During India’s first wave last fall, Dr. Harjit Singh Bhatti said he’d see one or two, maybe three extremely sick patients in his New Delhi hospital’s Covid-19 ward on any given day.
Now, there are so many people with severe Covid-19 that health care workers like him in several cities have to make difficult decisions about which patients to move to the ICU, who gets put on a ventilator, whom to give oxygen — if those options are even available.
“Every minute is a life-and-death situation,” he said.
This is the grim reality of India’s second, record-breaking coronavirus surge. Hospitals are desperate for oxygen and more beds for Covid-19 patients. Reported daily cases are now topping 350,000, and deaths reached more than 3,200 on Wednesday alone, though some experts believe the true number could be two to five times higher. One model from the University of Washington predicts India could see as many as 1 million deaths by August if conditions do not improve.
India’s surge has been building for weeks, and its government has asked the world for help. But the international community is only just now starting to respond.
The United States has promised to provide oxygen, materials for vaccine manufacturing, personal protective equipment, rapid-testing supplies, treatments for Covid-19, and other public health assistance.
Other countries have also rallied some assistance: The United Kingdom has sent oxygen concentrators and ventilators, Russia is sending aid and an unspecified number of doses of its Sputnik V vaccine by May 1. Taiwan is sending oxygen generators.
But such ad hoc efforts don’t appear to be enough so far to blunt the extraordinary scale of the crisis in India — or the next coronavirus emergency, wherever it will be.
India will not be the last country to see a major spike in Covid-19 cases, experts say. Many places that have so far dodged earlier waves of the pandemic remain vulnerable. That’s particularly true in lower-income countries, where vaccination rates and available supply are dismally low.
A global epidemic demands a global coordinated response, experts say. India is a perfect example of what happens when everyone tries to go it alone.
“If this pandemic is not controlled in every country in the globe, the globe will still remain at risk and we will see the evolution of new variants that will have implications for vaccines, and we will still have a disrupted world,” said Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security.
Helping India curb this unfolding tragedy and the staggering suffering it’s causing should be the top priority right now. But longer-term, the global community needs to ensure that there’s equal access to vaccines, effective treatments, and methods for controlling the spread of the virus around the world.
From delivering supplies to tracking variants to sharing intellectual property, countries can accomplish more to control this disease together than by themselves. And if enough infrastructure is in place, the world can prevent a great deal of suffering in the next pandemic hot spot.
“This isn’t altruism. This has to be a self-centered motive,” said Madhukar Pai, an epidemiologist and global health expert at McGill University, who is also advocating and working to raise money and supplies for India.
“The analogy I use is: Imagine you’re in a big building and one room in the building is burning,” Pai said. “You can’t live in the building. You cannot lock yourself in your room. You put out the fire for the whole building.”
Send more vaccines and supplies to India
India launched a massive vaccination campaign early this year, which sought to inoculate more than 300 million people by summer. The country also sent more than 60 million doses of the Oxford/AstraZeneca vaccine (known as CoviShield in India) and its domestically developed Covaxin to other parts of the world since the start of the year.
But its domestic vaccination campaign lacked a sense of urgency, with a relatively low case count in the first few months of the year and some hesitancy around getting the vaccines. So far, just 150 million doses have been given and less than 2 percent of the population is fully vaccinated, according to Johns Hopkins University. And now the vaccines are becoming scarce.
“We need more vaccines,” said Narendra Kumar Arora, executive director of INCLEN Trust International and chair of the working group on Covid-19 vaccines under India’s National Technical Advisory Group on Immunization.
According to senior Biden administration officials, the US is diverting its orders of raw materials used to make the Oxford/AstraZeneca vaccine to the Serum Institute of India, the world’s largest vaccine manufacturer.
The White House also said Monday that it would share up to 60 million doses of the Oxford/AstraZeneca vaccine — which has not been authorized for emergency use in the US — with other countries, after it passes a federal safety review.
India also needs more tests to keep tabs on the spread of the virus
Despite the surge in cases, political leaders in many parts of the country are reluctant to impose new lockdowns given their massive economic costs. And even with lockdowns in place, it has proven difficult to get everyone to adhere to the rules, and many cannot, even if they wanted to.
“You have to realize that there are going to be people that cannot socially distance,” Adalja of Hopkins said. “That’s where you have to come up with the ability to test, trace, and isolate.”
Testing could allow some Indians to continue working while also helping to limit new infections and keeping people out of overloaded hospitals.
In particular, cheap tests that return results quickly are needed. “Providing any surplus rapid-antigen tests that could allow people with Covid to test at home would help to alleviate stress on the testing infrastructure here,” Brian Wahl, an India-based epidemiologist with the Johns Hopkins Bloomberg School of Public Health, said.
