The COVID-19 Pandemic Dynamics and Response in India

In December 2019, COVID-19 was first identified in Wuhan, China, as a respiratory tract infection causing symptoms, such as fever, chills, dry cough, fatigue, and shortness of breath [1, 2]. This atypical viral pneumonia has disabled the world, causing health, economic, and humanitarian crises. The novel coronavirus belongs to the family of severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome coronavirus (MERS-CoV), but the impact of the former is more severe as illustrated by the exponential increase in infectious cases [2, 3]. The incubation period of COVID-19 is 1–14 days, during which asymptomatic carriers of the virus can transmit the disease to healthy people, as proven by the evidence of human-to-human transmission via droplets or contact [2,3,4]. At the end of January 2020, the World Health Organization (WHO) declared COVID-19 as a Public Health Emergency of International Concern according to the standards of International Health Regulations (2005) [5]. Due to the unprecedented spread of the virus, the world has gone into multiple lockdowns as several countries have imposed strict restrictions and screening of potential cases [6].

On January 30, 2020, India reported the country’s first case of COVID-19 in Kerala. The index case identified was a student returning from Wuhan. As of February 3, 2020, a total of three cases were confirmed in Kerala. By February 20, 2020, they were declared recovered [7]. Little information was provided regarding the initial COVID-19 cases in India, and thus, it is unknown whether they were contacts of the first case or whether they had a travel history [2]. However, after a month the number of cases started to increase dramatically. According to the Ministry of Health and Family Welfare, the transmission of COVID-19 was mainly related to travel and local transmission of imported cases. Limited community transmission was reported on March 30, 2020 [8]. However, Klein et al. indicate that community transmission in India most likely started at the beginning of March [9].

On March 14, 2020, India reported its first two COVID-19-related deaths. Both patients were over the age of 65 years and had comorbidities [7]. Throughout the first weeks of the outbreak and until mid-May, India’s case fatality ratio remained stable at a constant 3.2%. As of June 9, 2020, the case fatality ratio dropped to 2.8% by 0.6 deaths per 100,000. India’s case fatality ratio resembled the aggregated case fatality ratio of the South-East Asia Region [7].

The availability of desegregated data was sparce. However, according to a press release by the Ministry of Health and Family Welfare on April 6, 2020, 76% of confirmed cases were male. The age distribution of confirmed cases was as follows—47% were below 40 years, 34% were between 40 and 60 years, and 19% were 60 years and older. Furthermore, desegregated mortality data was reported: 73% of reported deaths were male and 27% female. Although only 19% of cases were among elderly people, 63% of deaths were in the age group of 60 and above. About 30% were between 40 and 60 years, and 7% were younger than 40 years. Moreover, 86% of the casualties suffered from comorbidities [10].

Travel Restrictions

On January 30, 2020, after the WHO’s declaration of COVID-19 as a Public Health Emergency of International Concern, the civil aviation authority began universal health screening of international passengers at the entry point from China by temperature check and filing self-declaration forms in line with the International Health Regulations 2005 for point of entry screening [2, 5, 7]. Screening expanded for passengers traveling from other countries as COVID-19 began spreading globally [11]. States with no international airports and/or seaports began monitoring the influx of travelers by rail and road to check for potential cases [7]. On March 11, 2020, when WHO declared COVID-19 as a pandemic, Indian authorities banned visas and nonessential travel from affected countries, including China, Iran, Italy, South Korea, France, Spain, and Germany. Travel restrictions began on March 13, 2020, as visa issuance was restricted to essential travel and delegates only. Subsequently, all international passengers entering India were required to go through screening tests. The travel ban expanded to all European countries and nations of the Middle East on March 18, 2020 [12].

Passengers with COVID-19, arriving from affected countries, were put in quarantine for 14 days in the port of arrival city, while asymptomatic and/or healthy passengers were advised to commence home quarantine and test for COVID-19 should symptoms appear [2, 13]. Passengers’ left hand was stamped with inedible ink to maintain the date and time for home quarantine, a move that could risk stigma on account of COVID-19 suspicion [14]. Individuals violating quarantine could be penalized under the Indian Penal Code sections 188, 269, and 270, that is, ‘violation of order promulgated,’ ‘negligently doing any act known to be likely to spread infection of any disease dangerous to life,’ and ‘malignantly doing any act known to be likely to spread infection of any disease dangerous to life,’ respectively [15].

As a stringent lockdown was imposed in Wuhan, the Indian Air Force evacuated 112 nationals stranded in Wuhan, 76 Indians, and 36 foreign nationals, to Delhi, while also providing 15 tons of medical equipment and safety kits to China [2, 16]. Following the subsequent surge of COVID-19 cases in Italy, Air India evacuated Indians from Rome and Iran. All evacuees were taken to quarantine in Delhi [17]. On March 14, 2020, all public gathering areas, such as cinemas, malls, marriage halls, pubs, marathons, and bars, were closed [7]. Section 144 of the Indian penal code on unlawful gatherings of more than four people was imposed to avoid crowds [10]. The Ministry of Home Affairs postponed indefinitely the decennial 16th National Population Census for 2021, originally to be conducted during April, 2020 [2, 18]. The Prime Minister of India declared March 22, 2020, as ‘Janta (People’s) Curfew’ to ensure social distancing, before enforcing a nationwide lockdown for 21 days, starting March 25, 2020 [18]. Any person caught violating the lockdown for nonessential reasons was baton charged by the police deployed in city streets. However, the baton charge and excessive force used by the police received criticism, as reported by Human Rights Watch [2, 14].

