Publication for Observer Research Foundation

At the best of times, India is a difficult country to govern, given its size, diversity and the argumentative Indian. Yet, it has successfully weathered many a crises. Never has it been so badly let down by its leadership that seems obsessed with scoring political gains, oblivious to the fact that the country faces its biggest challenge since the partition in 1947.

Smugness sets in

In January-February this year, Prime Minister Narendra Modi had good reason to feel satisfied. In India, Covid-19 numbers had declined steadily to one-tenth from the peak of 96000 daily infections last September and the death rate was down from 1200 to 80. In contrast, January saw the US undergoing its third wave with an unprecedented 500000 new cases daily and a daily death toll of well over 4000; European countries were in their third lockdown; and UK numbers had exploded with a new variant that was one and a half times more infectious.

Not only had India defied the dire predictions that many Western epidemiologists had made but India seemed to have also escaped a possible second wave or a new variant that was ravaging Brazil.

The economy had opened up. After an 8.5% contraction in 2020-21, 2021-22 projection was an encouraging double-digit growth.

On 16 January, India rolled out a three-stage vaccination programme covering the 30 million health workers and frontline essential public services in the first phase followed by the above 60 along with those with co-morbidities and then the above 45 age groups. This accounted for 22% of the population, about 300 million people and the vaccination was supposed to be completed in six months, by July-August. An acceptable time frame only if the current decline in case load held.

Triumphalism takes over

A sense of triumphalism began to emerge, buttressed by a faith in Indian exceptionalism. Leading the pack were the cheerleaders, as the BJP prepared to launch election campaigns in five states going to the polls in March-April. These included Assam, Kerala, Puducherry, Tamil Nadu and West Bengal, the last two seen as critical by the BJP. On 21 February, the senior leaders of the BJP and all the state unit chiefs met to adopt a resolution thanking Modi for his visionary leadership for effectively handling the pandemic and getting the country back to growth.

Under a newly appointed chief minister, Uttarakhand was getting ready for the Kumbh Mela where millions of devotees were expected to congregate to pray and bathe in the Ganga. To top it, even the requirement of a negative RT-PCR test report was done away with a conviction that faith would protect the devotees. According to one school, the Kumbh was brought forward by a year, presumably because the BJP election strategists calculated that pulling off a huge exercise like the Kumbh in the middle of a pandemic would be an unparalleled electoral boost among the majority Hindu community.

Addressing the annual conference of the Delhi Medical Association on 7 March, Health Minister Dr Harsh Vardhan proudly declared that we are in the “end game of the Covid-19 pandemic in India.” He went on to detail how India had emerged as “the world’s pharmacy” having supplied 55.1 million doses of the vaccine to 62 countries, in keeping with international obligations as a responsible global citizen. Praising Modi’s leadership at the time of a global crisis, he added that “India has emerged as an example to the world in international cooperation.”

These paeans of praise harmonised well with the idea of India re-emerging under Modi’s leadership to reclaim its glory as a vishwaguru and he, with his newly cultivated flowing white beard persona, as the Pradhan Acharya of this Vishwa Gurukul.

Wilful neglect and data denial

Even as the BJP was adopting its resolution, a new outbreak of Covid-19 was emerging in Maharashtra. While doctors in the Indian Council for Medical Research blamed it on Covid-inappropriate behaviour, local doctors were voicing concerns about the possibility of a new variant. The Health Minister was declaring the “endgame”, in the second week of March when daily deaths were up by 50% to 120 and daily cases had doubled to 18000.

But none of this registered. Cricket matches were played in stadiums packed to capacity. Goa saw a revival of domestic tourism. Domestic flights were running to over two-thirds capacity, amid complaints by some that often passengers were not even wearing masks. Hubris demanded that India was invincible. Home Minister Amit Shah, chief election strategist for the BJP was spending five days in a week on campaign rallies in the five states.

By the third week of March, the National Institute of Virology was pointing to the existence of a new double variant strain in Maharashtra. By 4 April, India had exceeded the daily new case load peak of last September. It was registering over a hundred thousand cases with a daily death toll of 700. Active cases went up from 145000 in early February to 800000 in sixty days, a pace far more rapid than that seen in 2020.

TV channels kept the focus on election rallies where neither the political leaders nor the crowds numbering hundreds of thousands wore masks. Th Election Commission issued proforma communications to the state administrations to take steps to ensure Covid-appropriate behaviour. No political leader was ever reprimanded for not wearing a mask.

