lakh in each account,” said Srivastava.

Since the basis of delivering direct benefits was JAM, the government’s focus was on strengthening this mechanism by not only expanding enrolment, but also stringently making all benefits conditional to this trinity. In 2014-19, the government issued more than 1,257 million Aadhaar cards. This was followed by opening Jan Dhan accounts using Aadhaar. The trinity’s third crutch of internet mobility also took root, with 200 million active internet users in rural India, 97 per cent of whom accessed it through mobile phones.

But ever since the DBT Mission started transferring money, gaps in JAM emerged. For instance, the linking of bank accounts with Aadhaar was still not foolproof or complete. Responding to a query in Parliament in February, 2020, the minister of state for finance said that 85 per cent of the current and savings accounts were linked to Aadhaar as of January 24, 2020. That meant that at least 15 per cent of Indians still did not have their bank accounts linked to Aadhaar. This turned out to be 160 million Indians.

Worse, 23 per cent of the poorest 40 per cent in India still didn’t have an account with any financial institution, as per 2019 data of the Reserve Bank of India (RBI). Most of them were likely to be migrant workers. “The government has to identify these 23 per cent who do not have bank accounts,” said Mehrotra. “The exclusion errors in JAM are too many. The government has to make sure every family is included,” said Srivastava. The large number of inactive accounts was another area of concern. Of the total accounts of the poorest in India, around 45 per cent were inactive as per “Report on Trend and Progress of Banking in India 2018-19”, released by RBI in December 2019. These people would have been left out of the relief measures.

A case in point was the money transferred to construction workers in Uttar Pradesh in the first week of April 2020. Of the 2 million labourers registered with the labour department, money could be deposited in only 0.59 million accounts, said Salil Srivastava, Uttar Pradesh State Programme Manager, Tata Trusts Migration Programme. The trust worked in coordination with the labour department. “Money was not be deposited in the rest of the accounts because they were inactive or had incorrect details. The labour department issued a WhatsApp number for those who did not get the money to send their account details again,” said Salil Srivastava.

Similarly, a large number of Jan Dhan accounts were inactive. As per a reply given by the then minister for state for finance Anurag Thakur to Parliament on August 3, 2018, over 60 million Jan Dhan accounts were inactive, as of July 11, 2018. “Many such accounts have been sequestered by the banks,” said Ravi Srivastava. However, government officials said the first installment of 500 for April had been transferred to all 200 million women Jan Dhan account holders. “If there is any issue of inactive accounts, it will be sorted out,” said L R Ramachandran, Chief General Manager, Department of Financial Inclusion and Banking Technology, National Bank for Agriculture and Rural Development (NABARD).

There was no doubt that bank were the epicentre of this gigantic relief operation and an indicator of whether cash transfer was effective. But there was a shortage of banking centres. The government had around 126,000 bank mitras orbankcorrespondentsto deliver branchless banking services in rural areas and provide last-mile connectivity. The government had issued travel passes to them so that they could move freely even during the lockdown.

The role of bank mitras was all the more important because India had 0.42 million un-banked centres and social distancing and lockdown had made access difficult. The digital financing services infrastructure was dismal in rural areas. An all-India survey by NABARD on financial inclusion in 2017 highlighted that less than 2 per cent of the rural population relied on mobile and internet banking. Mobile internet was common in rural India, but net banking was not. People needed cash for their basic needs during the pandemic crisis. Ramesh Prasad Pandey, a farmer of Pakara village in Madhya Pradesh’s Rewa district, said he received a message that 2,000 had been credited to his account, but was not able to withdraw as the bank branch was 13 km away. “The police were patrolling, and no one in my village had gone to the branch,” he said. Another challenge was the lack of digital infrastructure in rural areas. Of the 232,446 ATMs in the country in 2019, only 19 per cent were in rural areas. In the pandemic, when banks were asked to carry out basic work, maintaining ATMs and ensuring that people got the transfer on time became difficult.

For DBT to work, financial inclusion, financial literacy and real-time access to the amount were prerequisites. In the case of cash-for-food transfers, Saini and her team did an analysis of 26 states and Union Territories in 2017 and found all states were not equally ready for DBT and did not have the infrastructure for cash transfers. Remote areas of Odisha and Jharkhand, for instance, were not ready for cash transfer as there was no banking facility. There should be dedicated bank correspondents for these areas or the government should use non- profits, anganwadi workers and panchayati raj institutions to carry cash. This entire database was with the NITI Aayog.

See also: DTE coverage on Covid-19 Pandemic
GOAL 4
SDGs push will help India reach a secondary education gross completion rate of almost 100% by 2050

Source: State of India’s Environment 2022: In Figures/ Assessing COVID-19 impact on the Sustainable Development Goals, UNDP
GOAL 5
India can have more female population by 2050 through SDG push

Source: State of India’s Environment 2022: In Figures/ Assessing COVID-19 impact on the Sustainable Development Goals, UNDP
GOAL 6
India will be able to provide clean water and sanitation to all by 2030

Source: State of India’s Environment 2022: In Figures/ Assessing COVID-19 impact on the Sustainable Development Goals, UNDP
In the absence of basic health facilities and human resources in rural areas, the management of the epidemic proved extremely difficult in Madhya Pradesh; Photo: Rakesh Kumar Malviya

At Home

The story of the world’s largest public wage programme emerging as the saviour for the millions of migrant workers returning home and resulted in a water conservation boom in villages

HAS The next batch of work been sanctioned?” asked Ram Ratan from a distance on a humid July 2020 afternoon at the panchayat office of Dhurala village in Haryana’s Kurukshetra district. He was dressed in neatly ironed trousers, shirt and sandals. With a post-graduate degree in psychology, he was among the most qualified youths in the village. The official responded, “Yes.

We are in talks with the irrigation department about cleaning and de-silting a canal and with the Indian Railways about clearing the tracks.” This news pacified the crowd, including Ratan, who were eagerly waiting for more work under the country’s largest public wage programme, the Mahatma Gandhi National Rural Employment Guarantee Act, 2005, popularly known by its acronym MGNREGA.

The programme, implemented in 691 of the country’s 739 districts, is in fact dubbed the world’s largest state-sponsored job-scheme to eradicate poverty. As per its preamble, MGNREGA aims to enhance the livelihood security of rural households by guaranteeing them “100 days of unskilled manual work” every financial year. At least 75 per cent of the total works must be related to water conservation, the Act mandates.

Yet, the rush for MGNREGA works at the Dhurala panchayat office somehow appeared unusual. Well-qualified people like Ratan rarely scouted for jobs under the public wage programme. Besides, Haryana, being an industrial state, had never seen such a huge demand for MGNREGA works. Manoj Kumar, additional block programme officer (ABPO), Thanesar block in Kurukshetra, informed that they had implemented MGNREGA works in Dhurala in 2019, after a gap of three years, when they constructed a community centre. “Though the programme is demand-based, we had to cajole the residents to take up the work. People here are usually reluctant as most of them are skilled and work in adjoining cities as construction foremen, tailors, drivers, gardeners or teachers.”