On March 25, 2020, the Government of India imposed a sudden complete nationwide lockdown for 21 days, with the closure of nonessential markets and a complete halt to all national rail networks and international and domestic flights [2, 7]. However, these sudden restrictions turned into a challenge for daily-wage workers and migrant laborers who could not continue to earn their living nor return to their hometowns, due to the closure of rail and road networks [19]. The short notice before commencing lockdown of a population of 1.3 billion stranded thousands of migrants. This garnered severe criticism as the government had not managed the migrant crisis despite releasing 265 billion dollars of relief funds to tackle COVID-19 [2]. The sudden lockdown resulted in scores of migrants walking back home for miles, essentially risking viral transmission through their long journey [19]. The Home Ministry urged the creation of temporary shelters for citizens affected by the restrictions, with all states and union territories expected to follow suit [18]. However, the mass exodus of migrant laborers continued to occur, as only limited dedicated buses and trains for migrants were arranged by the state governments. Moreover, due to the onset of summer and heat waves, many migrant laborers perished during their journey home [20].

India went under four phases of lockdown extensions and entered its fifth phase on June 8, 2020, where regions deemed safe, called ‘green zones,’ eased restrictions for movement and business operations, whereas danger ‘red’ zones continued stringent travel and trade restrictions [18]. However, limited domestic air and rail travel resumed with appropriate safety precautions for citizens that demonstrated necessity post-May 25, 2020, and June 1, 2020, respectively. An ‘unlock’ phase coincided with the 5th lockdown in order to restart selected businesses, educational institutions, and local public transport, while maintaining distance and hygiene [7, 18].

COVID-19 updates were made available online through a crowd-sourced Web site, which was launched by a group of volunteers to present an estimate of cases occurring daily all over the country. This Web site gathered data from state press releases, official government links, and reputed news sources to compile information [21]. Other Web site sources included data from the Ministry of Health and Family Welfare which presented explicit, graphical information of infectious cases [22].

The Government of India also launched a mobile application called Aarogya Setu on April 2, 2020, for citizens to be informed about their potential risk of infection, medical advisories, and health practices to contain COVID-19, to self-assess their symptoms, as well as to ensure contact tracing. It was mandated that the application must be downloaded onto smartphones by domestic travelers to assist in contact tracing [7].

While the Indian government was praised for instituting an early lockdown, it has been criticized for imposing among the harshest lockdowns worldwide. Several of India’s prominent epidemiologists warned against a lockdown in the absence of civil organization [23]. Amid the government’s controversial Citizen Amendment Act, passed at the end of 2019, aimed at providing Indian citizenship to people of certain religious backgrounds, civil unrest that arose before the pandemic hit the country. Persisting stigmatization and persecution of Muslims resulted in their initial blame for spreading the infection in India [2, 24]. Such offensive behavior extended to healthcare workers who were dispelled as ‘carriers of the infection’ and denied entry to their own homes by neighbors. Moreover, the Prime Minister’s emphasis on ‘self-reliance’ during the pandemic raised questions, given the country’s scarce resources and inability to meet demands for healthcare provision, risk mitigation, and management strategies [24].

The COVID-19 Health Advisory

On January 30, 2020, with the advice of the WHO, the Government of India initiated awareness of proper hygiene and sanitation advice to prevent the spread of disease [25]. A major focus was put on proper hand-washing, covering oneself while coughing and sneezing, social distancing, thorough cooking of meat, and avoiding contact with live animals in farms and markets. The WHO Country Office (WCO) of India worked with the Indian Council of Medical Research (ICMR) and the National Center for Disease Control to build laboratory and disease surveillance capacity [26].

By March 9, 2020, WCO, along with the Ministry of Information and Broadcasting, directed all telecom operators in India to launch a special COVID-19 caller tune to raise awareness about prevention strategies [7]. In a bid to amplify sales, Reckitt Benckiser, a prominent health, hygiene, and home products company, released a liquid handwash advertisement, vilifying rivals Hindustan Unilever’s soap bar by claiming that the former’s liquid handwash was more effective for cleaning hands [2]. The Bombay High Court suspended the ad for one month from March 22 to April 21 to stop unverified claims and misleading information [27].

Guidelines on protection measures such as wearing face masks in public places were provided by the government after the first lockdown in March [28]. Guidelines, such as social distancing, avoiding spitting in public, and avoiding mass gatherings, were enforced [2].

Following the proliferation of misinformation through social media regarding false remedies and fake news, the Government of India launched a ‘MyGov Corona Helpdesk’ on the highly popular social media application WhatsApp. This channel served to distribute accurate and verified information to Indian audiences [28]. Widespread rumors were addressed by WHO and physicians about various false claims regarding surveillance, testing, and treatment (e.g., alcohol and garlic intake as a cure) and avoiding large-scale panic purchases [28].

Testing and Screening for COVID-19

By the end of March, through rigorous point of entry surveillance efforts, India had conducted thermal scans on more than 1.5 million passengers at the airports, placing thousands of passengers under surveillance and in home-based isolation [7]. As of February 5, 2020, India increased testing capacity with the help of eleven new laboratories including the National Institute of Virology in Pune [7]. By March 9, 2020, India further increased the network of laboratories fit for testing COVID-19 to 52. And, by the end of March, this network was further expanded to more than 100 laboratories [7]. As a result, the number of tested samples increased correspondingly. At the beginning of February, the laboratories tested 49 samples. This number moderately increased to 2880 by February 28, 2020, before testing began more rigorously and increased to 22, 928 samples by March 25, 2020 [29]. By mid-April, India further increased testing capacity to 229 private and government laboratories raising its testing to 195,748 samples [7, 29, 30]. On May 18, 2020, India reached a milestone of 100,000 tests in one day [7]. As of June 12, 2020, India ramped up its capacity to a total of 885 laboratories fit for testing for COVID-19, conducting more than 125,000 tests a day [7, 31]. However, despite the significantly increased capacity from 130 tests per million on April 11, 2020, India conducts remarkably fewer tests as compared to other countries [32]. Additionally, Ray et al. doubt that the cases reported reflect the actual epidemiological situation and mention that the number of truly affected cases ‘depends on the extent of testing, the accuracy of the test results, and, in particular, frequency and scale of testing of asymptomatic cases who may have been exposed’ [33].