Since the Election Commission had allowed political rallies, religious congregations could hardly be curbed. Three million pilgrims a day thronged the Kumbh sites on auspicious days, without masks or any social distancing.

No meeting of the National Executive Council, the apex decision making body under the National Disaster Management Act that had been invoked in 2020, was convened between November and March, either to track the behaviour of the virus or to follow-up on implementation of decisions taken in 2020 to augment health infrastructure. There was a wilful neglect of the approaching tsunami because the leadership caught up with politics, turned its back towards it. 

Temporary Covid facilities set up by central organisations that were lying largely empty since December began to be dismantled earlier this year. Genome sequencing proceeded at a leisurely pace. In 2020, over 9000 sequences had been carried out; beginning January, the numbers dropped to a few hundred a month, making it difficult to identify new strains in a timely fashion. One hundred and sixty six oxygen generating plants had been sanctioned after the 2020 peak but there was little follow up and only 32 had been set up by mid-April.

Other than banning exports of vaccines in end-March, no attempt was made to have a re-look at either ramping up vaccine production or accelerating the pace of vaccinations. Foreign vaccine developers that applied for authorisation were told to carry out bridging trials that would take a few months before emergency use authorisation could be given. By mid-April, the reality could no longer be denied.

The tsunami breaks

On 15 April India crossed 200000 new cases daily, doubling to 400000 cases on 30 April, with a total of 3.2 million active cases, and was suffering over 3500 deaths every day. Numbers have exploded in the last fortnight. Health infrastructure has collapsed with oxygen shortages leading to deaths in hospitals. The vaccination rates have dropped from above 3.5 million jabs a day to below 2.5 million, reflecting a looming vaccine supply crunch in the near term.

Since 17 April, Modi has been taking nearly daily meetings with his core group of advisers, with the three national task forces that had been set up last year to monitor disease spread, vaccine R&D and production, and medical infrastructure, state chief ministers and has addressed the nation twice. Emergency funding is being provided to ramp up vaccine production. Pending approvals of vaccines already approved for use in US, EU and Russia are being fast tracked. More than 500 new oxygen generating plants have been announced. Import duties of key drugs and vaccines have been slashed to zero.

Having used the brahmastra of a draconian lockdown once with damaging political fallout, this is no longer available. Instead, the states are being urged to create local containment zones. From 1 May, 18-44 age group will also be eligible for vaccination but this part has been delegated to the state governments, except that vaccine stocks are woefully short leading to states refusing to expand the vaccination coverage.

Election Commission has banned victory rallies when the results are declared on 2 May; in any case there will be little to celebrate in West Bengal that has seen a whopping 1800% increase in cases in a month.

At a national level, India registered a total of 11 million cases over one year and added 7.5 million in last two months. Out of a total death toll of 208000, one-fourth of the deaths have been added in March and April. From one million active cases during the last peak, India already has 3.2 million active cases and the peak lies somewhere in the future. The tsunami has crashed our shores and it is difficult to escape the waves now.

The collapse of vishwaguru

How did India go from being a vishwaguru and the world’s pharmacy to this when 60 days earlier, the ‘bhakts’ were caught up in self-congratulatory frenzy of having defeating the pandemic? How did we sleepwalk into a disaster of such magnitude, the worst India has faced since the partition in 1947? 

The answer can be given in one word – hubris, the fatal flaw in leaders, consumed by arrogance and over confidence.

For millennia, whether in the Mahabharat or in Greek mythology, we humans have been warned about the dangers of hubris, of the enormous ability of the human mind to delude itself out of its best interests by the mistaken certainties driven by false pride and over-confidence. If mythology is full of tales about heroes who sought to challenge the gods and then paid for their hubris, history is littered with tragic stories of leaders who ignored the warning signs and wilfully led their people into disaster.

Hubris made our leaders blind to what was happening in February in Maharashtra, and later in March and April. The sad part is that denials and lies continue. Inaugurating a number of blood donation camps on 27 April, Dr Harsh Vardhan said that India “is better prepared in 2021 to beat the pandemic compared to 2020.” Such statements fly in the face of the daily reality faced by hundreds of thousands of Indians struggling for even the most basic medical care or even a dignified death.

