📰 A pragmatic approach for COVID-19
Managing mild symptoms at home is vital to reduce the burden on an already stretched system
•The second wave of COVID-19 infections in India has turned into a public health emergency, and it has become difficult for most people to even access the healthcare system. Finding a hospital bed has turned almost impossible in many parts of the country, and if one does manage hospital admission, critical supplies like medical oxygen are hard to come by. Healthcare personnel have been trying to do their best under these trying circumstances, but they are now stretched to the breaking point. Amid this, a plethora of guidelines and lack of concordance across recommendations put forward by different States add to the confusion.
•Various drug cocktails with unproven or marginal benefits are being used widely. To address the confusion, the India COVID SOS team, a group of volunteers from across the world, including India, has developed clear guidance in various Indian languages to help in home-management of patients. This is not intended to be a substitute for medical care but rather a way to assist people with mild to moderate symptoms safely at home.
Moderate illness
•Starting with the basics, if one develops symptoms of COVID-19, like fever, sore throat, dry cough, headache, body aches, and loss of smell or taste, they should try to get tested. Given the high number of cases in India, if a person has one or more of these symptoms and lives in a highly affected area, they are very likely to have the infection. However, if testing is unavailable, they must assume that they have COVID-19 and should stay home, keep the windows open for ventilation, and follow other tips. Most importantly, avoid panic. It is important to remember that over 90% of people with COVID-19 recover fully without needing hospital care. A pulse oximeter must be used to check oxygen saturation levels three to four times a day, or more often if there is difficulty in breathing.
•There is some evidence that a steroid inhaler may be helpful for people over the age of 50 years. If available, an inhaled steroid (budesonide) may be used twice a day for five to seven days. If oxygen levels are at or above 92%, hospitalisation, blood tests or a CT scan are not needed. Further, oral steroids, intravenous Remdesivir, or plasma may not be beneficial for such patients. In fact, taking oral steroids at this stage could actually be harmful.
•In case the oxygen levels are less than 92%, one must reach out to a doctor and follow their recommendations. Our suggestions at this stage apply only if an individual cannot reach a doctor or find a hospital bed.
•The most important treatments at this point are oxygen and oral steroids. Dexamethasone is the most commonly used steroid medication, usually given at a dose of 6 mg per day for five days. In case dexamethasone is not available, there are several alternatives.
•If a patient has diabetes, it’s important to monitor their blood sugar while on steroids, and if it is higher than normal, the doctor must be informed. They should also stay in touch with a doctor and seek urgent help if oxygen needs increase to more than four litres a minute.
Unproven methods
•Most other treatments that have been tried for COVID-19 have shown no benefit. This includes widely prescribed treatments such as ivermectin, hydroxychloroquine, vitamin supplements, antivirals, and antibiotics. Convalescent plasma has not lived up to its initial promise and several trials have failed to demonstrate significant benefit with routine use. Collecting, testing, and administering plasma adds more strain to an already overburdened healthcare system and uses up valuable resources. Similarly, recent data indicate that Remdesivir has a limited role in COVID-19 treatment, and patients should not seek admission to hospitals solely to receive this drug.
•Most people will recover completely at home. Staying home if the symptoms are mild will help save hospital beds, oxygen, and other supplies for seriously ill patients. This also means that doctors, nurses, and other medical staff can do a better job of taking care of critical patients. However, worsening symptoms must not be ignored and a patient should not delay going to the hospital if needed.
•What else can individuals do? Wearing a mask, avoiding crowds, and washing hands are some ways through which people can prevent the spread. Getting vaccinated is the most important step. COVID-19 vaccines are safe and highly effective at preventing severe illness and death from the infection. One can still get COVID-19 after vaccination, but typically, the illness will be mild.
•The grave humanitarian crisis sweeping through India can be controlled only by large-scale public health measures. Curfews and lockdowns will work if implemented carefully. Mass gatherings should be prohibited. Large-scale vaccination drives are essential. Celebrities from the film industry, social media influencers and sports stars should promote vaccination, the use of masks, and physical distancing. Testing needs to be scaled up and test results should be reported in a timely manner. Medical supplies, including oxygen, should be made available, not just in healthcare settings but also to persons at home. Tools for triage of patients and accessible dashboards listing available resources are the need of the hour. At this point, many of these things are being cobbled together by volunteers. But an organised response would be much more effective.