In order to contain the spread of the disease, ICMR reviews and updates the testing strategy periodically. Accordingly, ICMR defined criteria for testing asymptomatic patients and patients with influenza-like symptoms and conditions on March 20, 2020, and April 9, 2020, respectively [34, 35]. ICMR’s sero-survey with IgG ELISA test showed that 0.73% of the enrolled 26,400 individuals had contracted SARS-CoV-2 leaving a large proportion of the population still susceptible [2, 36]. ICMR also issued infection control, clinical management, and treatment protocols for COVID-19. However, paradoxically, access to and distribution of treatment and pharmaceuticals have been affected by the pandemic itself.

COVID-19 Treatment and the Impact on Pharmaceuticals

With Chinese production activities suspended, Indian pharmaceutical companies were threatened by a short supply of pharmaceutical ingredients. China delivers almost 70% of the active pharmaceutical ingredients for medicines produced by Indian companies, leaving India vulnerable in managing its fragile supply chain during the COVID-19 pandemic [37]. In addition, hoarding and panic buying created an artificial shortage of active pharmaceutical ingredients, leading to a bulge in the price for paracetamol, vitamins, and penicillin [2, 37]. As a protective measure, the Government of India installed an export ban on essential medicines [2, 38]. Both disruption in supply and export restrictions threatened the availability of essential and generic medicines. Considering the production capacities of Indian pharmaceutical companies, preventing a disruption to India’s production and supply chains increased their preparedness for large-scale production for COVID-19 diagnostic tools and vaccine candidates. Furthermore, there was a political will to incentivize the industry to increase domestic manufacturing capacity of active pharmaceutical ingredients and strengthen national security by decreasing dependence on Chinese imports [37].

However, it is important to guard against what Newton et al. warn as risks to the supply and quality of tests, drugs, and vaccines imposed by a lack of evidence and quality [39]. For example, the Medicine Quality Monitoring Globe Index in India reported issues related to substandard or falsified medical products. There were reports regarding fake vaccines and hand sanitizers sold at exorbitant prices [40]. The antimalarial drug hydroxychloroquine was also substantially used as a prophylaxis for COVID-19 [41]. While ICMR’s revised treatment protocols allowed hydroxychloroquine to be prescribed to patients in the early course of the disease, they also advised against the use of the antimalarial in patients with severe disease since the evidence for its use ‘remains limited.’

India initially banned the export of hydroxychloroquine for meeting domestic demand; however, the ban was partially lifted after the US government requested the export of hydroxychloroquine for prevention [2]. The drug was later exported to 20 more countries that placed requests for the tablets [42]. India supplies 70% of the world’s hydroxychloroquine and aims to export 250 million hydroxychloroquine tables to countries seeking the medicine [43]. However, due to a lack of evidence on the efficacy of the drug, WHO recommended that hydroxychloroquine undergoes a solidarity trial in over 35 countries [44, 45].

In addition to various treatment options, there was a strong push to develop a COVID-19 vaccine, which could be distributed to the public quickly. Latest updates suggest that the Oxford–AstraZeneca vaccine is expected to become the mainstay of India's vaccination program. The Subject Expert Committee will analyze the latest data submitted by the Serum Institute of India on the indigenous vaccine candidate by Bharat Biotech. India rolled out its vaccination program in January 2021 with the aim of inoculating 300 million persons in the first phase by July 2021.

This section has provided insight into the initial pandemic dynamics and response in India based on a review of the literature. It is evident that the COVID-19 situation presents significant challenges for India’s healthcare infrastructure and economics. Given India’s population of 1.3 billion and its very limited expenditure on public health to meet the needs of its population, the impact of the COVID-19 pandemic on the country’s health infrastructure and economy may be difficult to fully and accurately assess at this point. However, all evidence suggests that the pandemic will likely cause a significant dent in the current health system.

India’s overall healthcare system has limited capacity and a strong focus on primary health care delivery. The country’s healthcare expenditure is 3.5% of the national gross domestic product (GDP). However, only 1.28% of government public expenditure of total government revenue is used for healthcare expenditure, indicating a high out-of-pocket burden [2].

After detecting the first case of COVID-19 on January 30, 2020, India experienced a delayed growth in its case count. The initial spread was mainly driven by imported cases and local transmission. However, there are some studies that indicate community transmission was prevalent by March 2020. Subsequently, India recorded a constantly increasing daily incidence. As of December 30, 2020, the number of cases in India was recorded at 10.2 million.

The Context of This Book

In this section, the multiple health dimensions of COVID-19 in India and other countries are summarized. The authors have contributed chapters on various health aspects of the problem. These include responses to the impact of the pandemic on health services, technologies such as tele-medicine and other virtual solutions, comorbidities such as tuberculosis (TB), clinical aspects of COVID-19, continuity of sexual and reproductive health and family planning services and self-care in Sub-Saharan Africa and Asia. The impact of COVID-19 on mental health is analyzed. Its effect on sexual and reproductive health and family planning is examined. And its impact on nutrition and hunger is discussed. The impact of the pandemic on vulnerable groups including interstate migrants and female sex workers is assessed. The gender dimensions of COVID-19 are also analyzed. Health financing in the COVID era is examined. A detailed description is provided on the development, procurement, and distribution of vaccines in India. And finally, the successful experience of New Zealand and lessons drawn from countries in Asia that have successfully contained the pandemic are discussed.