Ratan, who was preparing for the position of assistant professor in state colleges, also worked as a “Saksham” teacher—an assignment under the state government’s Saksham Yuva Yojana that provided employment to educated unemployed youth—in a government school in Kurukshetra city. But his whole world came crashing down on March 24, 2020, when the state government announced the lockdown to contain the spread of COVID-19 and the school was temporarily closed. Soon, the Union government extended the lockdown till the end of May, choking his only source of income. Ratan’s younger brother too lost his job and was back in the village. It dealt a huge blow to his family of 13, struggling to bear the treatment cost of Ratan’s two- year-old daughter, who suffered from a heart ailment, and an elder brother, being treated for psychological illness.

That was when Ratan decided to apply for a job card under MGNREGA. “I worked for 40 days and received much more than what I used to earn from teaching,” he said. Haryana offered him 309 a day as MGNREGA wage, which was one of the highest in the country. “I am not sure how we would have survived otherwise,” he said.

The management information system (MIS) maintained by the MGNREGA website showed that during the four months since the lockdown (April to July 2020), Dhurala generated 5,140 person-days of employment; the figure was just 3,630 for the whole of the previous financial year. In neighbouring Dayalpur village, where only one family demanded wage support in 2019, 204 availed employment under MGNREGA till July 2020.

Kumar said owing to the surge in demand, the district administration had expanded the coverage of the programme; nine new villages were added in Thanesar alone. The state followed the trend of Dhurala and Dayalpur. Haryana had budgeted 10 million person-days of employment under MGNREGA for 2020-21. But during the first four months of 2020 itself, the state had exhausted almost half of the labour budget by providing wage support to 4.5 million people. There was a 154 per cent increase in MGNREGA work demand, compared to the corresponding period in 2019.

The trend in other parts of the country was no different from that witnessed in Haryana. But what came as a surprise was the unprecedented surge in demand for MGNREGA works in the country during the leanest months of May, June and July in 2020. This was the period when people used to prepare their fields for kharif crops.

A majority of people who had migrated also returned to their villages to participate in the farm works. On an average, 21.5 million households sought work under MGNREGA in a month in the country, showed an analysis of the MIS data between 2013-14 and 2019-20. In April, 2020, when the country was still under COVID-19 lockdown, MGNREGA registered one of the lowest demands in recent times—12.8 million. But the demand curve moved skyward as soon as the government began easing lockdown measures and those engaged in the urban informal economy returned to their villages. By May, 2020, over 36 million households had registered for work.

The demands rose to over 40 million in June, 2020—almost double the average demand for the month during the past seven years. A state-wise analysis showed in June, 2020, that 57 per cent of the demand was generated from the five states that reported the return of a large number of informal-sector workers—Uttar Pradesh (that received 6.2 million workers), Rajasthan (5.3 million), Andhra Pradesh (4.4 million), Tamil Nadu (4.1 million) and West Bengal (3.5 million). In at least 30 states and Union Territories, more households demanded work in July than the average of the past seven years. Odisha witnessed the sharpest increase of 206 per cent, followed by Bihar (199 per cent), Karnataka (192 per cent), Jammu & Kashmir (182 per cent), Madhya Pradesh (164 per cent) and Uttar Pradesh (157 per cent).

What could have prompted this unusual surge? Did the rural agrarian economy fail to absorb the surplus labour? A similar surge in MGNREGA work demand was witnessed in 2009 when a severe drought gripped large parts of the country. This was believed to have helped the United Progressive Alliance in its re-election that year. Did that mean the May- July surge was propelled by the pandemic-induced unemployment and economic upheaval? There were no clear-cut answers to this. What was clear was that both the authorities and people were working in tandem, probably for the first time in MGNREGA’s history, to make the most of it. Districts with high job demands used this opportunity to create thousands of water conservation works, in letter and in spirit. The focus now was on rebuilding the villages’ base of natural resource-related capital.

Haryana has been a beneficiary as well as the victim of the Green Revolution. Due to over- exploitation of groundwater for irrigation, water table in the state had dropped to critically low levels. In Thanesar block, water table had dropped by almost 22 metres over the past 45 years, showed data with the Central Ground Water Board (CGWB). So, in early June, 2020, when people started demanding wage support, the block’s rural development agency came up with a win-win solution.

In Dhurala, it employed people to revive a johad, a traditional percolation pond on the village common land, which was lying abandoned for years. In Dayalpur, where people depended on groundwater for 90 per cent of their irrigation requirement, the village pond was desilted and deepened. Both the works were completed before the monsoon arrived. By the end of July, 2020, the johad in Dhurala had the capacity to hold 34,000 cubic metres (cu m) of water. Kumar said the pond at Dayalpur could now harvest and store over 52,000 cu m of rainwater by the end of the monsoon season. It could be used to irrigate almost one-sixth of the 600 hectares (ha) farmland in the village.

The pond at Dayalpur had, in fact, been selected to be developed as a model under a new campaign of the state government to reduce dependence on groundwater by rehabilitating ponds and using them for rainwater harvesting. The block officials were busy generating awareness among the farmers of Dayalpur on how to maintain the structure, budget the harvested water and use it for irrigation. “We utilised MGNREGA to create assets for the villages while providing residents the much-needed cash through wage. Since the residents had revived these together, there was already a sense of ownership among them towards the water structures,” said Kumar.

In neighbouring Yamunanagar district, where the demand for works under MGNREGA increased by 352 per cent during the four months in 2020 financial year, the authorities deployed the workforce to clean and maintain Hathnikund barrage and its network of canals, which diverted the Yamuna water for irrigation needs of the district and also to meet the drinking water needs of Delhi.

The barrage and its canals were choking over the past five years due to lack of maintenance. “Usually, the irrigation department hired contractors who used heavy machineries for desilting the barrage. But for the first time, desilting work was done manually to accommodate the high demand for MGNREGA works,” said Gurnam Singh, ABPO of Pratapnagar block in Yamunanagar.

In Punjab, which shared the same fate as Haryana in terms of groundwater, rural development minister Tript Rajinder Singh Bajwa too saw an opportunity in the surplus labour capital. In 2019, the state government had launched a drive to revive traditional ponds. The aim was to replenish and conserve groundwater, which according to the 2019 report of Central Groundwater Board (CGWB) was being extracted at a rate 165 per cent more than the recharge rate through a staggering 1.43 million tube wells.

CGWB had warned that if groundwater continued to be exploited at the current rate, Punjab would become a desert within 25 years. But of the 13,178 targeted ponds, the government could revive only 7,792—dirty water was removed from 5,352 ponds and another 2,440 were de-silted. This was not completed in 2019 due to the onset of monsoon. In 2020, as soon as lockdown restrictions were eased, the government resumed the pond restoration works, but changed the method. “In 2019, most works were done using mechanical dredging,” said Seema Jain, finance commissioner, rural development and panchayats department of the state. In 2020, the government did away with this provision.

Instead, when the project resumed on May 12, 2020, those who had lost jobs due to the COVID-19 pandemic, were roped in for the works. “The number of people employed under MGNREGA in Punjab was 0.15 million in 2019-20. The figure jumped to more than 0.22 million by July, 2020,” said Jain. By mid-June, 11,071 of the 12,296 ponds targeted for this year were dewatered and 3,176 of the 7,456 targeted ponds were desilted. These works generated 1 million person-days of employment under MGNREGA.