An unnecessary controversy has erupted about the differential pricing of vaccines. A back of the envelope calculation would indicate that if India were to vaccinate 75% of its 900 million strong population that is above 18 years, the total number of vaccine doses needed is 1.35 billion. If the government were to procure at Rs 200 a dose, it works out to Rs 270 billion or Rs 27000 crores. If the large corporates take charge of their employees and families, the amount will go down further. While a large sum, it is less than 0.5% of India’s GDP. PM Cares Fund can be effectively employed for this, ending the controversy surrounding it.

Running a state and governing India

Modi became chief minister of Gujarat in 2001 and from there was catapulted into the position of prime minister in 2014. It was a bitterly fought election, particularly within the BJP about who their candidate ought to be and whether this decision was even necessary a year before the elections in a parliamentary democracy but Modi supporters carried the day. The campaign in 2014 was fought in presidential mode, and Modi came to Delhi with his Gujarat experience and a closed mind. 

The problem is that he never realised the difference between running a state and being prime minister of a large, diverse federal structure, and consequently, failed to make the transition from being the chief minister of a state to being the prime minister of India. As chief minister, he had ignored the opposition; from 2001 to 2014, on average, he went to the state assembly less than once a year. Second, he ruled Gujarat like an executive governor, not with his cabinet colleagues but through a group of loyal and committed civil servants. Third, he ignored the national media blaming them of bias but effectively controlled the Gujarati press, radio and TV that was dependent on the state for advertisement revenue and access. Finally, when his schemes did not take off, he had a convenient bogeyman; the Centre could always be blamed for misguided fiscal and monetary policies or for damaging India’s FDI opportunities because of unwarranted restrictions driven by crony capitalism.

When Modi took over in Delhi in 2014, he often forgot that that the buck stopped with him. He continued to ignore parliament, confident of his majority till the rude realisation struck him that national parliament proceedings are telecast live and his absence aroused unfavourable comment. He retained an arrogant approach towards the opposition, justified perhaps given its diminished presence but contrary to the fundamental precepts of parliamentary democracy. Given his difficult relationship with the Delhi based national media, he cut himself off from it, adopting the direct communication radio chat Mann ki Baat (straight from the heart) medium. He surrounded himself with a bunch of loyal and committed civil servants to carry out his programs, forgetting that India is a federal country and the Gujarat governance model cannot not be scaled up for such a diverse nation.

The results soon began to show. The ill-conceived disastrous exercise of demonetisation in November 2016 reflected his penchant for the grand gesture. It smacked of Indira Gandhi’s political move on bank nationalisation that hobbled the economy for decades. Yet, Modi survived it because he played on the psychology that if the poor Indian suffered, the rich fat cat lost more; the reality later emerged that the fat cat had managed to escape fairly unscathed. The same incompetent planning showed up in the roll out of the GST. His election strategy relied on consolidating the majoritarian vote, through a blend of populism and nationalism. The removal of Article 370, the Citizenship Amendment Act, the Balakot air strike a month before the elections in 2019, are pointers to this toxic but heady blend.

Loyalty above all

Modi is a gifted orator and that gives him both credibility and legitimacy. He used it effectively to win elections, so much so that he is the campaign mascot of the BJP for every state assembly election. For governance, Modi resorted to cleverly coined slogans (sab ka saath sab ka vikas, Make in India, Digital India etc) and slick abbreviations (3 Ds, 5Ts, AMRUT, PRAGATI, SAGAR, UDAN, at last count numbering nearly 50). In 2016, at a BJP national meeting, he received the accolade of MODI – Modifier Of Developing India) coined by his admirers. More appropriate may have been NaMo – National Acronym Manufacturing Organisation.

Modi took pride in presenting himself as an ‘outsider’ in Delhi, dismissing the Delhi insiders with mocking references to ‘Khan Market gang’ or ‘Lutyen’s Delhi’. ‘Merit’ was conflated with ‘elitism’ and loyalty became the criteria of acceptance in the circles of power. The ‘elite’ always knew it was a minority but it also stood for the middle-class ethos of hard work as the road to ‘merit’ and success; now the ‘elite’ was dismissed as the oppressor, and jettisoned alongside were the notions of expertise and merit. Civil servants, judiciary and media fell in line, keeping their reservations to themselves, but for a handful of exceptions.

No first-time president or prime minister comes into position with prior experience. Effective and successful leaders grow into their roles but only if they have the tool kit to do so and the humility to accept that they need to grow. Modi has had some policy achievements to his credit but on balance, his reluctance to engage in a consultative process has led him astray more often. He has demonstrated, time and time again, that his skill lies in demagoguery and winning elections, not in translating that skill into effective governance.