Acknowledging the crisis
•Finally, much of the reporting of cases and deaths has been coming from media rather than government sources. Indeed, since the beginning of the pandemic, responsible science reporters have been the best sources of information, not just in India but around the world. We need robust data. In order to deal with the problem, it is important to acknowledge the enormity of it.
•India is facing an unprecedented public health crisis. The number of new cases being reported each day is higher than it has ever been in any country. As bad as the situation is currently, it could get much worse. We have seen that deaths from COVID-19 increase when the healthcare system is overwhelmed. But the damage can be greatly minimised by the measures described above: a combination of prevention and appropriate management.
•The massive spread can be arrested by following safety protocols and through rapid vaccination. If the vast majority of patients who can be treated safely at home stay home, so that hospital resources can be directed to critically ill patients who truly need them, we will be able to manage the crisis better. All eyes are on India and the actions we take now can help us turn the corner in the next few weeks.
Even as it waits for help from the U.S., India must accelerate its vaccination programme
•In a phone call with Prime Minister Narendra Modi on Monday, U.S. President Joe Biden said that his government would quickly deploy a number of COVID-19-related supplies to help India battle its current crisis with the pandemic. The move comes after what many saw as a delay in the U.S.’s response to the situation. After a few days, where the Biden administration seemed to dither, making the point that protecting Americans first was in the world’s interest, it appears to have amended its stand, in some part due to pressure from U.S. Congressmen, business chambers and academics. Over the weekend, senior U.S. officials reached out to India and made public comments expressing concern and sympathy for the people affected as India sees over 3 lakh new cases a day and a record number of deaths. In the short term, what India needs from abroad is two-fold: medicines and oxygen-management devices, including containers, concentrators and generators. It is heartening that more than a dozen countries, including the U.S., have promised to supply these within a week, and some of those supplies have already begun to arrive. In addition to the U.S. government’s supplies, the U.S. private sector has also mobilised aid for various COVID-19 resources in India. In the longer term, New Delhi wants Washington to consider a shift in its long-held state policies for the duration of the pandemic, which may be a more difficult proposition as it includes setting aside patent rights for pharmaceuticals produced in the U.S. and supporting the India-South Africa petition at the World Trade Organization for waiving all TRIPS (Trade-Related Aspects of Intellectual Property Rights) so vaccines can be manufactured generically for the next few years. The U.S. should consider its assistance to India both in light of their relationship and of the fact that as a key global supplier of pharmaceuticals and vaccines, India’s faltering steps in the fight against COVID-19 will impact the world.
•There is no denying that the perceived delay in the U.S.’s response to the crisis in India, which is not just a bilateral strategic partner but key to the U.S.’s Indo-Pacific strategy as a member of the Quad, has caused some disappointment in South Block. However, it is unlikely that this will seriously impact the partnership, nor should such matters affect the broader relationship. There is also a kernel of truth in the U.S.’s earlier assertion that the American government has a “special responsibility” to American citizens first and addressing their COVID-19 needs was also in the world’s interests. Instead of chiding the U.S. for its delay, New Delhi would do well to learn from this prioritisation, and complete its vaccination programme for all Indians, even as it uses all its resources and those received from the U.S. and other countries to rescue the nation from the current ravages of the pandemic.
📰 A ceaseless plight
Hundreds of fishermen have been languishing in Pakistan’s prisons for years with no end in sight
•Ramesh Taba Sosa, an Indian fisherman, is the latest victim of an inhuman and skewed system involving India and Pakistan, in which mortal remains of prisoners are not repatriated for months. Sosa died in a prison hospital in Malir Jail, Karachi, Pakistan, on March 26, 2021, but there is no guarantee when his family in Nanavada, near Kodinar in Gujarat, will be able to conduct his last rites.
•Sosa was arrested in May 2019 when the fishing boat he was in allegedly entered Pakistani waters. His sentence in the Pakistani prison ended on July 3, 2019. However, not only was he not repatriated, but he was also not given consular access till his death. Sosa’s case is one more statistic in a long story of insensitivity between the two governments that do not implement agreements. More than anything else, it is an issue of basic human rights.