As the pandemic is evolving rapidly, data related to COVID-19 changes almost every day. The data provided by the authors pertains to the time when they wrote their chapters. It will certainly change by the time this book is published.

Responding to the Impact of COVID-19 on Health Service Delivery

The COVID-19 pandemic has placed an enormous load on the health systems of all countries. The pressure on the health systems of low- and middle-income countries has been particularly serious as these countries have a fragile health infrastructure. The delivery of all health services, including essential services, has been affected because attention and resources have been deflected to providing services for COVID-19 patients.

The abrupt national lockdown implemented by the Government of India on March 24, 2020, resulted in an unexpected closure of the healthcare system which was devastating. There was a disruption in health services countrywide. There was no access to essential health services. People could not access sexual and reproductive health services or services for tuberculosis (TB) and other communicable and non-communicable diseases. The impact of and response to these service delivery problems are discussed by the authors.

Investing in a Resilient and Responsive Healthcare System During COVID-19 Pandemic

Bulbul Sood discusses strategies implemented by Jhpiego nationally and in 15 states of India to respond to the COVID-19 emergency and to counter the devastating impact of the pandemic. By the time the nationwide lockdown was imposed in March 2020, Jhpiego’s COVID-19 response strategy was in action. This strategy included strengthening the capacity of the health workforce, supporting the national and the state governments, and ensuring the continuation of essential health services including reproductive health services. Jhpiego mounted a swift multi-sectoral and multipronged program to provide technical support for enhancing the preparedness of the healthcare system across 15 states. Training and monitoring activities were conducted using virtual platforms. A decentralized approach was employed to co-design with the community local solutions for health problems. The thrust was on developing community-centered, community-owned, and community-driven programs. Digital technology, including tele-medicine and other innovative solutions, played a key part in these efforts.

The program envisaged providing technical assistance for building a resilient healthcare system by strengthening governance mechanisms and facility-based preparedness, piloting an integrated disease surveillance system, enhancing the use of data to guide evidence-based decision-making, redesigning public health facilities, and setting up rapid response teams which can be quickly mobilized to respond to crises.

Using Technology to Harness Existing Resources for an Emergency: COVID-19 Response

Gopi Gopalakrishnan discusses the use of technology to respond to the COVID-19 emergency. The sudden lockdown imposed by the government with just four hours’ notice resulted in a paralysis of the healthcare system. World Health Partners (WHP) responded immediately to this crisis. WHP worked in partnership with the state governments of Bihar and Andhra Pradesh. The plan was that the state governments would provide the personnel and WHP would set up a digitized system for providing health services to the people by using tele-medicine.

A quick-to-access dashboard was created to give details in real time of the number of doctors and assistants who were logged in, the number of calls received and was attended to, prescriptions issued, and COVID-19 suspects identified. Doctors’ absenteeism proved to be a challenge in Bihar. Consequently, the full potential of the project could not be realized in Bihar. In Andhra Pradesh, however, the project was very successful. Despite receiving less number of calls, more consultations were provided through tele-medicine project in Andhra Pradesh. The major reason for this success was the high level of political commitment by the state government which led to the availability of trained medical personnel for the project. The entire process of the project was successfully transitioned by WHP to the state government of Andhra Pradesh.

Unveiling the Clinical Face of COVID-19

Arti Singh and Ashutosh Singh discuss the clinical aspects of COVID-19. A picture of what happens in a hospital—the ward and the intensive care unit (ICU)—is described. The impact of the disease on patients, healthcare professionals, and hospital management is discussed. Case studies are provided of patients who recovered as well as those who did not. The lived experience of all these individuals is portrayed.

Arti Singh presents her own lived experience over the ten-month period of the pandemic. She describes her experience as well as that of her team from the inception—when the pandemic began. She traces changes made to date to diagnose and treat COVID-19 patients in the months that followed. Patient treatment and management regimens were refined and streamlined over time. And the health system was redesigned to cope with the influx of huge numbers of COVID-19 patients into the hospitals. During this time, diagnostic tools and treatment regimens evolved. Doctors and their teams of nurses and technicians worked tirelessly day and night to cope with the onslaught. The public, however, stigmatized healthcare workers as it was overcome with the fear of getting infected.

Ten months ago, the medical profession knew very little about the virus or the disease as both were new. But with its dedication and commitment, the medical fraternity managed to cope with the rising number of patients with whatever tools it had. The past ten months witnessed a rapid learning curve.

The Twin Epidemics: TB and COVID-19 in India

Chappal Mehra discusses the twin epidemics of COVID-19 and tuberculosis (TB) in India. He argues that COVID-19 has disrupted the health systems in low- and middle-income countries and has consequently unleashed a global health crisis. The lack of preparedness is visible at multiple levels of the healthcare system in India. The health system is overwhelmed by the influx of COVID-19 cases, dislodging all other patients. An inadequate healthcare infrastructure with less than optimal human resources along with a rising caseload and serious supply chain disruptions has resulted in fatigue, frustration, and anger among the health work force, on the one hand, and an atmosphere of fear among the patients and healthcare workers, on the other.