By early August, 2020, Uttar Pradesh received 3.4 million returning migrant workers—the highest in the country. But through a concerted effort, it turned the tide in its favour. It set up a commission—the Uttar Pradesh Labour (Employment Exchange and Job) Commission—to ensure their social and economic securities. Its mandate was to ensure that these people were gainfully employed, so that they could decide whether to stay or migrate again.

It ran a campaign in June, 2020, to convince the youth that MGNREGA works were not “undignified” and announced that it would create 10 million person-days of work every day from June 15, 2020, onwards. The strategy paid off. The state reported a three-fold increase in the demand during May-June, 2020, compared to the corresponding period in 2019. The success of Uttar Pradesh is clearly palpable in Siddharthnagar, among the country’s 250 most backward districts. Evidently, the district reported high levels of migration— estimates showed that almost a quarter of the people from the district migrated to cities in search of menial jobs.

Sensing a swell of the returning workers following the lockdown, district magistrate Deepak Meena put in place a plan for each of the 1,110 village panchayats in the district. A list was prepared, identifying those who would demand work, their skill and what works should be undertaken. Most village panchayats listed water conservation works like digging new ponds and tanks or renovating them as a priority work.

“In the four months till July, 2020, we utilised 61.4 per cent of the labour budget for the year and created close to 6 million person- days of works by rejuvenating 1,000 ponds and 140 traditional harvesting structures,” said Pulkit Garg, chief development officer of the district. At least 64 ponds had been dug under MGNREGA on private lands. Sanjay Sharma, in-charge of MGNREGA in Siddharthnagar district of the state, said that each of the newly-dug or renovated ponds now had the capacity to irrigate 30 ha. Besides, they would also control floods and water logging, which are major threats to agriculture. Altogether, these waterbodies added 40 million cu m to the water storage capacity of the district and would have benefited 10,000 to 12,000 families.

Across the state, some 83 per cent of the 0.7 million works that the government planned to undertake in 2020-2021 under MGNREGA were water conservation-related works, such as micro- irrigation, renovation of traditional waterbodies and rainwater harvesting structures. Rambraj, a 45-year- old resident of Bhitiya village in Siddharthnagar, was well aware of the potential of a waterbody. Since his return from Surat, where he had worked as a tailor, he was digging ponds. Along with 120 others who too had returned from various parts of the country following the lockdown were desilting an ancient pond in the village. “The pond was in ruins. Now, our future depends on its revival,” said Rambraj.

Untold side affect

There was a clear shift in the works selected under MGNREGA during the pandemic. In just four months of 2020-2021, MGNREGA surpassed the previous year’s national records on most of natural resources management (NRM) related works, which included soil and water conservation, groundwater recharge, irrigation and drainage-related works, plantation and land-related works. Between April 2019 and March 2020, some 0.55 million NRM works were undertaken under MGNREGA. As many as 0.61 million works were completed between April and July, 2020. Some of the popular water harvesting structures were farm ponds and dug wells, which assured irrigation to individual farms.

Providing immediate wage support to the returning migrant workers and keeping them gainfully employed for months was no easy task. So, in some districts, the authorities tweaked the programme to speed up the planning process. Usually, the identification of MGNREGA work starts bottom up. First, the gram panchayat identifies the works to be undertaken as per the local needs.

A plan in this regard is prepared around August 15, and submitted to the district authorities for approval. The district administration, along with the state government, approves the proposals by January-February, and the work starts in April. This process often gets delayed and the works start only around September-October.

In Uttar Pradesh’s Jalaun district, which falls in the arid Bundelkhand region and is infamous for large-scale migration, changed this process to open up more works. “Apart from the works that were carried over from the previous year, we started the works as soon as the gram panchayats approved it,” said Jitendra Kumar Saxena, senior assistant, MGNREGA. In Moradabad district, officials widened the scope of works.

“This year, considered bigger projects that could generate significant works and accommodated more labourers,” said Dinesh Kumar, additional programme officer for MGNREGA in the district. At the same time, officials were trying to rope in other departments that could provide work. One such breakthrough came from the horticulture department. Explained district horticulture officer Sunil Kumar: “To promote gardening, the government usually bears 50 per cent of the cost of materials like vermicompost. Now, we asked people to hire labourers whose cost would be borne by the government under MGNREGA.” In Madhya Pradesh, the district administration of Chhatarpur was promoting a kitchen garden, set up by a women self-help group (SHG), under MGNREGA.

In August 2019, non-profit Paramarth Samaj Seva Samiti (PSSS) created the SHG in Ragoli village by roping in 12 women. They removed encroachments from the village wasteland, spanning 1 ha, and used labour funded by MGNREGA, and created a garden. The land was now called community nutrition garden and was equally divided among the SHG members where they grow vegetables. “Our priority was to provide seamless supply of nutritious food to people.

And it also generated employment,” said Sanjay Singh, head of PSSS. Soon, the demand for works under MGNREGA shot up. In Chhatarpur, while the work demand in May, June and July 2019-20 stood at 26,218, 27,346 and 23,567 households respectively, the same for 2020-2021 jumped to 37,334, 46,097 and 45,151.

On April 12, 2020, on hearing the news of his father’s demise, Kishori Lal Kushwaha started his journey from Haryana’s Hissar district to Ragoli on foot. It took Kushwaha 20 days to reach home. Once in Ragoli, he was met with a different uncertainty. “I didn’t have a single penny left,” he said. But fortunately, the community nutrition garden provided him work. Along with 12 other people, he was employed to maintain the orchard that has 500 trees. I received R190 a day under MGNREGA,” Kushwaha said. “What we witnessed was the real potential of MGNREGA. If people’s labour was invested on water conservation and agriculture-related activities, the returns were very high; in fact, it was higher than the immediate wage,” said Sanjay.

To encourage more and more people to join the programme, the focus of MGNREGA shifted to the creation of assets that would benefit individuals. This ensured that people, particularly farmers from below the poverty line (BPL) category, got paid while creating their own assets like cattle shed. One such beneficiary was Javed Khan, a livestock rearer in Pratapnagar’s Tajewala village. “I had a makeshift structure to keep the cattle and would always be under the fear that it would catch fire. Now that the government helped build a hygienic and sanitised shed, I hope that milk production from my cows will go up,” said Khan. In the four months till July, Haryana completed 784 individual works; at least 200 cattle sheds were sanctioned in Thanesar block.

MIS reports available on the MGNREGA website showed that 336,272 individual works were taken up during the four months of lockdown across the country; this was about one-fifth of the total such works done during the whole of 2019. Of this, 199,820 were under rural housing category, and close to 33 per cent works were for land development, creating infrastructure for livestock and plantation. This was a significant development, given that the creation of individual assets had fallen out of favour after 2017-18. It seemed the lockdown and the consequent economic crisis in rural areas had made both people and the government realise the importance of MGNREGA.

