Could India’s Third Covid Wave Lead to a Silent Catastrophe?
In the long run Omicron is good news. In the short run it is terrible.
I have been following the course of Covid-19 in India with more than passing interest ever since the pandemic began. India is the country of my birth and I have friends, family, property and business interests there. Several of my friends, family and colleagues were infected by the SARS-CoV-2 virus. Unfortunately, a few passed away.
India’s current Omicron wave gives me a sickening sense of deja vu.
The Omicron variant of the SARS-CoV-2 virus, detected in South Africa, was named and designated a Variant of Concern by WHO on 26 November 2021. Since then it has spread rapidly across the world and is in the process of displacing the previously dominant Delta version from most geographies.
In the long run Omicron is good news. Both anecdotal evidence and data suggests that Omicron causes milder symptoms than Delta. Of the 2,252 Omicron cases reported in Singapore till 5th January, only 3 required oxygen support; none required ICU care or died. That is about 0.13% of the total. With a similar number of Delta cases, about 30 would have been oxygenated, in ICU or dead. The reduction in severity is probably largely due to most of these cases being vaccinated. But it may also be partly due to Omicron being intrinsically less virulent than Delta. A South African preprint suggests that Omicron’s reduced virulence may account for approximately 25% of the reduced risk of severe hospitalization or death compared to Delta.
Whatever the reason, it does seem that Omicron is no worse than flu — at least for most of the vaccinated. That’s excellent news of course. Omicron will likely smooth the transition from the pandemic to the endemic phase of the disease.
The shape of the endemic future is becoming clearer though we still have no idea of when it will arrive. In the endemic phase there would continue to be a steady base rate of Covid-19 infections with some — possibly seasonal- fluctuations. Most of the population would already have been vaccinated by then. Of course never vaccinated children would need primary shots and vulnerable adults may continue to require boosters. Anti-viral drugs and treatments would continue to improve so that case fatality rates decline. Eventually we will learn to live with Covid-19 just as we have learned live with so many other diseases.
Of course constant surveillance is the price of normalcy. As long as we co-exist with the virus it will be necessary to maintain a constant lookout for signals that the endemic phase is again swinging towards the epidemic.
Now the Bad News
We may learn to live with Covid-19. But we certainly can’t live with the Covid surge now taking place in many countries.
Omicron, though less virulent, is about twice as transmissible as Delta. It can also evade immunity, whether conferred by previous infection or vaccination to a considerable extent and cause re-infections and breakthrough infections.
So with Omicron we will have more infections. A lot more infections! Just see how the case numbers shot up once Omicron began taking over South Africa.
Now why should that matter if the majority of infections are mild?
With the less virulent Omicron, deaths and hospitalizations would certainly rise at a slower rate. Still, some people would fall seriously ill and require hospitalization, oxygen or intensive care and of these some would die. The unvaccinated, elderly and immune compromised are especially at risk, but others may be affected too. Since the total number of infections will be very large, even only a small fraction becoming severly ill would stress the healthcare system.
In fact, in the United States, Covid-19 hospital admissions are now at the highest level ever, though many admissions are “incidental”, meaning that Covid-19 was detected when the patient was tested after being brought to the hospital for a different reason. Covid-19 cases in hospital are also rising in many countries of Europe.
Omicron stresses healthcare services not only by increasing demand, but also through reducing supply. As doctors, nurses and other healthcare workers test positive for Covid-19 they need to be taken out of circulation. This stress is not merely hypothetical; it’s actually happening. Over 750 doctors and hundreds of nurses and paramedics are Covid positive in Delhi alone.
In fact, mild infections result in stress on not only healthcare but other key service sectors as well. The Omicron surge is disrupting supply chains from Australia to Germany. Several thousand flights had to be cancelled in the US during the peak travel season between Christmas and New Year as Omicron decimated airline crews.
And finally, we shouldn’t forget that Delta is still around killing and hospitalizing people in middle of the Omicron surge.
No, we can’t let Omicron rip. The surge must be damped. That is hard work because this variant is very contagious but it’s absolutely necessary.
The next few weeks will be critical for India and many other countries.
India’s First Covid Wave
By the third week of March 2020 lockdown was in the Indian air. Prime Minister Modi called for a “people’s curfew” on 22nd March. Our office in India carried out a drill the same week to make sure that we could seamlessly transition to work-from-home. At 8 p.m. on 24th March Modi announced a 21 day lockdown starting in four hours. The lockdown would be extended till the end of May and then relaxed piecemeal over several months.