The media is filled with messages on the COVID-19 crisis. Forgotten in the hyperbole is that numerous other diseases continue to devastate India’s population. Of these, the most important is TB. India continues to bear the highest burden of TB in the world accounting for estimated 2.8 million cases every year and killing more than 400,000 persons annually. TB kills 1200 Indians every day.

The symptoms of COVID-19 and TB are very similar. Both are respiratory airborne diseases. Both diseases are heavily stigmatized. And both are associated with mental health problems. Gender disparities are apparent in TB and COVID-19, but the gendered aspects of these diseases are ignored in programming. The author argues that for all these reasons, these two diseases should be addressed in tandem. It is time to fight COVID-19 and TB just as it is time to invest in public health.

Ensuring the Continuity of Sexual Reproductive Health and Family Planning Services During the COVID-19 Pandemic: Experiences and Lessons from the Women’s Integrated Sexual Health Program

One of the main aims of the UK-aid funded Women’s Integrated Sexual Health (WISH2ACTION-W2A) program is to strengthen government stewardship of sexual and reproductive health/family planning (SRH/FP) services across seven countries in South Asia and Sub-Saharan Africa. Options Consultancy provides technical assistance within four work streams: (1) creation of a favorable policy and planning environment; (2) improved public sector investment; (3) national stewardship over quality improvement; and (4) establishment of accountability systems to influence and track commitments and policies. This role became even more important since the coronavirus disease 2019 (COVID-19) outbreak shifted government’s priorities to the COVID response and led to the disruption in the delivery of essential health services, threatening to undo and reverse the SRH/FP gains made to date. The experiences in engaging governments to ensure that access to SRH/FP remains a priority and enabling environment is maintained are discussed by the authors. The authors draw out wider lessons on the range of actions that can be taken at policy and systems level to protect SRH/FP during a health emergency in different country contexts, including the severity of the outbreak, sociopolitical environment, and health systems preparedness. The authors also highlight how the pandemic can provide new policy opportunities, such as to accelerate self-care and strengthen health systems resilience.

COVID-19 Vaccine Development and Administration in India

Drishya Pathak and Philo Magdalene examine, in great detail, issues related to vaccine development, production, and distribution in India. They discuss the problems related to logistics for the distribution of vaccines to India’s large population. The role of international organizations engaged in vaccine development, procurement, and distribution is also examined.

The development of vaccines for COVID-19 within a ten-month period has been an extraordinary achievement given that in the past it has taken 10–15 years to develop a vaccine. Five vaccine candidates are in different stages of development in India.

India’s robust capacity for developing vaccines is globally acknowledged. India has also had a long history in organizing and implementing immunization programs for pregnant women and children. However, organizing a national vaccination program for COVID-19 is challenging because of India’s large population and fragile health infrastructure.

India rolled out the COVID-19 vaccination program in January 2021. The state governments have developed plans for the storage and distribution of vaccines and for the implementation of the vaccination program. Important elements within the program are communications and advocacy which aim to inform the people about the vaccine and its benefits and to encourage them to get vaccinated so that the problem of vaccine hesitancy, a major deterrent, can be prevented.

India and the world are at a critical juncture in the history of the pandemic where the availability of vaccines shows a glimmer of hope—a light at the end of a dark tunnel.

The Impact of COVID-19 on Mental Health, Nutrition and Hunger, Sexual and Reproductive Health and Rights, Family Planning, Gender, and Health Financing

The COVID-19 pandemic affected multifarious health dimensions. Since attention and resources were deflected for treatment of COVID-19 cases, all other health services were adversely impacted. This, in turn, impacted mental health, nutrition, sexual and reproductive health, gender, and health financing.

A Lifestyle Disorder that Spared Nobody: Mental Health and COVID-19

Komal Mittal and co-authors discuss the mental health problems that emerged during the COVID-19 pandemic. Mental health has manifested as a lifestyle disorder that is being experienced by everybody all around the world. The authors discuss a range of mental health problems due to COVID-19. Their prevalence and implications are assessed. In order to provide perspective, publications from India and other countries are cited. The causes and consequences of mental health problems associated with COVID-19 are analyzed by the authors.

In India, mental health problems were on the rise even before the pandemic. The pandemic, however, greatly exacerbated these problems. Stress, anxiety, and depression became a part of everyone’s life. No one was spared. Strong public health measures to contain the pandemic including the prohibition of movement and isolation took their toll. Being away from work, school, and peers, adjusting to new ways of working and learning, and dealing with job loss were all stressful. Fake news and miscommunication further fueled the problem.

A large section of the population was forced to reinvent its workplace, often in unfavorable environments, resulting in a deep sense of unease. Research shows that because of uncertainties related to finances, work pressure, and jobs, there was a rise in the number of cases of mental illness. The number of suicides also increased. Research in India and other countries underscores that COVID-19 has compounded all these problems. Stringent public health measures imposed by all governments, although necessary for containing the pandemic, has had a major impact on the psychological state of the people. Fear, anxiety, and anger are some of the psychological consequences. Anxiety producing information in the media, often incorrect, accentuated these problems.

Preoccupation with the pandemic resulted in a neglect of the mental well-being of the patients, healthcare professionals, and frontline workers. This caused psychological distress that varied from panic attacks and collective hysteria to pervasive feelings of hopelessness and desperation including suicidal behavior. The psychological wellness of individuals was influenced unfavorably by lifestyle changes caused by the pandemic that included isolation, limited mobility, social stigma, ever-spreading misinformation, and fake news on Web-based platforms.

Violence against women and girls also increased during the pandemic. Increased violence was perpetuated not only inside the home, but also in other spaces. Migrant workers, health workers, and sex workers were seriously impacted. The authors underscore the urgent need for setting up hotlines, crises centers, shelters, legal aid, and counseling services.

