India faced a severe second wave of Covid-19 – actionable public policy recommendations to prepare ourselves better

An unexpected, unprecedented 16X surge

Around end March 2021, with rapidly reducing active cases, India was getting back to its pre-Covid days in its economic and mobility indicators. Record-high Goods and Services Tax (GST) collection of Rs 1.24 trillion in that month underscored the return of the Indian economy. The turn of the new financial year was supposed to herald an unprecedented double-digit real economic growth.

April turned out to be very different. Cities like Ahmedabad, Delhi, Lucknow, Mumbai (to name a few of the severely affected), saw a sudden severe second wave of the Covid-19 pandemic. All the explanations that sought to explain India’s sharp fightback of Covid-19 (BCG vaccine, herd immunity, poor hygiene, etc.) were proven useless as various mutations of the virus (UK variant, double mutant, etc.) started to suddenly make a lot of people sick. From around 1.5 lakh active cases, India is suddenly grappling with 25 lakh active cases. It is difficult for systems to prepare for a 16X surge over a 2-3 week period.

Use peace to put on a war footing

This wave impacted some parts of the country and the time of impact, even in such areas, has been different. The epicentre of the pandemic attack kept moving to newer locations – it can be because of many reasons: mutations, spread by travellers, low immunity levels in those areas, etc.

While it is very unfortunate for the cities and regions where there has been a breakout, these ‘moving epicentres’ offer planners an opportunity to beef up the systems and processes in cities and regions that have been spared the wrath of a second wave. There is nothing like over preparation when it comes to meeting. There is every reason for the remaining set of cities and regions, if the pandemic were to indeed make its presence there, to be prepared.

It is always better to plan and execute in ‘peace time’ than to get things done on a ‘war-footing’ when a crisis strikes. The military equivalent of this saying is: the more you sweat in peace, the less you bleed in war. What this second wave has created is the awakening that cities and regions which have not seen the surge can use this time to prepare capacity. Logistics is easier, prices and costs are more in control, ability to improvise is higher, and the losses are lower.

A three-step plan

As we reflect on this wave, it is clear that three things have been in short supply: hospital beds with oxygen facilities, oxygen itself, and medicines. This note puts together suggestions on (1) how to tackle the immediate short supply, (2) disease management plans, and (3) some policy frameworks.

Immediate capacity expansion

• Medical equipment supplies to be augmented
  • Create mechanisms for people to voluntarily share the equipment lying at their homes: oximeters, concentrators, etc. A small financial incentive or a token to those sharing the equipment which gets them some priority in some other area (maybe medicines, oxygen to them or their near-and-dear ones), can be put in place.
  • Philanthropies can be channelised to get supplies (concentrators, oxygen cylinders, oxygen manufacturing plants, etc.) from Indian cities that are not impacted or be imported from abroad. NRI network may be put into action.

• Remove bottlenecks, if any
  • Items like oxygen and medicines can be exempted from customs, tolls, etc.
  • Create “green corridors” for inter-city and intra-city travel – similar to what is done during the case of organ donations
  • Use new age technologies like drones to transport medicines within cities, regions.
  • Use digital and last-mile access of e-commerce and gig-economy companies for getting medicines, medical equipment, and oxygen to patients and hospitals.
• Oxygen production
  • Set-up oxygen generation facilities near hospitals. On-site oxygen generation works at many industrial plants – set up such centres near hospitals. Hospitals in cities which are not impacted should start making such contingency plans.
  • Require retooling of chemical industries to quickly switch over to producing oxygen. However, smaller ones might be worried that all that retooling cost will go to waste as the shortage eases out. Financial incentives or guarantees for retooling can be considered for them.
  • Labs of large research institutes can produce oxygen directly or can tweak a few things to do so. Direct government-owned institutes to produce oxygen and urge private ones as well.
• Oxygen supply
  • Consider if the LPG distribution network and cylinders can be used for oxygen transport and supply. It may be possible to convert LPG cylinders to carry oxygen – if so, this can be activated as Plan B which is put into motion if we hit capacity constraints.
  • Transport of oxygen requires specialized trucks. Cities and states can order locally or import to keep some such vehicles as back-up. Build a GPS-enabled tracking of such trucks so that they can be moved around the country as required.
  • Designing a flexible train networks which carry oxygen from production zones to emerging need zones will be key. This is different from creating ‘green corridors’ – this is creating the flexibility to change directions as demand-supply balance changes in the country.
  • Create oxygen reserves in various regions which can then be transported to the hinterlands or other regions as the case may be. Creating these reserves should follow the easing of the current situation of oxygen deficiency/bottlenecks.
    • Once the reserves start to build, identify ways for dispersed evacuation allowing hospitals, nursing homes, care givers, etc. easy access to such oxygen. Consider setting up ‘oxygen pumps’ – similar to petrol pumps.
• Oxygen dispensation
  • Allow hotels to do oxygen rooms – similar to Sanjeev Bikhchandani’s idea of revamping Oyo rooms into oxygen dispensing centres
  • NGOs, religious institutions may also want to create such capacity – Delhi saw the creation of ‘oxygen langars’ at gurudwaras
  • Create capacity for BPAP machines and ventilator manufacture – possibly the sudden surge is already creating a supply response in these segments. Cities and hospitals augmenting their capacity when there is no surge can lead to less panicked responses later.
  • Similarly, hospitals should create oxygen tank capacity. This can be made mandatory for larger hospitals. Easy or concessional credit may be made available or accelerated tax deprecation may be allowed as an incentive.
• Medicine supply to be augmented
  • Deconstruct the value chain for specific medicines as done for oxygen above (production, supply, dispensation).