It was a Thursday, an official weekly holiday for MGNREGA works in Rajasthan. Yet, some 40 women in Bhilwara district’s Marwon Ka Kheda village were busy uprooting jungli babool (Prosopis juliflora) trees from a 10-ha land with hardened hillocks.

They knew they would not be paid for the work done that day. “But we know what this will result in: a piece of land for agriculture and a future where we don’t have to struggle every day for daily wage,” said Suman Devi, a 58-year-old resident. Once the land was cleared of invasive trees, they were going to level it to make it cultivable using MGNREGA funds, as the government permitted community cultivation. Then they would split the land into plots for nurseries and vegetable cultivation. They had already identified a pond and a feeder canal to irrigate the land. Though silted up and covered with weeds, the women planned to use MGNREGA to first revive the waterbodies and then implement drip irrigation system for judicious use of the harvested water. Across the village, several other households were also working on their own farmland under MGNREGA. In total, the village had 19 ongoing works, all related to natural resource management.

In Rajasthan, 3.2 million people had demanded works in 2019. In 2020, it increased to 5.2 million in just four months. Following the lockdown, some 0.99 million workers returned to the state by July, 2020. During the four months post-lockdown, the state data showed completion of 4,545 works of which 66 per cent were related to water conservation. “More than just opening up works, we made sure that communities picked up the works they felt would add to their future earnings. And most of them asked for water conservation and land-related works,” said Gopal Ram Birdha, who supervises MGNREGA in Bhilwara. This may be the reason, more and more people, particularly women, joined the programme, he added.

In Ajmer’s Meenao Ki Dhani village, almost all households had applied for work under MGNREGA for the first time. Nearly 60 per cent of them were women. When district officials asked them to choose a work, they opted to revive a dry tank and its 5-km- long feeder canal that had silted up. Four months later, when the system was revived the entire village gathered around the tank and witnessed the first gush of water into it. It was a rare sight for most in the village.

Women no longer had to walk 2 km a day to fetch drinking water as this tank would recharge the 24 wells in the vicinity, which too have dried up in recent years. Hansraj, a village elder, estimated that the tank with 16,000 cu m storage capacity would offer assured irrigation to 80 ha of farmland. “My wheat yield will simply double,” he said.

The focus on using MGNREGA for water conservation definitely yielded results in terms of enhanced agriculture and the availability irrigation locally. This provided economic benefits in the long-term. Amit Mathur, MGNREGA in-charge of Ajmer, said, “Getting such works done helped people in two ways. First, they received cash as an immediate relief. Now, they were using the land and irrigation facilities to grow vegetables, which would offer them regular income.” During the four months till July, the government spent about 65 lakh on the works; close to 70 per cent of it went to people as wages.

The enthusiasm could be clearly gauged from the completed works. In states like West Bengal that received a large number labourers who had left the state earlier, a huge amount of works were completed between April and July, 2020, compared to the same period the previous year. Over 72,000 works related to natural resource management were completed in 2020, compared to just 7,000 during the whole of 2019. Bihar, another state with a high number of people who returned to their state, completed nine times more works in the four months of 2020 than in 2019.

Creation of productive assets, whether for individual or for community benefits, has been the hallmark of MGNREGA. Starting with just 29 types of works allowed under the programme during its inception, it now included some 260 types of works. From the hills to the plains, deserts to flood- prone areas, and from the uplands to coastal areas, rural residents are paid for development works like deepening of ponds, creating shelter for livestock, or clearing a silted spring in the hills. All this on one condition: people must demand jobs under the programme.

Addition of new types of work over a period were made to upgrade the list so that it reflected people’s needs that were critical to their livelihood like farming, fishery and livestock rearing. But over the years, the works related to natural resource management had taken a backseat.

Take the example of water-related structures, which are common village assets. Between 2006-07 and 2019-20, more than 10 million such structures were built under MGNREGA at an expense of not less than 201,000 crore. But the fact was the number of water-related projects under MGNREGA and associated expenditure declined. Between 2014-15 and 2019-20, an average 35.14 per cent of the money was spent on water-related works in comparison to the expenditure on the total works under MGNREGA.

This is when the Act mandates that at least 75 per cent of the total works must be related to water conservation. But in 2020—in the four months between April and July—people completed 60 per cent of water conservation works undertaken during the whole of 2019-20. There was no doubt that a huge amount of work on NRM, especially on water conservation, was being done under MGNREGA during COVID-19 times. On the other hand, availing work under the scheme, individuals could now level their fields, create a farm pond or do vermicomposting, besides 35 other such activities in their own land and be paid wages under the programme.

Since 2015, a major emphasis was given to two kinds of works: irrigation facilities and rural sanitation. A study published in 2018 by the Institute of Economic Growth, Delhi, for 21 selected states said that work related to irrigation facilities increased from 30.6 per cent in 2015-16 to 58.9 per cent in 2017-18. According to the study, it was seen that creation of individual assets also increased from 31 to 48 per cent from 2015-16 to 2017-18.

The creation of individual assets in individual lands included contour bunds and farm ponds apart from vermicomposting and cattle shed. In 2010-11, the demand for works under the programme showed a consistent dip. One of the reasons was that people were losing incentive to join the programme. So, the government allowed several works with private benefits under the programme. This not only led to an increase in job demand, but also a boom in asset creation for individuals. Between 2015-16 and 2019-20, some 1.83 million farm ponds were created. These water harvesting structures benefited individual farmers. Given that a typical farm pond holds 1,200m3 of water, farmers had already created storage of 2,201 million m3.

A 2016 study by the International Crops Research Institute for the Semi-Arid Tropics (ICRISAT) showed that there was a huge increase in groundwater recharge due to MGNREGA work done in the three water-scarce states of Andhra Pradesh, Chhattisgarh and Rajasthan. The net irrigated area also increased between 5 and 95 ha.

The water harvesting structures increased the yield around bore wells and reduced soil erosion. Economic gains were observed in certain districts. For example, after creating rainwater harvesting and groundwater recharge structures under MGNREGA, farmers in Abhaypur panchayat of Rajasthan had shifted to growing wheat in place of mustard as practiced in the earlier days. This doubled the net income of farmers to 50,000 per ha. In one way, MGNREGA is an asset transferring programme.

This makes it attractive to local communities, and also adds to the income-generating activities. Several officials in-charge of MGNREGA are demanding to include more works related to natural resource management in MGNREGA. “Agriculture is the dominant occupation in eastern Uttar Pradesh. There are many jobs related to farming here. All such works should be included in MGNREGA. This would not only improve the situation of agriculture, but could also be a permanent solution to unemployment,” said Sanjay Sharma, who successfully implemented the programme in Siddharthnagar.

There is also a political déjà vu around MGNREGA. After coming to power in 2014, and in his first speech in Parliament, Prime Minister Narendra Modi termed MGNREGA as a symbol of the erstwhile UPA government’s “monumental failure”. Modi junked the programme as an affront to Indians’ dignity as it let them dig tanks and ponds. Soon after the labour crisis went out of control due to job loss under lockdown, Modi made MGNREGA the centrepiece of his relief package for rural India. In 2020, the Union government budgeted 1.20 lakh crore for the public wage programme, including an additional allocation of 40,000 crore in July. This allocation remained largely unchanged in the Union Budget of 2021-22.