The pandemic might be the much-needed wake-up call to make long-term improvements in India’s healthcare system. It offers an opportunity for India to take greater cognizance of mental health problems and to integrate services for addressing these problems within the primary healthcare system.

Malnutrition and COVID-19 in India

Shweta Khandelwal argues that while the world is battling, the new coronavirus known as SARS-COV-2, public health and nutrition services in India are getting disrupted and derailed. It is pertinent not to overlook the other existing gaps in our journey toward attaining the holistic Sustainable Development Goals (SDGs). In fact, it is now well established that comorbidities, especially malnutrition, diabetes, cardiovascular diseases, and other respiratory or kidney problems, exacerbate pathogenesis of COVID-19 because of an already compromised immune system. The whole world is off track in achieving SDG 2, known as Zero Hunger by 2030. At the current pace, approximately 17 countries including India will fail to even reach low hunger by 2030. India ranks 104 out of 117 countries as per the used metric, the global hunger index. Furthermore, these projections do not account for the impact of the COVID-19 pandemic, which may worsen hunger and undernutrition in the near term and affect countries’ trajectories into the future.

The author underscores the serious adverse impact of COVID-19 on public health, nutrition, and food security in India and other low- and middle-income countries. Estimates show that 135 million persons were hungry before the pandemic. By the end of 2020, the number will likely increase to 265 million. India carries a heavy burden of multiple forms of malnutrition including undernutrition, hunger, micronutrient deficiencies as well as overweight–obesity. The author suggests that public health and nutritional policies must urgently address these problems. She outlines the measures taken by the government during the pandemic to counter its negative impacts on the nutrition of women, children, migrant labor, and other vulnerable populations. The response of the international community to tackle COVID-19-related nutritional challenges and India’s policy measures for ensuring nutrition and food security are discussed.

Sexual and Reproductive Health of Adolescents and Young People in India: The Missing Links During and Beyond a Pandemic

Sapna Kedia and co-authors discuss the impact of the pandemic on the sexual and reproductive health of adolescents and young people. Adolescents and young adults (AYA) are at low risk from COVID-19, and hence, their needs may be assumed not to warrant immediate attention. However, it is important to understand how the pandemic may have affected their lives. Evidence from previous humanitarian disasters in India and elsewhere suggests that consequences for adolescents and young adults may be significant and multi-dimensional. The authors examine the impact (short and long term) of COVID-19 on the sexual and reproductive needs and behaviors of AYA in India, particularly their intimate relationships, sexual violence, access to services, and impact on their mental health.

Programs for AYA should be responsive to their needs, feelings, and experiences and should treat them with the respect they deserve, acknowledging their potential to be part of the solution, so that their life condition improves and the adverse impact of the pandemic is minimized. Programs must also address the needs of vulnerable AYA like migrants, those from the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community and persons with special needs, HIV-positive youth, and those who live in poverty. It is important to understand how gender impacts the sexual and reproductive health of AYA, of young girls and women, in terms of restriction and mobility, increase in dependence on male partners/friends/relatives, gender-based violence, control of sexuality, and the lack of privacy and confidentiality. The responses to these needs by youth-based and youth-serving organizations and the government are summarized. Recommendations are made to address the prevailing gaps from a sexual and reproductive health rights and social justice perspective.

Family Planning in India During the COVID-19 Pandemic

Sanghamitra Singh and Poonam Muttreja discuss the profound impact of the pandemic on women’s access to family planning services. They show how the interruption in the provision of reproductive health services resulted in a lack of access to contraceptives and consequent unplanned pregnancies and abortions. Unmet need for contraception increased while maternity care and immunization decreased. This resulted in an increase in unwanted pregnancies as well as maternal mortality and morbidity.

The COVID-19 crisis set back progress made in health services over the past decades. This was significant in the case of reproductive health programs. These programs were adversely affected because financial and manpower resources were diverted to services for COVID-19 patients. The authors provide estimates of the impact of the non-availability of sexual and reproductive health services on women. Suggestions are offered for mitigating the impact of COVID-19 on these health services.

Gender Insights into a Unique Threat to Human Development

Drawing from both primary and secondary data, Madhu Bala Nath examines the gender dimensions of the pandemic. While maintaining a focus on health, she discusses the linkages of health, poverty, and women’s agency. The COVID-19 pandemic has impacted the human development index that incorporates literacy, income, and life expectancy.

COVID-19 has severely impacted women’s reproductive health. Unintended pregnancies, abortions, and maternal mortality have increased as a consequence of the pandemic. The demand for services, especially nutritional services, child immunizations, and family planning services, was not met. Sexual and gender-based violence increased during the pandemic. Mental health problems also increased. All these problems affected women disproportionately. The impact of stigma on women’s health is discussed. Its effect on LGBT communities is underscored. The suicide rate in India was higher than that in other countries in South-East Asia even before the pandemic, but COVID-19 exacerbated this problem.

The author suggests that the government should support disadvantaged communities including the LGBTQ community by transferring leased assets as an eligible collateral for working capital loans. Relief packages for COVID-19 should be reworked so they are gender responsive.

COVID-19 is threatening the gains made by India to increase women’s education, livelihood opportunities, and labor force participation. It is also affecting women’s physical and mental health. The author makes a plea for strengthening women’s agency, a critical imperative for countering these problems.