Modi has made no secret of his visceral dislike for the Nehru-Gandhi dynasty. Yet, his secret ambition is to be remembered as the architect of 21^st century India just as Nehru is remembered as the institution building, architect of 20th century India. However, unless he changes his ways, he is more likely to be remembered as the institution derailing, insecure, autocratic “Indira Gandhi on steroids”.

Just as the prime minister gets the credit for a successful policy initiative even though many work to make it happen, and Modi has deservedly received praise for his initiatives like Swach Bharat, open-defecation free India or Jan Dhan Yojana, it is at the prime minister’s door that the blame comes to rest for political judgement failures. And it is on Modi’s watch that the current tragedy is unfolding.  

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Posted on April 8, 2021

Publication for Observer Research Foundation

India is squarely into its second wave of COVID-19. Will it be able to manage it better compared to the first wave? That will depend largely on the lessons it draws from those experiences.

The second wave

The number of new daily cases registered has increased more than ten-fold from below 9,000 on 1 February 2021 to over 103,000 in the first week of April. During the first wave, the peak was in mid-September when India crossed 97000. This time, despite far more extensive diagnostic and monitoring capabilities, the rate of increase has been much faster.

The number of related deaths has steadily risen from below 90 in early February to over 440 but there is invariably a lag between rising cases and related mortality numbers. These numbers are likely to rise further in coming weeks. Medical facilities, especially intensive care unit (ICU) beds are increasingly coming under strain in Maharashtra where the second wave has hit hardest.

Mutated variants of the virus with a higher infection rate, pandemic fatigue and increasing Covid-inappropriate behaviour are cited as reasons for the second wave. The beginning of the vaccination programme on 16 January 2021 gave a sense of complacency. The government’s message of not letting the guard down is diluted by the huge election rallies in recent weeks with nobody wearing masks and the Mahakumbh in Haridwar that is drawing 30 million visitors daily, convinced that their faith will protect them from the virus.

Lockdown is not an option

The first wave was during a period of complete uncertainty about the virus.  The central government quickly took control. Though health is a state subject, decisions were centralised and often announced without adequate consultation with states. On 24 March 2020 a nation-wide lockdown was announced when India had 525 cases and had suffered 11 deaths. The lockdown was lifted on May 31, after 68 days, with the number of cases standing at 190,606 and the death toll at 5,408. The pandemic spread slowed but then quickly gathered pace, reaching a peak in the second half of September, before the numbers began declining from November.

However, even with a more rapid second wave, nobody is talking about a repeat of the national lockdown. That Brahmastra was used and the belated realisation of its economic downside means that there is no appetite for such measures. Delhi would rather let individual states take that call and face the fallout. In fact, the central government is desperate to get the economy back on track. 

The only solution is a rapid increase in vaccinations. In January, before the vaccination programme was launched, the target was to complete vaccinating Indians in the priority category numbering 300 million (consisting of 10 million healthcare workers, 20 million frontline workers, 140 million above 45 years and suffering from co-morbidities and 130 million above 60 years) by July (later extended to August) 2021. Since the vaccines need two-doses, this meant 600 million vaccinations in five months, over and above the normal vaccination drives covering children, pregnant women and for other infectious diseases.

India has a large immunisation programme that has led to its emergence as the largest vaccine producer in the world. Annual immunisation against nearly a dozen infectious diseases and the natal and neo-natal immunisations number 400 million doses annually covering about 60 million people. This means nearly 34 million monthly doses and the Covid-19 drive would add another 100 million to it. However, this target needs to be revised in the face of the second wave.

Ramping up vaccination

It is clear that the COVID-19 vaccination rate is far too slow. In the first phase, beginning 16 January for healthcare and frontline workers, the offtake was lukewarm. Confusion was generated by statements about Covaxin (developed and produced by Bharat Biotech) use in “clinical trial mode” even as Phase III trial data was awaited while Covishield (developed by Astra-Zeneca and Oxford and produced by Serum Institute) was given “emergency use authorisation”. In Europe, there were reports about Covishield not being given to age group above 60 years because of suspected blood clot developments. On 1 March, the government opened vaccinations for those above 60 and also for those above 45 years suffering from co-morbidities and on1  April, to all above 45 years.

