Failed Leadership, Late Assistance Behind India’s COVID Crisis, Experts Say

On Thursday, three Duke University experts on vaccines, economics, public policy and India spoke to journalists

Failed Leadership, Late Assistance Contributed To India’s COVID Crisis, Experts Say
David Montefiori, Manoj Mohanan and Dr. Krishna Udayakumar spoke to the media Thursday

India is the epicenter of the COVID-19 pandemic. There are far too few vaccine doses and far too many cases of the disease – cases that are surely being under-counted, experts say.

On Thursday, three Duke University experts on vaccines, economics, public policy and India spoke to journalists during a virtual news briefing about the situation in India and what can be done there and globally to improve the situation.

Watch the briefing on YouTube.

Here are excerpts:

Manoj Mohanan, health economist

On the situation in India

“In the early stages of the epidemic in India, it looked like the number of cases and deaths were lower. But actually we have a lot of cases in India … there were far, far more cases than were reported globally in the official news sources. Part of that was because of lower testing, a part of that was because of the testing policies, and a lot of asymptomatic cases.”

“The advent of new variants, the mutant variants that are now being transmitted, appear to be much more transmissible and more people appear to be getting sick.”

“In the early stages … the pandemic was much more focused in the slums, in the rural and urban poor.”

“As the epidemic moved into a different group of the population – the upper middle classes and upper classes … you would find that now that these populations are getting infected, the rates of complications and deaths have gone up.”

“About November, December, when worldwide everyone was talking about India not being as affected by the epidemic, people started taking this epidemic very lightly. A lot more family events, a lot more social festivals, a lot more religious festivals, lack of social distancing.”

"But also, lack of masking. Despite a lot of messaging from public health, because people were not given clear messages from the government and from higher-ups about the importance of masking and distancing, you find that the transmission went up.”

“A significant failure in my opinion, India decided to have large elections, and allowed massive religious festivals to happen where hundreds of thousands of people were getting together. It continues to happen even as of this week. There are festivals where thousands of people are getting together. It’s an ongoing fire and sadly, the inability to make the right policy decisions .. continues to add fuel to the fire.”


On chances the India-specific crisis could happen elsewhere

“Some of the circumstances are replicable. We don’t know what the transmissibility looks like. If there are large populations getting together for music festivals, for example, and the transmission happens, we would be looking at a crisis.”

“As long as we are seeing current vaccines … give us some protection against these variants, I hope it won’t be nearly as bad. One thing I think all governments now realize is that holding massive political rallies or religious festivals is perhaps a very bad idea.”


On actual COVID case count in India

“The vast amount of data right now we have are only from official statistics. What that means is we know there’s an undercount. It includes acts both of omission and commission.”

“We are getting an undercount. There are probably at least a handful of offices where people are under pressure to not report as much as what they’re actually seeing.”

“Good data on deaths has been impossible to get. We know that there’s a huge gap between what’s reported and what has actually been happening.”


On leadership failures

“When government introduces policies, guidelines that conflict with the science, that’s where the challenge starts. You need to have the willingness to trust scientists to tell us what we know best and run with that. What we’re seeing in India now, even right now, the recommendations from state and central governments sometimes conflict with what scientists and clinicians tell us about how to manage this case. We need consistency of messaging.”


Dr. Krishna Udayakumar, professor of global health, medicine

On why the situation in India became so bad

“What we’ve seen is really a massive failure of leadership across multiple parts and systems in India. This was a foreseeable and foreseen second wave. Rather than using the time after the first wave that peaked in September to be better prepared, we saw many political leaders actually become complacent, declare victory and allow the loosening of public health tools and policies that we saw lead to exactly where we are now. It’s a tragic set of events that we’ve seen happen.”

“Vaccines are an incredibly important component of the global response, including the response in India, but unfortunately it won’t make much of a difference in the coming weeks. Much of the death and illness that we will see in the coming weeks is already built in. This number of 400,000 cases a day … 4,000 deaths a day … will continue to go up for weeks, unfortunately, no matter what we do today.”


On taking a coordinated global approach to dealing with variants

“Over and over, we’re seeing the same pattern. There are surges that take place. The surges are highly dynamic in nature. They’re not limited, geographically. We know India had a first surge in the fall that led to false confidence, and now we’re seeing a second surge. But go back a few weeks, and this is exactly what we were seeing in Brazil. Some of the local circumstances were different, the variant of dominance there was different, but it’s the same dynamics on the ground.”

“This will continue to be a global pandemic.”

“We’re starting to see a huge amount of global assistance flow to India, but frankly it’s too little, too late. The surge started weeks ago. Bringing huge planeloads of supplies in, when people are dying for lack of oxygen, that’s going to be weeks too late.”

“We’ve got to really become better at predicting where the next wave is going to happen.”

“In terms of political will, we have to move services, move supplies where they’re needed ahead of it becoming a crisis. We shouldn’t have to see, on television, thousands of people dying for lack of oxygen, or lack of basic supplies, before we mobilize our response.”