Financing for a Resilient Health System in India: Lessons from the COVID Pandemic

Indrani Gupta discusses the issue of health financing. COVID-19 has brought into focus the urgent need for building resilient health systems that can cater efficiently and equitably to the population during normal times as well as during unforeseen events like an epidemic, pandemic, or other unanticipated events that impact human health. To be prepared well in advance means to avoid unnecessary morbidity and mortality on the one hand, and to minimize socioeconomic impact on individuals and households, on the other. The author argues that each component that goes into building a resilient health system requires financing, making health financing the key policy knob for the government. A review of the pandemic situation and the country’s response shows that India has had to struggle in real time to fill the various gaps in the health system during the pandemic, by making emergency investments on a variety of essential goods and services for the health sector. A brief analysis of key health system parameters is done as a situational assessment to emphasize the importance of adequate health finances. The author analysis the trends in out-of-pocket expenditure and government investment on health up until the latest 2021–22 budget announcement was made to understand how and to what extent the government prioritized health investments, especially when compared to other countries in a similar economic situation. Finally, the latest budget outlays for health are examined to analyze whether India has been able to use the pandemic as a wake-up call for prioritizing the health sector and building a stronger health system.

The Impact of COVID-19 on Vulnerable Populations

COVID-19 disproportionately impacted the lives and livelihoods of vulnerable populations. The situation of interstate migrant laborers and female sex workers, who were hardest hit by the pandemic, is discussed.

‘I Just Want to Go Home’: What the Lockdown Meant for India’s Interstate Migrant Workers

Philo Magdalene and co-authors provide a commentary on the interstate migrant exodus that took place after the government imposed the national lockdown to control the transmission of COVID-19 infection. The lives of the interstate migrant workers were seriously disrupted when the national lockdown was imposed. The authors bring into focus the inequalities of our times that resulted in serious human right violations. Migrant laborers were the hardest hit during the pandemic. Migrants and their families were pushed to starvation, deprivation, and destitution. The authors study this problem from a rights-based perspective.

The unprecedented lockdown resulted in a migrant frenzy. Millions of interstate migrants, stripped off their livelihood, were forced to flood the roads across the country in the last desperate bid to return home to their villages. Many chose to walk for weeks and weeks covering thousands of miles in their desperation to get home.

The authors discuss the horror that migrants faced as they went through their journey. The nightmare that ensued was a severe violation of human rights. Bedraggled, starved, and exhausted, the exploitation and hardship that they endured along with their families continued over time.

The migrant crisis not only hit the headlines in India but also drew the attention of world media.

From Vulnerability to Resilience: Sex Workers Fight COVID-19

Sushena Raza Paul and co-authors describe the plight of sex workers, a particularly disadvantaged community that is highly marginalized and vulnerable. Sex workers were hard hit by the pandemic. The authors examine the impact of COVID-19 on sex workers’ lives and livelihoods, their response to the crisis, and the strategies that they employed to battle the pandemic.

During the lockdown, female sex workers lost their livelihoods which plunged them and their families into extreme poverty. Even when unlock measures were announced, the business of sex work did not return to normal. Sex work, by its very nature, demands physical proximity—not physical distancing. Consequently, sex workers had to innovate to find work to survive. Loss of livelihoods also brought to the fore hidden mental health problems. Gripped by anxiety and depression due to the uncertainty about when the pandemic would end, sex workers went into despair. Some even attempted suicide. Violence in the family increased significantly. For sex workers living with HIV, there was the added anxiety about the continuation of antiretroviral therapy (ART). Community-based organizations (CBOs) took on the responsibility of providing drugs to sex workers by developing a unique supply chain. The CBO members collected the drugs from the health centers and delivered them to sex workers at a mutually convenient place, thereby ensuring confidentiality.

The authors draw attention to sex workers who are invisible in most discourses. This vulnerable, marginalized community was seriously affected by the pandemic. Sex workers were victims but were also the first responders to the pandemic. Sex worker collectives formed to fight HIV were by their very nature well equipped to fight the COVID-19 pandemic.

The government’s announcement to provide rations to the poor was a welcome move, but it was not of much help to sex workers as they did not possess ration cards. The sex worker collectives valiantly fought this battle and won. The Supreme Court of India directed the states to provide sex workers with dry rations without insisting on any proof.

The stories of the lives and resilience of sex workers, narrated in this chapter, are inspiring. The authors discuss the plight of female sex workers during the COVID-19 pandemic. The community of sex workers was missing from all government policies and welfare schemes. The sudden lockdown robbed them of their livelihoods. Basic necessities like food and shelter became illusive. The authors portray the stories of the struggles of sex workers from different parts of the country. They discuss how despite uncertainty, stigma, and loss of livelihoods, sex workers emerged strong. The resilient spirit of sex workers should be celebrated. The stories of sex workers have a common thread of resilience, resourcefulness, grit, and determination in the face of unsurmountable challenges.

Changing Role of Media and Communications in the COVID Era

Media and communications played a significant role in providing information to the people. Communications to change behaviors to prevent the transmission of infection were an important intervention. The adverse impact of miscommunication and fake news was a serious problem during the pandemic. These issues are discussed by the authors.

Communicating COVID: Learnings and Way Forward

Nandita Suneja and Kaushik Bose underscore the importance of five key components of a successful pandemic communication strategy—trust, timeliness, transparency, public, and planning. The authors state that the rapid dissemination of information in social media and other digital platforms has led to an overabundance of information about COVID-19 and much of it is false. This has been termed by the World Health Organization (WHO) as an ‘infodemic.’ Misinformation and disinformation about the origins of the pandemic, how it spread, and how it can be contained, have adversely impacted efforts to save lives. However, several international and national organizations have successfully countered these messages by using low-tech and high-tech technologies to build trust and encourage compliance with public health measures. Drawing on past experiences with previous pandemics, the authors discuss how communication strategies have been refined over time. Examples are provided of the impact of misinformation and disinformation on the pandemic in different countries. The experiences of countries around the world as well as that of India are analyzed.

