Opinion: Is India Really Ready For the Next Big Outbreak?

Did India's political leaders learn anything from the deadly second wave of Covid-19? Hospitals in the capital, New Delhi, are once again overwhelmed with patients and the health authorities don't have beds for them. The disease has changed - dengue, not coronavirus - but the dysfunction remains the same.

For the country that wants to be the pharmacy to the world, its own health system is notoriously bad. With some of the lowest government spending of any nation, public hospitals are overcrowded and inaccessible. The multitude of private facilities are out of reach for most citizens. India's courts were forced to intervene earlier this year to address the dangerous inequities in hospital oxygen supplies, while state and federal authorities fought among themselves over procurement and citizens died in the back of autorickshaws gasping for breath.

The pandemic pushed many into serious debt to access health care, with families forced to sell assets, jewelry and even livestock to pay hospital bills. Even before Covid, India's out-of-pocket medical expenses were among the world's highest, accounting for about 60% of total health expenditure. Public health spending is less than 2% of gross domestic product, compared to 5.4% in China and a global average of nearly 10%, according to World Bank data. Researchers at Azim Premji University found the virus pushed an additional 230 million people - more than the entire population of Brazil - below the poverty line, with worrying increases in malnutrition and hunger.

The first warning signs that it would be a bad dengue season came in late August, when a hospital in Firozabad in the northern state of Uttar Pradesh reported a surge in deaths from a "mystery fever." But it was no mystery; it was mostly dengue and scrub typhus. The independent news outlet, News Laundry, reported chaotic scenes at one government-run facility in September, with patients sharing beds, lab reports delayed and a severe shortage of doctors. An open drain and ponds of stagnant water provided an ideal breeding ground for the mosquitos that transmit dengue, while monkeys, pigs, cows and dogs scrounged garbage dumps near the hospital for food.

As the number of dengue cases crossed 1,500 in Delhi last week, with serious outbreaks and spiking death rates across the country, the federal health minister Mansukh Mandaviya intervened. The ministry deployed teams of experts to nine states and territories and suggested Covid beds should be repurposed for dengue patients. Mandaviya also inadvertently highlighted one of the main shortfalls of India's pandemic response - the significant undercounting of cases and deaths. "Since testing is the most important step to identifying dengue, these deaths will not be reported as such and the disease will continue to be under-reported," he said.

Epidemiologists say India's actual Covid death toll could range between 1.3 million to 5 million, with even the most conservative estimate putting its tally at more than double the U.S., the highest recorded in the world so far. That's three to 10 times the official count - a claim denied by Prime Minister Narendra Modi's government, which has consistently used the low reported mortality rate of 459,000 to defend its pandemic response.

But unless India learns from its missteps, it is doomed to repeat them when the third wave eventually arrives. As a priority, it must increase  investment in public health, strengthen surveillance systems and significantly ramp up vaccinations. Its 1 billion-shot milestone last month was an important one, but when you consider that just 24% of India's 1.4 billion population is fully vaccinated, while 54% have had one shot, it is clear there's still a very long way to go. And that leaves us all vulnerable.

Experts from the Daniel K. Inouye Asia-Pacific Center for Security Studies say the government needs to do much more. Public health authorities should procure and stockpile excess essential medical supplies in anticipation of future Covid spikes and learn to manage health emergencies much faster. It is not a good sign that Modi's administration has taken months to recognize the seriousness of the dengue outbreak rather than acting when the early signs were so grim.

India must also strengthen its health security borders to avoid another mass movement of migrant workers, who left cities in their millions during the pandemic when their employment and housing disappeared, fanning out to villages across the country and taking the virus with them. It should also take seriously the urgent need to increase the number of health care workers to meet World Health Organization guidelines, and make sure they're properly paid and equipped.

The consequences of moving slowly on these reforms are too great to ignore. India has already slipped on the Global Hunger Index to 101st out of 116 nations, below countries like Myanmar and Pakistan, while unemployment, particularly in the vast hinterland, is surging. Even as the economy is showing signs of a recovery with the consumption-driven festive season, it will take a lot to ease the pain felt by the most vulnerable, who are in urgent need of food, jobs and housing. Here's hoping this dengue outbreak rings alarm bells for the government.

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