In March 2020, India — barring exceptions such as the state of Kerala — was poorly prepared for a pandemic. Public health experts such as Ramanan Laxminarayan had good reason to fear that rapid spread of the disease could overwhelm its patchy healthcare infrastructure. The lockdown slowed the first wave, which would otherwise have probably looked much more like the second one. It bought the country precious time to prepare. Modi was probably right in claiming that the lockdown saved hundreds of thousands of lives.
But the cost was high. Hi-tech companies like ours were prepared for a lockdown. Millions of migrant workers, who had come to Indian cities in search of employment, certainly were not. They were now trapped without livelihood and no way home. In retrospect, the Indian government — and I must confess I too — had vastly overestimated the danger of migrants spreading Covid-19 back home. A couple of days notice of the impending lockdown would have spared them much suffering.
There were other costs. Apart from migrant workers, the poor, the casually employed and urban slum dwellers suffered. The economy contracted by 7.7%. India’s IT infrastructure is good compared to many of its peers and many Indian educational institutions, including the Indian Institute of Management at Udaipur where I teach, transitioned to online learning with flying colours. But many schools in poorer urban neighbourhoods and villages couldn’t make the switch. As a result a large fraction of disadvantaged Indian children got left behind.
There has been much debate about lockdowns in general and the Indian lockdown in particular. Lockdowns are rather like scorched earth tactics to slow down an enemy. They often work and may indeed sometimes be the only option available. But they also hurt your own side badly. Ask the Russians who used it against both Napoleon and Hitler. The pandemic has provided numerous examples of effective lockdowns. But it has also made it painfully clear that low-to-middle income countries like India, Peru and the Philippines, should only lockdown as a last resort.
Between the Waves
India weathered the first wave much better than many had feared. However, this relative success left the country complacent and disinclined to impose further lockdowns.
Indian politicians, administrators, journalists and scientists consistently benchmarked their country against the developed countries of Europe and the Americas. This was a mistake. India should instead have looked eastward towards the Asia-Pacific. Australia, Japan, New Zealand, Singapore, South Korea & Taiwan all managed the pandemic much better than the West by using carefully calibrated mitigation strategies. Lockdowns were indeed used when deemed necessary, but by and large their Covid-19 responses did not swing wildly between severe lockdown and complete laissez-faire.
At the end of the first wave India’s reported Covid-19 mortality rates were significantly lower than those of western countries and India’s coronavirus death paradox became a subject of widespread discussion.
In hindsight the paradox is explained by:
- The relative youth of India’s population; its median age is just about 28 years
- India’s success in restricting the spread of the first wave of Covid-19 to mainly urban areas of the country’s more prosperous western and southern states
- Serious under-reporting of Covid-19 deaths; this would get much worse during the second wave.
But at that time many in India believed in what Gautam Menon, the noted epidemiologist & disease modeler, described as “Indian exceptionalism”. Some very well-established scientists published a somewhat dubious paper which tries to statistically establish that Indians possessed pre-existing immunity to Covid-19. There was also fairly widespread belief that India had already achieved herd immunity and therefore there would be no second Covid wave there. A Stanford statistician, for example, cherry-picked data to prove just this in January 2021. This flatly contradicted a survey showing that only about 20% of the population was sero-positive but inconvenient facts were simple ignored.
At the WEF summit in Davos in January 2021, Modi declared victory over the Coronavirus. In the same month there was a relatively small spike of infections in the Amravati district of Maharashtra. The Delta variant had begun its spread, though because of lack of sufficient genome sequencing, it would largely pass under the virologists’ radar till early March.
In early March of 2021, INSACOG, the institution set up in India for genome sequencing, would warn the government about the new and more contagious variant. Cases had by this time begun ticking up and a few scientists and data journalists had already sounded the alarm. However, administrators and politicians continued to allow — even positively encourage in some cases- large gatherings. These included mammoth political rallies, political protests and above all the once-in-twelve-years mega religious pilgrimage known as the Kumbh Mela, which attracts millions of pilgrims.
Mask mandates and social distancing requirements remained, in force, on paper but Indian citizens had by this time largely given up on them. It is hard to blame them too much given the mixed messages they were receiving.
And all this time Delta continued to gather force.
