With 0.55 hospital beds per 1,000 people, only 48,000 ventilators and a population of 1.3 billion, many observers wonder how India can handle a crisis as serious as the coronavirus.
The pursuit of collective immunity has been presented as a possible strategy in poor countries with young populations, such as India. This controversial approach, recently rejected by the UK, is based on the fact that a majority of the population (60 to 80%) acquires immunity or resistance to the virus by becoming infected and then recovering.
Although this is a common approach underlying mass vaccination campaigns against diseases like measles, which are based on safe and tested vaccines, trying it with a deadly, new and untreatable disease is a huge risk. In its cruelest form, it is a survival version of the fittest.
There are three reasons why collective immunity does not work in India and can also be potentially dangerous, leading to an increase in hospital admissions which overwhelms the health care system and ultimately causes a high number of deaths.
First, experts do not know much about immunity to COVID-19, in particular the length of immunity, the type of protection it offers and whether reinfection is possible. These are all questions that researchers around the world, including those from the World Health Organization, are still trying to understand.
Second, collective immunity is recommended for India on the assumption that, as the country has a large young population (more than 80% fall below the age of 44), many of these young adults will not have severe reaction to COVID-19.
However, this assumption is problematic because many young Indian adults have dangerous underlying conditions and risk factors that could lead to serious complications and death if they are infected with COVID-19.
Almost 40% of Indian adults aged 45 to 54 and 22% of those aged 20 to 44 suffer from hypertension; almost 4% of adults aged 15 to 44 reported type 2 diabetes, as well as a high rate of unreported cases; and 2.1 million people are living with HIV, 83% of whom are between 15 and 45 years of age. Finally, the prevalence of chronic lung disease and asthma in adults was 4.2% and 3%, respectively, and almost a third of adults smoke.
With such high co-morbidities and risk factors among the young population, letting the virus spread in the name of an experimental strategy of collective immunity could result in hundreds of thousands of people being hospitalized and receiving intensive care. In addition, seeking collective immunity among younger populations would still require protecting the elderly (about 50 million Indians over the age of 65) who are at higher risk.
This raises the question of how to isolate older Indians, many of whom live in multigenerational family homes, which is still the norm, especially in rural parts of the country.
Third, collective immunity cannot be implemented as an isolated strategy. It will also have to be supplemented by an increase in the capacities of the health system, increased cooperation between the public and private health sectors, an increase in tests, the protection of high-risk populations and the implementation of graded measures of social distancing, such as the mandatory use of face masks and the prohibition of large public gatherings and crowded spaces, which are common in urban India.
Relying solely on a collective immunity strategy can also be dangerous because it can reduce the perception of risk among younger populations, affecting their compliance with the necessary social distancing measures. It could also be seen as an easy way out of the current lockdown and could lead to a relaxation of the government’s current response measures.
India needs a strategic, decentralized and long-term approach.
First, central and state governments will need to implement a nuanced testing strategy that will shift from a targeted approach focused on high-risk individuals to mass community testing. Currently, the test criteria include asymptomatic and symptomatic people with a history of travel to high risk areas, but travel as a criterion is not relevant at this stage, as the country has closed its international borders weeks ago.
It also includes close asymptomatic, symptomatic and high-risk contacts of confirmed cases, symptomatic health workers and hospital patients with respiratory disease; this criterion will have to be widened to evolve towards mass tests (to detect asymptomatic cases among those who do not know that they could be infected) and repeat the tests for health workers (who are constantly at risk of re-exposure even if they are initially negative).
The central government will need to quickly address the current bottlenecks that hamper large-scale testing, including the shortage of rapid test kits and the delay in government approval of national test kits, and will also encourage biotech companies national to produce kits and private laboratories to perform tests.
Second, state governments should step up their district and block level tracing efforts. This can be done by setting up, training and supporting contact-tracer teams, including public health officials, police, front-line health workers, community leaders and volunteers. Tracking and tracking contacts through team visits and phone calls can be supplemented with mobile tracking apps.
However, several of these applications, including Aarogya Setu – a contact search application launched by the central government in India and downloaded by 50 million people – have raised privacy concerns, such as the possibility that the government can reuse information. private for reasons. other than disease control. These ethical issues will need to be addressed if the government is to ensure public trust and compliance.
Third, states can implement nuanced treatment and isolation strategies, such as separating patients with mild, moderate and severe symptoms from different settings to effectively manage cases. This should be complemented by personnel management plans, such as the allocation of staff into teams to ensure that personnel rest and avoid wear and tear. China has converted existing public places into large temporary “Fangcang” hospitals to isolate and treat patients with mild to moderate symptoms.
Likewise, the state of Kerala, in the south of India, has provided isolation services in medical schools, general and district hospitals, inns, educational establishments and unoccupied buildings. Private hospitals are struggling with a low number of patients and losses due to foreclosure. State governments should seize the opportunity to increase the number of hospitals and private clinics designated for the testing and treatment of COVID-19 and encourage them to share their capacity by establishing public-private partnerships and by reimbursing private establishments for each case treated.
Fourth, India must invest and build the capacity of the public health system by meeting short-term needs such as the storage of medicines, personal protective equipment and ventilators, as well as long-term needs, such as hiring epidemiologists, data scientists and immunologists — and strengthening health information systems.
Fifth, state governments should engage local communities by connecting district and local health teams with community leaders and volunteers. With adequate support and supervision, local communities can play a key role in finding contacts, monitoring social distance, protecting vulnerable people and encouraging people to seek care when they need it.
All of these strategies will require funding from the central government, which means India needs to increase its current allocation of just 0.8% of GDP to health care. While central and state governments have announced cash and food transfers for low-income households, they can go further by integrating existing social protection schemes, increasing cash transfers and ensuring coverage and maximum transparency. In addition, the government will need to identify vital sectors of the economy, such as small businesses and transportation, and offer stimulus packages such as credit, cash grants and tax breaks, as well as the creation of protocols. back to work for different sectors.
India cannot afford to stay in a prolonged lockdown, but letting the virus spread is certainly not the solution. Although a strategy of collective immunity is a seemingly attractive and easy route, it is little more than a Darwinian dice roll, which could lead to the deaths of millions of Indians.
If the Indian government wants to save lives and livelihoods, it will have to break out of the deadlock by expanding its screening, testing and treatment capacities, strengthening its public health system and ensuring a socio-economic safety net.