All states, barring Delhi and Union Territories, made special provisions under MGNREGA to create employment for returning workers. They used the programme as the sole vehicle to tide over the crisis of unemployment in rural areas. But during the pandemic, the political leadership used the programme as a tool to tide over the COVID-19 crisis. Trivendra Singh Rawat, the then chief minister of Uttarakhand, where several villages lie deserted due to the mass exodus of people from rural areas, felt the programme could play a critical role in reviving the state’s rural economy.

Following the lockdown, the state had witnessed a wave of reverse migration for the first time in years. Rawat, who wanted these people to stay, had pinned his hope on MGNREGA. People should be allowed to work on their own fields under MGNREGA, he demanded. That meant paying people to help them once again take up their primary occupation, which is agriculture. This was what the programme was already doing. It was the inadvertent fallout of the pandemic; but it has become a new understanding of MGNREGA.

See also: DTE coverage on Covid-19 Pandemic
A majority of people who had migrated also returned to their villages to participate in the farm works; Photo: Vikas Choudhary/ Centre for Science and Environment (CSE)
During the lockdown, the levels of particulate matter 2.5 (PM2.5) declined dramatically across the country; Photo: Vikas Choudhary/ Centre for Science and Environment (CSE)
PM2.5 levels were at their lowest possible range at several regions. Air cleaned up so much that the impact of pre-monsoon burning of crop residues during April in Punjab, Haryana, Rajasthan and western Uttar Pradesh on the air quality of Delhi-NCR went unnoticed by the general public, though it showed up in the air quality data; Photo: Vikas Choudhary/ Centre for Science and Environment (CSE)

Let There Be Blue Sky

The magnitude of the emissions rebound would depend upon the speed and scale of conditional recovery

The reactions were bewildering. During the first 70 days of the lockdown in India (March-May, 2020), many places across the country reveled in clear, blue skies and clean air. With a lot less traffic on road and closure of factories and industries, suspended particles thinned out from the air within a few days of the lockdown.

People were able to see the moon, the stars and sharp contours of trees, hills and monuments without the usual barrier of smog, and were able to breathe easier. Places like Delhi and exurbs—where people had become accustomed to intermittent closure of industry, suspension of schools and the use of N95 masks to battle winter pollution even before COVID-19 originated in Wuhan—witnessed history. The lockdown, imposed in phases from March 23, did not help much to flatten the COVID-19 infection curve, but it did bend the pollution curve. And there was hard evidence for this change.

During the lockdown, the levels of particulate matter 2.5 (PM2.5) declined dramatically across the country. PM2.5 are fine particulates, smaller than 2.5 microns that can go deep into the lungs and cause respiratory illnesses, heart diseases and even cancer. During the lockdown, their levels in Delhi, Mumbai, Kolkata, Chennai, Hyderabad and Bengaluru dropped by a phenomenal 45-88 per cent. The drop in Delhi and the National Capital Region (NCR) was 66-79 per cent, showed a study by Delhi- based Centre for Science and Environment (CSE), which conducted granular analysis of real-time air quality data recorded by the monitoring stations of the Central Pollution Control Board (CPCB) in these cities.

PM2.5 levels were at their lowest possible range at several regions. Air cleaned up so much that the impact of pre-monsoon burning of crop residues during April in Punjab, Haryana, Rajasthan and western Uttar Pradesh on the air quality of Delhi-NCR went unnoticed by the general public, though it showed up in the air quality data. Similarly, nitrogen dioxide (NO2)—which comes primarily from road transport and is linked to chronic obstructive pulmonary disease, asthma and hypertension—plummeted with the onset of the lockdown. Bengaluru saw a 55 per cent drop in NO2 levels, Delhi 49 per cent, Hyderabad 30 per cent, Kolkata 65 per cent and Mumbai 70 per cent from the week preceding the lockdown 1.0.

The most dramatic evidence of traffic off the roads was flattening of the hourly change in NO2 levels, which was present in high concentrations during the peak hour traffic periods. CSE analysis showed morning peak for NO2 collapsed in Mumbai and Delhi by 78 per cent and 60 per cent. Kolkata and Bengaluru saw 53 per cent drop in morning peak, while it was 29 per cent for Hyderabad. Likewise, evening peak for NO2 dropped in Mumbai by 77 per cent and in Bengaluru by 71 per cent. Delhi, Kolkata and Hyderabad saw a drop of 60 per cent, 55 per cent and 50 per cent respectively.

But the changes didn’t last. Pollutants returned as the country opened up during lockdown 4.0. CSE analysis showed that PM2.5 levels increased by two to four times in all the six mega cities during these 14 days compared to the previous three phases. Delhi- NCR alone experienced a rise of PM2.5 levels by four to eight times. The NO2 levels increased in Chennai by 77 per cent, in Delhi by 41 per cent, in Mumbai by 21 per cent and in Hyderabad by 16 per cent. Kolkata, however, registered a drop of 10 per cent due to cyclone Amphan that hindered reopening of the city. Overall, the trend established the impact of traffic on the build-up of air pollutants in our cities.

Yet, air pollution remained a complex story to narrate as certain disturbing trends continued. One was the increased levels of ground-level ozone, which irritates the airways and can worsen respiratory diseases like bronchitis and asthma. It is not directly emitted by any source, but is produced when pollutants, nitrogen oxides (NOX) and volatile organic compounds (VOCs), react with each other under the influence of sunlight and temperature. It exceeded the eight-hour average standard in several cities during the lockdown. However, its levels were largely lower than the levels recorded during the spring and summer of 2019.

So what made the difference? The lockdown provided an otherwise improbable opportunity for studying the influence of key sources of pollution on the ambient air quality of a city. So, in Delhi-NCR, CPCB rushed to estimate how different pollution sources might have contributed to the clean-up of the region’s air immediately after lockdown began.

Based on the available studies on source apportionment and pollution inventory in Delhi, CPCB estimated an overall reduction of 35-40 per cent in particulate pollution during the period. It said 10 per cent of the reduction was due to closure of industries, 15 per cent due to reduced transportation and 10-15 per cent due to less dust generated by road traffic. Other activities like burning of waste and reduced activities at the airport also contributed to Delhi’s clean air.

CSE conducted an in-depth study to assess this scale of change made possible in Delhi-NCR by industries and vehicles. On an average, key industry clusters of Sonipat, Panipat, Gaziabad, Gurugram, Faridabad, Alwar and Bhiwadi that surround Delhi-NCR consume 1.41 million tonnes of coal annually, whereas their dependence on cleaner fuel like natural gas is limited to just 0.22 tonnes. Sonipat is, in fact, the largest coal-consuming district and has the highest overall pollution load among all the seven regions. Some of its hotspot areas contributed between s35 and 80 per cent of the pollution load of the district. This pollution was nearly eliminated during the lockdown.

But power plants remained a challenge. While all coal-based power plants were shut down in Delhi, those in NCR did not meet the initial 2019 deadline to install pollution control devices. These were not expected to meet the extended deadline of 2022 either. It was thus clear that to sustain this temporary reduction in noxious emissions, dirty fuels in industry, including coal, would have to be replaced with cleaner natural gas. But the problem was dirty fuels had out priced clean fuels.

Coal is under the lowest slab of 5 per cent under the good and services tax (GST), which benefits industries. It is also under the open general licensing so that coal can be imported. But clean fuel like natural gas, which is outside the ambit of GST so that state governments can earn revenue from it, is heavily taxed at more than 40 per cent.

Similarly, gains made from reduction in vehicular emissions were not that straightforward. While a large number of vehicles disappeared from the roads, a major change was in the number of trucks entering Delhi every day. With radio frequency identification (RFID) systems at 13 key entry points for cashless collection of environment compensation charge, it was possible for the Environment Pollution (Prevention and Control) Authority to track the number of trucks entering Delhi on a real-time basis.

They said there was a 91 per cent drop in trucks and commercial vehicles that entered Delhi during April 2020 compared to December 2019-January 2020. This was a dramatic reduction keeping in view that in 2015 CSE found that unregulated entry of trucks was responsible for 30 per cent of the vehicle-generated particulate load in Delhi. Moreover, nationwide introduction of Bharat Stage-VI emissions standards and fuels that could have made vehicles 70-90 per cent cleaner coincided with the lockdown phase. Additionally, during the lockdown, most people worked from home. It was estimated that 40 million travel trips made daily in Delhi came to a near halt. This led to a massive decline in emissions. As the lockdown was lifted, emissions rose once again.

While regional experiences with pollution sources were expected to vary, Delhi-NCR mirrored change. COVID-19 outbreak and the lockdown had disrupted lives and lifestyles across India at an unbelievable scale and speed. But to ensure that our skies remain blue, it required implementation of an action agenda on a priority basis and at a similar scale and pace.

First, we need to curb vehicular pollution. The government must ensure there was no slip in the ongoing implementation of the BS-VI emission norms due to the pandemic. It should, in fact, use this opportunity as a double-win strategy, and scrap old heavy vehicles and replace them with the BS-VI-compliant ones. It must introduce cleaner battery vehicles for para-transit and public transport; mandate and pay for their revival starting with autorickshaws, taxis, buses and trams. It must use global best experiences of ensuring safety and financial stimulus to augment public transport in cities—bus, metro and light-rail. Cycle and walk must also be part of the “new-normal”. So, incentivise people to reduce travel and take cycles to work.

Second, to curb industry and power plant pollution, the government must urgently bring natural gas under GST to reduce tax burden for those using it and to incentivise clean fuel over dirty. Remove coal from open general license so that imports can be regulated and its use can be monitored. Ensure that power plants across the country meet the 2015 emission standards—introduce “First-Run” policy to allow only those plants that meet the new standards to sell electricity first, so that only clean plants get the priority to sell electricity. Third, speed up action on solid waste management to stop its burning and eliminate solid fuels for cooking.

How to keep the sky blue

The future trajectory would depend on the management of this transition. This crisis was big, but it was also an opportunity. A study published in The Lancet on December 21, 2020, said air pollution- related health cost could knock off 1.36 per cent of India’s gross domestic product (GDP), and the figure could be higher for some states. The State of Global Air 2020, a website on global air quality and health trends, had already warned that globally, air pollution had moved one notch up, from the fifth to the fourth rank, among 87 health risk factors in 2019.

India had the highest PM2.5 exposure and highest share of air pollution related newborn deaths worldwide This defied inter-generational justice. Nothing could have been more explicit in 2020 than the first-ever landmark ruling from a coroner in the UK that had directly attributed air pollution as the cause of death of a nine-year-old Ella Kissi-Debrah near London in 2013.

Everyone collectively experienced the clear blue sky. Similar deceptive change was evident in the temporary reduction of heat-trapping carbon emissions. The UNEP’s Emissions Gap Report 2020 said that the pandemic-linked economic slowdown might have caused a 7 per cent drop in carbon dioxide (CO2) emissions globally in 2020. But this was only a 0.01°C reduction of global warming by 2050, and too insignificant to meet the Paris Agreement goal of 2°C-1.5°C rise. The world needed green recovery to reduce emissions by up to 25 per cent in 2030 to be closer to the 2°C pathway.

Otherwise we were heading to a 3.2°C warmer world by the end of this century. The convergence of action for clean air and climate is unavoidable now. The temporary reprieve during lockdown was possible with the shutting down of the economy, and not due to systemic changes. The rebound effect with the economy reopening could be curtailed only with conditional recovery.

Governments rushed in with economic recovery packages to survive the pandemic. Globally, fiscal action on economic recovery as of September 2020 amounted to around US $12 trillion or 12 per cent of the global GDP. According to the Emissions Gap Report 2020, even though there were examples of measures to support low carbon action, recovery measures to support a low-pollution transition had largely been missed. As of October 2020, COVID-19 fiscal spending had primarily supported global status quo on high-carbon economic production.

But the 2030 emissions gap could be bridged only if major long-term sectoral transformations for net-zero targets were supported. In India, the government had announced a slew of packages estimated to be about 10 per cent of India’s GDP. These provided relief to low-income classes, liquidity and credit support measures for manufacturing and other sectors, and targeted sectoral reforms for increasing investments. But the focus on making recovery packages to drive investment and growth for environmental resilience was missing.

In India, on the contrary, there was slackening of environmental regulations across sectors that could delay and lock in enormous pollution and carbon in the future. The automobile industry was seeking to delay the implementation of Corporate Fuel Consumption Standards for passenger cars scheduled for implementation in 2022-23. There was pressure in the Supreme Court for permission to sell Bharat Stage (BS)-IV vehicles beyond the deadline. The silver lining is that the nationwide introduction of BS-VI vehicles in April 2020 was adhered to.

There was risk in slowdown, as the Indian industry could lose its competitive edge in the global market. India’s power plants had already pleaded for a delayed deadline to meet the new standards beyond 2022. A study by CSE had shown that about 70 per cent of the power plants in the country couldn’t meet the standards by 2022.

The recovery package called for private investments and ease-of-doing business in the coal sector for accelerated commercial coal mining, and removed end-use restrictions. Rules on ash content of coal had been waived off. This would flood the market with dirtier and cheaper coal. The economic recovery package for cash-strapped discoms was also not linked to reforming them but to allow greater fund flow to make investment in emissions control technology for nitrogen oxides and sulphur dioxides more bankable.

The Union Budget for 2020-21 had proposed retirement of old thermal power plants. Subsequently, 5.1 GW was earmarked for shutdown. Such decommissioning could help the debt-ridden utilities with contractual fixed cost obligations and improve the utilisation of more efficient and cleaner plants.

This could also avoid the cost of retrofitting old, dirty plants. But this would have to be taken forward. Such unconditional recovery packages could undo past gains and worsen the pollution trend. The influx of cheap and low-quality coal could increase industrial consumption of coal, especially in small- and medium-scale units. Resisting this trend would be tough because cleaner fuels, like natural gas, were more expensive than coal. While coal was under GST and was taxed low, natural gas attracted state taxes and was more expensive.

