Special: Covid is fast and furious 🚨

Exploring the aftershocks of the second wave in India

This is edition 289 of Beyond The First Order, a premium daily newsletter that demystifies the hidden models, incentives and consequences of the most significant events across India and Southeast Asia

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Good morning,

In March 2020, we started Beyond the First Order to map the consequences of Covid-19. Over a year later, we continue to bring you the second-order effects of this pandemic. As India battles the second wave, some of these consequences have become more brutal. This edition is a reflection of that.

Our healthcare reporters Ruhi and Maitri, along with our designer Prajakta, got together to map this impact that could push India’s healthcare system to the brink. Needless to say, it is a grim one. 

From a fungus that is spreading faster than the fastest-growing cancer to the lack of a central policy to tackle complications like Multisystem Inflammatory Syndrome in children. Besides health, the second surge is also exposing gaps in our child welfare system that can lead to more trafficking. This is an important edition, do share. 

State of Affairs

A fast and furious fungus

Imagine contracting Covid, recovering, and just when you think the worst is over, you’re struck by Mucormycosis or black fungus. 

It’s a lethal post-Covid fallout, largely seen in patients (even those in their 20s to 40s) with high blood sugar and a history of steroids intake.

Dr SP Kalantri, a senior physician from the rural district of Wardha in the central Indian state of Maharashtra, has seen at least 21 of the 1,000-odd Covid patients in his hospital contract the fungus in the last month alone. 

He says that the fungal infection can set in, in the uncanniest ways. On day one, it could be a stuffy nose, which progresses to pain in the teeth on day two. On the third day, there could be an unexplained infection setting in the teeth, which would swell painfully on the fourth day. By day five, patients are losing vision, as the infection spreads, rendering the entire face black and blue. 

Take the case of a 35-year-old police inspector hailing from Maharashtra’s Jalgaon district. A fortnight after his Covid infection, his teeth started loosening, so he rushed to a dentist. The dentist extracted a few teeth, but noticed that his palate (upper jaw) started shaking. He consulted two maxillo-facial surgeons and underwent a partial removal surgery as the infection had set in. 

His creatinine levels rose as the cheaper version of Amphotericin, a crucial drug to fight off the fungus, was administered to him during surgery (the costlier version was in short supply). He landed up at Dr Milind Navalakhe’s Mucormycosis clinic in the privately-run Global Hospital in Mumbai, where he underwent another surgery to remove his palate. 

“Healing from the infection and constructing a prosthesis in such patients takes up to three months. We have managed to save his eye until now, but the key to survival for patients is making it through a year post infection,” says Dr Navalakhe, who is seeing an increasing number of such cases lately.  

It is spreading faster than the fastest-growing cancer, he quips.

The treatment is exorbitantly expensive, involving costly drugs and multiple specialist doctors. It’s causing patients to sell their homes and land, as they run around seeking treatment.

The more expensive liposomal Amphotericin costs between Rs 7,000-10,000 (US$96-137) a vial. “Each adult patient may require anywhere between six to eight vials a day, which means they are spending up to Rs 80,000 (US$1,100) per day for 28-42 days. The drug itself will cost Rs 20 lakh (US$27,430). Also, it’s pertinent to note that the drug is in short supply, so access is an issue,” says Dr Navalakhe. 

India’s Ministry of Health and Family Welfare has asked states to announce that Mucormycosis is a notifiable disease, which means that every such case has to be reported to the government. But that does not really change things for patients desperate to access treatment in public hospitals. 

In Mumbai, civic hospitals like King Edward Memorial or Nair Hospital are teeming with such cases. Every hospital now has a separate ‘Mucor’ ward. In bigger hospitals, over 100 patients are admitted. But the lack of coordination between doctors of different specialties, dearth of funds for surgeries and care, as well as short supply of drugs is making the treatment of such patients next to impossible, said a senior doctor working in the civic administration, requesting anonymity. 

“If untreated, these patients will definitely die. In cases where patients are partially treated, the mortality is between 60-80%,” says Dr Navalakhe. 

The fungus in itself is not a new phenomenon. It is usually found in patients who consume immunosuppressants in cases of cancer treatment or organ transplants. A virus-altered immune response in case of Covid, with blood sugar of such patients spiking up and steroids reducing immunity, has created a perfect milieu for the fungus to flourish, Dr Kalantri says. 

The public health system in India is absolutely ill-prepared to treat patients with this deadly infection. “We are extremely worried that if these numbers start swelling they will destroy the healthcare system,” says Dr Kalantri. 