On intellectual property protection waivers

“Historically, what we have seen going back 20 years is a lack of affordable access in low- and middle-income countries to many of the interventions that could save lives and improve health that initially roll out in high-income countries. With the HIV/AIDS epidemic, shamefully, it took a decade before drugs that were effective became widely available in the other parts of the world.”

“In the instance of COVID, there of course has been a challenge to ramp up manufacturing and equitable access to COVID vaccines around the world. One of the areas that is an issue is around intellectual property. Most of the vaccines that have been developed … are protected by intellectual property.”

“Going back now several months, India and South Africa initially had made a request to the World Trade Organization … to waive intellectual property rights for specific vaccines, but also for diagnostics and therapies. Creating flexibility around IP would allow greater access to all the things that are necessary.”

“The U.S. clearly hears much of the rest of the world is willing to engage and be a good global citizen and is willing to do whatever it takes to mount a global response.”

“We’re looking at weeks to months to negotiate what is very likely to be a narrow waiver of IP. What I fear is this is not going to do anything substantive in the next three to six months, which is the critical time for the world to get access to vaccines.”


On short-term help to improve the situation in India

“We’ve got to figure out how to get more global assistance to India and get those supplies distributed to where they need to go. They cannot sit in airports or on tarmacs.”

“There also has to be a stronger receptivity by the central government in India. A recognition that India needs support at the moment and an openness to cutting through the red tape and bureaucracy to get things where they need to go.”

“There must be stronger public health measures put into place. Social distancing, masking where possible. We have to do things like actual travel restrictions, potential lockdowns.”

“We know there could be economic devastation, especially to the most vulnerable populations … so for them to be effective in terms of protecting public health, those types of lockdowns need to be coupled with social and other protections for the most vulnerable populations.”

“We have to ramp up manufacturing capacity in India to get us where we need to be.”


On leadership failures

“The biggest lesson is leadership matters. The countries that have done the best have had very strong leadership and the ones that have suffered the most have had poor leadership. It’s not that we don’t know the science. The science has overdelivered any reasonable expectation in the last year and a half. Our political leadership, our political will, is really what has failed us in many parts of the world.”


David Montefiori, vaccine expert

On the COVID-19 variant in India going global        

“We already know … that this variant is found in multiple other countries. It has spread. Whether or not it has an advantage for transmission … isn’t entirely clear. It’s out there in the rest of the world. It’s competing with a number of other variants.”

“It is spreading. It already has spread to many other countries. We’re keeping a close eye on it.”


On where else the India variant is found

“There have been at least 760 cases of it in the UK; that seems to be one of the other hotspots right now. They do a lot of sequencing there so that turns out to be a relatively small percentage of the total cases that are occurring there.”

“It is in many states in the United States and in many other European countries.”

“It’s not clear if this virus has a transmission advantage; how well it will compete with the other variants that are circulating. Almost anywhere you are in the world, it’s become a mix of variants that are circulating.”


On the India variant in the U.S.

“It is in multiple states right now (including five documented cases in North Carolina). Just looking at the map, I’d say it’s in at least half the states in the U.S.”


On whether vaccinated people can still carry, pass on the virus

“In some cases the vaccines are preventing infection altogether. There’s also evidence that vaccinated people who do get infected have lower virus loads so they’re less likely to transmit. And the virus doesn’t stick around as long. So, lower amounts of virus for a shorter amount of time.”


On restricting travel from countries with variants

“Given the number of cases that have already been observed in the United States, you can say the horse has already left the barn. But certainly if you have fewer people coming into the country carrying that particular variant, you can assume that there would be fewer cases with that variant. I suppose any measure to limit the number of additional cases is going to be helpful, but in the end, how helpful isn’t really clear.”


On what the U.S. and world should learn from the India crisis

“One thing we’ve learned from this pandemic is how effective the prevention measures have been. Wearing a mask, social distancing, avoid being in crowds, washing your hands frequently, are very, very effective. We saw that in the most recent flu season, which has been basically almost non-existent because these measures were in place.”

“In the United States, we were very slow to adopt those policies. It’s a very important lesson we’ve learned from this pandemic.”

Meet the experts:

Manoj Mohanan
Manoj Mohanan is a health economist and an associate professor at the Sanford School of Public Policy, the Duke Global Health Institute and Economics Department at Duke. His recent research includes estimating the true number of COVID cases in India.

David Montefiori
David Montefiori is a professor and director of the Laboratory for AIDS Vaccine Research and Development at Duke University Medical Center, where he has been studying the effectiveness of COVID-19 vaccines against new variants of the virus.

Dr. Krishna Udayakumar
Dr. Krishna Udayakumar is an associate professor of global health and medicine at Duke. He directs the Duke Global Health Innovation Center, which has been monitoring efforts to vaccinate the world’s population against COVID-19.