The horrendous second wave of covid-19 in India, home to nearly a fifth of the world’s population, has engulfed the vast nation in death, despair, and despondency. The graphic scenes of suffering, people dying for lack of oxygen and medical care amid a shortage of medications and basic amenities, coupled with mass cremations and burials, grieving families, over-stretched healthcare workers, and sheer human helplessness is hard to watch. India is already recording nearly 400,000 reported cases per day (the actual number may be eight to ten-fold higher), and some models project the numbers may rise to 800,000 or even a million cases per day and 5-10,000 deaths per day by mid- or late-May.

What went wrong? Why did a country that seemed to have kept a relatively good lid on the pandemic suddenly start experiencing such a steep and catastrophic second wave? Why is a nation that is a global vaccine powerhouse, supplying 60-70% of the world’s vaccines, struggling to mass vaccinate her own—only about 2% of people in India have received two doses of vaccine thus far? Hard as these questions are, the honest answers to them may help catalyze serious national and global action against the pandemic. Rapidly controlling the pandemic is critical to the economic health of nations and the future health of our children. It may even usher in a new and bold era of concerted, well-resourced, and collaborative national and global public health. 

The coming of the second wave in India was not for lack of warning. For example, in an interview with the Deccan Herald on 12 January 2021, Srinath Reddy, President of the Public Health Foundation of India (PHFI) warned the nation against complacency and called for ongoing public health prudence and avoidance of mass gatherings. In a tweet, Bhramar Mukherjee, Chair of Biostatistics at University of Michigan, cautioned India that the data signal dangers ahead. She urged for masks, social distancing, and avoidance of gatherings to continue. 

Unfortunately, the political leadership and the people of India decided to declare premature victory against the pandemic, and let their guards down almost completely. Crowded election rallies, and major religious festivals (e.g., Holi, Easter, and the mega-event Kumbh Mela, which drew over 4 million people at one place) were celebrated in massive public gatherings, mask use was declined, and life almost returned to “normal” for most Indians. While data are yet to be analyzed to implicate any or all of these activities, it is a reasonable hypothesis that although a second wave was unavoidable, the steepness of the second wave is probably  driven by these numerous potentially super-spreader events. To add to all this, the complacency that emerged from the illusion that the pandemic had ended conspired with other political considerations and led to a state of under-preparedness in terms of stockpile and health system readiness. In many ways, what is being witnessed in India resembles an amplified version of the chaos and confusion that engulfed the United States all through 2020, when partisan politics and power prerogatives trumped health priorities. 

A question that gets asked is why is it that India, a global vaccine powerhouse, is unable to vaccinate her own people rapidly? It is true that India has an excellent ecosystem for vaccine development and manufacturing, and supplies nearly two-thirds of the world’s vaccines, and at low cost. Yet, as of now, about 120 million people in India have received one dose of a vaccine, and only 30 million have been fully vaccinated with two doses. This is a miniscule 2% in a population of 1.4 billion people, and India has a long way to go to reach herd immunity, which would require at least 70-80% of the population vaccinated—needing about 2 billion or more doses of vaccine. This will be a mighty undertaking. 

The availability of good vaccines is only a first step. Vaccination of a population of 1.4 billion people needs much more. A rapid national vaccination plan that is well-coordinated, well-resourced, and well-operationalized is urgently needed. This will need strong political will; public cooperation supported by public health communication addressing peoples’ concerns; concerted strategies to stop vaccine misinformation and overcome vaccine resistance; real-time transparent data systems to plan, monitor, and evaluate implementation of vaccination; manufacturing of vaccines at large scale; attention to vaccine cold chain and quality assurance; supply and delivery logistics akin to a war-time operation; infrastructure; adequate trained workforce; quality assurance strategies; and above all excellent organization together with strategic and effectively delegated operational leadership. Nothing on this scale has ever been attempted in history but we are now faced with a health catastrophe of epic proportions. Failure to do so, will result in the loss of tens of millions of lives and also an economic decline that is unprecedented. While India has the experience and ability to deliver mass vaccination with its successes in childhood immunization, small-pox and polio eradication programmes, the scale of the efforts needed currently are much larger. India has to be on a war footing and it is not clear that the governments have prepared for this. 

While mass vaccination is a high priority and needs to be pursued on war-footing, its positive effect will take some time. In the meanwhile, the challenge will be an already over-stretched and under-resourced health system, often with limited access or affordability to India’s teeming millions living in the harsh realities of poverty or near-poverty. Active mitigation will be needed, and will need to be done thoughtfully and with sensitivity to population needs and livelihoods. Lockdowns, wherever needed and possible, may be required; masks should be mandated; testing, tracking, and quarantines widely implemented; and life-saving healthcare will need to provided. An added complication will be the need to alleviate acute financial sufferings in a country without adequate social safety nets. 

It is important that the tragedy that is devastating India is not seen in isolation as an Indian problem alone. It is a global issue of serious import. There is speculation that the B.1.617 variant—first detected in India—is partly responsible for the India covid-19 surge, and the fact remains that the high circulation of the virus in any population further creates continued opportunities for new variants to emerge. The virus respects no borders. Already some seventeen countries have reported the Indian B.1.617 variant of the virus in their shores demonstrating that no one is safe until everyone is safe. No country will have tamed the pandemic until every country in the world will have done so. 

Additionally, the sheer size and location of India means that any human tragedy spiraling out of control there can wreak economic and security disaster for the whole complex world, and fast.  This calls for a global public health response, so that the world community can collaborate, share resources and knowledge, and together assist India, and other countries (e.g., Latin American and African nations) where the horrors of the pandemic may be unfolding. 

The shock and grief of the unbearable tragedy unleashed by covid-19 in India has touched the consciousness of our common and inter-connected global humanity. It is now an opportunity to think global, and to aggressively resource and coordinate a global health plan (akin to the Marshall Plan) to deal with and contain the pandemic worldwide. This will need leadership and serious investment, and cooperation from nations and major donors across the world. Will the USA, EU, UK, China, India, Russia, Brazil, South Africa, Middle-eastern nations, and others rise in solidarity to this task, and soon? 

K.M. Venkat Narayan is member of the US National Academy of Medicine, and is Ruth and O.C. Hubert Professor of Global Health and Professor of Epidemiology and Medicine at Emory University Atlanta. 

Competing interests: none declared.

Editor’s note: This was amended on 8 May 2021, as Bhramar Mukherjee was incorrectly referred to as He.