•India and Pakistan signed the Agreement on Consular Access in 2008. Though the deal has a few lacunae, it was significant. Section 4 of the agreement said, “Each government shall provide consular access within three months to nationals of one country, under arrest, detention or imprisonment in the other country.” Further, Section 5 of the agreement stated, “Both governments agree to release and repatriate persons within one month of confirmation of their national status and completion of sentences.”
A long wait
•More than 300 Indian fishermen remain in Pakistan’s custody in Malir jail. Consular access is an exception. Without it, the nationality of the person is not confirmed and the repatriation process cannot begin. Though the agreement does not state a time limit, there are numerous instances in which both countries have not confirmed nationality for as long as 18 months, during which the arrested men languish in jails.
•Sosa’s case has many precedents. A shocking case is of Vaaga Chauhan, an Indian fisherman, who died in custody in December 2015. His mortal remains reached his village in Gujarat only in April 2016. Chauhan’s family went through unimaginable trauma and reached out to every resource for help.
•Then, there is Latif Qasim Sama’s case. Hailing from a village in Kutch near the International Border, he inadvertently crossed over to Pakistan in 2018. He was arrested and his sentence ended in April 2019. Latif still does not have consular access. His relative, Ismail Sama, returned from a Pakistan jail in January this year, though his sentence ended in 2016. Sama and Latif are not fishermen, they live near the International Border and inadvertently crossed it. Ismail returned home after 13 years. Worse, his family was informed a decade after his arrest.
•Fishermen from the Saurashtra region of Gujarat often get arrested when they unintentionally cross over into Pakistani waters. They suffer, and so do their families, who are now even more worried because of the COVID-19 pandemic.
Sluggish mechanisms
•Ideally, prisoners should be released and repatriated the day they complete their prison sentence. But this has happened in just one case, with Hamid Ansari, the only person who was released and repatriated on the day of completion of their sentence. Dharam Singh from Kashmir, who had unknowingly crossed over in 2003, spent 18 years in a Pakistani prison. He was eventually sentenced to 14 years’ imprisonment, which ended in December last year. But he reached home only this month.
•In 2007, India and Pakistan set up a joint judicial committee on prisoners comprising four retired judges from each side. The committee used to convene twice a year to meet prisoners. It made unanimous recommendations, including on the release and repatriation of fishermen and women prisoners. Its last meeting was held in 2013, after which it was discontinued. In 2018, efforts were made to revive it, but Pakistan is yet to nominate judges or call for a meeting. The delay is costing lives.
📰 A patently wrong regime
Over the last few decades, intellectual property rules have served as a lethal barrier to the right to access healthcare
•Even an unprecedented pandemic can do little, it appears, to upset the existing global regime governing monopoly rights over the production and distribution of life-saving drugs. If anything, since the onset of COVID-19, we’ve only seen a reaffirmation of intellectual property rules that have served as a lethal barrier to the right to access healthcare over the last few decades. The neo-liberal order, under which these laws exist, is so intractable today that a matter as seemingly simple as a request for a waiver on patent protections is seen as a claim unworthy of exception.
Request for waiver
•On October 2 last year, India and South Africa submitted a joint petition to the World Trade Organization (WTO), requesting a temporary suspension of rules under the 1995 Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS). A waiver was sought to the extent that the protections offered by TRIPS impinged on the containment and treatment of COVID-19. As we now know, quick and efficient vaccination is the surest route to achieving global herd immunity against the virus. Should the appeal for waiver be allowed, countries will be in a position, among other things, to facilitate a free exchange of know-how and technology surrounding the production of vaccines.
•The request for waiver has, since, found support from more than 100 nations. But a small group of states — the U.S., the European Union, the U.K. and Canada among them — continues to block the move. Their reluctance comes despite these countries having already secured the majority of available vaccines, with the stocks that they hold far exceeding the amounts necessary to inoculate the whole of their populations. Their decision is all the more galling when one considers the fact that for the rest of the world mass immunisation is a distant dream. Reports suggest that for most poor countries it would take until at least 2024 before widespread vaccination is achieved.