A similar story was unfolding in public transport that had nearly collapsed. A survey of 14 State Road Transport Undertakings (SRTUs) by the International Association of Public Transport, a Belgium-based non-profit, showed that 81 per cent of the operators had reported no ridership at all during the lockdown phases, while others had reported 90 per cent reduction in ridership from the pre-COVID level.

The additional burden of safety protocols and social distancing requirements had added to the cost of operation that, according to the Bus Operators Corporation of India, could be an additional 17 lakh per month to meet the requirements of safety protocols. Net losses of SRTUs in 2010 and 2016 had escalated by 48 per cent and traffic revenue was to reduce further by 48 per cent. Already the annual viability gap-funding need had increased by 69 per cent.

Public transport revival is a critical part of the clean air and climate solution. But without a bailout strategy, India cannot meet its target of augmenting the bus fleet to 188,500, as estimated by the Ministry of Housing and Urban Development. Poor bankability of the state transport corporations, limited revenue sources with urban local bodies, and disproportionate share of transport-related funding going to road infrastructure, have challenged the modernisation plan. There was, however, the encouraging news that the government had the approval to fund buses. Without a proper stimulus package, there were serious dangers of the electric vehicle programme getting derailed.

Electric vehicle registrations suffered a big blow, dropping by 93 per cent between March and April 2020, and even after a recovery between April and June, the numbers were still at 50 per cent of the pre-COVID levels of March. A longer-term incentive programme was needed to lower the upfront cost and the total cost of ownership, and bring cost parity between electric vehicles and internal combustion engines. India couldn’t slip on this when global markets were setting targets to phase out internal combustion engines in the time horizon of 2030-2040. While the state governments were at varying stages of progress, Delhi, despite the pandemic, had notified its electric vehicle policy to achieve 25 per cent of all new vehicle registrations by 2024.

Green shoots

In the face of the pandemic disruption, while there was hardening of conservative polices to maintain status quo on pollution and carbon-intensive pathways, there were also evidences of conditional bailout packages for green recovery. Sometime within the same country, the governments were taking conflicting decisions.

This was evident from the global review documented by the UNEP Emissions Gap Report 2020. This showed that several governments had framed conditional and preferential measures in the bailout and economic recovery packages to support green measures. They had provided direct support for zero-emissions energy technologies and clean energy infrastructure.

In the transport sector, Italy had increased government incentives for purchase of low carbon cars and support installation of charging infrastructure. Canada Infrastructure Bank had committed US $1.1 billion for the purchase of zero-emission buses and charging infrastructure. China had expanded its electric vehicle charging network with an additional 200,000 stations in 2020. The French government had backed loan of US $5.4 billion for car manufacturer Renault with environmental conditions. It should be noted that despite the drop in sale of internal combustion engines, electric vehicle sales had remained robust in Europe as the government support for electrification combined with tougher CO2 standards have continued. Electric cars were 10 per cent of the new car sales.

More dramatic was the support for walking and cycling infrastructure. The UK had provided funding for bike lanes, wider pavements and safer junctions. It had further committed US $2 billion bailout to Transport for London, the local government body responsible for the transport system in Greater London, to cover losses and has expanded congestion charge in the city’s Ultra-Low Emission Zone.

Mexico had invested to expand Mexico City’s cycling network in response to the pandemic. In Africa, Ethiopia, Lagos and Kenya had expanded infrastructure for active transportation. Nigeria had removed gasoline subsidies that increased end-consumer prices. Similar bailout support was available for renewal energy and to remove fossil fuel subsidy. The Republic of Korea had increased support for solar and wind capacity deployment in 2020- 2025. China had increased solar and wind energy targets to 240 GW each for 2020. Malaysia had tendered 1 GW solar announced as part of economic recovery efforts.

Chile promoted a Green Credit programme to make renewable energy investments. Germany and France were funding national hydrogen strategies to support green hydrogen technologies. In Canada, energy companies that were getting support from the Large Employer Emergency Financing Facility, a government programme, needed to disclose annual climate-related reports. In the industry sector, Denmark had committed funding for electrification and energy efficiency in industry between 2020 and 2024.

Sweden had introduced state credit guarantee programme for large-scale industrial investments to meet environmental and climate goals. USA was funding to support the transition from natural gas to clean hydrogen power and scaling-up of carbon capture and storage technology.

Inevitably, in several cases, financial incentives had continued for carbon-intensive manufacturing, deregulation of vehicle emission standards, or bailouts for the automobile industry without conditions for zero-emission transition. There were also waivers and rollback on environmental regulations.

USA, for instance, had relaxed several environmental regulations for industry and energy companies, suspended penalties for violation of environmental regulations and even done away with reporting requirements for fossil fuel electricity generators under the Cross-State Air Pollution Rule, Acid Rain Program and NOx State Implementation Plan of the Environmental Protection Agency. Several G20 member states bailed out industry without demanding zero-emission transition, or took steps that could be environmentally damaging. Bailouts were available for fossil fuel companies without zero emission targets.

In Canada, short- term unconditional liquidity support and higher-risk financing had been extended to oil and gas companies to stimulate economy and create jobs. There was unconditional support to the Russian automotive industry without requiring zero-emission transition. The Republic of Korea reduced car sales tax from 5 per cent to 1.5 per cent without requiring electric or hydrogen vehicles. At the same time, additional temporary tax cut on purchase of all-electric and hydrogen fuel-cell electric cars had been extended to 2022.

The magnitude of the emissions rebound would depend upon the speed and scale of conditional recovery. Otherwise, “retaliatory emissions”, as was observed after the 2008 global financial crisis, could worsen. India should recognise the evidence on the vulnerability of its economies to the pollution crisis, climate change, and extreme weather events. Even before the pandemic, a 2018 World Bank study, South Asia’s Hotspot, had estimated that weather events due to climate change could cost India 2.8 per cent of its GDP and depress the living standards of nearly half the country’s population by 2050.

Similarly, a 2020 McKinsey study on climate risk and responses had stated that heat and temperature rise would affect outdoor labour productivity. By 2030, this could cost between 2.5 to 4.5 per cent of India’s GDP annually. A 2013 World Bank study had shown air pollution can cost 3 per cent of India’s GDP. In a post-COVID world, it was not a matter of choice but a necessity to link economic recovery with pollution and carbon mitigation, while preventing economies from sinking deeper into economic shocks.

Co-benefits of green stimulus could stimulate short- and long- term emissions benefits and job creation. Bailouts must push for sustainable infrastructure, greening of the financial sector, clean manufacturing and zero- emissions transition in the mobility sector. We needed innovative methods for infusing more resources to enhance the level of ambition and performance in each sector despite the economic crisis.

See also: DTE coverage on Covid-19 Pandemic
Villagers wearing masks during the coronavirus pandemic, Nabinnagar, India – November 03, 2020; Photo: IStock
The pandemic’s spread to rural India has had huge economic ramifications for the country; Photo: Vikas Choudhary/ Centre for Science and Environment (CSE)

Residual Pandemic

Back in 2009, Anthony S Fauci, immunologist and chief medical advisor to the US president, wrote in The New England Journal of Medicine: “We are living in a pandemic era that began around 1918 [the 1918-20 influenza pandemic].” The paper Fauci co-authored with two other influenza experts analysed all the pandemics—in 1957, 1968 and 2009—and seasonal epidemics caused by the influenza virus since then. It shows that the 1918 virus has persisted in humans for nearly a century and has been evolving, with its descendants and lineages inflicting huge economic and health costs on millions.