Apocalypse 2021
An elderly relative of a colleague, infected during the Delta wave, was being administered oxygen in a hospital in the north Indian city of Meerut. The hospital had run out of oxygen. The cylinder to which she was connected was going to last for 12 hours. If her friends and family members could find a replacement within that time she would live; otherwise she would die. And the 12-hour cycle would start all over again when they did find a cylinder.
This lady was fortunate and survived her ordeal. Many were less lucky as the same scene played out across dozens of hospitals in northern India during the second wave from April to July. In Jaipur Golden Hospital — a private hospital in Delhi- on the night of 23 April, the oxygen ran out and 20 patients died within hours.
India’s second Covid wave was a public health failure on a scale not seen since the country became independent in 1947.
At Davos, Modi had mocked experts who had claimed that Covid-19 could claim up to 2 million Indian lives. How many actually died? While we will never know for sure, the number is certainly several times higher than the official figure of about half-a-million.
The most reliable estimate to date comes from a large scale study of Covid-19 mortality in India, by Prabahat Jha of the University of Toronto and others published recently in Science. According to this there were 3.2 (3.1–3.4) million likely Covid-19 deaths, during the period June 2020-July 2021. Of these about 2.7 (2.6–2.9) million occurred during the second wave from April-July 2021. The excess mortality, the increase in deaths over and above what would be normally expected, was close to 30% for the entire period and a staggering 100% during the second wave.
And Now Omicron
In many respects India is much better prepared for the Omicron wave. The availability of medical oxygen and tankers to carry it has increased significantly since the Delta wave. Even more importantly a much larger fraction of the population is now vaccinated.
India has also just started a program of booster doses for the elderly with comorbidities and healthcare workers. All this should significantly limit the damage done by the Omicron wave.
But mistakes of the second wave are still being repeated. One doesn’t need to be an epidemiologist to know that it is suicidally stupid to allow large public gatherings in the middle of a pandemic. Yet the pilgrimage to Gangasagar (in West Bengal) and similar religious festivals are still being allowed in the country. The Gangasagar Mela, being smaller in scale than the Kumbh, might not be as bad but it will be bad enough.
During the Delta wave blind faith, political expediency or a combination of the two, led some administrators to deny that the Kumbh had been a super-spreading event. The same denial still seems to be in force. In response to a plea to the Kolkata High Court to cancel the pilgrimage, the West Bengal government has bizarrely claimed that the risk of Covid spreading during the pilgrimage was low, since the pilgrims would dip in flowing rivers and salt water.
A common trope in India, during the pandemic has been that Covid-19 is less serious than tuberculosis (TB) which is estimated to kill 450,000 annually in India. The trope is false and had led to considerable harm by minimizing the impact of Covid-19. Covid has killed about six times as many as TB would in a normal year. Yet it does have an important grain of truth.
TB is an ongoing silent catastrophe in India. The vast majority of TB deaths are preventable and yet that fact rarely outrages or shocks us. Given the size of India’s huge population and its approximately 10 million deaths in a normal year a few hundred thousand deaths simply pass under the radar.
A pre-print by South African researchers indicates that the excess mortality during the Omicron wave was about a fifth of that during Delta wave. Even if we assume that the Omicron wave will only be a tenth as deadly as the Delta wave in India, it would still result in more than 200,000 deaths. Many of these may not even be recorded as Covid-19 deaths, so that the number of reported deaths could be in tens of thousands. This number would probably be too low to attract much attention either in India or abroad the way the Delta wave did.
A study by Bhrmar Mukherjee of the University of Michigan suggests that about 90% of the Delta wave deaths could have been prevented by a moderate lockdown in March. Most of the Omicron wave deaths to come can also be prevented by prompt and appropriate non-pharmaceutical interventions now. And, of course, we can also prevent much of the suffering due to long Covid. Indian politicians, administrators, scientists, journalists, healthcare professionals and above all normal citizens must all act promptly and responsibly to prevent another silent catastrophe.
Disclosure: I am the Director of Smart Consulting Solutions Pte Ltd, incorporated in Singapore and its subsidiary Radix Analytics Pvt Ltd, incorporated in India. I am also a Visiting Faculty Member at the Indian Institute of Management, Udaipur. However, the opinions expressed in this post are solely mine and not necessarily shared by any company or institution with which I am affiliated.
Some of the material used in this blog was shared on Prof Gautam Menon’s and Dr. Vipul Shah’s Facebook pages. Neither is of course responsible for the way in which I interpreted and used that content. I am, as always, grateful to my friend Dr. Ashish Kumar Dawn for his comments and corrections.
