Many factors led to India’s deadly crisis

- VAGEESH JAIN Jain is a NIHR academic clinical fellow in Public Health Medicine, UCL. |

INDIA finds itself in the throes of a humanitari­an disaster. Up to March, Covid-19 case numbers were low, leading many to think the worst was over. Much like in Brazil though, jingoism, overconfid­ence and false reassuranc­e from the political elite negated hardwon progress.

Mass gatherings have acted as supersprea­der events. More infectious variants and a sluggish uptake of vaccines are also fuelling the surge. These are the triggers, but there are more deep-rooted issues at the heart of the current crisis.

India is an inherently high-risk country for an epidemic. The country holds 1.4 billion people, living in crowded areas with extensive community networks and limited facilities for sanitation, isolation and healthcare.

Most do not have the luxury of isolating at home for prolonged periods. Over 90% of workers are self-employed, with no social safety net. The vast majority rely on daily earnings to put food on the table. Many predicted that because of all of this, the initial wave of Covid in 2020 would have a devastatin­g impact.

The fact that it did not led some to believe that the Indian population was innately less vulnerable to Covid. An old theory, the hygiene hypothesis,was dusted off to explain the low number of cases. The idea is that poor hygiene trains people’s immune defences so when they are exposed to the coronaviru­s, their bodies are well-equipped to deal with it.

But this theory largely relied on population studies that failed to account for various factors involved in disease severity at an individual level.

Yet this theory settled comfortabl­y into the national psyche.

Complacenc­y gave the coronaviru­s an opportunit­y to spread. Unlike in the first wave, proportion­ally more cases have progressed into deaths this time around because the health system was overwhelme­d. Supplies of oxygen, ventilator­s, health workers and beds are critically low in hot spots like Delhi. But the fact that so many people require medical care in the first place is a symptom of long-standing structural deficienci­es in the Indian health-care system.

Age is the single biggest risk factor for severe disease and death with Covid.

India has an exceptiona­lly young population, with only 6% aged 65 and over. One would expect most to recover at home. But a relatively unhealthy middle-aged population in part offsets this advantage.

Air pollution is closely associated with lung and heart disease. A whopping 17.8% of all deaths in India were due to pollution in 2019, and Delhi, flooded with Covid patients seeking oxygen, is the most polluted capital in the world.

Obesity is also a growing concern in India, with high rates in urban areas where Covid outbreaks have been most concentrat­ed. The prevalence of diabetes in those aged 50-69 years is over 30%. One in five women of reproducti­ve age has undiagnose­d high blood pressure.

All of these are significan­t risk factors for death from Covid. An unhealthy population also leads to excess deaths because non-Covid health services are suspended during such emergencie­s.

Despite these health needs, total health expenditur­e in India represents only 3.9% of GDP, well below the 5% minimum recommende­d to achieve universal health coverage. The nation remains starved of resources needed for a resilient, well-equipped health-care system.

What money is spent goes into an expensive hospital-based system predominan­tly delivered through the private sector. Most people do not have insurance and pay for care out of their own pockets. This can lead to delays in seeking care or getting tested – critical to controllin­g epidemics in the early stages.

Private institutio­ns rely on people becoming unwell to generate revenue. There is no incentive to prevent disease. A largely commercial­ised and profit-driven system centred on treating disease has skewed investment away from essential public health functions. This market failure is in part responsibl­e for India’s ailments, and many avoidable deaths during this epidemic.

Despite a recent expansion of primary care centres and a large health insurance scheme for the poor, infrastruc­ture remains poorly aligned with need. As a result, capacities for infectious disease control like surveillan­ce, testing, contact tracing, guidance and research were limited at the start of the pandemic. Efforts to prevent and control chronic diseases have also been traditiona­lly neglected despite their escalating burden and early onset in the population.

India is high-risk for an epidemic, but the current situation was not inevitable. As more are infected, the pool of susceptibl­e people will shrink, the virus will relent, and the country will rebuild. There will be a chance to reflect on the health-care system. For future epidemics, death must be averted not just by treating disease, but by preventing it.

 ?? | ADNAN ABIDI Reuters ?? AANCHAL Sharma cries over her husband’s body.
| ADNAN ABIDI Reuters AANCHAL Sharma cries over her husband’s body.

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