TThe world fears a repeat of the past. Will the novel coronavirus that causes COVID-19 also linger on? Two years after the outbreak of the disease, the world has started grappling with a parallel pandemic. Millions who have recovered from covid-19 say they still face a myriad health problems months, even years, after being infected by the virus.

Doctors have listed nearly 300 such effects, which are quite wide-ranging: respiratory, neurological and gastroenterological. People complain of shortness of breath, muscle pain, fatigue, cough, headache, joint pain, chest pain, diarrhoea and an altered sense of smell and taste. Other persistent symptoms include “brain fog” that makes one’s ability to think sluggish and fuzzy, memory loss, disordered sleep, palpitation and sore throat. Rare cases of self-harm, suicides and seizures have also been reported. Most of the symptoms are observed after the infection has clinically ended.

While the world has tracked the pandemic in terms of people affected and recovered, the rise in cases of recovered patients with such a long list of ailments has largely been ignored. However, it has emerged as the starkest sign of the virus’ continuance in our body. Some call this new health crisis post-COVID syndrome while some have named it post-acute sequelae of sars-cov-2 (PASC). Doctors also refer to those having persistent illness with one or more symptoms of the infection as “long haulers”. But the most common name for this condition the world over is “long COVID”. A report titled “A clinical case definition of post covid-19 condition by a Delphi consensus,” released by the World Health Organization (WHO) on October 6, 2021, and defines it thus: “Post COVID-19 condition occurs in individuals with a history of probable or confirmed sars-cov-2 infection, usually 3 months from the onset of COVID-19 with symptoms that last for at least 2 months and cannot be explained by an alternative diagnosis.”

With more cases, the size of the recovered population also increases. This means the probability of more people suffering from long COVID also rises. Calculations show that currently we have more long COVID patients than those getting the infection itself. The world has geared up for this crisis. In January 2021, who revised its guidelines for COVID-19 treatment to include a recommendation that all patients should have access to follow-up care in case of long COVID. In February 2020, the US National Institutes of Health declared a major four-year-long research initiative into “post-acute sequelae of COVID-19”, spending $1.15 billion. The UK’s National Institute for Health Research has also started four studies on long COVID.

In the last week of July 2020, India’s Union Ministry of Health and Family Welfare asked its Joint Monitoring Group to frame guidelines on managing long-term complications arising from COVID-19. This group advises the ministry on responses to various health events. A study on recovered patients supported by the Union government’s Science and Engineering Research Board flagged the criticality of an organised follow-up of recovered patients. “It needs to figure out [sic] if the virus-mediated organ damage completely improves on recovery? In order to determine the actual consequences of the condition, it is essential to maintain follow-up studies on patients, and it will help to determine diseases at initial stages and allow medical intervention in a timely manner. Moreover, this could provide enough comparative data among patients worldwide to determine the effects of COVID-19 on different populations,” says the study published in Science of The Total Environment on August 10, 2020.

In September 2021, the Centre released the “National Comprehensive Guidelines for Management of Post-COVID Sequelae”. This was the first official document to acknowledge long COVID and showed the government’s acceptance that the problem needed special attention. “Up to 20%-30% of patients hospitalized with severe COVID-19 have evidence of myocardial involvement manifested by elevated troponin levels, venous thromboembolism, heart failure and arrhythmias,” states the document. “Chest pain has been reported in ~20% of COVID-19 survivors at sixty-day follow-up. Palpitations have been reported in ~10% of COVID-19 survivors at sixty-day follow-up. Ongoing chest pain and palpitations have been reported in 5% and 9% respectively at six-month follow-up post acute COVID-19. Stress cardiomyopathy is 4-5 times more common during the COVID-19 pandemic when compared to pre-pandemic periods (7.8% versus 1.5-1.8%). Myocardial inflammation detected on cardiac MRI was found in as many as 60% of affected people more than 2 months after a diagnosis in one study,” it says.

As COVID-19, the most widespread pandemic to have hit the planet, enters its fourth year, there is hope that we are nearing the end of this public health threat.

So far, we had deployed the Orwellian dictum of “ignorance is strength” to manufacture a delusional end to the outbreak. “The Mahabharata war was won in 18 days. The war that the whole country is now fighting against corona will take 21 days,” Prime Minister Narendra Modi said on March 25, 2020, a day after declaring the world’s most stringent national lockdown to curb the spread of COVID-19.

Then in September 2022, US President Joe Biden declared, “The pandemic is over.” In between these two statements, the virus killed more than 6.5 million people.

It is not done yet; in the week from November 7 to 13, some 2.3 million new cases were reported worldwide, with over 7,400 deaths. When will this end? By now, everyone wants a definitive answer to this question.

But what will the world feel like without the pandemic—will it bring sighs of relief or another unimagined situation?

One thing is for sure, the virus will not go away. And the science vouches for it. It will continue to do its duty of looking for hosts, even if it does not intend to kill them.

So, experts are now visualising another scenario: the pandemic will reach endemicity. This means COVID-19, with its ever-evolving strains and variants, will continue to hit a particular region and population groups in regular episodes. Such an endemic situation, as experts always say, is “manageable”.

We have been living with several disease-causing viruses that once triggered pandemics. But how much can one “manage” an infectious disease in this globalised world?

The ongoing pandemic is a living example of how quickly one virus can cause a global emergency. Given the geographical spread of COVID-19, even if the virus causes localised and seasonal outbreaks in an endemic scenario, it would be as widespread as the pandemic and cause a significant health emergency.

Countries would continue to report thousands of cases in periodic outbreaks as they report now, with occasional fear of the virus getting out of control. This would require the same level of healthcare attention that is being needed now, and countries would remain invested in managing this viral infection.

Local and community-level quarantines and lockdowns would continue. Significant population groups would remain in morbid condition, which would affect their work hours and lead to an overall loss of earnings.

Moreover, there would be many new strains and variants developing in endemic phases as well. This year, when Omicron led to a wave, there was a sense of relief that it was a mild one; it was highly infectious but did not kill many people. Latest data, however, shows that Omicron has already killed more people than the dreaded Delta variant.

The pandemic might end, but it will leave a trail of illnesses that are already turning out to be crippling: long COVID or symptoms continuing for months after recovery.

According to estimates, the world might have close to 200 million people with long COVID. This effect of the pandemic, which is not much understood, will show up even in endemic phases.

This means a vast population will be in a morbidity phase for a long time after they have recovered from COVID-19, which will affect overall well-being, livelihood earning capability and add to their healthcare expenses. Eventually, an endemic COVID-19 will add to the world’s burden of diseases.

See also: DTE coverage on Covid-19 Pandemic
Source:

✿ The Pandemic Journal, Centre for Science and Environment (CSE)

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