Disease management plans

• Build a single digital, open repository of hospital bed, ICU, ventilator, medicine related status at least at a city level, even if not all India. This should ideally be part of the Arogya Setu and/or Cowin apps fetched real-time from an updated database. Cities which have been spared in this wave should put in place these systems and also take time to publicize and educate its citizens about the same.  
• There are non-emergency centres (like dental hospitals, eye hospitals, dermatological clinics, etc.) which have operation theatre facilities and also oxygen beds. Such centres should be identified and put on alert within the city.
• Work with housing societies and resident welfare associations (RWAs) to create make-shift hospital-like facilities within their compounds so that the moderately sick patients do not clog hospital capacity. This has been done in some cases for quarantine management earlier – it can be upgraded for managing the moderately unwell.
• Vaccine related:
  • Delaying second dose of vaccine (as much as is medically feasible) can create more capacity to deliver the first dose to those who do not yet have a shot. This will be especially true post May 1 when a large surge is expected.
  • Many more centres are needed. Crowding in vaccine centres is a reality – we need to avoid making these such centres as super-spreaders.
  • Create a well-publicized guide on whether vaccine will be available to those who have had Covid-19 and if so, after how many months
  • Have specific indications for vaccine dosage for those with allergies: the MOHFW portal under “What are the contraindications for this vaccine?” is open-ended with words like “etc.” which can cover a wide range of allergies.
  • Allow vaccine certificates generated on Cowin app as vaccine passport for internal travel in trains, planes, etc.
• Open non-identifiable data for analysis: co-opt the data community to track down various linkages, for example, between vaccine and infections, any cases of reinfections, location/geographic analysis, etc.
• Create increased capacity for sero-surveys and mutation identification.

Policy frameworks

• Clear Covid-19 treatment protocol for in-patients and out-patients to be disseminated in the wider population.
  • A senior medical figure, say AIIMS or ICMR director, to come frequently on major mainstream and social media and disseminate authentic information on treatment protocols. It is important to balance both positive and concerning news and data.
  • In some cases, risk-averse doctors and patients tend to get to hospital much sooner than required. Objective metrics to help determine hospitalization need should be given wide publicity.
  • Remove the forced Covid-19 message on mobile calls. It is unhelpful especially in the case of emergencies.
• Prepare for different surges: Apart from the sheer surge, one reason why oxygen and oxygen-beds were suddenly found to be in shortage in this wave is that the proportion of patients requiring oxygen treatment is higher than in the first wave. It is possible that different mutations of the virus may create different types of needs: different medicines, more home care instead of hospitalizations, different treatment regimens, etc.
• Create a global consensus on free flow of vaccines from countries with surpluses. The global distribution of vaccine will require active engagement with the key countries and via multilateral bodies.

This is a list of action-able and implementable ideas that cities and regions that have not been impacted by the second wave can put in motion. Cities that have been impacted will find that their peri-urban areas or nearby cities are as yet not as badly impacted. City and region leaders should collaborate to build overall capacity. Now is the time to work on “augmenting supply” rather than on waiting to “administer what is available”.

The second wave may have surprised many of us. The next set of waves need not!

This note has been compiled by Akhilesh Tilotia in personal capacity. It draws upon the ideas that batchmates from IIMA 2004 put together on the batch’s active WhatsApp group. This note neither is nor is meant to be medical advice.