Ramping up vaccination manufacturing for more doses will likely take months. A surge of vaccination supplies is one critical step, but experts say that India still faces challenges over vaccine hesitancy and that the current surge has stretched the health care system’s ability to distribute doses.
India is in need of other supplies too, like oxygen and personal protective equipment. Right now, the county is diverting its industrial oxygen supply to meet the needs of the pandemic. Countries and international organizations are donating oxygen concentrators and other equipment.
But donations of oxygen and even vaccine doses may not meet the scale of India’s immediate crisis. It takes time for supplies to arrive, and then to be distributed across states. The need is also profound. When referring to the United Kingdom’s donation of 600 ventilators and oxygen concentrators, a doctor in India called them a “drop in the ocean.”
And the world should still be acting with a sense of urgency to expand India’s vaccine manufacturing capacity and its available doses. Countries can invest now to prevent the next India from happening.
Intellectual property rules should be waived
In responding to India’s crisis, the world is playing catch-up. But unchecked spread in India threatens the entire region, and infections and deaths are rising in neighboring countries like Nepal and Pakistan. Places like Nepal relied on India’s exported vaccines, which are no longer available. And the more the virus spreads, the more the virus changes, becoming a threat to everyone, everywhere.
Except it doesn’t have to be this way. “We have the intellectual property, we have the expertise, we have the manufacturing capacity to produce these vaccines and just distribute them globally,” said Veena Sriram, assistant professor of global health policy at the University of British Columbia. “We’re just not doing it because we are working under a system whose rules are not designed for equity. And for us to really get out of this pandemic, we have to break those rules.”
One area of urgency, experts said, was tracking variants. In the case of India, with its “limited resources for genomic sequencing, it was harder to have an early signal not only about its spread, but its increased transmissibility and increased severity,” said Rebecca Weintraub, faculty director of the Global Health Delivery Project at Harvard University.
Variants are largely believed to be intensifying the virulence and severity of the epidemic in India. But there’s also not enough information to know this for sure, or where the variants might be spreading.
Some experts also say the US should support relaxing intellectual property rules around vaccines. That would leverage India’s capacity as the world’s largest vaccine manufacturer and help other countries with manufacturing capacity create their own vaccines.
India and South Africa — with backing from nearly 100 countries — have pushed a proposal at the World Trade Organization to temporarily waive certain trade and intellectual property rules for Covid-19 vaccines to increase production and manufacturing capacity around the world, especially in lower- and middle-income countries.
Right now, pharmaceutical companies control the rights to their vaccines and can decide where they’re made. Advocates say temporarily suspending these rules is necessary for an international health crisis of this scale, and such a waiver will speed up and increase the vaccine supply.
“It would unlock the ability of many different manufacturers, not just in India but around the world, to come online and start producing low-cost vaccines,” said Niko Lusiani, a senior advisor at Oxfam. “India shows we can’t base a global vaccination campaign on one or two countries, or three to four companies. We need redundancies.”
The Biden administration has not yet backed such a move, though White House press secretary Jen Psaki said Tuesday that the administration is looking at whether it’s an option. The proposal has support from some Democratic lawmakers, and more than 170 former heads of state.
Waiving trade rules isn’t a short-term solution, and it’s not so simple. It would also require vaccine makers to share proprietary information and technology, and that takes scaling up.
There are also currently constraints on some material needed to make vaccines, which also have to be produced at factories that meet international safety standards. And there are distribution constraints — just because you have a lot of doses doesn’t mean you can quickly get them into peoples’ arms. Local delivery systems and cold chain infrastructure have to exist, too.
Experts said these challenges are possible to overcome. It’s just going to take a collective effort — and money. “This is a problem we can solve: move the capital to the right place, stabilize the supply chain, and then invest in the distribution channels to get this as hyperlocal as possible,” Weintraub said.
Refocus on an international vaccine bank
Countries could also work together to create a global reserve of vaccines. The current system of bilateral agreements between countries and pharmaceutical companies remains a barrier to quickly deploying excess doses to where they’re needed most.
Harvard’s Weintraub suggested something like an international vaccine bank where countries could pool their excess doses, rather than the ad hoc donation structure currently in place.
Covax, the multilateral vaccine effort, is reserving 5 percent of its doses for such a stockpile. But it’s already short of funding and doses, and the program has nowhere near enough to deal with an emergency situation.
These solutions are also going to require international leadership and cooperation. Vaccine nationalism — of each country, doing it all on their own — is still the prevailing order. But one country vaccinating its population won’t do enough to stop the pandemic, and allowing Covid-19 to run unchecked elsewhere in the world increases the risk of variants that make even the vaccines we do have less effective. “We have to reimagine the system to be something that’s truly equitable, because the pandemic is not over until it’s over everywhere,” Sriram said.
Bhatti, the doctor in New Delhi, put it in another way: “If today, the suffering is in India, then in no amount of time it will go to the whole of the world.”