Covid in kids is no child’s play

An eight-year-old boy who was brought to Dr Bakul Parekh’s Mumbai-based children’s hospital with conjunctivitis and breathlessness is one of the many kids presenting Covid-like symptoms. But arriving at a definitive diagnosis is proving troublesome. 

An X-ray revealed pneumonia patches in the lungs. And he had a fever for four days, so he was given antibiotics. However, the boy’s RT-PCR test came back negative. His antibody tests, however, were positive, and Dr Parekh suspected that he had slipped into Multisystem Inflammatory Syndrome (MIS-C), a condition commonly being noticed in children. It is related to those who have already developed Covid and then tested negative, but portray acute post-Covid effects. 

In the whole of April, Dr Parekh saw 45 children with symptoms of fever, loose motions, abdominal pain, breathlessness, and MIS-C, of whom 22 children were hospitalised. 

While most children recover well over a week, of 100 symptomatic children, 10 require hospitalisation and one progresses on to a ventilator. It is for this reason that Maharashtra is readying its hospitals. Dr Parekh is also one of the members of the paediatric task force set up by the Maharashtra government to devise a plan for mitigating risks in children. Lest the pandemic’s third wave becomes brutal for kids. 

“We have recommended doubling our existing PICU (Covid Paediatric Intensive Care Unit) capacities, where a Covid PICU can be set up in a separate room, in the same facility which houses a regular PICU, because there is a dearth of Intensivists who can tend to children separately,” Dr Parekh explained. 

ICU care for kids developing severe post Covid MIS-C is crucial. Because kids whose heart muscle gets affected may get swollen feet, a distended liver, a fast heart rate, and low blood pressure. And these changes occur rapidly, sometimes in as few as 12 hours, says paediatric cardiologist Dr Swati Garekar, who has been monitoring such cases in Mumbai’s Fortis Hospital. 

In a Catch-22 situation where isolation of a child is tough, KP Sanghavi, a Mumbai-based neonatologist attached to private-run Jaslok Hospital, provides some practical tips to protect the family.

Here are a few:

  • Reverse isolate the elderly in the house, if it is difficult to tie down the kid to a room
  • If the child develops fever, they must be tested for RT-PCR
  • Kids who do not develop severe symptoms, will only require paracetamol, multivitamins, plenty of liquids, regular pulse oximeter readings
  • Do not neglect your child’s symptoms for a month post-Covid. If fever, stomach pain, breathlessness exacerbates or skin, lips, nail beds turn blue, it could be post-Covid MIS-C. Immediately seek a paediatrician’s help

From whatever little data is available, close to 80,000 children have been infected since the second surge in March.  Preparing adequate infrastructural facilities in case the number of cases in kids surge during the impending third wave is absolutely imperative, Dr Sanghavi says. Another imperative is to vaccinate. In the US, 600,000 children aged 12-15 years have received their first vaccine shot. Children in India still await their shot at hope. Vaccine trials for kids between 2-18 years may begin by June. 

Patriarchy + pandemic = Child trafficking

Earlier this month, the United Nations warned that vulnerable children are going to be adversely affected during the second wave of Covid-19 in India. 

“When we see that children are being orphaned and we do see that there is a lot of trafficking of children which is reported, children go missing, those systems are beginning to pick up on numbers…While there isn’t enough data yet, we can see that illegal adoption pleas have surfaced on social media, making these orphans vulnerable to trafficking and abuse,” said Yasmin Ali Haque, UNICEF Representative in India.

Haque was talking about messages like these shared on groups on Telegram, Instagram, and WhatsApp.

But this is illegal, as Smriti Irani, the Union Cabinet Minister for Women & Child Development, tweeted. The Central Adoption Resource Authority vets the parents willing to adopt and it usually takes at least two years for this process. 

The UN and other international agencies have also noted that human trafficking has been growing in India over the last decade. And according to a 2019 report by the Global Fund for Children, platforms such as WhatsApp are making it easier for consumers and traffickers to stay invisible and interact in India.

These two factors, along with the pandemic, have made government and non-government anti-trafficking efforts trickier and exacerbated the challenges in an imperfect system.

In India, 95% of the trafficked victims are forced into prostitution. However, more recently, there has been an increase in children trafficked for domestic work or other forms of child labour in cities. This is due to rising incomes in urban areas and wide-scale poverty in rural areas, according to HS Phoolka, a senior advocate at India’s Supreme Court and a human rights lawyer.

