India’s second coming of covid-19 is not just a wave, but a tsunami which has rapidly surpassed the daily tally of any other nation across the world. Delhi, the capital has taken the worst hit. But it’s not just about numbers. The acute shortage of beds and oxygen has led to gasping patients dying waiting for oxygen and beds. Families are lugging around oxygen cylinders for their close ones. A journalist tweeted pictures of falling saturations on his own pulse oximeter before he died without getting a hospital bed.  The BBC and other global news agencies have telecast these scenes from both hospitals and crematoriums, sending alarm bells ringing across the globe. Even as this sordid spectacle is unfolding, healthcare workers have been working as hard as they can despite the shortages, sometimes even when someone in their close family is sick or has recently succumbed to the disease.  However, not entirely unexpected paradoxical aspects of Indian healthcare have also emerged, which may have undermined some of the superhuman efforts of the healthcare community.
India is termed the world’s pharma capital; inexpensive quality drugs are readily available. And yet this has worked to the disadvantage of covid patients across all spectrums of severity. Patients with mild covid are receiving a cocktail of multiple ineffective drugs and unneeded investigations leading to a financially bloated treatment, while those with moderate-severe covid are currently struggling to procure indicated drugs and oxygen even on the black market.
The real-world treatment of mild covid in India is about considerably more expensive (not adjusting for per capita income) than the West, where guidelines recommend symptomatic treatment, and none or minimal investigations for managing mild covid.  With little regulatory control on prescription practices or disbursement in India, over prescription without a definite indication or scientific evidence has been common even in the pre-covid era under the pretext of not adding much to the patient’s cost.  Indeed, “what’s the harm?” and the need to appear to “do something” are important drivers of polypharmacy in India. Ordinary citizens have internalized the number of drugs prescribed and even their price as an indicator of a doctor’s expertise. This practice has continued unabated during the pandemic, starting from the use of hydroxychloroquine for prophylaxis last year. Currently, patients with asymptomatic or mild covid are routinely prescribed a combination of 7-8 drugs including ivermectin, doxycycline, azithromycin, and favipiravir. Many doctors indeed believed that India’s low initial mortality rate was due to the effect of one or more drugs in this cocktail. And while the second wave has swept this theory away, the polypharmacy continues unscathed. This has spilled over to diagnostics as well, with a battery of unneeded tests being advised even for mild covid, for example,complete hemogram, CRP (C-reactive protein), ferritin, D-dimer, LDH and IL-6 and a chest CT scan (all often repeated several times in those with a prolonged course). There is a belief among many doctors that abnormal tests in otherwise stable patients should be treated with systemic corticosteroids, Remdesivir, and anticoagulants, in the hope that this would improve outcomes. This, however, causes unneeded admissions only to allay the anxiety of abnormal reports in an otherwise clinically stable patient, thus further accentuating the hospital bed crisis.
An even bigger paradox though has been an acute shortage of drugs for moderate-severe covid in the “pharmacy of the world”, particularly Remdesivir. Despite seven pharma companies producing the drug locally, the sheer suddenness of the surge has led to demand far exceeding supply, with it being sold in the black market for as high as six times the official price to desperate patient kin. [5,6] Twitter and Whatsapp abound with requests for Remdesivir, Tocilizumab, and plasma, despite questionable evidence on their overall impact on survival. While there is a genuine shortage of these drugs, over-prescription and hoarding are also partly responsible for the situation. The aura created around these treatments by social media messages (despite categorical official statements to the contrary) also has a role, with celebrities and sports icons endorsing plasma and exhorting everyone to donate it. In fact, families often demand these treatments from their physician as well in the belief that they would help, further accentuating the shortage.
Once this is all over, one source of comfort for the medical fraternity would be the tenacity and dedication displayed by ordinary healthcare workers. Covid-19 has however provided the healthcare system and its guardians a once-in-a-lifetime chance to look inwards and seriously correct such systemic flaws, even if it involves radical changes. In the past, public memory and interest in healthcare problems has been rather short-lived. One can only hope that the covid-19 aftermath will be different.
Akshay D Baheti, Department of Radiodiagnosis, Tata Memorial Hospital, TMC, Mumbai, India; and Homi Bhabha National Institute, Mumbai, India
Trupti I Gilada, Infectious Disease Physician, Unison Medicare and Research Center, Mumbai, India.
Sanjay Nagral, Department of Surgical Gastroenterology, Jaslok Hospital and Research Center, Mumbai, India.
Competing interests: none declared.