India has become the epicenter of the global coronavirus pandemic as the country records an explosive surge in cases amid a critical shortage of medical supplies. This week, the country reported more than 400,000 new cases in one day–the highest daily case count of any country since the start of the pandemic. By mid-May, modeling shows daily cases peaking at over 800,000 with deaths expected to reach over 4,500 per day by the end of the month, according to scientists at the University of Michigan. The country’s official death toll stands at over 225,000.
But minimizing the impact of India’s second wave is still possible. To do so, the country will need to shift its approach to care, according to Dr. Satchit Balsari, a practicing emergency medicine physician and Assistant Professor at Harvard T.H. Chan’s School of Public Health and Harvard Medical School. Dr. Balsari and his colleagues are drafting evidence-based recommendations for providers treating India’s critically ill. Throughout the pandemic, Dr. Balsari has written extensively on the state of care in India and contextually relevant public health interventions.
This week, Direct Relief sat down with Dr. Balsari to discuss India’s current gaps in care and what, if anything, can be done to improve the severity of the crisis over the coming months.
Direct Relief: Why is India experiencing an explosion of cases at this point in the pandemic?
Balsari: Well, I think it is a combination of viral strains, low levels of vaccination, close to no masking for a long period of time–through early 2021 in most communities–and no physical distancing in most communities as well, including large political and religious mass gatherings, as well as, social gatherings–parties, weddings–since late winter.
Direct Relief: What are the current gaps in clinical care?
Balsari: The lack of adherence to well-established, standardized, evidence-based protocols. Medical practitioners across India are incorrectly managing and treating patients using a whole bunch of medications that have long been debunked, including antibiotics, anti-parasitic medications and inappropriately using treatments like Remdesivir or Tocilizumab, which will have an effect, if any, only when the rest of the care is optimized. In the current situation, when there is not adequate oxygen to care for patients with oxygen needs, subjecting patients to a battery of unnecessary lab tests and diagnostic imaging that has no bearing on what care can actually be provided for the patients is just gross malpractice. Families are draining their finances on trying to purchase these drugs on the black market and they’re not going to make a difference in their relatives’ lives when all other care is not optimized.
Direct Relief: Current modeling shows cases peaking at nearly 1 million by mid-May and daily deaths reaching 4,500 by the end of the month. What can India’s health system do now to reduce the number of virus-related deaths in the coming months?
Balsari: Patients with mild symptoms can monitor and self-care at home, but it is important that monitoring is initiated. So in the villages in India any attempts at isolating at home should be tightly plugged in with monitoring by community health workers who can identify patients at risk for requiring more oxygen. The only dent we may be able to make on mortality in India is by taking those patients that have moderate symptoms and giving them appropriate care so that they do not need specialized or critical care because India does not have the capacity to provide that. That is the only place where we can make an intervention. And interventions there are thankfully simple. They’re oxygenation, pronation, and steroids. And if we can protocolize this and provide support at the community level to do at-risk identification, early identification at home, transferring them to facilities that can provide oxygen, steroids and pronation we may be able to change mortality.
There are challenges. Without electricity, you cannot run oxygen concentrators. Oxygen cylinders are expensive to buy and transport and won’t provide enough oxygen at the flow rate that you need for it to be effective for COVID-19 patients. So, as people are thinking about field hospitals for India, you have to think about very context, specific issues like, backup generators when there’s no power so that you can actually run these oxygen concentrators and C-PAP machines that provide oxygen.
Direct Relief: With 1.4 billion people, India is an incredibly dense country. Local-level differences can change the contexts in which health care providers are working. What is the role of community-oriented care in responding to this current crisis?
Balsari: It’s extremely important. India has rich societal networks, a rich presence of community-based organizations, a vibrant civil society, and by and large people always caring for themselves and their communities in the absence of a robust healthcare system. So if there is any hope that we can decrease mortality, it will be through augmenting the support that communities need to care for patients with a mild amount of symptoms.
Direct Relief: Despite India being one of the world’s major producers of vaccines, only 2% of its population has been fully vaccinated. What if any role will vaccination play in subduing the current crisis?
Balsari: Vaccination will take a long time to achieve herd immunity, so one can only hope that the government does all that can to reduce financial, social and political barriers to vaccination.
This transcript has been edited and condensed.
In response to India’s second wave, Direct Relief is preparing a series of shipments bound for health facilities across the country including an 11 pallet shipment of personal protective equipment, 1 million KN-95 masks and over 3,600 oxygen concentrators–all bound for Mumbai. Six pallets of medical aid have been prepared for Calcutta and 4 pallets for Pune.