•A patent is a conferral by the state of an exclusive right to make, use and sell an inventive product or process. Patent laws are usually justified on three distinct grounds: on the idea that people have something of a natural and moral right to claim control over their inventions; on the utilitarian premise that exclusive licenses promote invention and therefore benefit society as a whole; and on the belief that individuals must be allowed to benefit from the fruits of their labour and merit, that when a person toils to produce an object, the toil and the object become inseparable. Each of these justifications has long been a matter of contest, especially in the application of claims of monopoly over pharmaceutical drugs and technologies.
A new world order
•In India, the question of marrying the idea of promoting invention and offering exclusive rights over medicines on the one hand with the state’s obligation of ensuring that every person has equal access to basic healthcare on the other has been a source of constant tension. The colonial-era laws that the country inherited expressly allowed for pharmaceutical patents. But in 1959, a committee chaired by Justice N. Rajagopala Ayyangar objected to this on ethical grounds. It noted that access to drugs at affordable prices suffered severely on account of the existing regime. The committee found that foreign corporations used patents, and injunctions secured from courts, to suppress competition from Indian entities, and thus, medicines were priced at exorbitant rates. To counter this trend, the committee suggested, and Parliament put this into law through the Patents Act, 1970, that monopolies over pharmaceutical drugs be altogether removed, with protections offered only over claims to processes.
•This change in rule allowed generic manufacturers in India to grow. As a result, life-saving drugs were made available to people at more affordable prices. The ink had barely dried on the new law, though, when negotiations had begun to create a WTO that would write into its constitution a binding set of rules governing intellectual property. In the proposal’s vision, countries which fail to subscribe to the common laws prescribed by the WTO would be barred from entry into the global trading circuit. It was believed that a threat of sanctions, to be enforced through a dispute resolution mechanism, would dissuade states from reneging on their promises. With the advent in 1995 of the TRIPS agreement this belief proved true.
•As the Yale Law School professor Amy Kapczynski has written, compelling signatories to introduce intellectual property laws like those in the global north was nothing short of a scandal. The follies in this new world order became quickly apparent when drugs that reduced AIDS deaths in developed nations were placed out of reach for the rest of the world. It was only when Indian companies began to manufacture generic versions of these medicines, which was made possible because obligations under TRIPS hadn’t yet kicked in against India, that the prices came down. But lessons from that debacle remain unlearned.
Refuting objections
•Instead, two common arguments are made in response to objections against the prevailing patent regime. One, that unless corporations are rewarded for their inventions, they would be unable to recoup amounts invested by them in research and development. Two, that without the right to monopolise production there will be no incentive to innovate. Both of these claims have been refuted time and again.
•Most recently, it has been reported that the technology involved in producing the Moderna vaccine in the U.S. emanated out of basic research conducted by the National Institutes of Health, a federal government agency, and other publicly funded universities and organisations. Similarly, public money accounted for more than 97% of the funding towards the development of the Oxford/AstraZeneca vaccine. Big pharma has never been forthright about the quantum of monies funnelled by it into research and development. It’s also been clear for some time now that its research is usually driven towards diseases that afflict people in the developed world. Therefore, the claim that a removal of patents would somehow invade on a company’s ability to recoup costs is simply untrue.
•The second objection — the idea that patents are the only means available to promote innovation — has become something of a dogma. But other appealing alternatives have been mooted. The economist Joseph Stiglitz is one of many who has proposed a prize fund for medical research in place of patents. Under the current system, “those unfortunate enough to have the disease are forced to pay the price… and that means the very poor in the developing world are condemned to death,” he wrote. A system that replaces patents with prizes will be “more efficient and more equitable”, in that incentives for research will flow from public funds while ensuring that the biases associated with monopolies are removed.
•The unequal vaccine policy put in place by the Indian state is indefensible. But at the same time, we cannot overlook the need for global collective action. If nation states are to act as a force of good, they must each attend to the demands of global justice. The pandemic has demonstrated to us just how iniquitous the existing world order is. We cannot continue to persist with rules granting monopolies which place the right to access basic healthcare in a position of constant peril. In its present form, the TRIPS regime, to borrow the law professor Katharina Pistor’s words, represents nothing but a new form of “feudal calculus”.