In a broken system, trafficking of orphans emerges as the second-order effect of the second wave of Covid-19. 

The governments—central and state—are trying to do what they can. In July last year, the home ministry had issued an advisory to the states and border security forces to step up vigil, identify high-risk groups, and bolster the Anti Human Trafficking Units, which are integrated task forces including representation from the government and non-government organisations. 

But it’s a piecemeal approach. The central government has not enacted the Anti-Trafficking Bill that was introduced in the Parliament in 2018. The bill suggests changes in current laws, including clear rights of victims, including compensation, and harsher punishment for traffickers and pimps.

Without any comprehensive plan to combat trafficking, the use of WhatsApp forwards calling for adoption has surfaced over the last year. 

Then, there are the increased child marriages.

In an interview earlier this year, the chairperson of Mumbai’s child welfare committee, Milind Bhidwai, noted that there was an increase in cases of child marriages during the Covid-induced lockdown in 2020 because of school closures. “Parents feel that they can just call the immediate family and get the girl married without anyone knowing. In some cases, if the girl has been sexually violated, they are being married off to the perpetrator as a form of “settlement” without anyone knowing,” he said.  

According to a paper published in October last year in the reputed journal, The Lancet, up to 2.5 million girls around the world are at risk of marriage in the next five years because of the pandemic. The burden would be borne more by Indian girls, as India accounts for one in three child marriages globally. 

The situation is no better for children rescued from traffickers, spokespeople from Prerana, an NGO that works in the red-light districts of Mumbai, noted in a post during the lockdown last year.

The lockdown has also affected the socialization needs of the children living in Children Homes. Their interaction with the outside world through education, vocational training, parents’ visits, field trips, and so on, has stopped, and this could affect their rehabilitation and subsequent social reintegration.

In November last year, the UN acknowledged that there was a direct link between the pandemic, socio-economic vulnerability, and the risk of exploitation. The government now needs to urgently track and rehabilitate children who have been trafficked and build a system in which they are safe.

Poverty and pandemic went hand in hand

Last week, The Economist summarised the extent to which the poor are impacted by the pandemic in India. 

After the first covid-19 wave swept India last year, numerous reports tried to tally the cost to the poor. Pew, a research institute, estimates that whereas just 4.3% of Indians were earning less than $2 a day in January 2020, a year later this had risen to 9.7%, or 134m people. An in-depth study by Azim Premji University in Bangalore suggests that in the wake of last year’s nationwide lockdown, some 230m Indians slipped below a poverty threshold tied to the national minimum wage (around $45 a month). Its researchers found that, during the lockdown, 90% of the poor consumed less food. Six months later, their diets had not returned to normal. Over the course of the year the earnings of Indian workers, including the lucky 10% who hold salaried jobs, declined by a third.

Earlier this month, The Wire had analysed the report by Azim Premji University to show which sections of the population were affected more.

The report also revealed that “women were more likely to lose employment compared to men”. It discovered that there was no recovery of employment for 7% men whereas in women the rate was 46.6%.

The structural inequalities have surfaced in Indians’ ability to earn a living and in access to basic healthcare. For instance, there was a decrease in child immunisation, according to data from India’s National Health Mission. It could worsen this year, with the second and the imminent third wave of Covid-19. 

However, there was one state in India that showed intent to prevent this, noted a report by the UN last month. The southern Indian state of Kerala has the highest literacy rate and generally better health indicators like infant and maternal mortality in the country. It differentiated itself by thinking “long term”.

Mix of draconian lockdown measures that were put in place before the national ones (closed schools, banned gatherings, a quarantine period that is double that of the national one, namely 28 days, and aggressive testing and contact-tracing) were matched with social outreach policies. Such policies included home-delivered meals to children who couldn’t attend school, communication channels to combat fake news, shelter and meals for thousands of citizens (including special provisions for over 150,000 migrant workers from other states), safety nets for the most vulnerable citizens and mental health helplines (psychosocial services have reached over 11.5 million people). In other words, the response has been characterised by an all-of-government and all-of-society action bounded by trust and compliance.

Still, due to a lack of economic activity, the migrant workers are leaving Kerala, despite the state’s best efforts. There is no silver bullet to avoid poverty in a pandemic.

If you like this edition, do share. And if you’d like to write for BFO about such second-order effects, pitch your ideas to us at [email protected].

Stay extra safe,
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