Demographic data indicates that the above 45 year cohort accounts for only 22 percent of the population. While it is true that this age group accounts for 60 percent of the cases of infection and 88 percent of COVID deaths, the second wave is also hitting the younger age groups hard because they are back at work, in fields, shops, factories and offices.

To date, 80 million vaccinations have been given; the current rate is approx. 3 million daily. At this rate, the target of 600 million doses for the priority population by July cannot be met. If it is assumed that for the 800 million Indians above 18 years that need 1.6 billion doses, at the current rate, vaccinations would continue till November 2022!

Currently, there are about 50,000 vaccination points with a target of 100 vaccinations each. However, because of reluctance and lack of effective communication strategies, the offtake is much less at many centres. In addition, there is a wastage of vaccines, estimated at 7 percent nationally and reflecting wide variations among states. Some wastage is inherent in such a large scale exercise but in a war-footing, every vaccine ought to get used. This has added to anxieties, especially among states worst impacted. It is therefore hardly surprising that Maharashtra, Delhi etc have started demanding that the government open up vaccination to all ages or allow the states to set their own rules to protect their populations and control outbreaks in most affected districts.

It is clear that the second wave is moving faster and according to preliminary calculations, 1.7 times faster than the first wave. At this pace, it could go beyond 150000 daily cases before it peaks. Second, the idea that the case fatality rate (CFR) is lower this time is turning out to be a fallacy because the delayed-CFR (using an 18 day lag) indicates that it is as deadly as the first wave. This means that we may soon see rates exceeding the peak of 1200 deaths daily during the first wave.

Policy changes

The first requirement is to open up vaccination and accelerate vaccinations to 10 million doses a day; in a manner that retains priority to those above 45 years, but below 45 years would also be accepted for vaccination, according to local situation and suitable guidelines. This requires delegating authority to states for establishing vaccination points and opening up vaccinations to age groups below 45 years.  Guidelines for monitoring the vaccinations would continue to be prescribed by the Indian Council of Medical Research (ICMR).

At three million-plus vaccinations daily, the government’s monthly demand of 100 million doses already exceeds the current production capacity of Serum Institute (SII) and Bharat Biotech (BB) that currently stands at 65 million and four million doses a month respectively. According to a report tabled by Department of Biotechnology in Rajya Sabha on 8 March, 2021, SII capacity is to go up to 100 million and BB to 10 million by mid-2021. Beyond that, the two companies have asked the central government for financial assistance to undertake scaling up production.

The central government has no choice in this matter. It had established a national task force to expand vaccine production under the Department of Biotechnology last year that has helped in development of diagnostics and promoted R&D for vaccine development. But the requirement now is different. The first priority is to fund an immediate expansion of production of the two approved vaccines, Covishield and Covaxin.

The second priority is to move forward on the approvals of the Russian vaccine Sputnik V for which the Russian company, Russian Direct Investment Fund (RDIF) has tied up with five Indian vaccine manufacturers to produce a total of 850 million doses in 2021. There are at least five other vaccines in the Indian pipeline, being developed by Biological E, Zydus Cadilla, Gennova Biopharmaceuticals, SII and BB’s nasal vaccine.

Meanwhile the single shot Johnson and Johnson should also be considered for early use, especially if Biological E is going to produce it in India. If the government finds it too expensive, its use can be allowed for the private sector. Large corporates will be glad to take on the responsibility for their workers and their families if they can be certain that their schedules will be spared the Covid outbreak disruptions.

The national wastage levels are estimated at 7 percent, with considerable variation among states. Opening up vaccination will put an end to this avoidable waste.

Current testing levels need to increase rapidly. The current level of 1.1 million tests daily is less than the 1.5 million tests conducted daily last September-October. With prices being much lower now, there is no reason why the testing numbers should not go to 2 million or even higher.

Finally, India has only undertaken sequencing of 11000, a fraction of 900000 genomes sequenced, of which nearly half are by US and UK. Large scale sequencing helps in early tracking of variants so that the mutations can be analysed. The ICMR labs are best suited to address this shortcoming. This will also help the Indian vaccine developers.

Finally, the most important lesson of the first wave is the need to change the mindset-from centralising control to delegating responsibility. In order to have a whole of government approach, the central government needs to focus on what only it can do and rely on the state governments to manage the ground situation. Local authorities are also better able to tailor communication strategies specific to demographic groups to ensure higher vaccination rates.

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