Based on learnings with various communication approaches, the authors make recommendations for future crises: trust the science, identify credible spokespersons, consistently relay and leverage technologies, invest in digital literacy, sustain media engagement, and build inter-sectoral cooperation.

Relevance of Social and Behavior Change and Communications in the Media on COVID-19 Response

Sanghamitra and colleagues discuss the important role of social and behavior change and communication strategies in the prevention of infection. These strategies have two complementary, albeit distinct roles: (1) Educate citizens on the health risks of COVID-19; and (2) promote desired behaviors to prevent infection.

The authors believe that messages for the prevention of COVID-19 should be clear and consistent and should be based on scientific evidence. These messages need to be reinforced to promote positive behavior change. They should be empathetic and inclusive and should counter misinformation and fake news. Government of India’s citizen engagement platform ‘MyGov’ has rolled out a series of campaigns for the prevention of COVID-19. Civil society organizations have complemented the official campaign. The Population Foundation of India developed the Corona Ki Adalat (the court of corona) animation series to disseminate key messages and reinforce a sense of solidarity around the fight against COVID-19.

India and the world have, for the first time, witnessed an amalgamation of science and mainstream media. The collaboration of the media and public health workers and doctors has been commendable. The authors illustrate this with examples of personalities who stepped up and gave their time to the media to convey important messages to the public. The last few months have truly witnessed the power of the media and behavior change communication efforts. Until a vaccine is widely available, the only way to protect people from COVID-19 and to minimize the burden it places on the public health system is to promote widespread behavior change. And this can only happen through the collaborative efforts of the government, media, public health experts, and civil society organizations.

Experiences of Countries that Have Successfully Contained the Pandemic

Countries that have implemented programs that have been effective in containing the pandemic can provide lessons for those that are still struggling to bring down the number of COVID-19 cases. The authors have analyzed the strategies that were employed by these countries to draw learnings that could be useful globally and in India.

‘Go Ahead, Go Early’: New Zealand’s COVID-19 Elimination Strategy

Rashmi Pachauri Rajan describes how New Zealand successfully eliminated the virus. ‘Go ahead, Go early’ was New Zealand’s moto. Strict border controls and high compliance with lockdown measures proved to be effective in controlling the pandemic.

New Zealand’s official campaign ‘Unite Against COVID-19’ was later changed to ‘Unite for Recovery’ as the focus shifted from elimination to recovery. It has now changed back to ‘Unite for Recovery,’ and this will remain until the international threat of COVID-19 is eliminated.

The strategy was guided by science and data. The government followed public health advice and evolving evidence. And, of course, leadership played a crucial role. The Prime Minister was resolute, confident, and pragmatic. The messages she reiterated at the daily press conferences became catch phrases. Discipline came to the fore. People did not complain. They did not protest. They simply followed the rules, placing utmost trust in their government and its clear communications. Trust in political leaders and health experts was the key reason for the success of the program. And kindness was the Mantra!

Amid the gloom and doom that our world is currently battling, God was spotted in New Zealand. Someone asked God ‘What are you doing?’ ‘Working from home, Bro.’

Learnings from Asia

Saroj Pachauri and Ash Pachauri draw learnings from Asia by examining the strategies employed by governments in countries that have successfully contained the pandemic. They study the policies and strategies undertaken in Taiwan, South Korea, Vietnam, Singapore, East Timor, and Mongolia, countries that have successfully countered the ravages of COVID-19.

Rapid response to the pandemic by strong leaders who used evidence-based strategies, forged partnerships to build a sustainable program, and provided transparent communication is discussed. The leaders of these countries acted decisively in the COVID-19 response with a whole of government approach. The presence of robust public health systems along with national institutions that can act swiftly to prevent the spread of infection was an essential prerequisite for containing the pandemic. The process of enforcing top-down programs was shifted to a multi-stakeholder, participatory approach. Strong and compassionate leadership was undoubtedly the defining trait of nations to navigate time-sensitive issues in today’s pandemic era. Their experiences showed that policies that addressed equity issues and were compatible with the cultural context had a more enduring impact. In countries, where large numbers of infections are still being reported, it is time that leaders acknowledge the importance of acting rapidly on the best available evidence, with transparency and responsibility that is particularly critical in low-income, fragile settings.

The Research Imperative

The magnitude of the health and economic impact of COVID-19 in India and the world is still unfolding as cases are increasing. While the Government of India was compelled to take drastic measures for the management of COVID-19, forecasts predict a plunge in India’s GDP growth to the extent of 3.3% compared to estimations prior to the COVID-19 outbreak. As a low–middle-income country, the challenge of fiscal responsibility on the growing demand of medical supplies added to the already low public expenditure on health is a major concern. The global slowdown in production and supply might have far-reaching consequences for the Indian pharmaceutical industry, notably an essential driver of the Indian economy and its capacity to produce preventive or therapeutic medical products crucial to the Indian and global response in tackling COVID-19.

As we attempt to identify the profound challenges and potential fallouts of COVID-19 in India, we must address the paucity of research regarding the health dimensions of the pandemic and investigate how responses can be devised and how research priorities require us to embrace complexity by deploying multi-dimensional perspectives. Authored by experts in the field, this book is a compilation of perspectives on the important health dimensions of COVID-19, lessons learned, and future directions and strategies for mitigating and managing risks in a pandemic era.