Expert Interview with Prof Shirish Prayag, Director, Critical Care Medicine at Prayag Hospital Shree Medical Foundation and Editorial Board Member, ICU Management and Practice.
What is the current state of COVID-19 in India?
The current state is really devastating. We are facing a tsunami - not just a wave of patients - but a tsunami, really. We are seeing a very large number of patients, and many of them are seriously ill and require hospitalisation with oxygenation and mechanical ventilation. It's a huge problem in India right now. The extent is variable in various states. From where I come, which is the state of Maharashtra, which is on the western coast of India, we are facing at least 10,000 to 15,000 patients per day in the city alone.
Why do you think there was such a sudden increase in the number of cases?
We knew there was a likelihood of the second wave, which the whole world was predicting, but I think, overall, the public became a little lax. The fact that in the western world, the second wave came towards the end of the winter, in the months of December and January, perhaps the general public thought that we'd beaten the second wave, not realising that in India, the first wave also occurred about three or four months after what happened in Europe and the U.S. Therefore, a large majority of the population became a little lax. Also added to the fact was that there was an economic disaster in the first lockdown which happened between March 2020 to about June 2020. When things were a bit relaxed, everyone started to go back to their original activities. There were lots of weddings, religious festivals, elections, meetings, get-togethers and travel. It sort of all came together to have this kind of a huge wave.
What do you foresee happening in the next few weeks, and do you think this can be controlled and if yes, how?
The only way to control is to have stricter lockdowns, although epidemiologists have always told us that lockdown is not the only way to control it. It has its own shape of the curve, and over a period of time, as social distancing increases and as the herd immunity builds up, the number of cases is expected to fall down. Another reason the number of cases is so high is the laxity in the vaccination programme, which happened between the months of January and March. I think we were taking it a bit too easy rather than forcing it very aggressively.
I see, over a period of time, the number of cases will take its own shape. It was almost 400,000 cases a day a few days ago across the country, and this is likely to be an inaccurate number. The reason why I'm saying that is that a large population still does not have access to PCR testing, which is the way to actually be counted. Number two - the number of deaths also has got to be registered online, and a large population still doesn't have clear access to the internet and the facilities thereof. Therefore, I suspect that the number is not at the 400,000 or the 3500 deaths which are officially quoted. It might be much larger than what we are seeing. What we're projecting anyway is that it's expected to go on for a few weeks more because just five states have gone through processes of elections, and large gatherings have taken place. We know that about three or four weeks down the line, we will start seeing a larger number of cases in those states. I think it's the population at large who have been a little undisciplined and who have not taken the warnings which have been given to them, at length, all the time. I think we all, as a general population, need to be accountable. I don't think there is any particular person or particular organisation where we can point fingers. We all have to point our fingers to ourselves, saying that we as a nation have not done the job right, and therefore we are facing this calamity.
What role could the government have played in preventing this level of devastation?
I think the government could have been more proactive in managing the vaccination drive. For example, when the vaccination roll-out started in January, there were lots of myths around it, so it took off very, very gradually. It was only available for healthcare professionals at that time. It was only at the beginning of March that it became available for 45 plus with comorbidities, and early April that it became available for 45 plus. I think this could have been much more intense, and they could have reached many more towns and cities in a better way than what they have done right now. I know a large number of countries in the western world have also been slow in vaccinating people, but I think India could have done better. India could have also ordered the number of vaccine doses in a much larger number and could have procured them much faster because we are a giant hub of production of these vaccines. We could have incentivised those pharmaceutical industries to actually manufacture a large number of dosages. If this could have been managed better, we could have been a little better off. Secondly, our preparations haven't been adequate for the number of patients that we are facing. The oxygen crunch the whole world is talking about and the lack of ventilators could have been anticipated in a better fashion. We thought we knew that there could be a second wave, but we never prepared ourselves for this large number, so today, we are struggling for these resources.
India is the largest producer of vaccines, but only a small fraction of the vaccines are actually staying in the country. Everything gets exported. Even the European Union has said they would not allow exporting these vaccines to other countries before they have vaccinated their people. What is your stand on this?
I feel that we should have managed the stocks of vaccines much better than what we have done. I think there's no harm in saying that we reserve it for our own country, to begin with, rather than allowing exports or trying to help other nations. It's a magnanimous move to give it off to smaller countries that do not have access. It's a great move politically, but I'm not sure whether it should have been at the cost of our own population. I personally feel that we should have managed our vaccination drive much better. Now we see everywhere these big problems that hospitals have a shortage of all resources and in particular oxygen. We have seen that a
a couple of companies and several states are flying in supplies in order to help, but we are still short of oxygen, especially in the smaller towns. The reach of oxygen could be better. There have been situations, even in my own city, which has a population of 5 million people, wherein hospitals have run short of oxygen supply, even in the hospital which I am managing. In the ICU that we are running, there have been instances where we had to shift our patients on a ventilator through ambulances to another centre just because there was a potential oxygen shortage coming up in a few hours' time. That's the worst-case scenario that can happen to any hospital, and these nightmares have been recurrent in a large number of hospitals in a large number of cities and in town centres. Only very big hospitals which have their own oxygen production capacities and tanks have handled them well, but India is a country that is dependent on 80% percent of their health care delivery through private channels. Amongst this 80%, only a small fraction is really controlled by the gigantic corporate hospitals. A large portion of the healthcare delivery comes from smaller setups - 50 beds, 30 beds or 100 beds. Those kinds of setups are numerous, and that's what the country is dependent on, and these are people suffering from oxygen shortages because they're entirely dependent on supply from outside agencies.
If you could reach out to the Indian Minister of Health and demand something from them or give them some advice, what would that be?
I think the least we could say is that we need to ramp up this oxygen issue much, much faster than what we are doing. We're told that they are trying to do everything. For example, in my city, there was a hospital which was going to run short of oxygen in four hours' time. They called the police, and the police ramped it up by getting oxygen cylinders from other hospitals, which eventually then ran short of oxygen. Then they went and got help from some suppliers of oxygen. Therefore, my first take on contacting the health minister would be to prioritise the oxygen delivery. I think the military needs to come in if required and make sure that the tankers of oxygen are flowing smoothly. Industrial oxygen consumption and utilisation have been stopped completely, but we need to open up those facilities which have oxygen generating abilities and just ramp up and start faster deliveries. Ventilators are another crucial issue, but then that doesn't have an immediate solution.
How much do you think this devastating crisis will change the Indian health system for now and for the future?
I'm not sure how much we'll learn our lessons from this debacle and from this devastation - from this new great human tragedy. I hope we do learn, but again, because the system is so dependent on private healthcare players, it finally leads to the mindset of those who are actually running the industry. It's a disjointed and unorganised healthcare sector. The government does not participate in healthcare delivery. It is then left to the private health care industry to have its own top-end officials to decide on the policies, to learn the lessons and to change themselves. There is, unfortunately, not a centralised audit for the healthcare industry in the private sector. The audits are left entirely to the leaders of the organisation. There is no system like in the U.S. where companies are audited for their performances and then given licenses.
You can view the complete interview here: